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Neurology Board Review. Question 1. A 72 year old man presents with acute onset vertigo, nystagmus, dysphagia, and horners syndrome. The most likely diagnosis is?. Your Choices…. 1. Acute Labryinthitis 2. Benign paroxysmal positional vertigo 3. Lateral Medullary Infarction

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question 1
Question 1
  • A 72 year old man presents with acute onset vertigo, nystagmus, dysphagia, and horners syndrome. The most likely diagnosis is?
your choices
Your Choices….

1. Acute Labryinthitis

2. Benign paroxysmal positional vertigo

3. Lateral Medullary Infarction

4. Opthalmoplegic Migraine

lateral medullary infarction
Lateral Medullary Infarction!

AKA Wallenberg Syndrome

Ipsilateral face

  • Pain and Temperature
  • Dysphagia
  • Dysarthria
  • Nystagmus
  • +/- limb ataxia

Contralateral Limbs

  • Pain and Temperature

-Lateral Spinothalamic tract

posterior circulation strokes
Posterior Circulation Strokes
  • The 5 D’s of Brainstem
  • Dysphagia
  • Dysarthria
  • Diplopia
  • Dystaxia
  • Dizziness
  • Syncope/ Drop attack
  • Ipsilateral Face, Contralateral Extremity
  • Visual Field Deficits
vertigo
Peripheral

-Sudden

-Tinnitus, Auditory

-Severe n/v/dizzy

-Horizontal Nystagmus

-May be positional, recent infections

Central

-Insidious

-No peripheral sx

-Less severe n/v/dizzy

-Vertical or Horizontal Nystagmus

-Not positional, may have peripheral neuro deficits

Vertigo
question 2
Question 2

A 74 year old female with history of DM, HTN, presents with 2 hours onset right face, arm > leg weakness with an associated right hemisensory deficit. No left sided deficits. No cranial nerve deficits. What is the most likely diagnosis?

  • Basilar Artery Occlusion
  • Subarachnoid Hemorrhage
  • Lacunar Infarction
  • Middle Cerebral Artery Occlusion
  • Posterior Cerebral Artery Occlusion
middle cerebral artery occlusion
Middle Cerebral Artery Occlusion
  • Lateral parietal, temporal, and frontal lobes
  • Contralateral Motor/ and Sensory Face and Arm > leg
  • Ipsilateral Hemianopsia
  • Aphasia/ Dysarthria (left sided stroke)
  • Agnosia / Neglect, extinction of double stimulus (right parietal lobe)- timing!
ct finding with mca occlusion
CT Finding with MCA Occlusion
  • Hyperdense MCA sign
  • Loss of cortical ribbon
  • Sulcal Effacement
  • Obscuration of the grey/white junction
the wrong answers
The Wrong Answers!
  • Basilar Artery Occlusion: Locked In
  • Subarachnoid Hemorrhage: HA
  • Lacunar Infarction: Pure motor or sensory
  • Posterior Cerebral Artery Occlusion: Primary visual disturbances
question 3
Question 3
  • A 43 year old female presents to the ER with her husband. Her husband states that his wife has been having the worst headache of her life and is “a bit off”. On exam she uncomfortable and confused without focal motor or sensory deficits. A CT scan is obtained.
question 31
What is the most common etiology for the diagnosis revealed by the CT scan?

1. AVM

2. Cavernous Angioma

3. Mycotic Aneurism

4. Neoplasm

5. Saccular Aneurysm

Question 3
saccular aneurysm
Saccular Aneurysm
  • 80% of non-traumatic SAH are associated with saccular aneurysm
  • 5% of the population have aneurysms; increase risk of rupture includes-
  • Smoking
  • EtOH
  • Stimulant Abuse
  • Uncontrolled HTN
subarachnoid hemorrhage
Subarachnoid Hemorrhage
  • Collection of blood in subarachnoid space
  • Secondary to trauma, ruptured aneurysm, AVM
  • 2-4% Patient visits for HA
  • 2-4% will have SAH; 12 % of pts with worst headache of life will have SAH, increases to 25% if abnormal neurologic exam
  • Headache 100%, Nausea and emesis 77%, focal deficits 64%, syncope 53%, neck pain 33%, photophobia, seizures in 25% of patients
  • 20-50% have prior warning headache “sentinel bleed” days to weeks prior
slide15
Cranial Nerve 6 (abducens) palsy; lateral rectus; ACOM
  • Cranial Nerve 3 (occulomotor) palsy; ptosis, medial, superior, inferior gaze, pupillary constrictors; PCOM
  • Subhyaloid Hemorrhage
question 4
Question 4
  • An 84 year old man with h/o HTN, DM, AFIB on coumadin presents with left sided hemiparesis and left sided hemisensory changes with left sided neglect. He has a GCS of 15. Thirty minutes into his assessment his GCS falls to 11 with profound confusion. What is the most likely cause?
  • Anterior Cerebral Artery Embolism
  • Internal Capsule Intracerebral Hemorrhage
  • Posterior Cerebral Artery Rupture
  • Posterior Cerebral Artery Thrombosis
  • Vertebral Artery Occlusion
internal capsule intracerebral hemorrhage
Internal Capsule Intracerebral Hemorrhage
  • Hemorrhagic transformation may occur during an apparent ischemic stroke
  • Sudden change in conciousness= ICH V.S posterior circulation CVA
  • Reversal of anticoagulation
intracranial hemorrhage
Intracranial Hemorrhage
  • 8-13% of all strokes
  • 30 day mortality 44%, brainstem ICH 75% 24 hour
  • Only 20% of pts regain full functional independence
  • Increase incidence: AA, Asian, age >55, EtoH, Smokers
  • Trauma, HTN, altered homeostasis, hemorrhagic necrosis, venous outflow obstruction
  • Causes brain injury via:

1. Increased Intracranial Pressure

2. Increase edema, mass effect

3. Decrease perfusion to local and adjacent tissue

4. 35% ICH will expand sig (>33%) within 24 hours; majority within 6 hours

slide19
ICH
  • Basal Ganglia 40-50%
  • Lobar: 20-50% (esp young, increased sz activity)
  • Thalamus 10-15%
  • Pons 5-12%
  • Cerebellar 5-10%
  • Brain Stem 1-5%
  • Intraventricular Hemorrhage 1/3 BG
  • Volume= (a+b+c)/2
slide20
ICH

GCS 3-4 2

5-12 1

___________13-15 0

ICH Vol >30 1

___________<30 0

IVH Yes 1

___________No 0

Infratentoral Yes 1

___________No 0

Age >80 1

___________<80 0

0-6

question 5
Question 5
  • A 45 year old male presents with nausea, emesis, and diarrhea. He is given 2 liters of IVF and 12.5mg of promethazine. 15 minutes later he is anxious and wants to leave the ED immediately. What is the diagnosis and management?
  • Anxiety or who cares. Let him go AMA
  • Is he tolerating PO? Give him some reglan and get him out.
  • I think he is delirious. Give him some haldol and call psych.
  • I think he is having a reaction to the med. Lets give him Prochlorperazine. Right?
  • I think he is having a reaction to the med. Lets give him some Benztropine.
akathisia benztropine
Akathisia- benztropine
  • Acute distonic reaction marked by anxiety, restlessness
  • Other distonic rexns include torticollis
  • Associated with high potency antipsychotic (haldol), and any dopaminergic medications (promethazine, metoclopramide, prochlorperazine)
  • Treatment includes anti-cholinergic medications such as diphenhydramine and benztropine (not to use in kids less than 3)
question 6
A 65 year old male with DM, HTN, BPH, recent diagnosis of sciatica p/w 2 days of progressive difficult ambulation with worsening back pain radiating down to left leg. Exam is noteable for hyporeflexia with downgoing toes, +4/5 lower extremity strength, saddle paresthesia, and deminished rectal tone.

1. Stroke

2. Sciatica

3. Cauda Equina Syndrome

4. Acute back pain

5. Spinal Abcess

Question 6
cauda equina syndrome
Ca, Infiltrative, Sarcoidosis, Trauma, Infectious, Ank Spon

Pain, radicular

Weakness- variable

Hyporeflexia v.s spinal

Saddle sensory changes

Overflow incontinance urine/stool

Cauda Equina Syndrome
cauda equina syndrome1
MRI or CT Myelography

Neurosurgical consultation

Steroids + RT- randomized controled high dose, non-radnomized low dose; end treatment and 6 months in ability to ambulate

Radical ressection + RT

Cauda Equina Syndrome
other options
Sciatica

Radicular Pain

Lateral or post leg to foot

Straight leg raise (10-60), crossed

Numbness, no weakness

NSAIDS

Epidural Abcess

Staph (MRSA) 63%; Gram Neg, Strep, Anaerobes, TB (potts)

Multiple levels

Epidurals, Surgical, IVDU, Cryptogenic

DM, ETOH, HIV

Pain, Fever, Weakness

MRI/ CT w/ gadolinium

Surgical Decompression /Aspitation

Abx: Nafcillin (Vanc)+Flagyl+

Ceftazidime or Cefotaxime

Other options
should i get the imaging
Progressive neurological findings

Constitutional symptoms (fever)

History of traumatic onset

History of malignancy

Age 18 years or 50 years

IVDU

Chronic steroids

HIV

Osteoporosis

Pain > 6 weeks

*American college of radiology “Red Flags”

Should I get the imaging….?
question 7
Which of the following pretreatment patient characteristics has been associated with an increased risk of intracerebral hemorrhage following treatment with TPA for acute ischemic stroke?

Advanced Age

Increased NIHSS

Isolated global aphasia

Major surgery within 14 days

Rapid improvement of neurological signs

Question 7
increased stroke severity
Increased Stroke Severity
  • Increase stroke severity via NIHSS and increasing radiographic signs of infarct size on CT are two independent predictors of ICH after TPA
slide30

Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. NEJM. 1995 333:1581-1587.

  • Double-blind, randomized, placebo controlled
  • Pts tx with rTPA are 30% more likely to have minimal to no disability at 3 months compared to standard care
  • Increase risk of symptomatic ICH (6.4%) with increasing NIHSS
  • American Heart Association, American Academy of Neurology, ACEP (if system in place)
slide31
Inclusion Criteria

Age > 18

Diagnosis of stroke with measurable deficit

Time of onset < 3 hours before treatment will begin

Relative Contraindications

Major surgery or serious trauma within 2 weeks

Only minor or rapidly improving stroke sx

History of GI or GU hemorrhage within 21 days

Recent arterial puncture as non-compressable site

Glucose >400, <50

Post MI pericarditis

Patient with observed seizure at time of stroke onset

Recent Lumbar Puncture

Exclusion Criteria

Evidence of ICH on CT

History of ICH or AVM

Suspected SAH with normal CT

Active internal bleeding

Platelets < 100,000

Heparin within 48 hours with an elevated PTT

Current use of oral anticoagulant with PT> 15sec

SBP > 185 or DBP >110 at time treatment is to begin

Within 3 months any intracranial surgery, serious head injury, or previous stroke (not TIA)

tPA
question 8
Question 8
  • A 32 year old man who lives in New England presents complaining of bilateral leg weakness. His symptoms began with paresthesias in his toes followed by progressive weakness in both legs. Cranial nerve exam is normal. Motor s 3/5 in both legs, 4/5 both arms and sensation to light touch is mildly decreased in both legs. DTR’s are absent in both legs and +1 in b/l arms. What is the most likely diagnosis?

1. Lambart-Eaton Syndrome

2. Familiar periodic paralysis

3. Guillan Barre Syndrome

4. Myasthenia gravis

5. Tick paralysis

guillain barre syndrome
Guillain-Barre Syndrome
  • Immune-mediated; motor, sensory, and autonomic dysfunction
  • GBS the most common cause of acute flaccid paralysis in the United States
  • Pure motor and motor + sensory subtypes.
  • 40-80% seropositive for Campylobacter jejuni
  • Haemophilus influenzae, Mycoplasma pneumoniae, and Borrelia burgdorferi. CMV, EBV, HIV
  • 85% of pts with normal recovery 6-18 months
guillain barre syndrome1
Guillain-Barre Syndrome
  • Ascending weakness from proximal thighs to trunk and upper extremities
  • Cranial nerves, respiratory muscles (1/3rd)
  • Paraesthesias distal to proximal, Proprioception, sensory
  • Autonomic dysfunction; HR, BP, Temp, Fecal and urinary retention
guillain barre syndrome2
Guillain-Barre Syndrome
  • Clinical diagnosis supported by:
  • Elevated or rising protein levels on serial lumbar punctures (90% pts) 1-2 weeks
  • CSF pleocytosis in HIV associated
  • Cauda Equina nerve roots enhance in 85%
  • ABG and FVC to assess respiratory function, intubate for ventilatory failure
  • IVIG and plasma exchange tx
others
Others

Myasthenia gravis

-Autoantibodies against post-synaptic Ach receptors

-Bulbar sx initialy- ptosis, diplopia, dysphagia, 1% resp

-Descending weakness

-Thymoma 10-15%

-Sx improve with rest

Lambart-Eaton Syndrome

-Autoantibodies against voltage gated calcium channels in pre-synaptic motor nerve terminal

-Proximal lower extremity weakness (up from chair), months

-Less common bulbar findings

-Highly associated with cancer (50-70%)

-Sx improve with movement

others1
Others

Familial periodic paralysis

-AD, variable penetrance

-Chanelopathy resulting in inexcitability of Na/Ca channels leading to periodic flacid paralysis

-Hyperkalemic and Hypokalemic subtypes

-Worsened by heat, stress, high carbohydrate meals

Tick paralysis

-Caused by neurotoxin from salivary gland

-Ascending paralysis 1-2 weeks

-Ataxia variant

-Rock Mountain wood tick (Dermacentor andersoni) and American dog tick (Dermacentor variabilis)

question 9
A 25 year old male presents with 1 day of severe right sided head and neck pain with blurred blurred vision. He states he went to his chiropracter in the morning before symptom onset. On exam he has right sided miosis and ptosis with normal motor function and sensory function. What is his most likely diagnosis?

Right brainstem cva

Cluster Headache

Bells Palsy

Tick Bite

Carotid artery dissection

Question 9
carotid artery dissection
Unilateral facial/neck/orbital pain

Hypoageusia

Transient blindness, amaurosis fugax

50% w/ partial horners syndrome- miosis, ptosis, no anhydrosis

25% pulsitle tinnitus

Neck swelling, bruise

May progress to CVA with dense hemiparesis

Trauma

Chiropractic manipulation

Sports, yoga

CTD

HTN

Smoking

Oral contraceptives

Carotid Artery Dissection
horners syndrome
Sympathetic fibers run upwards vis cervical spine ganglia

Bifruncate at division of CC to IC and EC (sweat glands)

Innervate pupilary dilators (dilation lag) and lids

Migraine, Brainstem CVA, Pancoast tumor, brachial plexus trauma, Lung lesion (TB, HMX), neuronal lesion

Horners Syndrome
diagnosis and treatment
Angiography gold standard

MRA optimal if available

CT angiogram evolving, esp for trauma pts

Anticoagulation with heparin

Neurosurgical consultation

Diagnosis and Treatment
question 10
A 43 year old male presents to the emergency room with 2 hours onset decreased movement of right side of face, ear pain, and thinks he might have had spoiled milk with his cereal this am because it tasted funny. What is the least important question for the diagnosis?

When was the milks expiration date?

Can he move his forehead?

Does he have a history of migraine?

Does he have clustered vesicles about the ear?

Does he have peripheral motor weakness?

Question 10
bells palsy not spoiled milk
Facial Nerve CN 7 palsy

Upper and lower facial weakness

Post auricular pain

Hyperacusis (stapedius)

Hypoageusia (ant 2/3 tongue)

Decreased lacrimation

30% pts w/ Crocodile tears, dysagusia, partial paralysis; 80-90% without sig deficit

Bells Palsy- Not spoiled milk.
bells palsy
Causes

HSV 1,2

VZV

Mycoplasma pneumoniae

Borrelia burgdorferie

HIV (b/l)

Adenovirus

coxsackievirus

Ebstein-Barr virus

Hepatitis A, B, and C

Cytomegalovirus

Treatment

Prednisone 60mg/day X 7 days

Acyclovir 800mg 5X/day for 7 days

Valacylovir 1000mg TID for 7 days

Artificial Tears

Bells Palsy
bells palsy treating ourselves
Bells Palsy- Treating Ourselves?
  • Prednisone treatment for idiopathic facial paralysis (Bell\'s palsy). N Engl J Med 1972 Dec 21; 287(25): 1268-72; 89% pred, 64% placebo
  • Cochrane Database 2002- Corticosteroids for Bell\'s palsy (idiopathic facial paralysis). No sufficient support for steroids
  • Cochrane Database 2004- randomized(?) trials of acylovir or valtrex with or without steroids for treatment of bells palsy ; insufficient evidence for support of antiviral medications
  • Valacyclovir and prednisolone treatment for Bell\'s palsy: a multicenter, randomized, placebo-controlled study; Otol Neurotol.2007 Apr;28(3):408-13. N=221; 6-8% improvement in severity and complete remission
ramsey hunt syndrome
Ramsey-Hunt Syndrome
  • Herpes Zoster Oticus; HSV1, HSV2, VZV
  • Triad of auricular pustules, ear pain, ipsilateral facial paralysis
  • +/- Hypoaguseia and hyperacusis
  • Worse prognosis
question 11
Question 11
  • 38 y/o female with a history of epilepsy presents with multiple seizures without return to consciousness for 30 minutes. Her finger stick is 100 and her blood ICON is negative. The patient has been given 4 mg of ativan X2 but continues to seize. What is your next step?
  • 4 mg Midazolam
  • 8 mg Ativan
  • Vitamin B6
  • Fosphenytoin load
  • Succinylcholine and etomidate with ETT
fosphenytoin load
Fosphenytoin Load
  • Status Epilepticus
  • 30 minutes of seizure activity without return of consciousness
  • If seizure >4-5 minutes consider status; neuronal injury- must wake up!
  • Non-convulsive- EEG!
  • Treatment of status based on universal guidelines and institutional protocol
  • Treatment and investigation parallel
status epilepcitcus
1/3rd new onset

1/3rd epilepsy

1/3rd:

Idiopathic

Hyper/hyponattremia

Hypercalcemia

Hypoglycemia

CVA

Trauma

Infectious

Mass

HE

Toxins

INH

Tricyclics (AVR, QRS)

Theophylline

Cocaine

Sympathomimetics

Alcohol withdrawal

Organophosphates (strychnine)

DM medications (glucose)

Status Epilepcitcus
status epilepticus
Status Epilepticus

1st Line: Ativan 4 mg over 2 minutes q5 min X2

  • If no access 20mg diazepam pr, 10mg midazolam IM
  • 2nd Line: IV Fosphenytoin (20mg/kg at 150mg/min; may add 10mg/kg)
  • May give IV Keppra, Valproic Acid, Phenobarbitol if pt is on it
  • 3rd Line: Pentobarbitol, Intubation with continuous drip of midazolam or propofol
  • Other: Vitamin B6 (70mg/kg up to 5 )
question 12
Question 12
  • A 35 year old female 1 week post-partum presents with 1 day of severe headache, nausea and vomiting. She is slightly confused and lethargic. She is afebrile, normo-tensive, with a negative UA. Given the clinical picture, what is the treatment of choice?
  • PCC or FFP
  • Emergent Craniotomy
  • Serial lumbar punctures
  • Magnesium Sulfate IV
  • Heparin
heparin venous sinus thrombosis
Heparin, Venous Sinus Thrombosis
  • Headache, nausea, emesis, ams, focal deficits; pesudotumor cerebri
  • Women, peripartum, hypercoaguable states, systemic inflammatory conditions
  • CT head, MRV
  • Atypical ischemic or hemorrhagic region
  • Tx: Heparin
question 13
A 70 year old male presents to the ER with weakness in the leg upon waking this morning. His exam shows left leg 2/5 strength with ataxia of limb, 4/5 left arm strength, no facial droop. He keeps asking what time it is. Where is his lesion?

Middle Cerebral Artery

Anterior Cerebral Artery

Posterior Cerebral Artery

Basilar Artery

Carotid Artery

Question 13
anterior cerebral artery stroke
Anterior Cerebral Artery Stroke
  • Affects medial parietal, temporal, and frontal lobes
  • Contralateral Motor and Sensory Leg > face and arm
  • Dis-inhibition, perseveration, primitive reflexes
basilar artery stroke
Basilar Artery Stroke
  • Bilateral sx
  • Coma
  • Locked in syndrome
question 14
A 23 year old patient presents is BIBEMS being bagged with a GCS of 3. His friend is with him and states that while doing “a lot” of cocaine his friend developed severe headache with sudden loss of conciousness. Which of the following considerations in further management is incorrect?

Pretreat with lidocaine and consider fentanyl and vecuronium

Do not allow single episode of hypoxia or hypotension

Hyperventilate to pC02 25-30

Raise head of bed to 30 degrees

Consider manitol or hypertonic saline for deterioration in neurologic status

Question 14
maintain pco2 between 35 40 not any lower
Pretreatment

Oxygen NRB

Lidocaine 1.5mg/kg 3 minutes before

Fentayl 2ug/kg

Vecuronium .01mg/kg (De-fasciculating Dose)

Intubation by most experienced MD; single episode of hypoxia associated with poor outcome

Ventilation

*Short term hyper-ventilation for nerologic deterioration

*Maintain pCO2 35-40

*Long term hyper-ventilation not Rx

Maintain pCO2 between 35-40, not any lower!
management of elevated icp
CPP=MAP-ICP

Maintain cerebral perfusion

Do not lower BP by > 20%

General rule is to maintain systolic between 160-180

A single hypotensive episode is assoicated with worse outcomes

Tx hypotension with IVF

Treatment of Increased ICP includes:

-Mannitol

-Raise Head of bed 30 D

-Hypertonic Saline (future)

-Hyperventilation

-Surgical evacuation

Management of elevated ICP
question 15
A 45 year old inmate with no pmhx presents with 1 hour of headache, right leg and arm paralysis, left forearm numbness, third right toe numbness, and a voice in his head telling him that he is hungry. Which of the following must you concsider in your differential?

Hypoglycemia

Metabolic Derangement

Migraine

CVA

All of the above

Question 15
all of the above
All of the Above!
  • Hypoglycemia (may be focal)
  • Seizure, Todds paralysis (may last 24 hours)
  • CNS infection
  • Bells Palsy (forehead affected)
  • Other Metabolic derangement
  • Migraine (focal deficits possible)
  • Conversion disorder
  • Malingering
  • Lower CNS lesion, trauma
  • Toxic
the end
THE END

THANK YOU!

Please also read

-Parkinsons

-Dimentia

-Delerium

-Multiple Sclerosis

-Everything else!

question 16 if you want more
Question 16 ? If you want more…
  • A 22 year old female presents with double vision. The symptoms disappear with either eye is covered. Extraoccular movements are intact when tested individually. On conjugate gaze testing there is nystagmus in the left eye and limited adduction in the right eye. What is the most likely cause?

1. Dislocated Lense

2. Tertiary neurosyphilis

3. Internuclear Opthalmoplegia

4. Sixth Nerve palsy

5. Third Nerve palsy

internuclear opthalmoplegia
Internuclear Opthalmoplegia
  • Occurs due to disruption in the medial longitudinal fasciculus (MLF)
  • Corrdinates conjugate eye movements
  • Most commonly due to MS
  • MS occurs in young women; deficits vary anatomically and temporally
diplopia
Monocular

Refractive error

Dislocated lenses

Iridodialysis

Malingering

Binocular

CN palsies

Brain lesions

HTN crisis

Cocaine

Wernicke’s

SLE

Retro-orbital mass/hematoma

Diplopia
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