Neurology
8 high-yield topics. Open a topic to review its pearls.
Headaches
Migraine, tension, cluster
Types
- Migraine: unilateral, throbbing, photophobia, aura, prefers dark room; triptans (avoid in CAD)
- Tension: bilateral, band-like, at end of day; analgesics
- Cluster: unilateral orbital, excruciating, male, lacrimation/Horner; 100 percent O2, triptans
Special Headaches
- Pseudotumor cerebri: young obese woman, papilledema, slit ventricles, acetazolamide, weight loss
- Temporal arteritis: unilateral, ESR over 50, start steroids then biopsy
- When to scan: first/worst, thunderclap, abnormal neuro exam
- When to tap: sudden onset, meningeal signs, confusion
CVA and Stroke
Ischemic, hemorrhagic, TPA
Stroke Types
- Thrombotic: preceded by TIA, gradual
- Embolic: rapid onset, cardiac source
- Hemorrhagic: HTN, amyloidosis
- CT better for hemorrhagic; MRI better for thromboembolic
TPA
- Ischemic stroke, well-defined onset, within 4.5 hours
- Measurable NIH deficit, no intracranial bleed
- Contraindications: rapidly resolving, recent surgery/trauma, SBP over 185, anticoagulants
- Bring down BP first, then can give TPA
Carotid Management
- Over 50 percent symptomatic or over 70 percent asymptomatic: endarterectomy
- Under 50 percent: ASA +/- dipyridamole or clopidogrel
- Pre-CABG: carotid dopplers first
Hemorrhage Types
- SAH: thunderclap headache, xanthochromia, CT first, nimodipine
- Subdural: bridging veins, concave, elderly falls
- Epidural: middle meningeal artery, lucid interval, convex
Seizures
Classification and AEDs
Types
- Simple partial: normal consciousness, single modality, carbamazepine/phenytoin/lamotrigine
- Complex partial: altered awareness, automatisms
- Generalized: loss of consciousness, valproate/lamotrigine/topiramate
- Absence: ethosuximide
High Yield
- Todd paralysis: transient focal weakness post-seizure
- Temporal lobe: deja vu, odd smells
- Status epilepticus: lorazepam, then fosphenytoin, then propofol/midazolam
- All new seizures: MRI/CT + electrolytes
Movement Disorders
Parkinson, tremor, Huntington, Wilson
Parkinson Disease
- Decreased dopamine in substantia nigra
- Resting tremor, cog-wheel rigidity, bradykinesia, postural instability
- Levodopa + carbidopa is definitive treatment
- Dopamine agonists, MAO-B inhibitors, amantadine
Hyperkinetic Disorders
- Essential tremor: postural, improves with alcohol, propranolol or primidone
- Huntington: autosomal dominant, chorea + dementia, CAG repeat chromosome 4
- Wilson: autosomal recessive, KF rings, low ceruloplasmin, penicillamine
- Restless legs: treat iron deficiency, ropinirole/pramipexole
Multiple Sclerosis
Diagnosis and DMTs
Symptoms
- Optic neuritis, internuclear ophthalmoplegia
- Lhermitte sign, sensory/motor deficits
- Symptoms worsen with heat, exercise, infection
Diagnosis
- Disseminated in time and space
- MRI with gadolinium: T2 flair lesions
- Oligoclonal IgG bands in CSF
Treatment
- Acute: methylprednisolone IV 3-5 days
- Relapsing-remitting: interferon B, glatiramer, natalizumab, fingolimod
- Interferon contraindicated in liver disease and depression
Peripheral Neuropathies
GBS, diabetic, radiculopathy
Guillain-Barre Syndrome
- Postinfectious autoimmune demyelinating polyneuropathy
- Ascending symmetric paralysis, after Campylobacter/URI
- CSF: albuminocytologic dissociation
- Intubate if NIF over -25 or VC under 20 mL/kg
- Treat with plasmapheresis then IVIG
Other Neuropathies
- Diabetic: most common in US, glove-stocking distribution
- Bell palsy: LMN 7th nerve, cant wrinkle forehead, steroids early
- Trigeminal neuralgia: lightning pain, carbamazepine
- Carpal tunnel: median nerve, wrist splint/surgery
Neuromuscular and Myopathies
MG, Eaton-Lambert, PM/DM
Myasthenia vs Eaton-Lambert
- MG: postsynaptic ACh receptor antibodies, worsens with repetition, ptosis/diplopia, thymoma
- Eaton-Lambert: presynaptic Ca channel antibodies, improves with repetition, small cell lung cancer
- MG treatment: pyridostigmine, immunomodulators, thymectomy
Inflammatory Myopathies
- Polymyositis: proximal weakness, elevated CK, anti-Jo
- Dermatomyositis: heliotrope rash, Gottron papules, cancer screening (15 percent)
- Inclusion body myositis: older men, finger flexors, no steroid response
Dementia
Types and distinguishing features
Dementia Types
- Alzheimer: gradual memory loss, aphasia, apraxia
- Vascular: stepwise, multiple infarcts
- Lewy body: parkinsonism, visual hallucinations
- Frontotemporal: personality changes, onset under 60
- Normal pressure hydrocephalus: dementia, gait, incontinence
- Creutzfeldt-Jakob: myoclonus, triphasic EEG, rapidly progressive