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UWORLD

Main Division: Medicine Sub Division: Neuro System Optha

Topic FEATURES TREATMENT


Aminoglycoside Toxicity Otoxicity (damage cochlear cells)
Oscillopsia (sensations of objects moving around visual field)
Esp Gentamycin can cause hair cell damage-->vestibuopaty
has abnormal head thrust
Anticholinergic toxicity Hot as a hare, dry as a one, red as a beet, blind as a bat,
mad as a hatter (confusion). HA, tachy, constipaton, dizzy
Atropine, Parkinsons drugs:Benztropine, Trihexyphenidyl
antiplatelet/antithrombotic Tx: IV: altepase
Ischemic stroke:
A w/in 3-4.5h of symp, no CI
antiplatelet/antithrombotic Tx: ASA
Ischemic stroke:
B w/in 3-4.5h of symp, no CI
antiplatelet/antithrombotic Tx: ASA + dipyridamole/Clopidogrel
Ischemic stroke:
C stroke on ASA
antiplatelet/antithrombotic Tx: ASA + clopidogrel
Ischemic stroke:
D stroke on ASA + intracrania
larger artery atherosclerosis

antiplatelet/antithrombotic Tx: Long term anticoagulation (warfarin, dabigatran, rivaroxaban


Ischemic stroke:
E stike with evidence of Afib
B12 deficiency Decreased b12 level, increacsed methylmalonic acid levels
Brain death Clinical diagnosis
absent cortical and brainstem functions
spinal cord may still work (reflexes)
Cavenous sinus thrombosis HA, bilateral periorbital edema, CN III/IV/V/VI deficits
Cerebellar dysfunction Common in Etoh users
Truncal ataxia, nystagmus, intention tremor, dysdiadocho-
kinesia, hypotonia, pendular knee swing after DTR
UWORLD
Main Division: Medicine Sub Division: Neuro System Optha

CEvsCMvsSCC: Gradual worsening back pain, worse at night


spinal cord compression early: Symmetric LE weaking, hypo/absent DTR
Late: Bilateral babinsky, sensory, loss, absent rectal tone,
Urinary retention
Immediate neurological (surgical) evaluation
MRI and possibly high dose gluccocorticoids

CEvsCMvsSCC: Usually bilateral, severe radicular pain


Cuada equina syndrome saddle hypo/anesthesia hyporeflexia/areflexia
Asym motor weakneses late bowel & bladder dysfx
CEvsCMvsSCC: sudden severe back pain Hyperreflexia
Conus medullaris syndrome Perianal hypo/anesthesia Early onset & bladder dysfx
Sym motor weakness
Chemo induced Sym distal sensory neuropathy, stocking glove pattern
peripheral neuropathy common agents: plantinum agents (ie cisplatin)
taxanes (ie Paxitaxel), vinca alkaloids (vinacristine)
Cortical laminar necrosis halmark of prolonged sz, >5min seizure
MRI: cortical hyperintensity on diffusion weighted imaging
suggests infarction
CT: radiology: Brain hmrge Hyperdense (white)
CT: radiology: Brain Infarct Hypodense
Cushing reflex Suggestive of brainstem compression
Hypertension, bradycardia, respiratory distress
Diffuse axonal injury CT: minute punctuate hemorrhages with blurring of
grey white interface but MRI more sensitive
Traumatic brain injury freq from traumatic deceleration -->
vegetative state
Gait: Apraxia (frontal gait) Magnetic (freezing): start and turn hesitation
Causes: frontal lobe degeration, hydrocephalus, dimentia
Gait: Cerebellar Ataxic: staggering wide base
Causes: Stroke, Drug/Etoh intox, B12 deficiency
Gait: Musclar dystrophy Waddling
Gait: Parkinsonian Short shuffling step, narrow-based,
stooped position, immobile arm movement
Cause: parkinsons
UWORLD
Main Division: Medicine Sub Division: Neuro System Optha

Gait: Sensory ataxia Wide-based high-stepping gait


cause: peripheral nerves, doral root, post. Columns lesion
Gait: Steppage Foot drop, excessive knee & hip flex, slapping, falls
Causes: motor neuropathy (MC L5 radiculopathy
common peroneal nerve)
Gait: vestibular Unsteady, falling to one side
Acute labrynthtitis, meniere disease
Glioblastoma Multiforme CT/MRI: Butterfly appearance with central necrosis
heterogenous, serpiginous contrast enhancement
Heat Stroke Acute confusion
Core body temp >40c
Coagulopathic bleeding
Tachycardia Tx: ice cold bath
Idiopathic Intracranial HTN Increased ICP (Papilledema) in Alert pt Acetazolamide:(-) choroid
(Pseudotumor cerebri) Obese, female, childbearing age with HA plexus carbonic anhydrase
Possible link to meds: GH, tetracyclins, hyper vit A, OCP Wt loss Stop offending agent
DX: LP: Nml CSF analysis with >250mmH20 pressure; shunting or optic n. sheath
No focal neural deficit, may w/ diplopia, transient vision loss fenestration to prevent
Pulsatile tinnitus "wooshing", CN VI palsy blindness

Internuclear opthalmoplegia Characteristic of MS


Demyelination of MLF:
(Medial Longitudinal Fasiculus)
ipsilateral eye cant adduct on lateral gaze
Contralat eye has nystagmus
Intracranial hypertension HA (worse at night), AMS, N/V, papilledema, focal neuro def
cushing reflex worrisome for brainstem compression

Leision: Hemorrhage: Homonymous hemianopsia


Basal Ganglia (putamen) Gaze palsy
Contralateral hemiparesis & hemisensory loss
Leison: Hemorrhage: Usually NO hemiparesis
Cerebellar Ataxia Neck stiffness Facial weakness
Nystagmus Occipital HA
UWORLD
Main Division: Medicine Sub Division: Neuro System Optha

Leison: Hemorrhage: Fontal lobe: contralateral hemiparesis


Cerebral lobe Parietal lobe: contralateral hemisensory loss
Occipital lobe: homonymous hemiamopsia
Eyes deviate AWAY from hemiparesis High incidence of sz
Leison: Hemorrhage: Pons Deep coma & total paralysis within minutes
PINPONT reactive putils
Leison: Hemorrhage: Thalamus Eyes deviate TOWARDS hemiparesis
Up-gaze palsy
Non-reactive miotic pupils
Contralateral hemipareis and hemisensory loss
Leison: Lacunar Infarct: Pure motor hemiparesis
Internal capsule posterior limb Mild dysarthria (slurring)
Leison: Lacunar Infarct: Dysarthric clumsy hand
Internal capsule genu
Leison: Lucunar Infarct: Ataxia hemiplegic syndrome
Base of Pons Weakness more in LE; incoordination of UE & LE
Lesion: Lacunar infarct RF: old age, smoking, DM, HTN-->lipohyalinotic thickening
No cortical signs
Lesion: Lucunar infarct: Pure sensory stroke
VPL and VPM in thalamus
Metoclopramide Side Effects Metoclopramide is a dopamine agonist --> watch out for EPS Treat dystonia with
side effects Benztropine
Dyphenhydramine
Multiple system Atropy Parkinsonism + orthostatic hypotension, incontinence,
(Shy-Dragger syndrome) impotence, or other autonomic dysfx

Myopathy: Painless proximal muscle weakness mostly in LE


Glucocorticoid induced ie difficulty getting up from chair
No inflammation, ESR & CK normal. Will stop with meds
Neurofibromatosis 2 mutation AD, acoustic schwanoma bilateral, NF, café au lait
Severe variant: wishart from non-sense mutation
Mild variant: gardner from missense
Silent of same sense make no change
MRI with gadolinium to see acoustic neuroma
UWORLD
Main Division: Medicine Sub Division: Neuro System Optha

Ophta: subconjuntival hmrg caused by trauma or valsalva


well demarcated area of extravasated blood
most are benign and need no treatment
Optha: Amurosis Fugax Painless, transient vision loss "curtain falls"
Impending stroke warning--> most like from retinal emboli in
ipsilateral atherocsclerotic carotid artery
Get US/duplex of neck; most emboli from carotid bifurcation
Cholesterol bodies (hollenherst bodies) may be seen
Optha: ant uveitis (irisitis) infection of uveal tracts
Pain, miosis, photophobia
Optha: endopthalmitis Invasive infection of eye 2/2 disruption of external surface
Purulent haziness, hyopyon pus in anterior chamber
Optha: episcleritis localized patchy red eye with mild pain
self limited, no cornea involvment, may be rltd to RA
Optha: herpes zoster Dendritic ulcers and vesicular rash in trigeminal distribution
opthalmicus tx w/in 72h with high dose acyclovir to prevent complication
Optha: keratitis: HSV Most common cause of corneal blindness
characteristics are vesicular and dendritic ulcers
epithelial scrapings show giant multinucleated cells
associated with outdoor workers, too much sun,
immunodeficiency, fever. TX antivirals (oral or topical)

Optha: Ketatitis: Most cases from gram (-) pseudomonas & serratia
contact lens associated painful red eye, opacification, and ulceration of cornea
Treat with broadspectrum abx
Optha: Retinitis: Aids patient VZV & HSV: pain, keratitis, uveitis
Fundoscopy: Peripheral pail lesions w central retinal necrosis

CMV: Painless, not usually assoc w keratitis on conjuntivitis


Fundoscopy: fluffy granular lesion around retinal vessels
Optha:Keratitis: viral Corneal infx related to HSV, VZV
vesicles, opacification, dendritic ulcers
Restless leg syndrome urge to move legs w/ dysesthesias, exacerbated by
no movement, better with movement, worse at night
Tx: Dopamine agonist Pramiprexole, alpha 2 gama
ca channel ligands ie (gabapentin)
UWORLD
Main Division: Medicine Sub Division: Neuro System Optha

Riley Day syndrome Famila autonomia, AR, Ashkenazi Jews child


Orthostatic hypotension, gross dysfx of autonomic syndrome
Spinal epidural abscess Triad: Fever, focal back pain, neurological deficits
RF: IV drug use, immunocomp, infections spread from
contigous/distant source, spinal trauma or surgery
use MRI with gadolinium
Abx, surgical decompression, drainage
Stroke type: Hx uncontrolled HTN, illicit drug use, coagulopathy
Intracerebral hemorrhage Symptoms progress from minutes to hours
Focal neuro symp early ff by Inc ICP symp
(vomiting, headache, bradycardia, decreased alrerness)
Stroke type: Rupture of saccular berry or AVM
Spontaneous SAH Severe HA at onset of neuro symp(vs intracerebral hmrg)
Menigeal symptoms; focal neural def uncommon
Stroke type: Ischemic: History of cardiac disease
Embolic Symptoms aburpt & maximal from the start
Multiple infacts within different vascular territories
Stroke type: Ischemic: Atheroslcerotic RF +/- TIA; LOOK for carotid bruit
Thrombotic Local insitu obx of artery; symptoms fluctuate, stuttering
progressing w periods of improvement
Tick-borne paralysis Rapidly progressive (hours) ascending paralysis
No fever, no autonomic dysfx, normal csf (vs GBS)a
Ulnar nerve syndrome Decreased sensationof 4th and 5th finger, weak grip due to
interosseous muscles
MC site entrapment: medial epicondylar grove (elbow)
Upper Thoracic Spinal Lesion Paraplegia, bladder & fecal incontinence
Absent sensation nipple down
Vertigo cause: Due to viral syndrome NO hearing loss
Vestibular Neuritis Single severe episode of vertigo Patient falls to lesion
Vertigo cause: BPPV Recurrent brief episodes brought on by predictable moves Epley maneuver
Dix-hallpike causes nystagmus Dislodged otolith
Vertigo cause: Labrynthitis N/V Nystagmus Hearing loss
Preceeded by a URI
Vertigo cause: Meniere Vertigo Unilateral hearling loss (low freq) Salt restriction
Tinnitus Ear fullness Thiazides
UWORLD
Main Division: Medicine Sub Division: Neuro System Optha

Vitreous hemmorhage Sudden loss of vision, onset of floaters, hard to visual fundus
MC cause: diabetic retinopathy
Warfarin induced cerebral Reverse with IV vitamin K and prothrombin complex-
hemorrhage concentrate. Fresh frozen plasma maybe used if no PCC
Wernicke's Encepholopathy Thiamine (B1) def, seen with alcoholics
Encepholapthy, oculomotor defect, gait ataxia
Administer thiamine