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Neurology Notes for Boards
Dyanne P. Westerberg, DO
7/24/2015
Neurology Review
Dyanne P. Westerberg, DO FAAFP
Associate Professor and Chair, Department
of Family and Community Medicine
Cooper Medical School of Rowan University
Type
Function
Olfactory
1
S
Smell
Optic
2
S
Sight
Oculomotor
3
M
Medial, superior and inferior rectus , inferior oblique, ciliary muscle,
sphincter muscle of the eye
Trochlear
4
M
Superior Oblique
Trigeminal
5
B
Sensation of face, muscles of mastication
Abducens
6
B
Lateral Rectus
Facial
7
B
Taste ( anterior 2/3 tongue) muscle of facial expression, stapedius
muscle, stylohyoid muscle, digastric muscle, lacrimal, submandibular and
sublingual glands
Vestibulococular
(Auditory)
8
S
Hearing and balance
Glossopharyngeal
9
B
Taste( posterior 2/3 tongue) Pharyngeal sensation, parotid gland,
styrlopharyngeus muscle
Vagus
10
B
Sensation of trachea, esophagus,viscera,laryngeal,pharyngeal muscles,
visceral autonomics
Accessory
11
M
Sternocleidomastoid and trapezius muscle
Hypoglossal
12
M
Tongue
Cranial Nerve
Overview of the CNS arterial supply.
Nolte, John, PhD - Essentials of The Human Brain, 37-42
© 2009 Copyright © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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Lateral ( A ), medial ( B ), and cross-sectional ( C ) views of the hemisphere showing the regions served by the anterior
cerebral ( green ), middle cerebral ( blue ), and posterior cerebral ( pink ) arteries. The distal territories of these vessels
overlap at their peripheries and create border zones. These zones are susceptible to infarcts ( C ) in cases of
hypoperfusion of the vascular bed. Small border zones also exist ( A ) between superior ( green ) and inferior ( blue )
cerebellar arteries.
Haines, D.E.,Lancon, J.A. - Fundamental Neuroscience for Basic and Clinical Applications, 109-123.e1
© 2013 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Headache
• Primary
– Migraine
– Cluster
– Tension
• Secondary
–
–
–
–
–
–
–
–
Hemorrhage
Encephalopathy
Meningitis
Temporal arteritis
Neoplasm
Sinus
Exertional
Trauma
Which headache is the most
common?
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Which headache is the most
common?
Tension accounting for 40%
Migraine
Cluster
Tension
Patient
10 to 30 years
F>M
Young Men
F>M
Types
Without aura
With aura
Precipitating factors
Stress, BCP, menstruation,
exertion, food containing
tyramine or nitrates, chocolate,
cheese, processed meats
ETOH, vasodilators
Stress, fatigue
Associated symptoms
photophobia, visual
abnormalities, aura
Horner’s syndrome,
lacrimation nasal
congestions
Pain radiates to the jaw
and teeth
Anxiety
Duration
4 to 72 hours
30 Min to 3 hours
Variable
Treatment
NSAID, ergots,triptans,
Antiemetics,
prophylaxis: tricyclics, Bblockers
Calcium channel blockers
Ergots, OMT
Also, 100% oxygen
7 L/minute for 15
minutes, OMT
Also relaxation exercises.
OMT
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Characteristics of the headaches
Migraines
Cluster
Tension
Nausea
Photophobia/phonophobia
Increase with activity
P-pulsatile quality
O- onset 4 to 72 hours
U-Unilateral
N- N/V
D- Disabling
Aura- flickering lights, spots
Fully reversible neurological
symptoms
Can be bilateral
Several per day ( 1 to 8)
Between 15 and 180
minutes
Episodes 6 to 12 weeks
Remission for 12 months
Bilateral
Like a tightening band
around the head
Non pulsating
No increase with physical
activity
No N/V
No
Photophobia/Phonophobia
Characteristics of the headaches
Migraines
Cluster
Tension
Nausea
Photophobia/phonophobia
Increase with activity
P-pulsatile quality
O- onset 4 to 72 hours
U-Unilateral
N- N/V
D- Disabling
Aura- flickering lights, spots
Fully reversible neurological
symptoms
Can be bilateral
Several per day ( 1 to 8)
Between 15 and 180
minutes
Episodes 6 to 12 weeks
Remission for 12 months
Bilateral
Like a tightening band
around the head
Non pulsating
No increase with physical
activity
No N/V
No
Photophobia/Phonophobia
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Medical Treatments
Acute
•
Acetaminophen/Aspirin/Caffeine
•
•
•
•
•
•
•
NSAID
Triptans
Antiemetics
Dexamethasone
Ergotamine
Intranasal Lidocaine
Isometheptene
Chronic – First Line
• Propanolol
• Amitriptyline
• Sodium Valproate
• Topiramate
• Divalproex
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Exertional Headache
• Headache after physical activity
•
•
•
•
Running
Coughing
Sexual Intercourse
Bowel Movement
• Evaluation i.e. MRI if
•
•
•
•
•
>40
Vomiting
Prolonged duration
Cardiac evaluation if risk factors
A literature review from the early 1990s, of 219 a structural
lesion was found in 22 percent
Meningitis
• Infection of the covering of brain and spinal
cord- meninges
• Risk Factors: ear infections, sinusitis,
immunocompromise, neurosurgery, maternal
group B infection during childbirth
• H and P: headache, neck pain, photophobia,
nausea, vomiting, confusion, fever, seizure,
Kernig, Brudzinski, rash
Meningitis by Age
Age
Most common
organism
Other organism
Emperic Treatment
Newborn
Group B strep
E.Coli, Listeria
H.influenza
Ampicillin
Cefotaximine
1 m to 2 y
S.pneumonia
N.meningitis
Group B Strep
Listeria, H.influenza
Vancomycin
Ceftriaxone
2-18 y
N.meningitis
S.pneumonia
Listeria
Vancomycin
Ceftriaxone
18 to 50 y
S.pneumonia
N.meningitis
Listeria
Vancomycin
Ceftriaxone
50+y
Altered cellular
immunity
Alcoholic
S. pneumonia
N. Meningitis,
Listeria , gramnegative rods
Vancomycin
Ceftriaxone
Ampicillin
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Viruses
• Viral Meningitis:
– Numerous viruses -Enteroviruses most common
– Nausea, vomiting, headache stiffness
– LP helps in diagnosis, more specific- PCR testing
• Encephalitis:
– Numerous viruses i.e flavivirus- West Nile*
– Headache, vomiting, change in mental status
* Increased incidence since 1999
LP findings
Patient
WBC
Pressure
Glucose
Protein
Healthy
<5
50-180mm
H20
40-70 mg/dl
20-45mg/dl
Bacterial
Increased
Esp. PMN
increased
decreased
increased
viral
Increased
Esp.
Lymphocytes
increased
normal
normal
Fungal or TB
Increased
Esp.
Lymphocytes
Increased
decreased
increased
Prevention
• Vaccines for general population and aspleenic
patients
– Hib Vaccine
– Pneumococcal Vaccine
– Meningococcal Vaccine
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Prevention
• The Advisory Committee on Immunization Practices
(ACIP) today stopped short of recommending routine
use of serogroup B meningococcal vaccine in young
people, instead leaving the decision to doctors and
their patients.
• The committee voted 14-1 for individual choice on use
of the vaccine in adolescents and young adults ages 16
through 23, with 16- to 18-year-olds as the preferred
age-group. The move came in the wake of several
meningitis B outbreaks and a number of sporadic cases
on college campuses in the past 2 years.
• INSURANCE may not cover this.
Trigeminal Neuralgia
• Recurrent- Head and Facial Pain in the trigeminal areamade worse by palpation with radiation to the
maxillary and mandibular areas.
• Stabbing and electrical
• F> M age >50
• The mechanism by which compression of the nerve
leads to symptoms appears to be related to
demyelination in a circumscribed area around the
compression
• MRI to r/o lesions such as tumor or MS
• Treatment: carbamazepine 200 to 1,200 mg/day
recommended
Trigeminal Neuralgia
Most Common Cause
• Recurrent- Head and Facial Pain in the trigeminal areamade worse by palpation with radiation to the
maxillary and mandibular areas.
• Stabbing and electrical
• F> M ,age >50
• The mechanism by which compression of the nerve
leads to symptoms appears to be related to
demyelination in a circumscribed area around the
compression
• MRI to r/o lesions such as tumor or MS
• Treatment: carbamazepine 200 to 1,200 mg/day
recommended
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Temporal( giant cell) Arteritis
• The diagnosis of giant cell arteritis (GCA) should
be considered in a patient over the age of 50 who
complains of or is found to have:
●New headaches
●Abrupt onset of visual disturbances
●Symptoms of polymyalgia rheumatica
●Jaw claudication
●Unexplained fever or anemia
●High erythrocyte sedimentation rate
(ESR) and/or high serum C-reactive protein (CRP)
Temporal( giant cell) Arteritis
• The diagnosis of giant cell arteritis (GCA) should be
considered in a patient over the age of 50 who
complains of or is found to have:
●New headaches
●Abrupt onset of visual disturbances 15 to 20% blindness
●Symptoms of polymyalgia rheumatica
●Jaw claudication
●Unexplained fever or anemia
●High erythrocyte sedimentation rate (ESR) and/or high
serum C-reactive protein (CRP)
Trigeminal Neuralgia
Temporal Arteritis
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TIA
• American Heart Association/American Stroke
Association 2009 definition of TIA –
Transient episode of neurological dysfunction caused by
focal brain, spinal cord, or retinal ischemia, without acute
infarction
• Underreported
• Sudden onset of unilateral paresis, speech
disturbance, transient monocular vision loss
• NOT tinnitus, dizziness, vertigo, memory loss
( mimics)
Evaluation
• Thorough History – Is it recurrent?
• Physical exam esp. neuro
• Imaging- within 24 hours
– Diffusion weighted MRI
– CT scan often completed in the ER
• Cardiac Assessment:
– EKG
– Transthorasic echo/TEE
• Patent foramen ovale, thrombus, valvular disease
– Telemetry
– Labs
Treatment- prevent future strokes
10 to 20 % risk at 90 days often within 48 hours
• Modify risks:
– hypertension, smoking, obesity, inactivity etc.
• Statins regardless of LDL:
– Reduce by 50 % or less than 70
• Antiplatelets if non cardiac
– 81 mg aspirin
– Dipyridamole/aspirin
– Clopidogrel
• Carotid endarterectomy or angioplasty
– If 70 to 99% blocked and risk <6%
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Treatment- prevent future strokes
10 to 20 % risk at 90 days often within 48 hours
• Modify risks:
– hypertension, smoking, obesity, inactivity etc.
• Statins regardless of LDL:
– Reduce by 50 % or less than 70
• Antiplatelets if non cardiac
Not ASA and Plavix
– 81 mg aspirin
– Dipyridamole/aspirin
– Clopidogrel
• Carotid endarterectomy or angioplasty
– If 70 to 99% blocked and risk <6%
Atrial Fibrillation ( AHA)
• Warfarin with INR between 2 and 3
• Control group 4.5 % stroke
• Warfarin group 1.4% stroke
• Other agents: ( Do NOT have AHA approval)
–
–
–
–
Dabigatron- (Pradaxa)
Rivaroxaban (Xarelto)
Apixaban (Eiquis)
Edoxaban ( Savaysa)
Who needs anticogulation?
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Stroke
• symptomatic cerebral ischemic events of > 24
hour duration
– 80%-87% ischemic ( thrombus or emboli)
– 13%-20% hemorrhagic
• Intracerebral
• subarachnoid
• Risk Factors: Age, FMH, obesity, DM, HTN,
tobacco, AFIB, Stress, High Alcohol
Acute Treatment
•
•
•
•
EKG
Labs
Imaging to r/o Bleed
Thrombolytic Therapy if within 3 hours if acute and
clinically meaningful defecit
•
•
•
•
•
No bleed or AV malformation
Normal platelets
No anticoagulants
No trauma
BP < 185/110
• oxygen if hypoxic
• Aspirin within 48 hours ( if no thrombolytics)
• Do not lower BP unless extreme i.e. 220/120 or patient
has CAD to maintain cerebral perfusion
• Monitor for complications i.e seizures, edema, bleed
Imaging
• For diagnosing ischemic stroke in the emergency
setting:
– CT scans (without contrast enhancements)
• sensitivity= 16% specificity= 96%
– MRI scan
• sensitivity= 83%specificity= 98%
• For diagnosing hemorrhagic stroke in the emergency
setting:
– CT scans (without contrast enhancements)
• sensitivity= 89%specificity= 100%
– MRI scan
• sensitivity= 81%specificity= 100%
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Seizure
• Sudden change in neurological activity (e.g.
behavior, movement, sensation) causes by
excessive synchronized discharge of cortical
neurons in a limited (focal) or generalized
distribution of the brain.
• Epilepsy: 2or more seizures that are not
precipitated by illnesses or other inciting
events i.e. alcohol withdrawal
Common Causes of Seizure by Age Group
• Infant
• Adult
– Hypoxic injury
– Metabolic defect
– Genetic or congenital
abnormality
– infection
• Children
–
–
–
–
Idiopathic
Infection
Fever
trauma
–
–
–
–
–
–
–
Idiopathic
Metabolic defect
Drug or drug withdrawal
Trauma
Neoplasm
Infection
CVA or stroke
Types of Seizures
Type
Involvement
Comments
Simple Partial
Focal, cortical region of
the brain
Focal sensory of motor
deficit with no LOC
Complex Partial
Focal Region of the
temporal lobe
Hallucinations and
repeated coordinated
movements
Generalized
Bilateral cerebral cortex
Tonic- clonic repetitive
contraction and
relaxation
Absence
Bilateral Cerebral cortex
Mostly in children
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Status Epilepticus
• Either > 30 minutes of continuous seizure
activity or ≥ 2 sequential seizures without
recovery of full consciousness between
seizures
• Due to : numerous- infections , brain tumor
• Treat with IV benzodiazepines, then start
phenytoin or phenobarbitol if refractory
• Mortality > 20 % if untreated.
Febrile Seizures
•
•
•
•
•
•
•
Between age of 6 months and 5 years
Prevalence 2 to 5%
Males > female
No evidence of intracranial infection
Simple < 15 minutes, complex > 15 minutes.
Greater risk of developing epilepsy
LP should be performed in patients
• < 12 months
• Complex seizure
• Symptoms of meningitis
Parkinson Disease
• Idiopathic dopamine depletion:
– loss of dopaminergic striated neurons in the substantia
nigra and Lewy formation leading to abnormal cholinergic
input to the cortex.
• Symptoms:
–
–
–
–
–
–
–
–
Resting tremor: pill rolling
Cogwheel rigidity
Bradykinesia/ akinesia- shuffling gait
Mask-like faces
Memory loss
Difficulty initiating movement
Postural instability
Stooped posture, decreased arm swing
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Parkinson Disease
• Idiopathic dopamine depletion:
– loss of dopaminergic striated neurons in the substantia
nigra and Lewy formation leading to abnormal cholinergic
input to the cortex.
• Symptoms:
–
–
–
–
–
–
–
–
TRAP
Resting tremor: pill rolling
Cogwheel rigidity
Bradykinesia/ akinesia- shuffling gait
Mask-like faces
Memory loss
Difficulty initiating movement
Postural instability
Stooped posture, decreased arm swing
Treatment of Parkinson Disease
Drug
Mechanism
indication
Levodopa
Dopamine precursor
Initial therapy
Carbidopa
Dopamine decarboxylase
inhibitor that reduces
levodopa metabolism
Combined with levodopa to
augment effects
Bromocriptine
Dopamine receptor agonist
Increases response to levodopa
in patients with declining
response
Selegiline
Monamine oxidase type B
inhibitor
Early disease – may help delay
need to start levodopa
Amantadine
Increases synthesis, release
or reuptake of dopamine
More effective against rigidity
and bradykinesia
Antimuscarinic
agents
Block cholinergic
transmission
Adjuvant therapy
Drug induced Parkinson Disease
• the older major tranquilizers such as
Haloperisol ( Haldol), Trifluoperazine
(Stelazine)
• the newer major antipsychotic drugs such as
Risperidone (Risperdal), Olanzapine (Zyprexa),
• drugs used for nausea, vomiting, and acid
reflux such as Metoclopramide (Reglan)
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Myasthenia Gravis
• Autoimmune disorder
• Antibodies bind to acetylcholine receptors at neuromuscular
junctions and block normal neuromuscular transmission
• Bimodal distribution younger women, older men
• H and P
•
•
•
•
•
Fatigue
Ptosis
Diplopia
Dysphagia
Dyspnea
• Lab: + positive Ach receptor antibodies
• Tensilon Test: symptoms improve with edrophonium or the Ice pack
test
Guillain Barre Syndrome
• Inflammatory neuropathy associated with progressive weakness
usually symetrical and ascending
• Autoimmune
• Can be associated with recent viral infection, surgery ot
immunization
• Peak 20’s and 70’s
• Self resolving in 1 month- sooner with plasmapheresis or
immunoglobulin
• H and P:
• Rapid bilateral weakness in distal extremities in stocking/glove distribution and
going proximal
• Decreased sensation
• Absent DTR’s
• Respiratory Failure
Amyotrophic Lateral Sclerosis
• Progressive neuro degenerative disease of the
motor neurons
• Loss of central nervous system
– lower motor neurons
» anterior horn cells in spinal cord
» cranial nerve nuclei (most often X, XI, XII)
– upper motor neurons
» corticospinal tract
• Ages 20 to 80
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Amyotrophic Lateral Sclerosis
• H and P
– Asymmetrical progressive weakness in the limbs and
face
– Possible change in personality and impaired judgment
– Increase or decrease in DTR
– Flaccid paralysis
– Babinski
– Fasciculations of the muscles
• EMG: Widespread muscular denervation and
motor block
• Treatment: riluzole- supportive therapy
Alzheimer’s Disease
• Most common cause of Dementia
• Due to neurofibrillary tangles, neuritic plaques, amyloid
deposits,neuronal atrophy
• Cortical atrophy on Imaging
• H and P
•
•
•
•
•
Progressive short term memory loss
Depression
Confusion
Inability to perform complex tasks or movements
Personality changes and delusions
• Treatment
– Cholinesterase inhibitors
– Memantine ( alone or in combination)
– Herbals?????
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Multiple Sclerosis
•
•
•
•
•
Possible autoimmune
Demyelinating disorder of brain and spinal cord
Most patient women 20 to 40
Mri with contrast shows white matter lesions
H+ P: various symptoms, visual changes( Optic
Neuritis- 10 year risk 38%), babinski, positional
instabilities, spasticity, dysarrthria
• McDonald Criteria for diagnosis
• Treatment: steroids, methotrexate,interferon,
glatirmer lacitate
Radiculopathy
Form of neuralgia due to irritation
of the spinal nerve
Neuropathy
Nerve
Reflex
Motor Deficit
Sensory Deficit
C5
Biceps
Deltoid, biceps
Anterior Shoulder
C6
Brachioradialis
Biceps, wrist extensor
Lateral forearm
C7
Triceps
Triceps, wrist flexors, finger
extensors
Posterior forearm
C8
None
Finger flexors
Forth and fifth fingers, medial
forearm
T1
None
Finger interossei
Axilla
L4
Patellar
Tibialis anterior
(foot dorsiflexiion)
Medial leg
L5
None
Extensor hallucis longus
(first toe dorsiflexion)
Lateral lower leg, first web space
S1
Achilles
Peroneus longus and brevis( Lateral foot
foot eversion)
Gastrocnemius
(foot plantarflexion)
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Osteopathic Manipulation
• Numerous studies support the use of OMT in
the treatment of patients with
musculoskeletal complaints.
• No studies on radiculopathy found.
• Many modalities- should not just think of high
velocity techniques.
• High velocity should be used with caution in
the cervical spine
Carpal Tunnel
•
•
•
•
Compression of the median nerve at wrist
Ages 30 to 55
F>M
H and P
– Wrist pain radiates up the arm
– Decreased grasp
– Numbness in thumb middle and index finger
– Thenar atrophy in advanced cases
+ tinel
+ phalen
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Treatment
• Most of questionable benefit
– Wrist splints
– Activity modification
– NSAID
– Steroid injections
– Surgical release of the transverse carpal tunnel
ligament
20