EPILEPSY
STROKE
NEUROANATOMY
NAME THE DISORDER
FUN FACTS
100
Status epilepticus is neurological emergency (mortality up to 20 %) and is defined as persistence of seizure or recurs without recovery for 30 minutes. Which is the 1st first line therapy for status epilepticus?
Answer: What are benzodiazepines? KEY POINTS: Algorithm for treatment of convulsive status epilepticus would be benzodiazepine (ex: Lorazepam 0.1 mg/kg IV or 4mg IV for up to 3 doses, alternative intramuscular (IM) midazolam 10 mg for adults), -> fosphenytoin (Cerebyx) or phenytoin (Dilantin) 20 mg/kg or alternatively valproic acid (Depakote) or levetiracetam (keppra) -> if still seizing intubate and start continuous midazolam or propofol infusion -> if still seizing pentobarbital induced coma
100
The most common cause of intracerebral hemorrhagic stroke is?
Answer: What is hypertension? KEY POINTS: For all causes of ICH, can use mnemonic MID HAITI DVT. M = Moya Moya (a genetic syndrome seen in mostly Asians, “puff of smoke” due to appearance of tiny collateral vessels seen surrounding a severely narrowed proximal large vessel intracranial vessel, these tiny brittle vessels can rupture and cause hemorrhage of can cause ischemia), I = inflammation (vasculitis), D = Dissection of a vessel, H = hypertension, A = amyloid angiopathy (causes lobar ICH), I = ischemia (hemorrhagic conversion), T = trauma, I = infection (such as HSV), D = drugs, blood dyscrasias such as sickle cell, V = vascular malformation such as cavernoma, AVM, as venous such as cerebral venous thrombosis, T = tumor (especially metastatic such as melanoma, lung, breast, choriocarcinoma, papillary carcimoa of thyroid). Hypertension cause lipohyalinosis of small vessels, causing hardening and stiffness, which can lead to ischemia or hemorrhage.
100
This Cranial Nerve has four unique features: 1. Only CN that exits the brainstem on the dorsal aspect. 2. Only CN that crosses 3. Longest Intracranial course 4. Lesions that affect it causes head tilt toward the contralateral side (away from the affected eye).
Answer: What is CN IV: The Trochlear Nerve?
100
This disorder involves abnormal production of autoantibodies to nicotinic acetylcholine receptors.
Answer: What is myasthenia gravis? KEY POINTS: Thymus gland of MG patients is almost always abnormal. Under age 40: Women >>> men. Age 50-70: Men>women. Cardinal features: 1) Weakness varies from day to day; 2) Ocular muscle weakness. Diplopia, Ptosis; Limb/Neck Weakness: Proximal > distal. 3) Responds to Cholinergic drugs. Daignosed by tensilon/edrophonium test, “Ice-Pack” test: Cooling the eyelids can improve ptosis, and single fiber EMG with repetitive nerve stimulation.
100
What is the difference between gray matter and white matter? No need to answer in form of a question.
Answer: White matter is myelinated; gray matter is not.
200
Name two specific side effects of phenytoin (Dilantin).
Answer: What is 1) Gingival hyperplasia 2) Acne 3) Facial hairs/Increased hair growth 4) Ataxia/Incoordination ? KEY POINTS: Phenytoin is useful for the prevention of tonic-clonic seizures, partial seizures, but not absence seizures (makes it worse!). Phenytoin acts on voltage gated sodium channels and blocks sustained high frequency repetitive firing of action potentials. Blood levels can be measured to determine the proper dose. Phenytoin is an inducer of the CYP3A4 and CYP2C19 families of the P450 enzyme responsible for the liver's degradation of various drugs and is metabolized by the liver (unlike levetiracetam, topiramate, pregabalin and gabapentin).
200
What are the two most common causes of subarachnoid hemorrhage?
Answer: What is trauma and aneurysms? KEY POINTS: Other less common cause can include vasculopathis from cocaine or methamphetamine use, amyloid angiopathy, sickle cell, cerebral venous thrombosis, brain tumors, reversible cerebral vasocontriction syndrome (RCVS), arterial dissection. Clinical presentation = severe thunderclap headache, "worst headache of my life", meningeal signs, seizures. The sensitivity of head CT for detecting SAH is highest in the first 6 to 12 hours after SAH (nearly 100 percent) and then progressively declines over time to about 58 percent at day five. Brain MRI may be as sensitive as head CT for the acute detection of SAH, have a high sensitivity in patients with a subacute presentation of SAH (eg, >4 days from the bleed). If unsure of diagnosis = perform lumbar puncture, look for xanthochromia (signs of hemoglobin degradation products). MRA or CTA or cerebral angiogram is recommended to investigate for causes.
200
This is the abnormality/syndrome seen involving extra-ocular eye movements commonly seen in multiple sclerosis patients who describe “double vision”.
Answer: What is an intranuclear ophthalmoplegia (INO)? KEY POINTS: INO are caused by lesions of the MLF (Medial Longitunal Fasculus), causing a disorder of conjugate lateral gaze in which the affected eye shows impairment of adduction, and the contralateral eye abducts, however with nystagmus. Other clinical manifestations of MS can include “lighting shock” sensations up and down the spine called “Lhermitte’s” sign, Can also get a APD (Afferent Pupillary Defect) = Marcus Gunn Pupil.
200
These headaches can present with horizonal diplopia and peripheral visual field loss. Usually seen in pregnancy or in obesity.
Answer: What is Pseudotumor Cerebri aka idiopathy intracranial hypertension? KEY POINTS: Occurs mostly in premenopausal obese women, associated the Steroids, tetracycline use, and Vitamin A. Papilledema is a hallmark finding. CSF pressures >250 mmH20 (normal 50-180) Rx: Acetazolamide or lasix. Lumboperitoneal shunts reserved for cases refractory to meds.
200
What is the purpose of the gyri and sulci in the brain? No need to answer in form of a question.
Answer: To increase surface area.
300
This antidepressant medication can lower seizure threshold and should be avoided in patients with history of epilepsy.
Answer: What is Bupropion (Wellbutrin, Zyban)? KEY POINTS: One of the most frequently prescribed antidepressants in the United States. Next most common use is as an aid for smoking cessation. In comparison to many other antidepressants, it does not cause as much weight gain or sexual dysfunction. Acts as a norepinephrine-dopamine reuptake inhibitor. The risk of seizure is strongly dose-dependent.
300
What is the term for multi infarct dementia, or dementia caused by multiple strokes?
Answer: What is vascular dementia? KEY POINTS: Two types: Large (infarct or hemorrhage) and small vessel (arteriosclerosis and amyloid angiopathy). Multiple strokes leading to worsening cognitive decline that occurs step by step. The temporal relationship between a stroke and cognitive deficits is needed to make the diagnosis. Alzheimer's dementia often co-occurs with vascular dementia. Currently, there are no medications that have been approved specifically for prevention or treatment of vascular dementia. The use of medications for treatment of Alzheimer's dementia, such as cholinesterase inhibitors has shown small improvement of cognition in vascular dementia. This is most likely due to the drugs' actions on co-existing AD-related pathology.
300
In the flow of CSF, the lateral recesses of the fourth ventricle communicate with the subarachnoid space via these two foramen.
Answer: What is the Foramina of Luschka and Majendi? KEY POINTS: There are several foramina, openings acting as channels, that connect the ventricles. The foramen of Monro connects the lateral to the third, the third to the fourth is via cerebral aqueduct of Sylvius, and fourth to subarachnoid space is median aperture via Magendie, and lateral aperture via Luschka.
300
What is the name of this chronic daily headache disorder which occurs at least 15 days in a month in a patient with primary headache disorder who regularly takes acute headache medications more than 10 days per month?
Answer: What is medication overuse headache? KEY POINTS: These patients will have a history of analgesic use more than two to three days per week in a patient with chronic headaches. Most commonly occurs in people with primary headache disorders like migraine, cluster, or tension-type headaches using less effective or nonspecific medications resulting in inadequate treatment response and redosing. Unfortunately if long term headaches can become refractory to both pharmacological and non-pharmacological prophylactic medications, and also reduces the efficacy of acute abortive therapy for migraines. Best way to treat = discontinuation of the medication that is overused and a combination of pharmacological, non-pharmacological, behavioral and physical therapy interventions.
300
Approximately how many in the millions are there pain receptors are in the brain?
Answer: 0. KEY POINTS: The brain lacks nociceptors. This feature explains why neurosurgeons can operate on brain tissue without causing a patient discomfort, and, in some cases, can even perform surgery while the patient is awake. The meninges (coverings around the brain), periosteum (coverings on the bones), and the scalp all have pain receptors however. Chemicals released from blood vessels near the dura and pia can activate nociceptors, resulting in headaches and migraines.
400
Sometimes referred to as a petit mal seizures (from the French for “little illness”), this seizure syndrome has a particular rhythm on EEG. What is: 1) the name of the syndrome, 2) the EEG pattern, 3) first line medication? (MUST KNOW ALL THREE)
Answer: What is 1) absence seizure, 2) 3 Hz generalized spike-and-wave, 3) Ethoxusamide or valproic acid (depakote)? KEY POINTS: Hallmark of the absence seizures is abrupt and sudden-onset impairment of consciousness, interruption of ongoing activities, a blank stare, possibly a brief upward rotation of the eyes or with automatisms (Purposeful or quasipurposeful movements occurring in the absence of awareness, such as lip licking and swallowing). Easily induced by hyperventilation in more than 90% of people with typical absences (reason why we ask patients to hyperventilate as part of an EEG). T-type Ca++ channels are believed to be involved, which ethosumaxide targets.
400
In patients with stroke (ischemic or hemorrhagic) this IVF should be avoided.
Answer: What is D 5 (dextrose) containing fluids? KEY POINTS: Persistent hyperglycemia ( >140) is associated with poor outcome in patients with both ischemic or hemorrhagic stroke.
400
A relatively rare form of aphasia characterized by intact auditory comprehension, speech production, but poor speech repetition.
Answer: What is conduction aphasia? KEY POINTS: Typical lesion is damage to the arcuate fasciculus in the supramarginal gyrus of the parietal lobe, which causes a disconnection between the brain areas responsible for speech comprehension (Wernicke's area) and speech production (Broca's area). Common aphasias: Fluent/sensory/Wernicke’s= poor comprehension, Non-fluent/motor/Broca’s = poor fluency, Anomic = word finding difficulty, cannot name, Transcortical Sensory = Like Wernicke’s but with intact repetition involving areas adjacent to the inferior left temporal lobe of the brain but sparing the arcuate fasciculus, Transcortical Motor = Like Broca’s but with intact repetition involving surrounding areas of left superior frontal lobe, Global/Mixed = Both Broca’s + Wernicke’s.
400
This type of dementia is associated with progressive non fluent aphasia, behavior and personality change.
What is fronto-temporal dementia? KEY POINTS: Characterized by atrophy in the frontal lobe and temporal lobe of the brain. Mutations in the Tau gene are involved. Diagnosed by (MRI) and positron emission tomography (PET) scan. There is no cure for FTD. Treatments are available to manage the behavioral symptoms.
400
Which part of the brain is named because of its resemblance to a seahorse and is involved in memory?
Answer: Hippocampus. KEY POINTS: from the Greek, from hippos, for "horse" and kampos, "sea monster". Structure elevating from the floor of each lateral ventricle in the region of the inferior or temporal horn. Involve in memory and inhibition response. Involved in transient global amnesia (dramatic, sudden, temporary, near-total loss of short-term memory lasting < 24 hours).
500
Juvenile myoclonic epilepsy (JME) usually starts in adolescence and requires lifelong treatment. Which is first line drug?
Answer: What is Lamotrigine or Valproic acid? KEY POINTS: JME is a an inherited genetic syndrome, typically first manifests itself between the ages of 12 and 18 with brief episodes of involuntary muscle twitching (myoclonic jerks) occurring early in the morning, and can generalize into absence or generalized tonic-clonic seizures. Usually provoked by sleep deprivation, alcohol or exposure to flickering lights (reason why we use flickering lights as part of an EEG test).
500
This stroke syndrome involves ipsilateral cerebellar ataxia, Horner’s syndrome, vertigo, dysphagia, dysarthria, hiccups, ipsilateral face and contralateral arm/leg hemianesthesia.
Answer: What is Wallenberg’s syndrome (lateral medullary syndrome)? KEY POINTS: Caused by infarction of posterior inferior cerebellar artery (PICA), causing injury to the lateral part of the medulla in the brain. Dysfunction in: vestibular nuclei (causing vertigo and nystagmus), inferior cerebellar peduncle (causing ataxia), lateral spinothalamic tract (causing contralateral deficits in pain and temperature), spinal trigeminal nucleus (causing ipsilateral loss of pain, and temperature sensation from face), descending sympathetic fibers (causing Horner’s)
500
This Disease is defined by MRI-T2 evidence of “finger-like” extensions along the blood vessels called “Dawson’s Fingers”.
Answer: What is Multiple Sclerosis? KEY POINTS: Most common autoimmune disorder affecting the central nervous system. A demyelinating disease. Cause is not clear, the underlying mechanism is thought to be either destruction by the immune system or failure of the myelin-producing cells. Proposed causes include genetic, environmental, viral. More common in people who live farther from the equator (lack of vitamin D?). Can have almost any neurological symptom or sign. Diagnosis by McDonalds criteria, dissemination in time and space.
500
This syndrome named after a German neurologist involves the dominant parietal lobe and presents with 4 distinct clinical signs and symptoms: finger agnosia, acalculia, right to left confusion, and alexia with agraphia.
Answer: What is Gerstmann’s Syndrome? KEY POINTS: Caused by a lesion, usually stroke, in the dominant (usually left) angular and supramarginal gyri near the temporal and parietal lobe junction, causes finger agnosia (Impaired ability to recognize fingers), left-right disorientation, dyscalculia/acalculia: difficulty in learning or comprehending mathematics, alexia: inability to read, agraphia: inability to write.
500
This disease entered the public eye in 2014 when its fundraising campaign the Ice Bucket Challenge went viral.
Answer: What is amyotrophic lateral sclerosis or Lou Gehrig's Disease? KEY POINTS: Characterized by stiff muscles, muscle twitching, and gradually worsening weakness due to muscles decreasing in size. Results in difficulty in speaking, swallowing, and eventually breathing. Cause is not known in 90% to 95% of cases. About 5–10% of cases are inherited from a person's parents (A defect on chromosome 21, which codes for superoxide dismutase is involved). No cure for ALS is known. A medication called Riluzole may extend life by about two to three months. Non-invasive ventilation may result in both improved quality and length of life. The disease usually starts around the age of 60 and in inherited cases around the age of 50. The average survival from onset to death is two to four years.[8] About 10% survive longer than 10 years. Most die from respiratory failure.
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