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Neuro USMLE

QuestionAnswer
CN I innervates? Syndrome to look for and its cause? smell; Kallman's syndrome=anosmia and hypogonadism due to gonadotropin rel hormone defic
CN8 innerv? Defic causes? (vestibulocochlear nerve) for hearing and balance; defic: deafness, tinnitus, vertigo
CN9 innerv? Defic causes? (glossopharyngeal) pharyngeal mscles, afferent gag reflex, parotid, taste in P 1/3 tongue, skin external ear; defic: loss of gag and loss of taste P 1/3 tongue
CN10 innerv? Defic? (vagus) palate, pharynx, larynx, abd viscera, skin of ext ear; defic: hoarseness, dysphagia, loss of gag or cough
CN 11 innerv? Defic? (spinal access nerve) sternocleidomastoid, trapezius; defic: can't turn head to side opp to lesion, shoulder droop
CN 12 innerv? Defic? (hypoglossal) innervates tongue; defic: tongue on protrusion deviates ipsi
name 3 spinal tracts and their fxns corticospinal=mvmt contra limbs, dorsal column=tactile, vibration, sensation; spinothalamic=pain, temp
CNV innervates (aka trigeminal nerve) mastication and facial sensation, afferent limb corneal reflex
characteristics trigeminal neuralgia, treatment, rule out other diagnoses (CN V) unilateral shooting pains in face, incl w brushing teeth, tx: carbamazepine [could be MS, or if bilateral could be stroke]
CN3 fxn eye mvmt, pupil constriction, accomodation, eyelid open
CN4 fxn eye mvmt
pneumonic for which CN are sensory, motor Some say marry money but my brother says big brains matter most
pneumonic for eye mvmt mscls innerv LR6SO4R3-lateral rectus=VI, superior oblique=IV, rest=III
how differentiate CNIII, IV, V, VI, and VII problems wrt to eye exam III: eye is down and out and can only move laterally, IV: can't look down when medial, V/VII: blink reflex, VI: can't look lateral
nerves involved in pupillary reflex; 2 types of reflexes CN II to sense light, III to constrict pupil; direct reflex if light was in that eye, consensual reflex if light was in other eye
nerves involved in blink reflex ophthalmic branch (V1) of CN V to feel stimulus, CNVII to close eyelid
if L optic n damaged, what see on pupillary reflex stimulating L eye causes no response in either eye, stimulating R causes both to respond
if L occulomotor n damaged, what see on pupillary reflex stimulating L eye causes R to respond, stimulating R eye causes R to respond
characteristics CN7 UMN? LMN? MC cause for each? UMN=contralateral lower facial paralysis **forehead is spared, usu cause is stroke; LMN=ipsi upper and lower facial paralysis, **forehead is involved on affected side, usu due to Bell's palsy or tumor
Bell's palsy-- how can be difft from CNVII LMN? Causes? can also have hyperacusis (noises loud) bc stapedius muscle is paralyzed; MC causes: AIDs, Lyme, sarcoid, tumor, DM
how difft UMN from LMN UMN have incrsd tone, spastic, and DTR (although initially may be decrsd for ea) + Babinski's; LMN has decrsd tone, flaccid and DTR, atrophy, fasciculations
nerve for ea DTR achilles=S1,2; knee=L3,4; biceps=C5,6; triceps=C7,8 [just count up]
what number cause of death is stroke? % isch v hemorrh number3, 85% isch
how define TIA; usu cause/type neuro deficit for <24hrs, (usu <30min). Usu embolic and high risk of stroke in next mos.
characteristics of carotid stroke/TIA loss speech, paralysis/paresthesia/clumsy contra extremity; can have amaurosis fugax (chol emboli to retinal/ophthalmic artery causes ipsi vision loss)
define amaurosis fugax chol emboli to retinal/ophthalmic artery causes ipsi vision loss
characteristics of vertebrobasilar stroke/TIA dizziness, dbl vision, vertigo, numb ipsi face & contra limb, dysarthria, hoarseness, dysphagia, HA, projectile vomitting, drop attacks
what paradoxial stroke venous clot goes through ASD/VSD/PFO and into head
4 causes/types stroke/TIA embolic (MC, usu from heart), thrombotic (usu atheroscl), lacunar (small vessels), non vascular (anoxic injury, low CO)
describe subclavian steal and sympt stenosis of subclavian before vertebral, so retrograde down vertebral artery to back fill subclavian; BP less in that arm and claudication when exercise that arm
causes of stroke in younger pts OCP, preg, hypercoag (prot C, S), cocaine, amphet, polycythemia, SC
risk factors for stroke, which most impt Age, HTN most impt; smoking, DM, hyperlipid, A Fib, CAD, prev stroke, Fm Hx, carotid bruits
MC embolic stroke site MCA
sympt MCA stroke aphasia (if L (dominant)), neglect/apraxia/confusion (if R), contra paresis face and arm, gaze twd lesion, homo hemianopia
stroke a cerebral artery causes contra paresis and sensory loss in leg (incl foot drop, gait dysfunction), amnesia, personality changes, cognitive changes [this artery also supplies frontal lobes]
stroke posterior cerebral artery causes homo hemianopia, memory deficits, dyslexia/alexia
stroke basilar artery coma, locked in syndrome, CN palsies, apnea, visual symptoms, dysphagia, dysarthia, drop attacks, **crossed weakness/sensory affecting ipsi face and contra body
MC site circle of willis aneur anterior communicating
anterior communicating artery aneur sympt bitemp hemianopsia + frontal lobe
posterior communicating artery aneur sympt CNIII (often see first impaired pupillary light reflex, unlike isch CNIII where that is spared until late]
cerebral v subcortical strokes cerebral: contra motor or sensory face, arms, trunk not usu legs (interhemisph), aphasia if L, visual/spatial more if R; subcortical: hemiparesis is complete (tracks all run together thru internal capsule)
key plegias from brainstem crossed, ipsi face, contra body
how to differentiate peripheral neuropathy from myopathy peripheral neuro: usu asymm, weakness more distal, can have sensory; myopathy: symm w weakness prox>distal, nml sensation
how difft NMJ v peripheral neuro or myopathy NMJ: fatigability, nml sensation
general features of spinal cord injury, that are unique to these lesions decrsd sensation below a sharp band
general features of radiculopathy pain! Affects muscles supplied by that root (myotome), and sensory area supplied by that root (dermatome) Weakness, atrophy, sensory deficit in a dermatomal pattern
general features Cb lesion incoord, intention tremor, ataxia
general features of brainstem lesion cranial nerve and spinal cord findings; ipsi face and contra body hemiplegia
fxn radial nerve lesion no supination, no extension (radial is SUPER), w wrist drop, sensation back hand finger 1-3
fxn ulnar nerve lesion can't cross fingers or V sign, sensation 1/2 of ring finger and pinkie
fxn median nerve lesion can't flex fingers of wrist, thenar eminence atrophied (ie carpal tunnel), sensation 2,3,1/2 of ring from underside to nails, loss pronation. Thumb's up, all's ok when you flex yr nail polish w carpal tunnel
axillary n lesion innerv deltoid, can't abduct to horiz
long thoracic n injury (metastetcomy) serratus anterior, winged scapula, can't abduct past horiz
common peroneal n lesion foot drop, anterolateral sensation leg
femoral n lesion paralysis of quad, can't extend leg and loss of knee jerk, sensation anterior thigh
upper brachial plexus lesion Erbs palsy, arm by side, rotated inward, waiter's tip. Can't abduct arm, felx elbow or supinate
lower brachial plexus lesion Klumpke, median/ulnar n; clawed hand and Horners
fxn of interosseus palmar adduct, dorsal abduct PAD DAB
how long might it take for isch stroke to show by non contrast CT 24-48hrs
what order if present s/s acute stroke non contrast CT, ECG, CXR, CBC, PT/PTT, Lytes, Glu, caortid U/S, Echo
when to tx acute stroke w tPA <3hrs no contraindications, incl: prior hemorrh stroke, sz w onset stroke, stroke or head trauma w/in 3mos, HTN BP>185/110, BG<50 or >400, age <18, bleeding (GI, urinary <21d), plt <100K, INR>1.7 or elev PTT, surg<14d, recent MI, think TIA (rapid improve)
tx of acute stroke other than maybe tPA 1) ASA (don't give if tPA), 2) tx HTN only if >220/110, 3) treat F, hyperglu
once give tPA what must control BP <185/110
longterm tx s/p stroke ASA if sm vessel dz, manage risk factors (HTN most impt, also DM, hyperlipid, etc), carotid endartectomy if nec
epidural bleed: describe clinical present and anatomy (where blood is, how appears on imaging) lucid interval, often temporal bone fx m. meningeal artery; biconvex blood bw dura and skull
subarachnoid hemorr: describe clinical present and anatomy (where blood is, how appears on imaging) worst headache, ruptured berry aneurysm (MC A. commun artery, blood in CSF, blood bw pia and arachnoid)
subdural bleed: describe clinical present and anatomy (where blood is, how appears on imaging) elderly pts, EtOH, may not remember fall, bridging veins, blood bw dura and arachnoid, crescent moon shaped on imaging
order of compartments for cranial bleeds moving from brain surface outwards pia-[subarachnoid space]-arachnoid-[subdural space]-dura-[epidural space]-skull
clinical signs transtentorial (central) herniation bilateral small and reactive pupils, Cheyne-Stokes respirations, flexor or extensor posturing
clinical signs uncal herniation CNIII gets entrapped, fixed and dilated ipsilateral pupil [from mass in middle fossa]
clinical signs cerebellar tonsillar herniation compression medulla, respiratory arrest, usu rapidly fatal [from mass in posterior fossa]
describe Cushing triad from incrsd ICP: HTN, bradycardia, repir irreg
cerebral perfusion is determined by MAP-ICP (nml ICP 5-15)
MC location intracranial hemorrh BG (66%), then Pons and Cb ea 10%
key clinical factors suggesting intracranial hemorrh focal neuro deficit that WORSENS over next 30-90min, AMS, signs incrsd ICP
how pupils help differentiate place of intracranial hemorrh pin point=pons, poorly reactive=thal, dilated=putamen
tx intracranial hemorrh (after CT confirms) control BP if >16-180/105, but slowly, if elevated ICP give mannitol and diuretics…surgery maybe for Cb hematomas, otherwise no
if CT in suspected SAH is negative, what do LP, diagnostic if xanthochromic (yellow CSF) bc means RBC have been there for a while (v traumatic tap)
once SAH diagnosed, what do cerebral angiography and call neurosurg; quiet rest in dark room w head elevated and stool softeners, nifedipine for vasospasm, control HTN
name 5 key adult brain tumors glioblastoma (type IV astrocytoma), meningioma, schwannoma, oligodendroglioma, pit adenoma
name 5 key pediatric brain tumors pilocytic atrocytoma, medulloblastoma, ependymoma, hemangioblastoma, craniophrangioma
name where ea of 5 pediatric tumors occur: pilocytic atrocytoma, medulloblastoma, ependymoma, hemangioblastoma, craniophrangioma pilocytic atrocytoma=P fossa, medulloblastoma=Cb, ependymoma=4th ventricle, hemangioblastoma=Cb, craniophrangioma=supratentorial
what are the 3 MC primary adult brain tumors, in order 1) glioblastoma, 2) meningioma, 3) schwannoma
which primary brain tumor is found in the cerebral hemispheres and can cross the corpus callosum glioblastoma
majority of adult primary brain tumors are supra or infratentorial? Pediatric? adult are usu supratentorial, pediatric are infratentorial
what brain tumors suspect for hydrocephalus in kids ependymoma (4th ventricle), medulloblastoma (Cb but can compress 4th v)
what brain tumor assoc w von Hippel Lindau hemangioblastoma in Cb
what brain tumor can cause bitemporal hemianopia (so confused w pituitary adenoma) craniopharyngioma (benign childhood tumor, MC childhood supratentorial tumor)
supratentorial tumor in kid--think what? Benign or malignant? craniopharyngioma, benign
diffusely infiltrating brain tumor in P fossa in child, dx? Benign or malignant? pilocytic astrocytoma, benign
MC primary CNS neoplasm, characteristics astrocytoma (ie glioblastoma), arise IN cerebral hemispheres, infiltrate brain w indistinct boundaries and can cross corpus callosum
besides astrocytomas, what cancers appear in parenchyma? mets (50%)-in order of freq: Lung, breast, melanoma, kidney, GI
differential for ring enhancing lesion met, brain abscess, glioblastoma multiform, lymphoma, toxo
name 2 extraparenchymal brain tumors meningioma, scwhannoma
are schwannomas unliateral or bilateral? Assoc? always unilateral, if bilateral then its NF II
describe population that get meningiomas usu 40-50, females >2x than males
how do meningiomas appear on imaging extracerebral, rounded w well-defined dural bases that compress underlying brain
schwannomas--malignant or benign? benign (no malignant potl)
where schwannoma arise? Presenting symptom? cerebellopontine angle, involved 8th cranial; first present w hearing loss (+/- tinnitus, loss of balance, nystagmus)
schwannoma and meningioma--surg excision? yes, although meningiomas have high recurrence rate
calcified lesion external to brain parenchyma in adult--think what? meningioma
4 types of MS 1)clinically silent/stable/benign (may progress late), 2) relapsing and remitting (MC), 3) 2ry progressing (relaps/remit gradually worsens), 4) 1ry progressive
key clinical features MS white matter plaques; scanning speech, intention tremor/INO/incontinence, nystagmus. Also optic neuritis w sudden vision loss
describe INO, where injury is injury medial longitudinal fasculus (MLF), If R MLF is affected and pt looks L, the R eye can't adduct and stays midline while the L abducts and start nystagmus (pt also sees dbl looking L)
tx acute MS attack hi dose IV steroids can shorten but won't alter overall progression dz, most attacks resolve <6wks
disease modifying MS tx INF, can cause flu-like sympt. Only use cyclophosphamide and other non specific immunomodulators in rapidly progressive bc many SE
Rx for mscl spasticity in MS baclofen (deriv of GABA)
neurpathic pain tx carbamazepine (Na channel) or gabapentin (neurontin, GABA analog)
describe Guillan Barre clinical progression infxn (often URI) or immun 1 wk before, symmetric distal weakness starts in legs w loss DTR **sensation intact, ascending paralysis, watch for respir paralysis (use spirometry to monitor)
treatment Guillan Barre usu stops spontaneously, plasmaphoresis reduces severity and length **don't give steroids, could make it worse!
mech MG autoantibodies Ach R at NMJ
key characteristics MG clinically mscl fatigue, esp extraocular, often asymm prox mscl wknss at end of day
compare Lambert-Eatn Myasthenic syn to MG Lambert-Eaton is often w SCLC, Ab to Ca++, sympt get better with use
test for MG 1) auto Ab (20% neg), 2) edrophonium (Tensilon, anticholinesterase) improves sympt
what extra diagnostic need MG CT to evaluate thymoma (10-15% on scan), but histol abnl ~75%
tx MG longterm pyridostigmine, steroids if not responding
vit B12 and Friedrich ataxia damages which neural tracts, signs on exam? demyelin of dorsal columns, corticospinal, and spinoCb; ataxic gait, hyperreflexia, impaired position/vibration sense
describe Friedrich's ataxia (genes, pathophys, clinical) AR triple repeat expansion dz of mitochondria; leads to demyelin of dorsal columns, corticospinal, and spinoCb; ataxic gait, hyperreflexia, impaired position/vibration sense
describe syringomyelia (pathophys and clinical) (basically a cyst of CSF) crossing fibers of [spinothal tract I think] are damaged; leads to bilateral loss of pain and temp sensation in shoulders (capelike distrib), +/- muscle atrophy hands
what leads to destruction of anterior horns spinal column? Cause? Symptoms? polio and werdnig-Hoffman; flaccid paralysis (LMN)
occlusion ventral spinal artiery causes what? Clinical? damages everything except dorsal columns, so only have tactile, vibration, sensation
3 syphillis, aka? Damages? tabes dorsalis damages dorsal roots and columns; impaired propioception and locomotor ataxia
symptoms of ALS (amyotrophic lateral sclerosis=Lou Gehrigs)? asymmetric, progressive weakness, UMN and LMN signs (spasticity, hyperreflex, + Babinski AND fascicul, atrophy, flaccidity); treatment is supportive
pyramidal tract aka corticospinal=mvmt contra limbs
Pseudotumor cerebri-describe what it is and how it presents incrsd ICP papilledema, daily headaches worse in am +/- N/V; young obese women
Pseudotumor cerebri-describe how diagnose and treat CT, MRI negative; concern about vision loss; treatment supportive w wgt loss and lumbar puncture or CSF shunt
Pseudotumor cerebri-potl causes large doses vit A, tetracyclines, wdrawal from corticosteroids can cause
differentiate resting tremor, intention tremor, and hemiballsimus as to causes hemiballismus (involuntary, unilateral flailing limbs) from subthalamic nucleus, intention tremor due to Cerebellar dz, resting tremor due to basal ganglia
Brown-Sequard syndrome--distrib of lesion and clinical findings hemisection of spinal cord; contra pain and temp, ipsi hemiparesis and ipsi loss of position/vibration (dorsal columns)
what Rx may help extend life ALS rituzole (glutamine blocking agent)
2 main types of sz, which more common partial (70%), generalized
subtypes of partial sz 1) partial; simple partial (consciousness intact), complex=LOC, postictal, may have automatisms, olfactory or gustatory halluc
subtypes of generalized sz tonic-clonic, absence (45% of these can have minor clonic, ie eye blinking)
what's name of paralysis s/p seizure Todd's paralysis, can last hrs-days
tx generalized tonic clonic or partial sz phenytoin and carbamzepine
tx for absence sz ethosuximide and valproate
describe Rinne test vibrating tuning fork on mastoid until they can’t hear it, then move to outside ear—they should be able to hear (+ test).
describe Weber test tuning fork on forehead, which side is louder
outcomeof Weber/Rinne if conductive loss abnl (-) Rinne (bone conduction>air); Weber louder in affected (think of cotton in yr ear)
outcome Weber, Rinne if sensorineural loss nml (+) Rinne (air >bone conduction); Weber louder in unaffected (good) side
types of Vertigo (4) 1) Peripheral: benign positional, Meniere's, labyrinthitis; 2) central (tumor, CVA, MS)
how test for benign positional vertigo in the office have pt go rapidly from sitting to laying while turning head->should reproduce
describe Meniere's dz and px thgt 2/2 fluid retention, recurrent severe vertigo, tinnitus, hearing loss lasting for hrs to days; recur mos-yrs later and hearing loss eventually permanent
tx Meniere's low Na diet, diuretics, maybe also anti chol and anti His [meclizine]
when pt falls w vertigo, which side do they fall to same side as lesion
dominant lesion in R handed person? L handed? 95% R handed are L dominant, 50% of L handed are L dominant
describe location of lesion and clinical presentation of Wernicke's aphasia Posterior superior temporal gyrus, wordy receptive/sensory/fluent aphasia, use wrong or nonsensical words; they don't comprehend written or spoken language; can't follow commands or repeat
describe location of lesion and clinical presentation of Broca's aphasia expressive/nonfluent broken, short sentences but meaningful. Comprehension intact. Impaired repetition. Posterior inferior frontal gyrus
describe conduction aphasia can't repeat bc no cxn bw Broca's and Wernicke's
defect causing L homo hemianopia w macula sparing R visual cortex
defect causing L homo hemianopsia R optic tract
defect causing L upper quad anopsia R optic radiations in R temporal lobe
defect causing L lower quad anopsia R optic radiations in R parietal lobe
defect causing L homo hemianopsia w macular sparing R occipital lobe, from P cerebral artery occlusion
lesion causing bitemporal hemianopsia optic chiasm (usu pit tumor)
define difft types of glaucoma, general features open angle (90%): painless, incrsd intraocular P 20-30mmHg, progressive visual field loss, incsrd cup-to-disk on fundo exam; closed-angle: sudden ocular pain, see halos around light, intraocular P >30, N/V, sudden decrsd vision, fixed, mid-dilated pupil
tx closed angle glaucoma pilocarpine, oral glycerin and/or acetazolamide
tx open angle glaucoma can include b-blockers, a agonist, prostaglandins (latanoprost), acetazolamide
types of macular degeneration exudative wet=neovascular w sudden vision loss; atrophic/non exudative/ dry (90%)=yellow-white dposits drusen
findings on fundo exam: cotton wool HTN
findings on fundo exam: dot blot hemorr DM
findings on fundo exam: neo vascul DM
findings on fundo exam: pale fundus, cherry spot central retinal artery occlusion
findings on fundo exam: tortorous retinal veins retinal vein occlusion
findings on fundo exam: focal yellow-white deposits macula drusen (macula degeneration)
findings on fundo exam: incrsd cup to disk ratio glaucoma
findings on fundo exam: blurred optic disk margins papilledema or papillitis
differentiate fundo changes see with DM, HTN DM: dot-blot hemorrhages, neovasc retina; HTN: ateriolar narrowing and cotton-wool spots and may see papilledema in severe HTN/HTN emergency
common causes blindness in US, infxs causes (3) DM in younger adults, macular degen in >55; river blindness (onch volvulus, a helminth, give ivermectin), chl trachomatis, toxo carnis (if granuloma)
what's river blindness? What's the treatment river blindness (onch volvulus, a helminth, give ivermectin),
how recognize central retinal artery occlusion? Tx? Assoc? sudden, painless, unilateral loss of vision; most common due to emboli (carotid, heart), but also temporal arteritis; no tx exc temporal arteritis give corticosteroids
3 causes of sudden, unilateral vision loss, painless 1) central artery occlusion (pale fundus, cherry red spot), 2) central vein occlusion (distended retinal veins, retinal hemorrhages), 3) retinal detach (pt reports floaters, flashes of light, curtain coming down)
describe Sturge Weber neurocutaneous dz; SKIN: congenital port wine stain (hemangioma), NEURO: leptomeningeal angio, glaucoma, sz, hemiparesis, MR
describe tuberous sclerosis neurocutaneous dz; hamartomas in skin, CNS, organs; astrocytoma, MR, sz **facial lesions with ash leaf spots, shagreen patches (thickened skin)
describe neurofibromatosis neurocutaneous dz; café au lait, axillary freckling, Lisch nodule (iris), neurofibromas in skin, neural tumors (meningiomas, acoustic neuromas), optic path glioma, Pheorenovascular HTN, scoliosis, sz
NF1 v NF2 NF1:café au lait, Lisch nodule (iris), gliomas, meningiomas, pheo, scoliosis; NF2: bilateral acoustic neuroma, juvenile cataracts (Step 1 pdf)
von Hippel Lindau neurocutaneous dz; **renal cell carcinoma, hemangioblastoma cerebellum, retinal angiomas, cysts in kidney and liver, pheochromocytomas, polycythemia,
name 4 neurocutaneous dzs Sturge Weber, tuberous sclerosis, NF, von Hippel Lindau
NF2? Chromosome? Gene? bilateral acoustic scwhannoma, juvenile cataracts; chrom 22, gene NF2
Lisch nodules are charact of? (found in iris) Neurofibromatosis
NF1 aka? Chromosome? von Recklinghausen's disease=NF type 1; chrom 17
café au lait spots with normal IQ? With MR? with anemia? nml IQ:NF; MR: McCUne Albright or tuberous sclerosis; anemia: Fanconi's anemia
which neurocut has hamartomas (incl skin)? skin hemangioma? Skin neurofibromas? hamartomas: tuberous sclerosis; skin hemangiomas: Sturge Weber and von Hippel-Lindau; skin neurofibroma: NF
which neurocut has MR? tuberous sclerosis, Sturge Weber
describe corticospinal tract path and where decussates Start in motor cortex, cross over in medulla, become LMN in anterior horn of spinal cord at that level.
describe dorsal/posterior column tract path and where decussates Start in mscl spindles, golgi tendon organs, Pacini&Meissner’s disks, signal through dorsal root ganglion up fasciculus gracilus and cuneatus (upper body), cross in medulla
describe spinothal tract path and where decussates Afferent/ascending. Start free nerve endings, pain fibers, cross at level of spinal cord (anterior/ventral white commissure), then go the length of the spinal cord to thalamus.
Created by: ehstephns on 2010-12-05



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