The conscious state depends upon appropriate communication between both cerebral hemispheres and the ..
RAS-reticular activating system
list the 7 levels of consciousness:
confusion
delirium
lethargy
obtunded
stupor
coma
A patient who is awake, alert, and oriented to person, place, time, and situation. The patient follows commands appropriately and is aware of his/her surroundings. on exam, an alert patient will open their eyes, look at you, respond completely and appropriately. They will respond to a normal voice tone.
conscious
The patient responds appropriately, however is disoriented, difficult to arouse, and may have memory impairment.
Memory issues are the most common
confusion
The patient is agitated, restless, resistant, and uncooperative, but alert. This is an acute, reversible state of confusion. Symptoms wax and wane. ...really easy to upset
delirium
The patient is in deep, prolonged unconsciousness. He/She appears drowsy. on exam, the patient will open his/her eyes, look at you, answer questions, then fall asleep. Will respond only to a loud voice.
lethargic
The patient appears more sleepy. You must provide some physical stimulus to arouse the patient. Answers to questions are confused. shake and shout
Obtunded
May require a sternal rub or Tina's nipple twist
Obtunded
The patient will respond only to a continuous painful stimulus. They may respond slowly or not at all. once the painful stimulus is halted, the patient returns to the unconscious state.
Stupor
An unresponsive state to any type of external stimulus. This is caused by some type of compromise of the RAS, or diffuse, simultaneous insult to both cerebral hemispheres. eyes remain closed
Coma
Coma is an unresponsive state to any type of external stimulus. This is caused by some type of compromise of the__ or diffuse, simultaneous insult to___
This is caused by some type of compromise of the RAS, or diffuse, simultaneous insult to both cerebral hemispheres.
DDX for delirium
D-Drugs: ETOH, toxins
E-Electrolyte Imbalances
L-Low pO2 (hypoxia)
I-Injury to the brain
R-Relapsing fever
I-Infection (UTI, pneumonia)
U-Uremia
M-Metabolism (liver damage)
Dx: Global impairment of cognitive function that interferes with normal activities.generalized and sustained decline in intellectual capabilities. progressive declinememory, cognitive abilities, adaptive behavior affected without affecting consciousness
The etiologies of AMS can be grouped into two different categories: __ or __
structural or metabolic
Typically with__ lesions you first get changes in consciousness, then pupil changes (unequal or not responsive)
structural
Typically with__ problem you first get pupil changes, then changes in mental status
metabolic
Which etiology of AMS: compression or damage to arousal areas of the brainstem, either directly or indirectly, LOC changes initially, followed by pupillary changes
structural lesion
Which etiology of AMS (structural or metabolic)? LOC changes after changes in pupils occur; generally pupils are equal and reactive to light; signs and symptoms present slowly and lack localized signs
metabolic etiology
Bilateral small pinpoint pupils suggests ___ damage vs ___ __
SNS damage vs. metabolic encephalopathy
Pinpoint pupils (< 1mm) suggest __ hemorrhage vs. drugs (morphine, heroin, other narcs), neurosyphilis, organophosphates
Pinpoint pupils (< 1mm) suggest pons hemorrhage vs. drugs
Bilateral midposition fixed pupils suggest structural damage to the __
midbrain
Bilateral large pupils, fixed and dilated suggest ...
anoxia (cardiac arrest)
One large fixed, dilated pupil suggests ___ (*like from tumor, swelling, bleeding [pressure])
CN 3 compression from temporal lobe herniation
Corneal reflex tests CN __ and __?
CN 5 (trigeminal nerve, sensory portion) and CN 7 (facial nerve, motor portion); absence of blinking suggests lesion of one or both of theses nerves; very useful in eval of comatose patients
How do you test vestibuloocular reflex of CN 8?
cold calorics:
Cold water in ear causes eyes to drift to side you put water in. If the reaction is different, damage to CN8 or brainstem injury
Vestibuloocular reflex: cold calorics, CN 8: Cold water in ear causes eyes to drift to ___. If the reaction is different, damage to CN8 or brainstem injury
side you put water in.
what should you do before testing for Doll's eyes?
clear c-spine
describe Doll's eye movement, what CN does it involve? and what does it tell you?
in a coma pt with a FUNCTIONAL brainstem, when you move their head to the right, their eyes move to the left. no eye movement occurs when there is damage to the midbrain or pons.
papilledema is a sign of..
late sign of increased ICP
name those respirations: alternating episodes of deep breathing with apnea
Cheyenne-Stokes respirations
what are some causes of Cheyenne-Stokes respirations (alternating episodes of deep breathing with apnea)?
causes include damage to both cerebral hemispheres, uremia, drugs, and heart failure
Apneustic breathing = breath held for 2-3 seconds with each inspiration. What type of lesion does this suggest?
pons
Biots respirations = no regularity in pace or depth of respirations. This usually indicates lesions where? (2)
traumatic pons, medulla lesions
hyporeflexia = __ motor neuron lesion
lower
hyperreflexia = __ motor neuron lesion
upper
a GCS of what = fully alert?
15
a GCS of what = comatose?
< 8
what 4 criteria must your pt HAVE to declare brain death?
1. documentation of LOC
2. absent motor response to painful stimuli (nailbed pressure, sternal rub, supraorbital pressure)
3. absent brainstem reflexes (fixed, unresponsive pupils, positive cold calorics/doll s eye, absent corneal reflexes, no cough or gag response
4. apnea, pCO2 < 60 mm Hg
they're not dead until they're __ and dead
warm and dead
Brain death is a clinical diagnosis. Perform the exam __ hours after onset of the insult creating brain death. May follow with another exam __ hours later (optional)
6 hours
Pt returns to ER one week later with altered mental status. Pt not responsive to loud voice. Must gently shake the pt to arouse. Speech is incomprehensible, opens eyes for a few seconds, then closes them again. What is his level of consciousness?
obtunded
18 y/o male college student found down in the bushes at a Widespread Panic concert. Initially responsive to only painful stimuli. Minutes later, patient responsive to voice. He is restless, agitated, uncooperative. Both pupils dilated and reactive to light. Abrasions to face, hands, and knees. LOC?Work up?
initially stupor, now delirious
drugs? diabetes?
less precise term that is frequently used synonymously with polyneuropathy, but can also refer to any disorder of the peripheral nervous system including radiculopathies and mononeuropathies.
peripheral neuropathy
specific term that refers to a generalized, relatively homogeneous process affecting many peripheral nerves, with the distal nerves usually affected most prominently.
polyneuropathy
Focal involvement of a single nerve, usually due to a local cause such as trauma, compression, or entrapment. Carpal tunnel syndrome is a common example.
mononeuropathy
Carpal tunnel syndrome is a common example of which type of neuropathy?
mononeuropathy
Most common nerve entrapment disorder. Due to compression at the flexor retinaculum, with resulting median nerve compression; results in weakness of supplied muscles DISTAL to this (e.g. index finger-thumb apposition task) and thenar muscle atrophy, and numbness along lateral portion of hand
carpal tunnel
carpal tunnel is a compression of which nerve?
median
treatment for carpal tunnel?
first, brace..if no better, surgical decompression
physical findings of median nerve compression?
1) a positive Tinel sign or a positive Phalen test
2) diminished or absent sensation to pin prick in the median nerve distribution
median nerve - carpal tunnel
Pt c/o: Hand-shaking, particularly at nighttime; Pain wakes me up. Features are variable --pain is common--paresthesias ie numbness, tingling, pins and needles
carpal tunnel
Due to compression (usually) at the elbow, with resulting weakness in hand intrinsics & hypothenar muscle atrophy; also associated with numbness @ medial aspect of hand
ulnar neuropathy - cubital tunnel syndrome
Chronic axonal polyneuropathies (eg, due to __ or __) are the most common of the polyneuropathies. Injury tends to be related to axon length; thus, longer axons are affected first, resulting in symptoms that begin in the lower extremities. Sensory symptoms usually precede motor symptoms
diabetes mellitus or uremia
History: Pain in leg (travels along nerve root, thus radiculopathy) may or may not be related to trauma or action; Exam: Use the motor and sensory exams to determine nerve root affected. A disc is between 2 levels, and will affect the LOWER nerve root e.g. L5-S1 HNP causes S1 radiculopathy, which may reveal ankle plantar flexion weakness and decreased sensation at the bottom of the foot; also + straight leg raise
herniated lumbar disc dz
treatment for herniated disc dz?
conservative, NSAIDs, PT, injections
if >4 weeks, get MRI
must give time for inflammation to resolve
The single best test to dx lumbar path; Indicated for patients with > 1 month of symptoms & signs of nerve root compression
MRI
etiologies of which syndrome: Sagging musculature related to aging, obesity, or heavy breasts.
Postural etiologies
Weakness of the trapezius muscles due to aging, inactivity, or nerve damage
thoracic outlet syndrome
when should you operate on thoracic outlet syndrome?
never, really
in a young female with facial pain in the trigeminal distribution, what must you r/o?
MS
Trigeminal neuralgia is mainly found in what age patients?
elderly
one of the most common causes of facial pain. sudden, usually unilateral, severe, brief, stabbing or lancinating recurrent episodes of pain in the distribution of one or more branches
trigeminal neuralgia
how should you workup trigeminal neuralgia?
1. MRI to r/o mass or lesion
2. dental exam
primary management of trigeminal neuralgia pt?
meds,
then injections
then radiosurgery
Ball's palsy is a lesion of which CN?
VII-facial
Diffuse facial nerve involvement manifested by paralysis of the facial muscles, with or without loss of taste on the anterior two-thirds of the tongue or altered secretion of the lacrimal and salivary glands. ACUTE onset, hours to 1 or 2 days max
Bell's palsy, CN VII
How do you treat Bell's Palsy?
Try Steroids and
Try antiretrovirals if HIV/HSV
Eye care
course is progressive, maximal paralysis within 3 weeks, recovery within 6 months
Cause of Bell's Palsy?
Histopathology is consistent with an inflammatory and possibly infectious cause
CN 7
term: perception of movement where no movement exists
vertigo
term: transient loss of consciousness accompanied by a loss of postural tone with spontaneous recovery
syncope
Define: spinning, weaving, seasickness, ground rising and falling, rocking, merry go-roundnausea, vomiting, and diaphoresis may be presenttinnitus and hearing loss indicate injury to the auditory component of the 8th cranial nervenystagmus present or can be produced
vertigo
Vestibular problems: peripheral or central? cochlear or retrocochlear, occurs in isolation except for presence of timmitus or hearing loss
peripheral
Vestibular problems: peripheral or central?: vertigo in association with other brainstem deficits
central lesion
Vestibular problems: peripheral or central? vertigo is acute onset, intermittent and severe, associated with intense nausea, vomiting, provoked by movement
peripheral
Vestibular problems: peripheral or central? Vertigo is Progressive, constant and less severe, associated with mild nausea, not affected by movement
central
Vestibular problems: peripheral or central? Nystagmus: Always present; unidirectional,horizontal or rotatory (never vertical); latency (20-40 sec.) and fatigability present; inhibited by ocular fixation
peripheral
Vestibular problems: peripheral or central? Nystagmus May be absent, can be bidirectional (vertical nystagmus almost always central in origin), latency and fatigability absent, not inhibited by ocular fixation
central
Vestibular problems: peripheral or central? Associated symptoms: hearing loss or tinnitus may be present. Brain stem or cerebellar findings absent
peripheral
Vestibular problems: peripheral or central? Hearing loss or tinnitus not often present. Brain stem or cerebellar findings often present
central
is benign positional vertigo peripheral or central lesion?
peripheral
definition: common in elderly, experienced with certain positionssudden onset usually within a few seconds of assuming the triggering positionsymptoms stop after few minutes in same position, but will resume if position changesresolves within 6 months
benign positional vertigo (peripheral lesion)
dx: idiopathic endolymphatic hydrops, damages hair cells because of swelling of the semicircular ducts, tinnitus, pressure in ear, hearing loss with vertigo can be disabling, episodes paroxysmal, lasting minutes to hours, then decrease in frequency after multiple attacks only to recur in months or years
Meniere's disease (peripheral lesion)
Is Meniere's Dz peripheral or central lesion?
peripheral
Dx: secondary to viral infections of cochlea and labyrinth, pt. c/o vertigo, tinnitus, and decreased hearing following a URI, resolve in 1-6 weeks
acute labrynthritis (peripheral lesion)
dx: most worrisome of the peripheral lesions; retrocochlear with mild hearing loss, tinnitus, vague dizziness
Acoustic neuroma (benign schwannoma of the 8th cranial nerve); (peripheral neuropathy)
Dx: most worrisome of the peripheral lesionsretrocochlear in location, mild hearing loss ability to produce serious brainstem compression, which cause facial numbness, gait ataxia, weakness, decreased corneal reflex
Acoustic neruoma (benign schwannoma of the 8th cranial nerve)
is MS peripheral or central lesion?
central
dx: focal demelination in vestibular pathways of brainstem transient nature of attacks and subtlety of accompanying symptoms (slight facial numbness or deepening of voice) progress to repeated attacks central type of positional nystagmus persists after vertigo resolves
MS
True Vertigo: Peripheral or Central?
True Vertigo: Peripheral or Central?
1. __ likely to represent potentially life-threatening disorders
2. __ more intense, associated with nausea, vomitin, daphoresis, tinnitue, hearing loss, and photophobia
1. Central likely to represent potentially life-threatening disorders
2. Peripheral more intense, associated with nausea, vomitin, daphoresis, tinnitue, hearing loss, and photophobia
Combining findings of nystagmus with findings from Romberg and Rinne testing favors (central or peripheral) lesion? ie; if slow phase of nystagmus moves toward same side as hearing loss, patient reports spining is away from the side of the hearing loss and the Romberg is positive and pt. sways toward the side of the hearing deficit.
peripheral
Dx: recurrent attacks, tinnitus/vertigo/unilateral hearing loss
Meniere's Dz
sensation of faintness or inability to maintain normal balance in standing or seated postion, sometimes assoc'd with confusion, anusea, weakness
dizziness
dx: a head sensation of abnormal movement or abnormal movement of the environment spinning
vertigo
Episodic auditory and vestibular disease characterized by sudden onset of vertigo, hearing loss, tinnitus and sensation of fullness in the affected ear.
The cause is unknown, but results in an overproduction or impaired absorption of endolymph in the inner ear.
Diagnosis is made on clinical history and detailed audiology tests; other investigations may be required to exclude other causes.
Dietary changes and diuretics may control symptoms in early stages of the disease; specific medical therapies for vertigo control can be trialed if required.
If symptoms persist despite maximal medical therapy, several surgical interventions are available.
Meniere's Disease
Common, often self-limited condition, but can be chronic and relapsing.
Diagnosis is based on a suggestive history and physical exam with a positive Dix-Hallpike maneuver or a positive supine lateral head turn. Other tests are not usually required.
Medication is not an effective treatment option.
Repositioning maneuvers are highly efficacious in resolving an episode of BPPV.
Surgery is highly effective but is reserved for intractable and severe cases.
Benign Positional Vertigo
Paresis = __
Plegia = __
Paresis = weakness
Plegia = paralysis
Hemi = ___
Para = __
Quadri (tetra)= __
Hemi = both limbs same side
Para = both lower extremities
Quadri (tetra)= all 4 extremities
Neuropathy or Myopathy:
Neuropathy or Myopathy: Typically manifests distally; Usually has associated sensory symptoms; Tend to be a endocrinopathy, affects distal extremities first; usually assoc with numbness/tingling, not just motor weakness
neuropathy (DMII is MCC)
Neuropathy or Myopathy: Typically manifests proximally first in the larger, anti-gravity muscles.; Not usually associated with sensory symptoms;
Myopathy
EMG measures fasciculation potentials - involuntary/spontaneous contraction of a motor unit indicates __ problem
LMN
ElectroDiagnostics: measures motor potentials
EMG = electromyography
ElectroDiagnostics: Measuring the time it takes for an electrical stimulus to travel along a nerve
NCV - nerve conduction velocities
ElectroDiagnostics:
Measures brain activity at rest and in response to stimuli
Assess level of consciousness
Assess seizure disorders
As part of evoked responses
EEG - electroencephalogram
mneumonic of causes for neuropathy?
DAG C. THERAPIST: Diabetes; Alcohol; Guillain-Barre; Compression; Toxins; HEreditary; Refsum s; Amyloid; Porphyria; Infection; Systemic; Tumor
A chronic autoimmune disorder of the postsynaptic membrane at the neuromuscular junction in skeletal muscle. Characterized by muscle weakness that increases with exercise (fatigue) and improves on rest. Commonly presents with drooping eyelids, double vision, oropharyngeal and/or appendicular weakness and shortness of breath.
Myasthenia gravis
Tx for myasthenia gravis?
Treatments include anticholinesterases and immunotherapy. Thymectomy may be required.
Most patients enjoy good quality of life and normal lifespan due to advances in diagnosis and immunosuppressive treatment.
Dx:
- Neuromuscular junction disease
- Affects voluntary muscles
- No familial or genetic connection.
- Autoimmune - antibodies to acetylcholine receptors
2. Serology for antibodies to acetylcholine receptors
general treatment for myasthenia gravis?
immunosuppression and steroids
Dx:
- acute idiopathic polyneuritis - immuno-mediated
- Most common acquired demyelinating neuropathy
- Ascending, peaks 3 days - 3weeks
Guillain Barre
Myasthenia Gravis, ALS, Guillian Barre or Multiple Sclerosis:
- Weakness(usually proximal), hypotonia, hyporeflexia (or areflexia)
- No atrophy, usually no fasciculations, little or no sensory involvement.
Guillian Barre Syndrome
Tx for GBS?
1. Admit! Reserve ICU. Frequent VS.
2. Plasmapheresis first 2 wks of a severe case to decrease severity of disease course.
3. Immunoglobulins IV
4. Steroids not usually helpful.
20-40 y/o female grew up up north
MS
Myasthenia Gravis, ALS, Guillian Barre or Multiple Sclerosis:
- Optic neuritis, vertigo, Unsteady gait, scanning speech (no inflection in voice)
- Trigeminal neuralgia
- incontinence
MS
weakness or paralysis: loss of muscle power
weakness
weakness or paralysis: loss of motor fxn
paralysis
MRI of this condition shows multifocal, hyperintense lesions/plaques
MS
Type of MS: most common with sudden onset of neurological deficit with each new plaque and improvement after each crisis as plaque resolves, although return of fxn is not back to prior state
relapsing/remitting (RRMS)
Myasthenia Gravis, ALS, Guillian Barre or Multiple Sclerosis:
- CSF: Oligoclonal banding
- IgG index = comparison of serum and CSF IgG levels
- VER - visual evoked responses (75% + even if no symptoms) - cerebrum
MS
first test for MS?
MRI to find hyperdense lesions
MS treatment?
1. immunosuppression
2. oral prednisone & IV methylprednisolone for crises
the very reliable and objective diagnostic test for myasthenia gravis?
single fiber EMG
Bells Palsy: central or peripheral?
peripheral
Myasthenia Gravis, ALS, Guillian Barre or Multiple Sclerosis:
- Usually starts in UE
- Fasciculations often first in the forearms and tongue
- Corticospinal/anterior horn cell degeneration
- Weakness, UE, slight LE spasticity, gen hyperreflexia
- UMN & LMN findings in the same limb
- No sensory changes
ALS
definition: Neural deficits lasts no more than 24 hours; Neural deficits clear completely
TIA
definition:
- aggregate of blood factors building on a vascular wall to the point of occlusion
- platelets/fibrin/trapped cellular elements, etc on an underlying plaque
thrombus leading to ischemic stroke
definition: clot, plug or detritus brought by blood circulation from another location to lodge in a smaller vessel
embolus leading to ischemic stroke
definition: Decreased flow if you are drowning or you have heart failure and the hearts not pumping blood to the brain
hypoperfusion leading to ischemic stroke
which type of stroke:
- Onset gradual or sudden
- Progression of symptoms is stepwise or stuttering
- Deficits focal to area of ischemia
- Happens when asleep or inactive (stuff building up on a wall, slower flow at night)
- Headache associated sometimes
- Usually preceded by TIAs for days or weeks
thrombosis leading to ischemic
Step wise ssx progression, stuttering: this is because when we're young, we have a good balance of build-up/break down mechanisms in place; but in older pt's, their artery is almost closed, buildup on both sides causing narrowing, when you build-up just a little more, suddenly it closes, but then the lytics kick in and opens it back up again, this happens cyclically so that they get worse each time, then get better and get worse
which type of stroke:
- Onset sudden
- Deficit usually maximal at onset
- Deficits focal to area of ischemia
- Onset with activity (due to high blood flow)
- Headache associated sometimes
- Not usually preceded by TIAs
embolus leading to ischemic strokes
which type of stroke:
- Sudden onset
- Neural deficit develops over minutes to hours
- Deficits focal to area of hemorrhage pressure, may have papilledema
- Usually awake and active prior to onset
- Headache very common
- No TIAs associated
intracerebral hemorrhage
- having a baby, pooping, sitting smoking a cig and drinking coffee
- High flow, high pressure situation, so HA is very common; stretching adjacent structures
which type of stroke:
- Sudden onset
- Deficit absent or non-focal, no papilledema
- Awake & active often with sudden exertion
- Headache - always - WORST HEADACHE OF MY LIFE
- Nuchal rigidity (neck stiffness)
- Nausea/vomitingBrief loss of consciousness
- TIAs - never
- Prodrome of sentinel headaches/III palsy/VI palsy/field cut in many cases
subarachnoid hemorrhage
worst HA of my life?
subarachnoid hemorrhage
which type of stroke:
- No deficit, no papilledema
- Mechanic who is lifting the car battery or 22 y/o mother who is in her first labor, these situations where they blow an aneurysm
- Always HA
- Instant HA, loss of consciousness
- Neck stiffness/N/V looks like meningitis - this is b/c all this blood irritates the meninges
subarachnoid hemorrhage
first line diagnostic test for stroke w/u?
CT NO CONTRAST!
this type of stroke will show up immediately bright white on CT scan with no contrast
intracerebral hemorrhage
this type of stroke takes 6-24 hours to show up hypodense on CT
ischemic
why should you do CT NO CONTRAST as first line for any type of suspected stroke?
Infarct (ischemic) takes 6-24 hours to become hypodense; CT doesn't tell you they've had an infarct, but it does tell you they haven't had a bleed this is important info to have
this type of stroke shows hazy in the peri-Willis space on CT, can have intraparenchymal extension
Subarachnoid hemorrhage
this study is almost immediately positive for ischemic stroke
MRI, but CT is first line
after you've done a CT no contrast and established that your stroke pt does not have a bleed, what's first line?
*Anticoagulation:
****Heparin drip first line
*Thrombolytics for emboli (clot busters)
Angioplasty for thrombosis
treatment for intracerebral hemorrhage stroke? (4)
Control BP to avoid rebleed
Correct any coagulopathy
Control ICP
Surgery for clot removal if feasible
tx for subarachnoid hemorrhage?
Surgery! endovascular coiling, slipping
6-8 days after a subarachnoid hemorrhagic stroke from this cerebral artery, you'll have vasospasm
ACA
apply triple H therapy:
- hemodilution hct 33-37%
- hypervolemia, using volume expanders w/o free water
- Albumin/plasmanate (hepatitis/AIDS)
- Dextran (0.05% anaphalaxis)
- hypertension
85% of all cerebral aneurysms leading to SAH arise from where in the circulation?
anterior circulation
15% from posterior circulation
aneurysms are most likely to occur at what point in the vessle?
bifurcations:
Acom / AC
ICA / Pcom
MCA bifurcation
Basilar tip
Vertebral
approximately 80% of strokes are__ in origin
ischemic
2 pairs of major arteries, the __ (anterior circulation) and __ (posterior circulation) arteries supply the brain
carotid (anterior)
vertebral (posterior)
the internal carotid bifurcates into the __ and ___, with the __ being a straight shot, and the __ turning at 90 degrees
branches into the anterior cerebral and the middle cerebral. the middle cerebral is a straight shot, the anterior cerebral curves at 90 degrees to enter the middle of the brain
__ of the cerebral vasculature accounts for approx 2/3 of strokes, either thru emboli or in situ thrombosis. ___ make up the majority of the remaining 1/3 of ischemic strokes
atherosclerosis = 2/3 of ischemic strokes
cardiogenic emboli = 1/3 of ischemic strokes
ischemia in this artery produces various combo's of ssx such as vertigo, diplopia, ataxia, bilateral sensory or motor ssx and fluctuating episodes of drowsiness
vertebral-basilar insufficiency
acute occlusion of this artery usually results in contralateral hemiplegia and hemisensory loss, reflecting ischemia to the MCA territory. Headache also
internal carotid artery stenosis/occlusion
occlusion of this artery causes weakness and sensory loss in the contralateral leg. Other clinical manifestations include incontinence.
anterior cerebral artery
occlusion to this artery results in contralateral hemiplegia, hemianesthesia, and homonymous hemianopsia, aphasia
middle cerebral
most anterior circulation TIAs (75%0) occur in the setting of significant stenosis or ulceration of this artery; cardiogenic embolism accounts for the remainder
internal carotid artery
Mild attacks of__ insufficiency may be associated with orthostatic hypotension
vertebrobasilar
Patients with___ insufficiency present with episodic vertigo lasting 1 to 15 minutes, with diplopia, dysarthria, ataxia, drop attack, and clumsiness of the extremities.
vertebrobasilar
this imaging technique is the most reliable test for differentiating ischemic stroke from hemorrhage, but only 5% of acute ischemic strokes are visible in the first 12 hours
CT no contrast
what are 4 main risk factors for stroke?
HTN
smoking
diabetes
hyperlipidemia
T/F: as a primary preventative measure, antiplatelet agents reduce the risk of ischemic strokes in pt's without vascular risk factors
false
t/f: no evidence has been found to support the use of anticoagulation (heparin) in the management of acute stroke.
true. although heparin might reduce the risk of recurrent stroke in the short term, any benefit is offset by the increased risk of intracranial hemorrhage
___ therapy remains the treatment of choice to prevent recurrent thromboembolism in the majority of patients with stroke
antiplatelet
which is more common: viral or bacterial meningitis?
viral
__ meningitis typically occurs in the late winter and early spring, and __ meningitis is more common in the warm summer monehts
bacterial = winter/spring
viral = summer
4 etiologies of infectious acute meningitis
bacterial
viral
fungal
TB
2 etiologies for non-infectious acute meningitis?
SLE
sarcoidosis
This maneuver is positive for meningeal irritation when there is flexion of the hips and knees as the neck is passively flexed by the examiner
Brudzinski's sign
This maneuver is positive when there is pain and increased resistance to extending the knee, bilaterally
Kernig's sign
2 named signs which suggest meningeal irritation and inflammation
Brudzinski's and Kernig's signs
pathogenesis for meningitis
pt's have a precursor infection, like URI
The cilia of the mucosa in that area stop clearing and the bacteria are able to enter the skull area, cross the blood brain barrier and enter the CSF (which is usually sterile). Host defense mechanisms must also be ineffective in order for the bacteria to grow.
The top two causes of bacterial meningitis are __ and __. (80% of all cases of community-acquired bacterial meningitis in adults)
S. pneumonia and
N. Meningitidis
__ pathogen causes sporadic disease or epidemics in closed populations in the young (eg students in dormitories or schools)
Neisseria
A bacterial cause of meningitis in children is ___, with most cases by the age of 10
Haemophilus influenza
Most common bacterial pathogen of meningitis in adults
strep pneumo
Name that pathogen of bacterial meningitis:
- 2-25 years old
- Occurs in epidemics
- With DIC, purpuric skin rash, adrenal hemorrhage
Neisseria meningitidis
the over 60 age group usually gets this pathogen causing their bacterial meningitis
Listeria monocytogenes
The CSF of bacterial meningitis will show mostly...
PMNs
the CSF of viral meningitis will show mainly...
lymphocytes
glucose will be decreased in the CSF of bacterial or viral meningitis?
bacterial
always get this type of imaging for SAH
angiography
Dx:
- Inflammation of the brain parenchyma with degeneration and phagocytes of neural cells
- Etiology includes bacterial or viral causes although viral etiologies are more common
encephalitis
dx: Inflammation of membranes of the brain or spinal cord
meningitis
The changes in consciousness and personality are seen in __, NOT __
encephalitis, not meningitis
encephalitis is most commonly caused by (bacterial or viral)
viral!
meningitis or encephalitis:
- Most commonly
- Fever
- Headache
- Change in personality
- Signs of meningeal irritation
- Alteration of consciousness
- Focal neurologic deficits
- Seizures
encephalitis
__ is the most frequent, treatable, and devastating cause of sporadic severe focal encephalitis. It accounts for 10% of encephalitis cases.
HSV. no age, sex, seasonal or geographic preference exists
Dx:
- A collection of infective and purulent material
- Occurs secondary to infection outside of CNS
- Infection becomes necrotic and encapsulated
- Usual age 20-50
brain abscess
MCC of brain abscess?
Streptococci identified in 50%
S. milleri
T/F: It may be impossible to differentiate between viral and bacterial meningitis clinically.
true:
Empiric antimicrobial therapy may be necessary as bacterial meningitis is associated with significant morbidity and mortality and requires urgent treatment. Lumbar puncture may confirm a diagnosis of viral meningitis and allow antibiotics to be stopped and the patient discharged from hospital.
Case 1: 2y/o UNIMMUNIZED boy with 1 seizure, recent OM and URI, 3 day fever, photophobia, nuchal ridgidity, rash on trunk and extremities, both signs = +
Dx?
acute bacterial meningitis
probably H flu (we immunize against that now)
Case 1: 2y/o UNIMMUNIZED boy with 1 seizure, recent OM and URI, 3 day fever, photophobia, nuchal ridgidity, rash on trunk and extremities, both signs = +; do an LP?
do an LP, expect to find high Open pressure, high WBC, high protein, low glucose
Case 1: 2y/o UNIMMUNIZED boy with 1 seizure, recent OM and URI, 3 day fever, photophobia, nuchal ridgidity, rash on trunk and extremities, both signs = +; Treatment?
1. tx: start abx and dexamethazone while in the hospital
2. prophylax everyone in the family with rifampin or rocephin
3. complications = brain damage, coma, death paralysis, seizures; tell mom to immunize
a rash is noted in 80-90% of pt's with which CNS infx?
bacterial meningitis
Case 2: 23 y/o college student URI x 5 days, fever, photophobial, nuchal rigidity , both signs +
tx: broad spectrum abx like rocephin b/c you're waiting for CSF results; he doesn't necessarily need to be in the hospital; viral men is usually self-limiting, will go away with fever reduction and analgesics for pain
Case 3: 6 hour old infant, vaginal delivery: grand mal seizure, no pre-natal care; bulging of fontanelles, no response to pinching of the toes (=AMS); Dx?
encephalitis (viral); vaginal delivery, no pre-natal care = mom has HSV, passed it to child
Case 3: 6 hour old infant, vaginal delivery: grand mal seizure, no pre-natal care; bulging of fontanelles, no response to pinching of the toes (=AMS); workup? (2)
1: do CT head first, with and w/o contrast
2: LP
Case 3: 6 hour old infant, vaginal delivery: grand mal seizure, no pre-natal care; bulging of fontanelles, no response to pinching of the toes (=AMS); Treatment?
encephalitis from HSV most likely
start acyclovir (7-10 days) immediately b/c it won t affect the CSF;
Case 4: 70 y/o female chemo pt for glioblastoma, recent brain surgery. Presents with low grade fever, HA, difficulty waking, AMS paralysis of RUE, both signs are +; Diagnosis?
brain abscess from strep, probably S. milleri;
she is very immunocompromised. You can get brain abscess from surgery, trauma
MCC for brain abscess?
strep and staph
Main: strep milleri
Case 4: 70 y/o female chemo pt for glioblastoma, recent brain surgery. Presents with low grade fever, HA, difficulty waking, AMS paralysis of RUE, both signs are +; Workup?
do CT first because you don't usually do LP for brain abscess cases
Case 5: 38 HIV + male, fatigue x months, fever, HA, Cd4 500 1 year ago; diagnosis?
toxo
most common cause of focal encephalitis in AIDS pts
toxo
- Dementia caused by direct HIV infection in the brain parenchyma
- Occurs in late HIV infection in those with severe immunosuppression
- A diagnosis of exclusion
- Usually occurs in the late stages of HIV infection
- Acquired and persistent cognitive decline with preserved alertness that usually dominates the clinical presentation
- Diagnosis?
AIDS dementia complex
Top 2 CNS infx assoc'd with AIDS
toxo
cryptococcus
Which of the following is INCORRECT regarding infections of the CNS?
A. Meningitis is an infection of the leptomeninges and brain parenchyma
Which of the following is INCORRECT regarding infections of the CNS?
B. Give prophylaxis to close contacts of the child, Rifampin 600mg in four daily doses
In a child with suspected acute bacterial meningitis treated with antibiotics, what would be the best next immediate plan of therapy?
A. Give prophylaxis to close contacts of the child, Rifampin 600mg in four daily doses
You suspect that a patient has a CNS infection. Which one of the following is correct?
A. Viral infections are the most frequent cause of aseptic meningitis with most being caused by Enteroviruses or Herpes Virus
2/3 of patients have the classic presentation
D is wrong
B is characteristic of bacterial
Management of a patient, whom you suspect has viral meningitis, would include
C. Symptomatic and supportive treatment of the patient
You suspect that a child has a CNS infection. Which of the following is INCORRECT?
a. Encephalitis is suspected rather than meningitis because there are signs of altered consciousness
b. 1/3 of all encephalitis is caused by HSV, which has no preference for age, gender, season or geography
c. Although CSF may be normal in encephalitis, it usually shows a lymphocytic pleocytosis (0-1000 WBC/mcl)
d. The patient should be treated with Acyclovir until HSV encephalitis is ruled out
B is incorrect, only 10% is caused by HSV. It has an affinity for temporal lobe, is debilitating and treatable
You suspect a patient has a CNS infection. Of the following, which is NOT a COMMON opportunistic CNS infection associated with AIDS?
a. Candida
b. Toxoplasma gondii
c. Cryptococcus neoformans
d. Pneumocystis jirovecii
e. Progressive multifocal leukoencephalopathy
The correct answer is D;
- Pneumocystis jirovecii causes pneumonia not CNS infections.
- Progressive multifocal leukoencephalopathy is a demyleninating disease caused by a papovavirus. Symptoms are progressive dementia, visual impairment, seizures and or hemiparesis.
All of the following are correct concerning the AIDS Dementia complex (ADC) EXCEPT:
a. Also termed HIV encephalopathy, is dementia caused by direct invasion and infection of HIV to the brain
b. Cognitive impairment, altered motor performance and abnormal behavior with preserved alertness define the clinical triad
c. AZT therapy has been shown to retard and reverse impairment of this treatable dementia
d. Complications of untreated ADC include a near-vegetative state characterized by global dementia, mutism, and paraplegia or quadriplegia, although the patient usually remains arousable.
The correct answer is C. AZT therapy may retard the progression but will not reverse it.
Name that motor pathway: Voluntary movements, integrated skilled, complicated, or delicate movements. Ex: pianist, something that takes a lot of dexterity. It originates in the cerebral cortex, so if you have a stroke and damage the cerebral cortex, you may not gain back all your delicate movements
corticospinal tract
Name that motor pathway: automatic mvmts you don't think about - chewing, swallowing, blinking. Parkinson's or a stroke may lead to loss of these automatic movements. Damage to this is what causes the Parkinsonian "stare"
basal ganglia
name that motor pathway: coordinates and smoothes out muscle activity, controls posture. If your pt is drifting to one side while walking or standing, they fall to the side where the lesion is.
cerebellum
this type of tremor is unique to Parkinson's dz. Slow, rhythmic, only occurs at rest. AKA "pill rolling"
resting tremor
this type of tremor is most noticeable when holding your hands out straight. Bilateral fine, fast tremor found in normal individuals and assoc'd with caffeine, anxiety, hunger. Not relieved by EtOH or Beta-blocker
postural tremor
this type of tremor is worse when approaching a target. Assoc'd with voice, chin tremors, also seen in MS.; Better with EtOH, Beta-blocker
intention tremor
This type of tremor worsens as it nears target, but if you ask them to touch their nose and touch your finger, as their finger gets closer to your nose, their finger goes in a circular, sinusoidal pattern like it's circling the earth; Worse with EtOH; no effect from beta-blocker
cerebellar tremor
rhythmic, repetitive, bizarre movements chiefly involving face, mouth, jaw, tongue. Tardive is slow mvmts which can be 2ndary to meds used to treat schizo like Thorazine or Haldol (still used today); usually involves just face and tongue, not the limbs
oral facial dyskinesia
- loss or impairment of voluntary action
- classically with a stroke, with a smile only one side is lifted, or with Bell's Palsy; usually damage to central or peripheral nerve
akinesia
- writhing, slow, sometimes seen with cerebral palsy, involves hands, feet, shoulders, hips
- face and distal extremities
- Ex: cerebral palsy
athetosis
- Sudden, brief, jerky, can't control it, like going to get a glass of water and they knock it over; involves face, hands, legs
- can occur at rest or interrupt a normal movement
- Ex: Huntington's
chorea
Bizarre, grotesque, or twisted POSTURES...not something distal, but proximal, larger body parts, shoulder towards chin, stays stuck in that position, like torticolis (chin stuck over shoulder position). Can be caused by meds
dystonia
very common, twitchy, clearing your throat or blinking your eyes; if they become anxious or stressed, the tic manifests with greater frequency; there s no treatment, but Marinol (marijuana drug) has shown some improvement; Ex: Tourette's
tics
twitch right before you fall off to sleep; or generalized, Grand Mal seizure: flexion, extension of extremities
shock like movements, like with a seizure
myoclonus
ask pt to hold their arms/hands out and their hands flop down, called liver flop b/c if you have acute encephalopathy and high ammonia levels, AMS, one of your exam findings will be this flapping action
asterixis
AKA scissor gait, specifically in pt s who have recovered from a stroke; one arm/hand/fingers slightly flexed (stroke on that side), they fling their affected leg around because they ve lost dexterity to lift leg/foot/ankle and bring it down gently, so they used larger muscles of hip and torso to lift leg and bring it forward
Ex: stroke
spastic gait
assoc d with a foot drop; not a stroke or problem in brain, but a lumbar disc problem affecting L5 peripheral nerve that affects your foot/great toe; they can t lift up on their foot; pt c/o shooting pain down one leg and tripping over their foot; called marching gait b/c it slaps down on the ground b/c you can t elevate that foot appropriately; toes land first
Assoc'd with lumbar disc herniation
steppage gait
sensory nerves of periphery (diabetic polyneuropathy or B12 polyneuropathy resulting in lack of sensation in the feet; walk with a wide gait and SLAM their feet down hard b/c their forcing vibration into those nerve endings to tell them where to place their feet; +Romberg s eyes closed, arms out, they are unstable b/c their feet can t tell where they are in space; tend to look down to see where they re going
sensory ataxia
Staggering, widebased, unsteady: get out of bed and they fall back, or just to one side.
Ex: if you ve had a stroke to this area, MCC
cerebellar ataxia
just from old age, decreased strength, walk more slowly, wide-based, tend to be hunched over, just to try to be stable
senile gait
rigid, short steps, quick shuffling steps, gradually faster shuffles and looks like they re going to run into you; Perched forward, very stiff, tend to stick their chin out. Stiff turns
Ex: Parkinson's!!!
Festinating
Parkinson's pathophys is a lack of... in the...
dopamine in the substantia nigra
This finding is assoc'd with Parkinson's . There is a development of these hyalin things, a hard encapsulation around neurons that prevent continued production of dopamine
"Lewy bodies"
triad of classic ssx of Parkinson's
1. rest tremors (pill rolling)
2. Bradykinesia (slowness in deliberate movement), akinesia (decreased spontaneous movement), masked face (stare)
3. rigidity (cogwheel); Cogwheel rigidity: flex your elbow and you try to extend it but it s very rigid and clonic-like
Management for Parkinson's, including drug
goal of therapy is to delay progression of disease, relive symptoms, preserve function
Leva-dopa effective for ~10 years
prognosis for Parkinson's
slowly progressive
w.o treatment, 60% dyfxn @ 5 years, 80% @ 10years
pathophys of Huntington's Dz: genetic? loss of..
autosomal dominant genetic disease - if you get one allele, you'll develop this at some point
neurodegenerative
loss of the neurotransmitter GABA
Huntington's is a genetic disease characterized by loss of...
loss of the neurotransmitter GABA
Describe the ssx for Huntington's Dz related to Movement, Cognitive, and Psychiatric
Movement: chorea, dystonia, bradykinesia
Cognitive: memory loss, global dementia, disheveled appearance
what 2 things do you do for the workup of Huntington's?
CT/MRI
diagnose with genetic testing
management of Huntington's? meds?
supportive counseling
Tx chorea mvmt disturbance with Thorazine, Haldol
No real meds, could use anti-psychotic to help with mvmt disorders, but you can t control the progression
prognosis for Huntington's
long, progressive, disabling course (10-25yrs)
lose ability to fxn independently, must institutionalize
Definition of seizure
a sudden, abnormal, and excessive discharge of neurons resulting in a clinical event
May have altered consciousness
May have motor/sensory phenomena
May have unusual cognitive perceptions
what are the 2 types of seizures?
partial
generalized
partial or generalized:
Focal, Localization-related
Origin: a point in the cerebral cortex
Consciousness maintained
Lasting seconds to minutes
Unilateral
Symptoms correspond to the location in brain
partial
your seizure pt is having jerking of the left arm. where is his lesion and is this partial or generalized?
R sided brain lesion, partial
are partial seizures unilateral or bilateral?
unilateral
symptoms correspond to the location in the brain
Partial seizure (simple or complex) or
Generalized seizures (grand or petit mal):
your pt is having paresthesias of left arm
or twitching of face
or entire side of body is twitching ("Jacksonian March")
simple partial
Partial seizure (simple or complex) or
Generalized seizures (grand or petit mal):
Your pt has AMS and is doing chewing motions
Complex partial (aka temporal lobe)
May also have a strange sense of unfamiliarity, opposite of D�j� vu
Depersonalization: step outside of body as a 3rd party observing
Originate in temporal lobe in hippocampus
can your pt have a partial seizure with secondary generalization?
yes, there is cortical spread deep to the diencephalon, then transferred to all parts of brain
Partial seizure or
Generalized seizures:
lost consciousness, bilateral and symmetric shaking
lasts seconds to minutes
generalized
Both sides involved b/c it s deep in brain, diencephalon spreads to both sides
when is the usual onset of generalized seizures? what age?
onset usually in childhood
Grand mal seizure is AKA...
generalized tonic clonic
Partial seizure (simple or complex) or
Generalized seizures (grand or petit mal):
Your pt presents with evidence of tongue biting, incontinence, and they have post icthal confusion. The mom states pt had a sudden loss of consciousness and then rigid and contracted muscles followed by jerking muscles.
grand mal (aka generalized tonic clonic)
which is tonic and which is clonic:
-jerking
-all muscles are rigid and contracted
Tonic: all muscles are rigid and contracted
Clonic: jerking
which type, Grand mal or petit mal, affects children and usually resolves by adulthood?
absence, aka Petit mal
Partial seizure (simple or complex) or
Generalized seizures (grand or petit mal):
affects children
lost consciousness
body posture and tone is maintained
smacking the lips or chewing or blinking the eyes
Petit mal, aka Absence seizure
5 item DDX for seizures
1. syncope
2. migraine aura
3. TIA
4. panic attack
5. seizure
Out of the seizure DDX list (syncope, migraine aura, TIA, panic attack, seizure), what is this:
lost consciousness, within a minute afterwards, you are yourself and not post-icthal state
syncope
Out of the seizure DDX list (syncope, migraine aura, TIA, panic attack, seizure), what is this:
see lights or smells
migraine aura
Out of the seizure DDX list (syncope, migraine aura, TIA, panic attack, seizure), what is this:
may last 5min to several hours, accompanied by paresthesias and numbness
TIA
seizure is usually shorter-lived
in the diagnostic workup of seizures, which imaging do you want to get now and which one do you want to get soon?
CT now (check for lesion)
MRI soon (regardless of CT is normal)
name some first genration AEDs and their 2 main problems
Phenobarbitol
phenytoion (Dilantin)
carbamazepine (Tegretol)
Valproic acid (Depakote)
problems: toxicity, drug interactions
this first generation AED lowers your IQ
phenobarbitol
name some second generation AEDs and the benefits of some
gabapentin
lamictal
Keppra
benefits: same efficacy as 1st gen; fewer SE; fewer DIs
What are the 2 characteristics of status epilepticus?
an unrelenting seizure:
-lasting >20 minutes or
-successive seizures without an interictal period
what 2 types of seizures may develop into SE?
tonic clonic (Grand Mal)
Absence (Petit mal)
Name some physical interventions and drug therapies for treatment of SE
physical:
-prevent pt from injury
-maintain airway w/o obstruction
-prevent aspiration
Drug Therapy:
-Ativan IV
-Dilantin IV
-Valium rectal gel
-Thiamine, glucose to treat acidosis
A localization-related seizure is also known as a __ seizure. It has focal manifestation in the body caused by a focal abnormality in the brain
partial
What differentiates a complex seizure from a simple seizure?
LOC
Movements in a complex partial seizure are (coordinated/random jerking)?
coordinated
During a seizure, actions such as lip-smacking, blinking, or chewing are known as___
automatisms
bilateral and symetric movements are characteristic of a (partial/generalized) seizure?
generalized
You examine a pt 10 minutes after a generalized seizure. Name some signs you expect to see on PE.
tongue biting
incontinence
post-ictal confusion
febrile seizures are more typical of (adults/children)?
children
seizures due to alcohol withdrawal typically begin how long after the last drink?
12-24 hours
trauma may produce seizures, especially head trauma with what features?
hemorrhage
skull fracture
LOC
weakness of an arm after a seizure would be an example of "__ paralysis"
Todd's paralysis
Which of these features are suggestive of seizure rather than syncope? (focal neurologic deficit/cardiac arrhythmia/carotid disease/history of malignancy / urinary incontinence/tongue lacerations)
focal deficit
history of malignancy (with new brain met)
incontinence
tongue lac
Which is more sensitive imaging study for evaluation of an anatomic brain lesion in a seizure pt? (LP/EEG /CT /MRI)
MRI
What study is the most important diagnostic tool for definitive evaluation of seizure type? (LP/ EEG/ CT /MRI)
EEG
If seizures are not well controlled on an AED, what would be the next step? (increase dose if possible/add second agent/switch to a different anticonvulsant)
maximize the dose
Drug interactions with AEDs are common and are often due to inducing or inhibiting what metabolic pathway?
CYP 450
oral contraceptives may be (more/less) effective in a pt on an anticonvulsant
less
Name the 2 most commonly used antiepileptic drugs
phenytoin (Dilantin)
and carbamazepine (Tegretol)
Alcohol use or binge drinking (improves/worsens) seizure control?
worsens
classic triad of ssx for intracranial tumors?
1. HA (worse at night, with valsalva)
2. N/V (increased ICP activates emesis centers in brain)
3. papilledema (increased ICP impairs outflow of venous blood from retina, causes congestion around optic disc)
Local mass effect of intracranial tumors: pushes other brain structures out of the way; clinical result is ___
focal neurologic deficit (this tumor may cause L sided weakness)
Midline shift from intracranial tumor: mass is so large that it pushes whole contents of brain from right to left; its effect clinically: ___
decreased level of consciousness
UNCAL ("transtentorial") herniation: the uncus (medial aspect) of temporal lobe is forced over the edge of the tentorium... eventually it compresses the brain stem and kills you. But before that, how does it present clinically?
Clinically: blown pupil; CN III branches off where the herniation is (medial temporal lobe), CNIII causes pupil to constrict, so with CNIII compression, you ll have unopposed dilatation
both upper and lower motor neuron spinal tumors present with these 2 ssx
weakness, atrophy
(Upper/lower) motor neuron tumor presents with hyperreflexia and spasticity?
upper
(upper/lower) presents with hyporeflexia and fasciculation)
Glioma recurrence is (common/uncommon) post-treatment
common recurrence after tx, because they spread go much and permeate into surrounding brain
1. Glioma
2. Meningioma
3. Pituitary Adenoma
4. Acoustic Neuroma
which primary CNS tumor originates from neuroglia like astrocytes, oligodendrocytes, ependymal cells?
glioma
1. Glioma
2. Meningioma
3. Pituitary Adenoma
4. Acoustic Neuroma
Which arises from the arachnoid of meninges?
meningioma
usually benign, recurrence rare
1. Glioma
2. Meningioma
3. Pituitary Adenoma
4. Acoustic Neuroma
Which one has a high recurrence rate post-treatment?
glioma
1. Glioma
2. Meningioma
3. Pituitary Adenoma
4. Acoustic Neuroma
Which one is usually benign and has a low recurrence rate?
meningioma
This type of pituitary adenoma presents with bitemporal hemianopsia. Accompanying the visual changes is hypopituitary fxn
non-secreting
This type of pituitary adenoma causes amenorrhea and galactorrhea in females and decreased libido and impotence in males
secreting prolactinoma
what are the 3 types of secreting pituitary adenomas?
1. proliactinoma
2. GH secreting (Acromegaly)
3. ACTH secreting (Cushing's Dz)
this type of pituitary adenoma causes acromegaly
GH secreting pituitary adenoma
this type of pituitary adenoma causes Cushings Disease
ACTH secreting
Most common peripheral nerve tumor in the head
acoustic neuroma
classic triad of ssx for acoustic neuroma?
1. unilateral hearing loss
2. tinnitus
3. vertigo
Your pt presents with:
1. unilateral hearing loss
2. tinnitus
3. vertigo
Dx?
acoustic neuroma
what other CN ssx (2) may accompany acoustic neuroma?
CN VII - hemifacial weakness
CV V (hemifacial numbness)
what are the 3 most common primary sites for metastatic brain tumors?
lung
breast
melanoma
RCC
__% of spinal tumors are benign
60
3 classifications of spinal tumors
extradural
intradural, extramedullary
intradural, intramedullary
Which classification of spinal tumors:
Metastatic tumors
Hallmarks: cord compression, bony destruction
Symptoms: local back pain esp at night
extradural
which classification of spinal tumors:
Example: Schwannoma, meningioma
Symptoms: nerve root symptoms (radiculopathy)
intradural, extramedullary
which classification of spinal tumors:
Glioma
Ependymoma (line the ventricles, classic location is at the end of the spinal cord, L1)
Astrocytoma
Symptoms: cord compression (myelopathy) or nerve root (radiculopathy)
intradural, intramedullary
where is the classic location for an ependymomal glioma spinal tumor? (intradural, intramedullary)
ependymal cells line the ventricles, so as they combine with the spinal cord, gravity pulls them down toward the end of the spinal cord, classic location is at end of spinal cord at L1
You find a clump of abnormal tissue at the end of the spinal cord, what classification is it almost always?
ependymoma (intradural, intramedullary)
the most common solid tumor of childhood
brain tumors from leukemia
in childhood brain tumors, the majority are supra-or infratentorial?
infratentorial
A 12 y/o awakes with a HA most mornings for 2 weeks. Funduscopic exam shows papilledema, and a CT scan shows a mass causing an obstructive hydrocephalus. Based on these findings, and knowing the incidence of various tumors in children, you are not surprised at the location in the
a. supratentorial compartment
b. infratentorial compartment
c. cervical spinal cord
d. cauda equina
b. infratentorial
A pt with visual field defects is found to have a pituitary tumor. The next step toward diagnosis of the tumor type would be a lab study of
a. CBC w/diff
b. serum checmistry panel
c. endocrine panel
d. osmolality of blood serum and urine
c. endocrine panel
Stereotactic radiosurgery (focused radiation) is an appropriate first line tx for
a. AV malformations
b. intracerebral hematoma
c. glioblastoma
d. pituitary adenoma
a. AV malformations
A pt reports mid back pain awakening him at 4am for 2 weeks. He has no prior muscular or skeletal complaints and denies trauma. PE shows point tenderness at the T7 spinous process, but no neurologic abnormalities. The imaging study you would order first would be
a. intravenous pyelogram
b. MRI
c. myelogram with post-myelogram CT
d. plain x-rays of T spine
d. plain x-rays of T spine
A 56 y/o man has imbalance after arising from a chair. W/u for postural hypotension was negative. Your exam demonstrates no ataxia, dysmetria or dysdiadochokinesis An MRI shows a mass in the infratentorial compartment, abutting the cerebellum and pons. Which study is most appropriate for further w/u of this tumor?
a. audiometry
b. formal visual field testing
c. endocrine studies including GH, prolactin, serum cortisol and TSH
d. CT scan of chest and abdomen
a. audiometry
This tumor accounts for 40-50% of all intracranial tumors. It arises from the supporting cells of the CNS. Complete resection is generally not possible because extensions of tumor penetrate surrounding brain tissue
a. glioma
b. meningioma
c. pituitary adenoma
d. acoustic neuroma
a. glioma
This tumor is well circumscribed, generally benign, and amenable to total resection. Recurrence is uncommon. It arises from the arachnoid. It is more prevalent in females than males.
a. glioma
b. meningioma
c. pituitary adenoma
d. acoustic neuroma
b. meningioma
A pt complains of low back pain radiating to the right posterior thigh, with numbness at the right heel and lateral foot for several months. Now for 2 days he has new scrotal numbness, difficulty initiating micturation, and incomplete voiding. The most significant PE to perform is
a. plantar stroke for Babinski's sign and rapid ankle dorsiflexion for clonus
b. DTRs at knees and ankles
c. digital rectal exam and perianal sensory exam
d. motor exam for weakness, fasciculations, and muscle atrophy
c. digital rectal exam and perianal sensory exam
Match the signs and ssx with tumor location
cerebellum
temporal
frontal
parietal
occipital
a. depression and outbursts of anger
b. loss of upper quadrant of right visual field
c. seizure with tonic-clonic activity beginning in the left arm
d. staggering gait and loss of balance while standing
e. a cooperative pt does not understand or follow commands
d, e, a, c, b
Many HA can be diagnosed and treated w/o CT or MRI. However, you would need to order a CT or MRI to w/u a new HA assoc'd with any of these situations except
a. a first-ever seizure in a 36 y/o male
b. band-like head pain worse in the afternoon
c. lethargy wit N/V
d. spasticity of left arm and leg with ankle clonus
b. band-like head pain worse in the afternoon
Brain tumors cause ssx based on local mass effect and general increase in ICP. Which of the following is/are manifestations of increased ICP leading to possible brain herniation and death?
a. cranial nerve dysfunction such as a fixed and dilated pupil or weakness of temporal gaze
b. muscle weakness with fasciculations and depressed reflexes
c. confusion, irritability, and restlessness
d. acromegaly with prominent brow, nose, and mandible
e. a and c
f. a, b, and c
e. a and c
Migraine, Cluster or tension:
pain is in and around only one eye
cluster
Migraine, Cluster or tension:
pain is like a band squeezing the head
tension
Migraine, Cluster or tension:
pain, nausea, and visual changes are typical of the classic form
migraine
Sudden onset: Severe or persistent headache that reaches maximum intensity in a few seconds or minutes... makes you think what?
subarachnoid bleed
No similar headache in the past?
FIRST or WORST warrants further evaluation
Suggests __ or __
intracranial hemorrhage or CNS infection
do this imaging If suspected hemorrhage (superior to MRI for identifying bleeds)
Sinuses
Tumor
CT scan
do this imaging if you need more detail of soft tissues, brain stem, cerebellum and medulla
Tumor
Aneurysm, AV malformations, vascular abnormalities