Board Review: Neurology Matthew Volk 6/5/2009. MKSAP Question #1.
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Board Review: Neurology
Matthew Volk6/5/2009
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MKSAP Question #1
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Guillain-Barre Syndrome
Immune-mediated, demyelinating polyneuropathy Proximal and distal weakness – including
respiratory failure; Distal sensory loss Autonomic and cranial nerve
involvement Most cases triggered by infxn,
surgery, or immunization CMV, EBV, HIV, Hepatitis, Lyme,
campylobacter jejuni
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Guillain-Barre Syndrome
Treatment Supportive care
Follow FVC and NIFs Mechanic 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
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MKSAP Question #2
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MKSAP Question #2
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Acute Ischemic Stroke
Inclusion criteria for tPA Age >18 years Clinical diagnosis of ischemic stroke Onset of symptoms within 3 hours of
rx CT without evidence of ICH
Key exclusion criteria Rapidly improving symptoms Persistent BP > 185/110
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Acute Ischemic Stroke 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
Hypothermia not studied in acute stroke Aim for normoglycemia
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Acute Ischemic Stroke
More on Blood Pressure control: Hypertension protective unless
extreme Many would not treat unless >220 systolic EXCEPT treat to goal 140-150 with MI,
aortic dissection, hemorrhagic conversion Recommended agents
Nicardipine, labetalol, nitroprusside
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MKSAP Question #3
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Parkinsonism
Drug-induced Parkinsonism Antiemetics, Antipsychotics, CCBs Reversible with removal of offending
agent Neurodegenerative processes
Progressive Supranuclear Palsy Multiple System Atrophy Corticobasal Degeneration Huntington’s Disease
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Parkinsonism
Essential Tremor Restless Leg Syndrome Focal/generalized dystonias
Cervical dystonia Blepharospasm Oromandibular dystonia Spasmotic dysphonia
Ideopathic Parkinson’s Disease
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Parkinson’s Disease
Symptoms: resting tremor, rigidity, bradykinesia, postural instability
Treatments Levodopa/carbidopa – older patients Dopamine agonists – young patients Amantadine – mainly works with
tremor Anticholinergics – young patients MAO inhibitors – adjunctive therapy
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MKSAP Question #4
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Multiple Sclerosis
Signs and Symptoms – develop over hours to days to years Diplopia or Optic Neuritis Hemiparesis Hemisensory disturbance Band-like sensations around trunk Urinary retention Cognitive decline
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Multiple Sclerosis
Treatment Solumedrol followed by prednisone
taper in acute exacerbations Disease-modifying therapy – for
relapsing-remitting disease Interferon beta (Betaseron, Avonex, Rebif) Glatiramer acetate (MHC interaction)
Combination therapy – for progressive dz
Combine with cyclophos or Mitoxantrone
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MKSAP Question #5
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Migraine Headaches
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
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Migraine Headaches
Treatment NSAIDs – nonspecific; for mild headaches Triptans – direct trigeminal nerve binding;
for moderate to severe headaches Contraindicated in CAD
Ergot derivatives – hospitalized patients Rescue medications – Haldol, lidocaine,
magnesium, dilantin, tizanidine, zyprexa. Opioids can be used occasionally
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MKSAP Question #6
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MKSAP Question #7
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Epilepsy
Two or more unprovoked seizures Etiologies: unknown (ideopathic) or
focal abn (symptomatic) Vascular malformation Tumor Restricted scar Focal cortical dysgenesis
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Epilepsy Treatment
After first seizure – decision to start treatment is individualized
No driving for 6 months to 1 year Risk for recurrence is 30 to 60%.
Abnormal EEG indicates higher risk After second seizure recurrance rate
is 80 to 90%.
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Epilepsy Treatment
Choice of medication Absence – Ethosuximide GTC – Phenytoin, Carbamazepine,
Phenobarbital, Valproate Partial – Gabapentin, Lamotrigine,
topiramaate, oxcarbazepine Cognitive impairment – Phenobarb,
Phenytoin, Carbamazepine, Topiramate
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Status Epilepticus
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
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MKSAP Question #8
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MKSAP Question #8
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Primary CNS Lymphoma Presentation: confusion, lethargy,
memory loss, focal neuro signs, and/or seizures
Solitary or multiple brain masses Diagnostic evaluation
Evaluation for uveitis, retinitis CSF EBV viral load brain biopsy
Treat with MTX and whole brain XRT
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Toxoplasmic Encephalitis
Similar presentation to PCNSL Diagnostic criteria
Seropositive for Toxo IgG antibody CD4 < 100 and not getting prophy Multiple ring-enhancing lesions on MRI
If all three present 90% likelihood Presumptive
pyrimethamine/sulfadiazine Otherwise brain biopsy recommended.
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MKSAP Question #9
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Compressive myelopathy Presentation:
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
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MKSAP Question #10
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MKSAP Question #10
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MKSAP Question #10
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MKSAP Question #10
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Viral Encephalitis Symptoms of encephalitis
AMS – subtle to unresponsive Usually no meningeal signs Seizures common Focal neurologic findings; abn reflexes
CT/MRI Findings VZV, HSV, HHV-6 – temporal lobe West Nile – temporal lobe, basal
ganglia, thalamus, brainstem, cerebellum
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Viral Encephalitis
CSF Findings Elevated protein but <150 mg/dl Normal glucose Elevated WBC count but <250/mm3 No red cells except in HSV
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References
MKSAP 14 – Neurology MKSAP 14 – Infectious Disease Uptodate Online