Transcript Board Review: Neurology

Board Review: Neurology
Matthew Volk
6/11/2010
Question #1
Guillain-Barre Syndrome
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Immune-mediated, demyelinating
polyneuropathy
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Proximal and distal weakness – including
respiratory failure; Distal sensory loss
Autonomic and cranial nerve involvement
Most cases triggered by infxn, surgery,
or immunization
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CMV, EBV, HIV, Hepatitis, Lyme,
campylobacter jejuni
Guillain-Barre Syndrome
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Treatment
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Supportive care
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Follow FVC and NIFs
Mechanical ventilation as needed
IVIg – avoid in CKD, CHF, IgA deficiency
Plasmapheresis – avoid in infxn, low BP
No benefit to combination therapy
Steroids not shown to help
A few kinds of weakness
Guillaume-Barre (AIDP)
 Demyelination
 Acute after viral infxn
 Worsens over 2-4 weeks
then plateaus, resolves
 Proximal limbs first
 Absent reflexes
 Can include sensory
Myasthenia Gravis
 NMJ dysfunction
 Chronic and progressive
 Worsens with exertion,
late in the day
 Oculomotor first
 Normal reflexes
 Sensory not involved
A few kinds of weakness
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ALS – chronic progressive, ocular
muscle sparing, hyperreflexia and
spasticity (UMN disease)
Lambert Eaton – chronic but can
resolve if malignancy-related, improves
with exercise
What does this patient have?
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HPI: 54 y/o F with worsening SOB and
inability to swallow x 2 days. Has had
fatigue, difficulty keeping eyelids open,
intermittent double vision x 1 month.
PE: shows bilateral ptosis, mild proximal
weakness, normal reflexes.
Question #2
Question #2
Acute Ischemic Stroke
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Inclusion criteria for tPA
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Age >18 years
Clinical diagnosis of ischemic stroke
Onset of symptoms within 3 hours of rx
CT without evidence of ICH
Key exclusion criteria
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Rapidly improving symptoms
Persistent BP > 185/110
Acute Ischemic Stroke
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Aspirin to reduce rate of recurrent
stroke; effect within 2 weeks
Subcutaneous heparin to prevent DVT
Airway protection/dysphagia screening
Blood pressure control in certain cases
Maintainence of normothermia
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Hypothermia not studied in acute stroke
Aim for normoglycemia
Acute Ischemic Stroke
More on Blood Pressure control:
 Hypertension protective unless extreme
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Many would not treat unless >220 systolic
EXCEPT treat to goal 140-150 with MI,
aortic dissection, hemorrhagic conversion
Recommended agents
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Nicardipine, labetalol, nitroprusside
Question #3
Parkinsonism
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Drug-induced Parkinsonism
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Antiemetics, Antipsychotics, CCBs
Reversible with removal of offending agent
Neurodegenerative processes
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Progressive Supranuclear Palsy
Multiple System Atrophy
Corticobasal Degeneration
Huntington’s Disease
Parkinsonism
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Essential Tremor
Restless Leg Syndrome
Focal/generalized dystonias
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Cervical dystonia
Blepharospasm
Oromandibular dystonia
Spasmotic dysphonia
Ideopathic Parkinson’s Disease
Parkinson’s Disease
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Symptoms: resting tremor, rigidity,
bradykinesia, postural instability
Treatments
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Levodopa/carbidopa – older patients
Dopamine agonists – young patients
Amantadine – mainly works with tremor
Anticholinergics – young patients
MAO inhibitors – adjunctive therapy
Normal Pressure Hydrocephalus
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Gait Impairment
Cognitive Decline
Urinary Incontinence
Some Dementias
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Frontotemporal Dementia
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Impaired executive function
Preserved visual-spatial function
Lewy Body Dementia
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Visual hallucinations
Fluctuating cognition
Parkinsonism
Question #4
Multiple Sclerosis
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Signs and Symptoms – develop over
hours to days to years
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Diplopia or Optic Neuritis
Hemiparesis
Hemisensory disturbance
Band-like sensations around trunk
Urinary retention
Cognitive decline
Multiple Sclerosis
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Treatment
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Solumedrol followed by prednisone taper in
acute exacerbations
Disease-modifying therapy – for relapsingremitting disease
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Interferon beta (Betaseron, Avonex, Rebif)
Glatiramer acetate (MHC interaction)
Combination therapy – for progressive dz
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Combine with cyclophos or Mitoxantrone
Question #5
Migraine Headaches
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Throbbing pain with photophobia and
phonophobia.
Brainstem involvement results in
nausea, pallor, flushing, tearing,
rhinorrhea, and sinus congestion.
60-70% with prodrome 24 hr prior
15-25% with aura 1 hr prior
Migraine Headaches
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Treatment
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NSAIDs – nonspecific; for mild headaches
Triptans – direct trigeminal nerve binding;
for moderate to severe headaches
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Contraindicated in CAD
Ergot derivatives – hospitalized patients
Rescue medications – Haldol, lidocaine,
magnesium, dilantin, tizanidine, zyprexa.
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Opioids can be used occasionally
Distinguishing Headaches
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Migraine/Cluster versus Tension
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Cause disability versus able to work
through them
Migraine versus Cluster
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Stay still versus pace and even strike head
>4 hours versus <3 hours
Question #6
Question #7
Epilepsy
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Two or more unprovoked seizures
Etiologies: unknown (ideopathic) or
focal abn (symptomatic)
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Vascular malformation
Tumor
Restricted scar
Focal cortical dysgenesis
Epilepsy Treatment
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After first seizure – decision to start
treatment is individualized
No driving for 6 months to 1 year
Risk for recurrence is 30 to 60%.
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Abnormal EEG indicates higher risk
After second seizure recurrance rate is 80
to 90%.
Epilepsy Treatment
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Choice of medication
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Absence – Ethosuximide
GTC – Phenytoin, Carbamazepine,
Phenobarbital, Valproate
Partial – Gabapentin, Lamotrigine,
topiramate, oxcarbazepine
Cognitive impairment – Phenobarb,
Phenytoin, Carbamazepine, Topiramate
Status Epilepticus
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Secure ABCs – including intubation
Ativan 0.1 mg/kg then
Phenytoin/phos-phenytoin 18 mg/kg
Phenobarbitol 15 mg/kg
Pentobarbitol 5-15 mg/kg
Question #8
Question #8
Primary CNS Lymphoma
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Presentation: confusion, lethargy,
memory loss, focal neuro signs, and/or
seizures
Solitary or multiple brain masses
Diagnostic evaluation
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Evaluation for uveitis, retinitis
CSF EBV viral load
brain biopsy
Treat with MTX and whole brain XRT
Toxoplasmic Encephalitis
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Similar presentation to PCNSL
Diagnostic criteria
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Seropositive for Toxo IgG antibody
CD4 < 100 and not getting prophy
Multiple ring-enhancing lesions on MRI
If all three present 90% likelihood
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Presumptive pyrimethamine/sulfadiazine
Otherwise brain biopsy recommended.
Question #9
Compressive myelopathy
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Presentation:
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Initial spinal or radicular pain
Bilateral motor or sensory dysfxn
No brain or brainstem findings
Evaluate with MRI spine
Surgical decompression for epidural
abscess and spondylosis
Steroids and XRT vs. surgery for
epidural tumors
Question #10
Question #10
Question #10
Question #10
Viral Encephalitis
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Symptoms of encephalitis
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AMS – subtle to unresponsive
Usually no meningeal signs
Seizures common
Focal neurologic findings; abn reflexes
CT/MRI Findings
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VZV, HSV, HHV-6 – temporal lobe
West Nile – temporal lobe, basal ganglia,
thalamus, brainstem, cerebellum
Viral Encephalitis
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CSF Findings
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Elevated protein but <150 mg/dl
Normal glucose
Elevated WBC count but <250/mm3
No red cells except in HSV
References
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MKSAP 14 – Neurology
MKSAP 14 – Infectious Disease
Uptodate Online