neurology notes for oards
TRANSCRIPT
Neurology Notes for Boards Dyanne P. Westerberg, DO
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Neurology Review
Dyanne P. Westerberg, DO FAAFP
Associate Professor and Chair, Department of Family and Community Medicine
Cooper Medical School of Rowan University
Cranial Nerve Type Function
Olfactory 1 S Smell
Optic 2 S Sight
Oculomotor 3 M Medial, superior and inferior rectus , inferior oblique, ciliary muscle, sphincter muscle of the eye
Trochlear 4 M Superior Oblique
Trigeminal 5 B Sensation of face, muscles of mastication
Abducens 6 B Lateral Rectus
Facial 7 B Taste ( anterior 2/3 tongue) muscle of facial expression, stapedius muscle, stylohyoid muscle, digastric muscle, lacrimal, submandibular and sublingual glands
Vestibulococular (Auditory)
8 S Hearing and balance
Glossopharyngeal 9 B Taste( posterior 2/3 tongue) Pharyngeal sensation, parotid gland, styrlopharyngeus muscle
Vagus 10 B Sensation of trachea, esophagus,viscera,laryngeal,pharyngeal muscles, visceral autonomics
Accessory 11 M Sternocleidomastoid and trapezius muscle
Hypoglossal 12 M Tongue
Overview of the CNS arterial supply. Nolte, John, PhD - Essentials of The Human Brain, 37-42 © 2009 Copyright © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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Lateral ( A ), medial ( B ), and cross-sectional ( C ) views of the hemisphere showing the regions served by the anterior cerebral ( green ), middle cerebral ( blue ), and posterior cerebral ( pink ) arteries. The distal territories of these vessels overlap at their peripheries and create border zones. These zones are susceptible to infarcts ( C ) in cases of hypoperfusion of the vascular bed. Small border zones also exist ( A ) between superior ( green ) and inferior ( blue ) cerebellar arteries. Haines, D.E.,Lancon, J.A. - Fundamental Neuroscience for Basic and Clinical Applications, 109-123.e1 © 2013 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Headache • Primary
– Migraine – Cluster – Tension
• Secondary – Hemorrhage – Encephalopathy – Meningitis – Temporal arteritis – Neoplasm – Sinus – Exertional – Trauma
Which headache is the most common?
Tension accounting for 40%
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Migraine Cluster Tension
Patient 10 to 30 years F>M
Young Men F>M
Types Without aura With aura
Precipitating factors Stress, BCP, menstruation, exertion, food containing tyramine or nitrates, chocolate, cheese, processed meats
ETOH, vasodilators Stress, fatigue
Associated symptoms photophobia, visual abnormalities, aura
Horner’s syndrome, lacrimation nasal congestions Pain radiates to the jaw and teeth
Anxiety
Duration 4 to 72 hours 30 Min to 3 hours
Variable
Treatment NSAID, ergots,triptans, Antiemetics, prophylaxis: tricyclics, Bblockers Calcium channel blockers Ergots, OMT
Also, 100% oxygen 7 L/minute for 15 minutes, OMT
Also relaxation exercises. OMT
Characteristics of the headaches
Migraines Cluster Tension
Nausea Photophobia/phonophobia Increase with activity P-pulsatile quality O- onset 4 to 72 hours U-Unilateral N- N/V D- Disabling Aura- flickering lights, spots Fully reversible neurological symptoms
Can be bilateral Several per day ( 1 to 8) Between 15 and 180 minutes Episodes 6 to 12 weeks Remission for 12 months
Bilateral Like a tightening band around the head Non pulsating No increase with physical activity No N/V No Photophobia/Phonophobia
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Characteristics of the headaches
Migraines Cluster Tension
Nausea Photophobia/phonophobia Increase with activity P-pulsatile quality O- onset 4 to 72 hours U-Unilateral N- N/V D- Disabling Aura- flickering lights, spots Fully reversible neurological symptoms
Can be bilateral Several per day ( 1 to 8) Between 15 and 180 minutes Episodes 6 to 12 weeks Remission for 12 months
Bilateral Like a tightening band around the head Non pulsating No increase with physical activity No N/V No Photophobia/Phonophobia
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Medical Treatments
Acute
• Acetaminophen/Aspirin/Caffeine
• NSAID
• Triptans
• Antiemetics
• Dexamethasone
• Ergotamine
• Intranasal Lidocaine
• Isometheptene
Chronic – First Line
• Propanolol
• Amitriptyline
• Sodium Valproate
• Topiramate
• Divalproex
Exertional Headache
• Headache after physical activity • Running
• Coughing
• Sexual Intercourse
• Bowel Movement
• Evaluation i.e. MRI if • >40
• Vomiting
• Prolonged duration
• Cardiac evaluation if risk factors
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Meningitis
• Infection of the covering of brain and spinal cord- meninges
• Risk Factors: ear infections, sinusitis, immunocompromise, neurosurgery, maternal group B infection during childbirth
• H and P: headache, neck pain, photophobia, nausea, vomiting, confusion, fever, seizure, Kernig, Brudzinski, rash
Meningitis by Age Age Most common
organism Other organism Emperic Treatment
Newborn Group B strep E.Coli, Listeria H.influenza
Ampicillin Cefotaximine
1 m to 2 y S.pneumonia N.meningitis
Group B Strep Listeria, H.influenza
Vancomycin Ceftriaxone
2-18 y N.meningitis S.pneumonia Listeria
Vancomycin Ceftriaxone
18 to 50 y S.pneumonia N.meningitis Listeria
Vancomycin Ceftriaxone
50+y Altered cellular immunity Alcoholic
S. pneumonia N. Meningitis, Listeria , gram-negative rods
Vancomycin Ceftriaxone Ampicillin
Viruses
• Viral Meningitis:
– Numerous viruses -Enteroviruses most common
– Nausea, vomiting, headache stiffness
– LP helps in diagnosis, more specific- PCR testing
• Encephalitis:
– Numerous viruses i.e flavivirus- West Nile*
– Headache, vomiting, change in mental status
* Increased incidence since 1999
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LP findings
Patient WBC Pressure Glucose Protein
Healthy <5 50-180mm H20
40-70 mg/dl 20-45mg/dl
Bacterial Increased Esp. PMN
increased decreased increased
viral Increased Esp. Lymphocytes
increased normal normal
Fungal or TB Increased Esp. Lymphocytes
Increased decreased increased
Prevention
• Vaccines for general population and aspleenic patients
– Hib Vaccine
– Pneumococcal Vaccine
– Meningococcal Vaccine
Trigeminal Neuralgia
• Recurrent- Head and Facial Pain in the trigeminal area- made worse by palpation with radiation to the maxillary and mandibular areas.
• F> M
• age >50
• MRI to r/o lesions such as tumor or MS
• Treatment: carbamazepine 200 to 1,200 mg/day recommended
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Temporal( giant cell) Arteritis
• Caused by subacute granulomatous inflammation of the external carotid and vertebral arteries
• Pain in the temporal region and radiating to the scalp and jaw. Transient or permanent blindness
• May be associated with polymialgia rheumatica
• Increased sed rate
• Biopsy for diagnosis
• Prednisone, ASA to reduce risk of stroke
Trigeminal Neuralgia Temporal Arteritis
TIA • American Heart Association/American Stroke
Association 2009 definition of TIA – Transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction
• Underreported
• Sudden onset of unilateral paresis, speech disturbance, transient monocular vision loss
• NOT tinnitus, dizziness, vertigo, memory loss
( mimics)
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Evaluation
• Thorough History – Is it recurrent?
• Physical exam esp. neuro
• Imaging- within 24 hour – Diffusion weighted MRI
– CT scan often completed in the ER
• Cardiac Assessment: – EKG
– Transthorasic echo/TEE • Patent foramen ovale, thrombus, valvular disease
– Telemetry
– Labs
Treatment- prevent future strokes 10 to 20 % risk at 90 days often within 48 hours
• Modify risks: – hypertension, smoking, obesity, inactivity etc.
• Statins regardless of LDL: – Reduce by 50 % or less than 70
• Antiplatelets if non cardiac – 81 mg aspirin
– Dipyridamole/aspirin
– Clopidogrel
• Carotid endarterectomy or angioplasty – If 70 to 99% blocked and risk <6%
Treatment- prevent future strokes 10 to 20 % risk at 90 days often within 48 hours
• Modify risks: – hypertension, smoking, obesity, inactivity etc.
• Statins regardless of LDL: – Reduce by 50 % or less than 70
• Antiplatelets if non cardiac – 81 mg aspirin
– Dipyridamole/aspirin
– Clopidogrel
• Carotid endarterectomy or angioplasty – If 70 to 99% blocked and risk <6%
Not ASA and Plavix
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Atrial Fibrillation ( AHA)
• Warfarin with INR between 2 and 3 • Control group 4.5 % stroke
• Warfarin group 1.4% stroke
• Other agents: ( Do NOT have AHA approval)
– Dabigatron- (Pradaxa)
– Rivaroxaban (Xarelto)
– Apixaban (Eiquis)
Who needs anticogulation?
Stroke
• symptomatic cerebral ischemic events of > 24 hour duration
– 80%-87% ischemic ( thrombus or emboli)
– 13%-20% hemorrhagic
• Intracerebral
• subarachnoid
• Risk Factors: Age, FMH, obesity, DM, HTN, tobacco, AFIB, Stress, High Alcohol
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Acute Treatment • EKG • Labs • Imaging to r/o Bleed • Thrombolytic Therapy if within 3 hours if acute and
clinically meaningful defecit • No bleed or AV malformation • Normal platelets • No anticoagulants • No trauma • BP < 185/110
• oxygen if hypoxic • Aspirin within 48 hours ( if no thrombolytics) • Do not lower BP unless extreme i.e. 220/120 or patient
has CAD to maintain cerebral perfusion • Monitor for complications i.e seizures, edema, bleed
Imaging
• For diagnosing ischemic stroke in the emergency setting: – CT scans (without contrast enhancements)
• sensitivity= 16% specificity= 96%
– MRI scan • sensitivity= 83%specificity= 98%
• For diagnosing hemorrhagic stroke in the emergency setting: – CT scans (without contrast enhancements)
• sensitivity= 89%specificity= 100%
– MRI scan • sensitivity= 81%specificity= 100%
Seizure
• Sudden change in neurological activity (e.g. behavior, movement, sensation) causes by excessive synchronized discharge of cortical neurons in a limited (focal) or generalized distribution of the brain.
• Epilepsy: 2or more seizures that are not precipitated by illnesses or other inciting events i.e. alcohol withdrawal
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Common Causes of Seizure by Age Group
• Infant – Hypoxic injury
– Metabolic defect
– Genetic or congenital abnormality
– infection
• Children – Idiopathic
– Infection
– Fever
– trauma
• Adult – Idiopathic
– Metabolic defect
– Drug or drug withdrawal
– Trauma
– Neoplasm
– Infection
– CVA or stroke
Types of Seizures Type Involvement Comments
Simple Partial Focal, cortical region of the brain
Focal sensory of motor deficit with no LOC
Complex Partial Focal Region of the temporal lobe
Hallucinations and repeated coordinated movements
Generalized Bilateral cerebral cortex Tonic- clonic repetitive contraction and relaxation
Absence Bilateral Cerebral cortex Mostly in children
Status Epilepticus
• Either > 30 minutes of continuous seizure activity or ≥ 2 sequential seizures without recovery of full consciousness between seizures
• Due to : numerous- infections , brain tumor
• Treat with IV benzodiazepines, then start phenytoin or phenobarbitol if refractory
• Mortality > 20 % if untreated.
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Febrile Seizures
• Between age of 6 months and 5 years • Prevalence 2 to 5% • Males > female • No evidence of intracranial infection • Simple < 15 minutes, complex > 15 minutes. • Greater risk of developing epilepsy • LP should be performed in patients
• < 12 months • Complex seizure • Symptoms of meningitis
Parkinson Disease • Idiopathic dopamine depletion:
– loss of dopaminergic striated neurons in the substantia nigra and Lewy formation leading to abnormal cholinergic input to the cortex.
• Symptoms: – Resting tremor: pill rolling – Cogwheel rigidity – Bradykinesia/ akinesia- shuffling gait – Mask-like faces – Memory loss – Difficulty initiating movement – Postural instability – Stooped posture, decreased arm swing
Parkinson Disease • Idiopathic dopamine depletion:
– loss of dopaminergic striated neurons in the substantia nigra and Lewy formation leading to abnormal cholinergic input to the cortex.
• Symptoms: – Resting tremor: pill rolling – Cogwheel rigidity – Bradykinesia/ akinesia- shuffling gait – Mask-like faces – Memory loss – Difficulty initiating movement – Postural instability – Stooped posture, decreased arm swing
TRAP
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Treatment of Parkinson Disease Drug Mechanism indication
Levodopa Dopamine precursor Initial therapy
Carbidopa Dopamine decarboxylase inhibitor that reduces levodopa metabolism
Combined with levodopa to augment effects
Bromocriptine Dopamine receptor agonist Increases response to levodopa in patients with declining response
Selegiline Monamine oxidase type B inhibitor
Early disease – may help delay need to start levodopa
Amantadine Increases synthesis, release or reuptake of dopamine
More effective against rigidity and bradykinesia
Antimuscarinic agents
Block cholinergic transmission
Adjuvant therapy
Drug induced Parkinson Disease
• the older major tranquilizers such as Haloperisol ( Haldol), Trifluoperazine (Stelazine)
• the newer major antipsychotic drugs such as Risperidone (Risperdal), Olanzapine (Zyprexa),
• drugs used for nausea, vomiting, and acid reflux such as Metoclopramide (Reglan)
Myasthenia Gravis
• Autoimmune disorder • Antibodies bind to acetylcholine receptors at
neuromuscular junctions and block normal neuromuscular transmission
• Bimodal distribution younger women, older men • H and P
• Fatigue • Ptosis • Diplopia • Dysphagia • Dyspnea
• Lab: + positive Ach receptor antibodies • Tensilon Test: symptoms improve with edrophonium
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Guillain Barre Syndrome
• Inflammatory neuropathy associated with progressive weakness usually symetrical and ascending
• Autoimmune • Can be associated with recent viral infection, surgery ot
immunization • Peak 20’s and 70’s • Self resolving in 1 month- sooner with plasmapheresis or
immunoglobulin • H and P:
• Rapid bilateral weakness in distal extremities in stocking/glove distribution and going proximal
• Decreased sensation • Absent DTR’s • Respiratory Failure
Amyotrophic Lateral Sclerosis
• Progressive neuro degenerative disease of the motor neurons
• Loss of central nervous system – lower motor neurons
» anterior horn cells in spinal cord
» cranial nerve nuclei (most often X, XI, XII)
– upper motor neurons
» corticospinal tract
• Ages 20 to 80
Amyotrophic Lateral Sclerosis
• H and P – Asymmetrical progressive weakness in the limbs and
face – Possible change in personality and impaired judgment – Increase or decrease in DTR – Flaccid paralysis – Babinski – Fasciculations of the muscles
• EMG: Widespread muscular denervation and motor block
• Treatment: riluzole- supportive therapy
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Alzheimer’s Disease
• Most common cause of Dementia • Due to neurofibrillary tangles, neuritic plaques, amyloid
deposits,neuronal atrophy • Cortical atrophy on Imaging • H and P
• Progressive short term memory loss • Depression • Confusion • Inability to perform complex tasks or movements • Personality changes and delusions
• Treatment – Cholinesterase inhibitors – Memantine ( alone or in combination) – Herbals?????
Multiple Sclerosis
• Possible autoimmune
• Demyelinating disorder of brain and spinal cord
• Most patient women 20 to 40
• Mri with contrast shows white matter lesions
• H+ P: various symptoms, visual changes( Optic Neuritis- 10 year risk 38%), babinski, positional instabilities, spasticity, dysarrthria
• McDonald Criteria for diagnosis
• Treatment: steroids, methotrexate,interferon, glatirmer lacitate
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Radiculopathy Form of neuralgia due to irritation of the spinal nerve
Neuropathy Nerve Reflex Motor Deficit Sensory Deficit
C5 Biceps Deltoid, biceps Anterior Shoulder
C6 Brachioradialis Biceps, wrist extensor Lateral forearm
C7 Triceps Triceps, wrist flexors, finger extensors
Posterior forearm
C8 None Finger flexors Forth and fifth fingers, medial forearm
T1 None Finger interossei Axilla
L4 Patellar Tibialis anterior (foot dorsiflexiion)
Medial leg
L5 None Extensor hallucis longus (first toe dorsiflexion)
Lateral lower leg, first web space
S1 Achilles Peroneus longus and brevis( foot eversion) Gastrocnemius (foot plantarflexion)
Lateral foot
Osteopathic Manipulation
• Numerous studies support the use of OMT in the treatment of patients with musculoskeletal complaints.
• No studies on radiculopathy found.
• Many modalities- should not just think of high velocity techniques.
• High velocity should be used with caution in the cervical spine
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Carpal Tunnel
• Compression of the median nerve at wrist
• Ages 30 to 55
• F>M
• H and P
– Wrist pain radiates up the arm
– Decreased grasp
– Numbness in thumb middle and index finger
– Thenar atrophy in advanced cases
+ tinel + phalen
Treatment
• Most of questionable benefit
– Wrist splints
– Activity modification
– NSAID
– Steroid injections
– Surgical release of the transverse carpal tunnel ligament
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