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Board Review: Neurology

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Board Review: Neurology Matthew Volk 6/11/2010 Primary CNS Lymphoma Presentation: confusion, lethargy, memory loss, focal neuro signs, and/or seizures Solitary or ... – PowerPoint PPT presentation

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Title: Board Review: Neurology


1
Board Review Neurology
  • Matthew Volk
  • 6/11/2010

2
Question 1
3
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

4
Guillain-Barre Syndrome
  • Treatment
  • Supportive care
  • 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

5
A few kinds of weakness
  • Guillaume-Barre (AIDP)
  • Myasthenia Gravis
  • Demyelination
  • Acute after viral infxn
  • Worsens over 2-4 weeks then plateaus, resolves
  • Proximal limbs first
  • Absent reflexes
  • Can include sensory
  • NMJ dysfunction
  • Chronic and progressive
  • Worsens with exertion, late in the day
  • Oculomotor first
  • Normal reflexes
  • Sensory not involved

6
A few kinds of weakness
  • ALS chronic progressive, ocular muscle sparing,
    hyperreflexia and spasticity (UMN disease)
  • Lambert Eaton chronic but can resolve if
    malignancy-related, improves with exercise

7
What does this patient have?
  • 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.

8
Question 2
9
Question 2
10
Acute Ischemic Stroke
  • Inclusion criteria for tPA
  • Age gt18 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 gt 185/110

11
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

12
Acute Ischemic Stroke
  • More on Blood Pressure control
  • Hypertension protective unless extreme
  • Many would not treat unless gt220 systolic
  • EXCEPT treat to goal 140-150 with MI, aortic
    dissection, hemorrhagic conversion
  • Recommended agents
  • Nicardipine, labetalol, nitroprusside

13
Question 3
14
Parkinsonism
  • Drug-induced Parkinsonism
  • Antiemetics, Antipsychotics, CCBs
  • Reversible with removal of offending agent
  • Neurodegenerative processes
  • Progressive Supranuclear Palsy
  • Multiple System Atrophy
  • Corticobasal Degeneration
  • Huntingtons Disease

15
Parkinsonism
  • Essential Tremor
  • Restless Leg Syndrome
  • Focal/generalized dystonias
  • Cervical dystonia
  • Blepharospasm
  • Oromandibular dystonia
  • Spasmotic dysphonia
  • Ideopathic Parkinsons Disease

16
Parkinsons 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

17
Normal Pressure Hydrocephalus
  • Gait Impairment
  • Cognitive Decline
  • Urinary Incontinence

18
Some Dementias
  • Frontotemporal Dementia
  • Impaired executive function
  • Preserved visual-spatial function
  • Lewy Body Dementia
  • Visual hallucinations
  • Fluctuating cognition
  • Parkinsonism

19
Question 4
20
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

21
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

22
Question 5
23
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

24
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

25
Distinguishing Headaches
  • Migraine/Cluster versus Tension
  • Cause disability versus able to work through them
  • Migraine versus Cluster
  • Stay still versus pace and even strike head
  • gt4 hours versus lt3 hours

26
Question 6
27
Question 7
28
Epilepsy
  • Two or more unprovoked seizures
  • Etiologies unknown (ideopathic) or focal abn
    (symptomatic)
  • Vascular malformation
  • Tumor
  • Restricted scar
  • Focal cortical dysgenesis

29
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.

30
Epilepsy Treatment
  • Choice of medication
  • Absence Ethosuximide
  • GTC Phenytoin, Carbamazepine, Phenobarbital,
    Valproate
  • Partial Gabapentin, Lamotrigine, topiramate,
    oxcarbazepine
  • Cognitive impairment Phenobarb, Phenytoin,
    Carbamazepine, Topiramate

31
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

32
Question 8
33
Question 8
34
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

35
Toxoplasmic Encephalitis
  • Similar presentation to PCNSL
  • Diagnostic criteria
  • Seropositive for Toxo IgG antibody
  • CD4 lt 100 and not getting prophy
  • Multiple ring-enhancing lesions on MRI
  • If all three present 90 likelihood
  • Presumptive pyrimethamine/sulfadiazine
  • Otherwise brain biopsy recommended.

36
Question 9
37
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

38
Question 10
39
Question 10
40
Question 10
41
Question 10
42
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

43
Viral Encephalitis
  • CSF Findings
  • Elevated protein but lt150 mg/dl
  • Normal glucose
  • Elevated WBC count but lt250/mm3
  • No red cells except in HSV

44
References
  • MKSAP 14 Neurology
  • MKSAP 14 Infectious Disease
  • Uptodate Online
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