MIND-blowing
Name 3 clinical findings of basilar skull fracture.
Blood behind tympanic membrane, raccoon eyes, battle sign (mastoid ecchymosis), clear d/c for nares or ears
What part of the brain do movement disorders like Parkinson's or Huntington's affect?
Basal ganglia
How long can a TIA last before it becomes a stroke?
< 24 hrs
What are two tests that can show meningeal signs?
Brudzinski sign- neck flexion produces knee and/or hip flexion
Kernig sign- inability to extend the knee/leg with hip flexion
Don't forget about nuchal rigidity.
What's the most common brain tumor?
Meningioma
What is cerebral perfusion pressure (CPP)?
CPP = MAP (Mean Arterial pressure) - ICP (Intracranial pressure)
CPP < 50 mmHg autoregulation is lost and Cerebral Blood flow declines -> PaCO2 decreases leading to vasoconstriction while PaO2 decreases leads to vasodilation (leaky vessels and increased edema)
What is the 1st line treatment for Essential Tremor?
Propranolol and Primidone
What are the classic signs for an anterior cerebral artery occlusion?
Contralateral sensory & motor deficits, greater in lower extremities (leg).
Urinary incontinence.
Personality/cognitive deficits (eg confusion, flat affect, impaired judgement)
List the age group most affected by Neisseria meningitides. What's the prophylactic treatment?
Adolescents - young adults.
Common clinical sign is petechial rash on trunk, legs, and conjunctivae.
Prophylaxis - Ciprofloxacin
What is the Cushing Reflex?
Widening pulse pressure, decreased HR, and irregular RR. (Hypothalamus is compressed)
Caused by an increase in Intracranial Pressure secondary to subarachnoid or intracerebral hemorrhage, CNS infection, tumor, and traumatic brain injury (TBI).
What is the treatment for moderate/severe migraines? (abortive)
Ergotamine, triptans (5-hydroxytryptamine-1 receptor agonists) alone or in combination with Dopamine receptor antagonists (eg Metoclopramide, Prochlorperazine, Chlorpromazine)
Also CGRP antagonists or 5-HT 1F receptor agonists
What disease process has clinical manifestations of symmetric, ascending, progressive flaccid muscle weakness that is treated with plasmapheresis or IV immune globulin?
Guillain Barre Syndrome
What issue is a thunderclap headache associated with?
"Worst headache of my life" - Subarachnoid hemorrhage.
Arterial bleed between arachnoid and pia, most common is a Berry aneurysm
Normal Pressure Hydrocephalus has a classic triad of clinical findings. What are they?
Wacky, wobbly, and wet.
Dementia/cognitive dysfunction, gait disturbances, urinary incontinence.
What is the most common malignant brain tumor in children? What about adults?
Kids- Malignant medulloblastoma arising from the posterior fossa.
Adults- Astrocytoma -> Grade IV astrocytoma aka Glioblastoma multiforme
List 3 signs of an upper motor neuron lesion.
Muscles are SPASTIC.
Slight muscle loss
Positive Babinski
Absence of fasciculations
Strong tone (spastic paralysis)
Tone increased
Increased deep tendon reflexes
Clonus
Conditions: Stroke, Multiple Sclerosis, Cerebral Palsy, Spinal cord or brain damage
What are 3 hallmark signs of Huntington Disease?
3 M's: Mood, Movement, Memory
Behavior/mood changes, chorea (rapid involuntary movements), and dementia.
Tx: Tetrabenazine for dyskinesia or chorea
List 2 differences between an epidural hematoma vs a subdural hematoma.
Epidural hematoma: lens-shaped bleed on CT, most commonly arterial bleed b/w skull and dura with temporal bone fx -> middle meningeal artery. If increased ICP tx with mannitol, hyperventilation, head elevation
Subdural hematoma: crescent-shaped bleed on CT, most commonly venous bleed b/w dura and arachnoid (tearing of bridging veins), blunt trauma ('contre-coup). Look for midline shift on CT
List some differences between CSF infected with a bacteria vs viral.
Bacterial: Opening pressure increased, Turbid appearance, Increase in protein, Decrease in glucose, Elevated WBC count (high neutrophils-polymorphonuclear neutrophils)
Viral: Opening pressure normal or mildly increased, Clear appearance, Normal protein, Normal glucose, Elevated Lymphocytes
What autosomal dominant condition can cause tumors to form in the brain, spinal cord, and nerves?
Neurofibromatosis
Type I: NF1 multiple cafe au lait spots, axillary and inguinal freckles, iris hamartomas, dermal neurofibromas, osseous lesions.
Type II: NF2 bilateral vestibular schwannomas, multiple meningiomas
What is Waddell's triad?
Pediatric pedestrian patients with blunt forced trauma
1) Ipsilateral femoral shaft fx
2) Ipsilateral intra-thoracic or intra-abdominal injury
3) Contralateral head injury
How will you diagnose and treatment a patient suspected of Parkinson Disease?
Motor triad: resting tremor, bradykinesia, and muscle rigidity
Resting tremor often 'pill-rolling' of the hand.
Rigidity can have a cogwheel pattern, shuffling gait may be present (festination).
Postural instability- flexed, stooped posture.
Tx: Levodopa-Carbidopa for pts >65y/o; Dopamine agonists (eg Pramipexole, Ropinirole) for initial tx < 65y/o; Amantadine, Anticholinergic, MAO-B inhibitor, COMP inhibitor
What are the classic presentations of a lacunar stroke?
1) Pure motor (most common): hemiparesis or hemiplegia with absence of sensory or cortical signs
2) Pure sensory deficits: numbness, paresthesias of arm, leg, or face on one side of body w/ absence of motor or cortical signs
3) Ataxic hemiparesis: ipsilateral weakness and clumsiness in leg>arm
4) 'Clumsy hand syndrome': dysarthria, facial weakness, dysphagia, and slight weakness/clumsiness of one hand (no cortical signs)
What is the empiric treatment for a 55 y/o M patient complaining of nuchal rigidity, fever, and a positive Brudzinski and Kernig sign. Pt has a history of Type 2 diabetes and works at a cottage cheese plant.
Vancomycin, Ceftriaxone, and Ampicillin (crosses blood-brain barrier, needed for Listeria monocytogenes)
What is an uncal herniation and what are clinical signs of it?
Transtentorial herniation of the Uncus through the tentorium secondary to intracranial mass effect -> encroaches CN3 causing a fixed and dilated pupil (ptosis, mydriasis, strabismus "down and out")
Remember: Tonsillar/Brainsten can cause Cushing's Triad and loss of blink and gag reflex & Cingulate/Subfalcine cause contralateral leg weakness, impaired decision making, and aniscoria.