Download MBBS Neurology and Psychiatry Lecture Notes

Neurology and Psychiatry
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? Muscle Stretch Reflexes
? Biceps C5-C6
? Supinator (brachioradialis) C6

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? Triceps C7
? Knee L4
? Ankle S1
? Cutaneous reflexes
? Abdominal ? upper umbilicus T8-T10

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? Abdominal ? below umbilicus T10-T12
? Cremasteric L1-L2
? Anal S2-S5
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Dermatomes (Nerve Roots)
? C4: clavicle "C" is for "clavicle"
? C6: thumb & index Left hand "OK" sign
makes a "6" with
thumb and index

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? C7: middle finger
? C8: little finger
? T4: nipple line "T" is for "thorax"
? T10: umbilicus Bel ybutTEN
? L1: inguinal ligament IL-L1

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? L4: knee "Down on al fours" ?
Down on L4
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The

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Cranial
Nerves
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Cranial Nerve 3 Palsies
Pupil Sparing

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Pupil Affected
? Infarction
? Compression
? DM/HTN
? r/o aneurysm

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Glasgow Coma Scale
? Eye Opening (1-4)
? Verbal (1-5)
? 4: Spontaneous

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? 5: Ful sentences /
? 3: Verbal
oriented
? 2: To Pain
? 4: Ful sentences /

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confused
1: None
? 3: Understandable
words

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? Motor Response (1-6)
? 2: Garbled, moans
? 6: Fol ows commands
? 1: No vocalization
? 5: Localizes pain

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? 4: Withdraws to pain
? A dead person has a
? 3: Decorticate (Flexes)
GCS of 3
? 2: Decerebrate (Extends)

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? 1: Flaccid
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Altered Mental Status
? ABCs
? Glucose check

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? Consider thiamine, naloxone but not flumazenil
A - Alcohol
T - Trauma, temperature
E - Epilepsy
I - Infection

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I - Insulin
P - Poisonings
O - Opioids
P - Psychiatric
U - Uremia

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S - Stroke, shock
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Brainstem Reflexes (1)
? Dol 's eyes (oculocephalic reflex)
?Test in comatose patient (usual y absent if

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patient is awake)
?Contraindicated in known or suspected C-
spine trauma
?If brainstem is intact: Eyes move in
opposite direction of head movement

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?If brainstem is injured: Eyes stay fixed in
orbits
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Brainstem Reflexes (2)
? Cold calorics (oculovestibular reflex)

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?Test in comatose patients
?Patient supine with head elevated 30?
?Examine external canal first
?Irrigate ear with ice-cold water
?If brainstem and cortex are intact: Nystagmus

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with fast component directed to opposite ear.
"Cold Opposite, Warm Same" = COWS
?Cortex injured but brainstem intact: Eyes
deviate toward cold ear
?Brainstem injured: No eye deviation

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Brainstem Reflexes (3)
? Corneal reflex
?Test in awake patients
?Test CN V and CN VII (touching the cornea

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elicits bilateral blink)
?Decreased blink in opposite eye suggests
brainstem or cortical injury
? Lateral gaze
?Test in awake patients

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?The MLF connects the oculomotor nuclei and
it runs through the brainstem
?INO (intranuclear ophthalmoplegia): Eye on
affected side can't look at nose
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Brainstem Reflexes (4)
Right Internuclear Ophthalmoplegia
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Headache

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Trigeminal Neuralgia
(Tic Douloureux)
? Facial pain
? Compression of trigeminal nerve (r/o MS)

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? Middle age, women > men
? "Electric," brief, intermittent attacks of pain
? Neuro exam is normal
? Treatment: Carbamazepine, surgical
decompression

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Migraine (1)
? Female, age 10-30, positive family history
? Unilateral
? Severe, throbbing, 1-4 hours duration

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? Nausea, vomiting, photophobia
? Migraine without aura (common migraine)
? Migraine with aura (classic migraine):
Scotomata, focal neurological deficits
? Aura depends on area of brain involved

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Migraine (2)
? Prevention = TCAs, beta blockers, calcium
channel blockers
? Abortive therapy

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? Ergotamine, DHE: contraindicated in CAD, PVD,
HTN, RF, pregnancy
? Sumatriptan: Contraindicated in heart disease,
HTN, ergotamine, migraine with focal findings
? Dopamine antagonists: Prochlorperazine,

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promethazine, metoclopramide
? Rescue analgesics: Opioids
? May be required. Abortive therapy is preferred.
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Cluster Headache

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? Middle age, male > female
? Unilateral headache lasts 30-90 minutes
(multiple headaches daily over several weeks)
? No prodrome
? Conjunctival injection, lacrimation,

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rhinorrhea, miosis, ptosis
? Alcohol, nitroglycerin, histamine may cause
attack
? Treatment: 100% O2, lidocaine 4%
intranasally, sumitriptan, dopamine

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antagonists, opioids
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Tension Headache
? Head "tightness," constant, bilateral headache
? Lasts minutes to days

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? No nausea, vomiting, photophobia, focal deficits
? Not aggravated by activity
Toxic Metabolic Headache
? Usual y bilateral
? Vasodilation of pain-sensitive arteries

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? Fever is the most common cause
? Others: CO, hypoxia, alcohol, tyramine foods
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Idiopathic Intracranial Hypertension

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(Pseudotumor Cerebri)
? Young, obese, female, ages 20-40 years, irregular
menstrual cycles, amenorrhea
? Nausea, vomiting, headaches, visual changes
? Impaired CSF absorption

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? Elevated CSF pressure without mass or obstruction
? Serious outcome: blindness
? Papil edema, no focal signs
? CT: "Slit-like" or normal ventricles, no mass
effect

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? LP: High opening pressure
? Treatment: Repeated LPs, acetazolamide, weight
loss, surgical shunt if severe and refractory
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Post-Concussive Headache

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? Fol ows trauma (hours to days)
? Vertigo, nausea, vomiting, concentration
? Physical exam and CT normal
? Prognosis is excel ent
? Common in children

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? Neuropsychiatric sequelae
Spinal Headache
? Pulsatile, worse with upright posture
? Correlates with size/type of needle, amount of
fluid removed, # of attempts, pre-LP headache

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? Treatment: Caffeine, other analgesics, hydration;
blood patch is definitive
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Subarachnoid Hemorrhage (1)
? Usual y 2? to aneurysm, occasional y AVM

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? Occur in al age groups
? Many have sentinel headache (leaking
aneurysm)
? Sudden onset, maximum at onset and different
than previous headaches

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? May be "worst headache of life", nausea,
vomiting, hypertension, meningismus
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Subarachnoid Hemorrhage (2)
? CT shows most, but always do LP if story is

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good
? CT scan sensitivity decreases after 12
hours
? LP findings for SAH
?Xanthochromia (takes 6 ? 12 hours to develop)

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?Non-clearing RBCs (e.g. from tubes 1-4)
? Treatment: Aggressive blood pressure
control, nimodipine PO/NG (to prevent
vasospasm), neurosurgical consult
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Subarachnoid Hemorrhage
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Hydrocephalus (1)
? Obstructive
? Signs and symptoms of increased ICP

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(headache, nausea, vomiting, decreased LOC,
papil edema, CN VI palsies)
? Obstruction of CSF flow (tumor,
postinfectious, post-SAH, VP shunt
blockage)

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? Diagnosis: CT, MRI (dilated ventricles)
? LP should be avoided (risk of herniation)
? Treatment: Ventriculostomy, surgery (shunts)
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Hydrocephalus (2)

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? Hydrocephalus ex vacuo
? Passive enlargement of ventricles due to severe
cerebral atrophy
? Normal pressure hydrocephalus
? Clinical y misdiagnosed as Alzheimer's or Parkinsonism

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? Treatable cause of dementia
? Cause by a chronic communicating form of hydocephalus
? Classic triad: progressive dementia, ataxia (leg
symptoms are early), urinary incontinence ("wet,
wacky and wobbly")

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? CT: Enlarged ventricles, no atrophy
? LP: Opening pressure not elevated (high normal)
? Treatment: Shunt
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Hydrocephalus (3)

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Hydrocephalus
Shunt in lateral ventricle
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Hydrocephalus (4)
Obstructive Hydrocephalus

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Ex-vacuo changes
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Ventricular Shunt Headache
? Rule out infection, shunt malfunction
? Shunts divert CSF to bloodstream or body cavity

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? All valves operate with 1-way flow and have
flush mechanism
? Outflow tracts: Right atrium, pleural or peritoneal
cavity
? If valve cannot be compressed, consider

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obstruction
? Shunt malfunction: Obstruction, kink,
disconnection
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Ventricular Shunt Headache

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Mass Lesions (1)
? Subdural hematoma
?More common than epidural hematoma
?Associated with bridging veins

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?Headache, mental status, trauma, elderly
?May be acute, subacute or chronic
?CT: Crescent shape
?CT with contrast for subacute (may be isodense)
?Worse prognosis than epidural

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? Epidural hematoma
?Trauma brief LOC lucid interval
headache, decreased mental status
?Skul fracture, middle meningeal artery injury
?CT: Lens-shaped hematoma

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Subdural Hematoma
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Med-Chal enger ? EM

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Epidural Hematoma

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Cerebral Contusions
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Mass Lesions (2)
? Tumor

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? New headaches,
increasing in
frequency or
duration, pain on
awakening, worse

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with Valsalva, worse
when lying down
? Nausea, vomiting
? Diagnosis: CT with
Toxoplasmosis

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contrast
Most common CNS mass
lesion in AIDS
CT shows contrast ring-
enhancing lesion

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Bacterial Meningitis (1)
? Early diagnosis and treatment is critical
? Headache, fever, nuchal rigidity, photophobia,
altered mental status, rash, focal neuro exam

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? Infants: Irritability, poor feeding, bulging
fontanel e, neck stiffness often absent
Brudzinski's sign: Flexion of the hips caused by
passive flexion of the neck
Kernig's sign: Pain in hamstrings causes inability

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to straighten leg when hip is flexed to 90?
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Brudzinski and Kernig Signs
Kernig
Brudzinski

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Bacterial Meningitis (2)
? Petechial rash: Consider meningococcemia
? LP: OP, WBC, PMN, protein, glucose
? Gram's stain is unreliable in partial y treated cases

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? Focal neurologic findings
? S. pneumoniae (most common) & N. meningitidis
(col ege age) predominant causes >1 month
? S. pneumoniae associated with highest morbidity/
mortality

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? Penicil in - and ceftriaxone-resistant S. pneumoniae
are prevalent. Add vancomycin empirical y
Don't delay treatment for CT or difficult LP
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Bacterial Meningitis (3)

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? Bacterial lysis by antibiotics causes harmful CNS
inflammation
? Dexamethasone 10mg IV q6h for 4 days in adults
? 15 minutes before or simultaneously with antibiotics
? Decreases morbidity and mortality, particularly in

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pneumococcal meningitis
Steroids first / then antibiotics in seriously il
patients or those with CSF WBC
> 1000 / hpf
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Bacterial Meningitis (4)
? CT before LP in suspected meningitis?
? Concern = Identify risk factors for brainstem
herniation
? Predisposing factors for an abnormal CT:

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? Age at least 60
? Immunocompromised (HIV, immunosuppressive
treatment and transplant pts.)
? A history of CNS disease (mass lesion, stroke or focal
infection)

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? Seizure within the last week
? Abnormal neuro exam / altered mental status
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Aseptic Meningitis
? Viral

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?Varicel a, herpes (HSV), enterovirus, West Nile
?Rash, headache with viral syndrome
? TB
? Lyme disease (weeks after rash)
? Syphilis

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? Fungal: AIDS, transplant, chemo, chronic
steroids
? Noninfectious: Neurosarcoidosis,
connective tissue disease, vasculitis
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CSF Findings in Meningitis
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Meningitis Empiric Treatment
AGE

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Bacterial Agent
Antibiotic
0-1 months
Group B Strep,
Amp + 3rd ceph (or

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E.coli, Listeria
gentamycin)
1 ? 3 months
Pneumococci,
3rd ceph + vanco

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Meningococci,
H. flu (no HIB vac)
3 mos. ? 50 years
Pneumococci,
3rd ceph + vanco

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Meningococci,

H. flu (no HIB vac)
>50 years,
Pneumococci,

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Amp + 3rd ceph +
Alcoholism, AIDS,
Listeria, Gram negs vanco
debilitating disease
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Meningitis Empiric Treatment
Special Situations
Patient Category Bacterial Agent
Antibiotic
Immune

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Pneumococci,
Vanco + 3rd ceph +
compromised
Meningococci,
Amp

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Listeria, Gram negs
Trauma (CSF leak), Pneumococci,
Vanco + 3rd ceph
neurosurgery
Staph, Gram negs

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V-P shunt
Staph. epi
Vanco + 3rd ceph +
shunt removal
Staph. aureus

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LP positive for
HSV encephalitis
Acyclovir
cells but negative
(viral)

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Gram's stain
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Neuromuscular
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Landry-Guillain-Barr? Syndrome

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? Autoimmune demyelination
? 30-40 year old with weakness, areflexia,
paresthesias
? Often preceded by viral syndrome
(gastroenteritis, mycoplasma)

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? Associated with Campylobacter, flu vaccine
? Hallmark finding: Loss of DTRs
? Respiratory failure can develop
? CSF: Increased protein
? Treatment: Admit, airway/respiratory support,

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plasmapheresis, IV immunoglobulin
Progressive ascending weakness is most common
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Multiple Sclerosis (1)
? Multiple neurological deficits separated by time

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interval
? Demyelination of multifocal areas of CNS
slowed nerve conduction
? 30s, F > M (males have more progressive
disease)

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? Often presents with optic neuritis
? Unilateral
? Central vision loss, pain with eye movement and
papil itis (papil edema of one eye)
Pathognomonic: Bilateral internuclear ophthalmoplegia

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(eyes can't look at nose)
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Multiple Sclerosis (2)
? Diagnosis: MRI (plaques), LP (increased protein,
increased IgG, oligoclonal bands)

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? Treatment for exacerbations:
short course of steroids, ACTH,
interferon
? Increased incidence postpartum
? Visual evoked response, a test that evaluates the

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conduction of electrical impulses from the optic nerve
to the occipital cortex of the brain, is abnormal.
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Pure Muscle Weakness
(Normal Sensation)

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? Hypokalemic periodic paralysis
? Myasthenia gravis
? Lambert-Eaton syndrome
? Tick paralysis
? Botulism

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? Certain toxins
? Amyotrophic lateral sclerosis (ALS)
? Polio
? West Nile Virus
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Acute Periodic Paralysis
? Rapidly progressive extremity weakness in
young males
? Limb paralysis after exercise
? No pain, normal sensation

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? Associated with hypokalemia, thyrotoxicosis,
steroids, alcohol, renal disease
? Hypokalemic periodic paralysis
? Hereditary: Autosomal dominant, most common,
avoid high-carbohydrate, high-sodium diet

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? Thyrotoxicosis: Young Asian males, onset after
exercise
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Myasthenia Gravis (1)
? Auto-antibody against acetylcholine receptors

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? Women (20-30 yrs) > men (50-60 yrs)
? Associated with thymoma (25% have one)
Hal mark = Muscle weakness and fatiguability
with diplopia, ptosis
? Weakness of eyelids, extraocular muscles, face

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? Limb weakness proximal > distal
? Weakness worsens with repetitive use
? Precipitants = infection, fever, stress, adverse
reactions to medication
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Myasthenia Gravis (2)
? Diagnosis
? Tensilon (edrophonium) test: Increases ACh, by
blocking breakdown of ACh by cholinesterase =
increases muscle strength / EMG = rapid fatigue

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? Blood: Anti-acetylcholine receptor antibodies
? Tensilon can cause AV block, cardiac arrest - give
atropine first
? Increased weakness may be due to over-medication
? Life-threatening respiratory arrest may be:

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? Exacerbation vs. inadequate treatment (myasthenic
crisis)
? Over-medication (cholinergic crisis)
? Treatment: Physostigmine or neostigmine (ACH
inhibitors), thymectomy, prednisone, plasmapheresis

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Myasthenia Gravis (3)
t=0
t=5 minutes
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Lambert-Eaton Syndrome
? Clinical y similar to myasthenia gravis
? Autoimmune, effects calcium channels (muscle function)
See decreased DTRs
? Remote effect of cancer on the nervous system

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? Failure of release of acetylcholine from terminal
presynaptic axons of motor neurons by calcium channel
antibodies
? Weakness and fatigue of proximal muscles, especial y
thighs and hips (weakness improves with use)

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? 50% associated with cancer (esp. smal cel lung CA)
? Treatment: Remove tumor, plasmapheresis
? If possible avoid neuromuscular blocking agents,
aminoglycosides, IV contrast, calcium channel blockers
(al may cause worsening weakness)

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Tick Paralysis
? Reversible, rapidly ascending paralysis
? Similar to Guil ain-Barr?, but no paresthesias
? Treatment: Find and remove the tick

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Toxin-Mediated Neuropathy
? Metal ic poisons: Arsenic, lead
? Organic compounds: Ethanol, methanol,
alcohol, phenothiazines, aminoglycosides
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Wernicke's Encephalopathy
? Malnourished chronic alcoholics
? Thiamine (B 1) deficiency
? Classic findings = Encephalopathy (altered mental
status), nystagmus, ophthalmoplegia (esp. lateral

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rectus), ataxia, short-term memory problems
? Mortality can be high
? Treatment: Admission, thiamine (B1), magnesium
? Sugar prior to B1 can precipitate encephalopathy
? Can lead to Korsakoff's psychosis if not treated

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? Amnesia and confabulation (invented memories which
are taken as true due to gaps in memory)
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West Nile Virus (1)
? "Bird-mosquito-bird" cycle / dead crows

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? August and September are times of highest risk
? Only about 20% of infected individuals become il
? Severity of il ness increase with age
? Flu-like il ness
? Encephalitis /

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meningitis
(less than 1%)
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West Nile Virus (2)
? Flaccid paralysis

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?Anterior horn cel s affected
?Sensation intact
?Persistent neuro deficits common
? CSF: Increased protein and pleocytosis
(usual y lymphocytic)

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? Send CSF and serum for IgM antibodies to
WNV
? Treatment is supportive
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Seizures

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Seizures (1)
? Etiology
?Epilepsy (idiopathic recurrent seizures)
?Metabolic (glucose, or Na+, ,

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2 Mg++)
?Structural (CVA, mass)
?Traumatic
?Toxins, drugs (alcohol withdrawal, cocaine)
?Febrile

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?CNS infections
?Eclampsia, hypertensive emergencies
?True seizure: Abrupt onset, non-purposeful
movement, LOC, postictal state
Todd's paralysis: Residual neuro deficits last up to 24 hours

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Seizures (2)
? New onset
? Search for underlying cause
? Ful workup: Glucose, lytes, CT, LP, toxicology screen

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? Pediatric: Hyponatremia (most common in afebrile
children <2), gastroenteritis (rotavirus, Shigel a)
? Outpatient work up (MRI, EEG) if above negative
? Chronic
? Ful workup if focal seizure, neuro deficit, atypical

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? Breakthrough seizures: Check anticonvulsant
levels, glucose, no further treatment or testing
Lorazepam (Ativan) for alcohol withdrawal seizures not
phenytoin (Dilantin)
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Seizures (3)
Generalized
? Grand mal: Generalized, tonic-clonic
? Petit mal: "Absence", school age, usual y resolve
Partial

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? Focal seizures imply structural lesions
? "Jacksonian march:" Focal seizures that may
progress to generalized seizures
? Simple: No LOC, mental status is preserved
? Complex: Temporal lobe, altered mental status,

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bizarre behavior; "psychomotor" seizures
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Seizures (4)
? Treatment
? Diazepam 0.2 - 0.5 mg/kg

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? Lorazepam 0.05-0.1 mg/kg (longer acting;
drug of choice)
? Phenytoin 18 mg/kg
? Phenobarbital 8-20 mg/kg
Pseudoseizures

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? Voluntary control
? Consciousness is preserved
? Absence of EEG changes
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Status Epilepticus

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? Continuous (20-30 min), or repeated seizures
before ful recovery
? Petit mal (absence) status often misdiagnosed
? Watch for subtle signs (tonic eye deviation)
? Consider trauma, CNS infections, drugs

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(including alcohol, INH), prior seizures, Vit. B6
(pyridoxine) deficiency (INH OD)
? Treatment: ABCs, glucose, thiamine, lorazepam
(Ativan) phenytoin (Dilantin), phenobarb,
paraldehyde, general anesthesia

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? Must monitor EEG with paralysis
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Spine
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Motor Neuron Syndromes

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Upper (CNS/cord)
Lower (Peripheral Nerve)
Definition
Definition
? Lesion above the

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? Lesion from the
anterior horn cel s of
anterior horn cel s to
the spinal cord or the
the muscles

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motor nuclei of the
cranial nerves
Manifestations:
Manifestations
? Hyperreflexia

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? Weakness
? Clonus
? Atrophy
? Normal muscle mass
? Fasciculations

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? Spasticity (increased
? Decreased DTRs
tone and reflexes)
? Babinski's sign
65

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---

Amyotrophic Lateral Sclerosis (ALS)
? Etiology unknown, degeneration of upper and
lower motor neurons
? Muscle wasting,
fasiculations

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? Weakness, difficulty eating
and swal owing
? Diagnosis: Upper and lower motor neuron
symptoms, EMG
? Upper motor neuron disease: Spasticity, no

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sensory deficits
? Lower motor neuron disease (anterior horn
cel s): Atrophy, fasciculations
? Slowly progressive, death 2? respiratory failure
66

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---

Cauda Equina Syndrome
? Compression of peripheral nerve roots S2-S5
? Disc herniation, epidural abscess, tumors
? Lower motor neuron lesion
? Motor and sensory loss

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? Hyporeflexia, saddle anesthesia
? Urinary retention
and overflow incontinence
? Decreased anal tone, fecal
incontinence

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? Neurosurgical emergency,
recovery possible
? Conus medul aris injury: Similar in
presentation but due to cord lesion; no
recovery potential

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67

---

Epidural Abscess
? Back pain +/- fever, deficits come later
? Risk factors
?Bacteremia (indwel ing catheters,

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instrumentation)
?DM, IVDA, immune compromised (HIV,
alcoholism)
?Epidural/Intrafacet injections
? Staph, Strep, Bacteroides

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? Hematogenous spread
? Diagnosis
?X-ray usual y not helpful; may show osteo
?Elevated ESR, CRP
?MRI

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? Treatment delay may cause irreversible paralysis 68

---

Vertebral Osteomyelitis/Discitis
Bony destruction
IVDA with back pain

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69

---

Extrinsic Lesions
? Compression of spinal cord
? Disc, trauma, tumor, fracture, hematoma,
abscess

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? Decreased sensation, decreased sphincter
tone, decreased reflexes
? Diagnosis: MRI
? Treatment: steroids, surgery
70

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---

Syringomyelia
? Expanding central cavity in spinal cord
? Post-traumatic (e.g., whiplash, post-infectious
or idiopathic)
? Usual y involves

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cervical cord
? Intraosseous muscle
wasting
? Loss of pain/temperature sensation in hands
(vibration/position preserved)

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? Associated with cerebel ar (Chiari) defects
? MRI is diagnostic
71

---

Stroke
72

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Hemorrhagic Stroke
? Chronic hypertension
? Smal vessel disease
? Basal ganglia, thalamus often involved
? Location of bleed dictates symptoms

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? Cerebel ar bleed can deteriorate rapidly
? Goal is to decrease MAP to 160/90
?Labetalol (preserves cerebral blood flow)
?Nicardipine
?Nitroprusside

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73

---

Hemorrhagic CVA
74
Med-Chal enger ? EM

---

Intraventricular Hemorrhage

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75

---

Stroke Syndromes
Neuro Deficits
? Cerebral (cortical): Contralateral motor and
sensory deficits, contralateral cranial nerve

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palsies
? Brainstem: Cranial nerve nuclei (uncrossed)
and corticospinal tract (crossed). Ipsilateral
facial weakness and contralateral extremity
weakness

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? Pontine: Coma, miosis, gaze paresis, altered
respiratory pattern (ataxic breathing)
? Cerebel ar: Nystagmus, dizziness, N/V, ataxia
76

---

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Ischemic Strokes
? Can be thrombotic
(most common) or
embolic
? Anterior cerebral artery

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? Middle cerebral artery
? Posterior cerebral artery
? Vertebrobasilar artery
? Cerebel ar infarct
? Lacunar infarct

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77

---

Anterior Cerebral Artery (2%)
? Contralateral paresis, legs
? Sensory deficit (same distribution)
? Gait disturbance

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Middle Cerebral Artery (90%)
? Contralateral paralysis, arms and face
? Sensory deficit (same distribution)
? Aphasia (if dominant hemisphere) or
hemineglect (if non-dominant)

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? Homonymous hemianopsia (blindness in the
same field of vision of each eye) (eyes look
toward the side of the stroke)
78

---

Middle Cerebral Artery (cont'd)

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? Left MCA
?Right hemiparesis
?Right homonymous hemianopsia (looks to left)
?Aphasia
? Right MCA

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?Left hemiparesis
?Left homonymous hemianopsia (looks to right)
?Left hemineglect
79

---

Posterior Cerebral Artery (5%)

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? Supplies occipital cortex
? Homonymous hemianopsia
(contralateral)
? Visual agnosia (can't recognize objects)
? Cortical blindness (e.g. after CPR)

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? Motor involvement minimal
80

---

Vertebrobasilar Artery (1)
? Supplies brainstem, cerebel um, visual cortex
? Vertigo, nystagmus

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? Visual field deficits, diplopia
? Dysarthria, dysphagia
? Quadriplegia
? Coma, syncope
81

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---

Vertebrobasilar Artery (2)
? Wal enberg's syndro
me
? Vertebral artery thrombosis
? Ataxia, vertigo, nystagmus, nausea, vomiting

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? Decreased pain and temperature sensation,
ipsilateral face and contralateral body
? Ipsilateral Horner's syndrome (ptosis, miosis,
anhydrosis)
? "Locked-in" syndrome

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? Basilar artery occlusion at pons
? Also seen with pontine hemorrhage, central pontine
myelinolysis
? Patient is awake and lucid, able to feel and
understand

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? No motor activity except diaphragmatic breathing
? Vertical eye movements are spared
82

---

Cerebellar Infarct
? Sudden inability to walk or stand (drop attack)

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? Headache, dizziness, nystagmus, ataxia,
nausea, vomiting
? Can present with only nausea and vomiting
? Early neurosurgical consultation
? Rapid deterioration with hemorrhage, infarct

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edema; Watch for respiratory arrest
83

---

Lacunar Syndromes
? 15-25% of ischemic strokes
? Smal , deep penetrating vessel disease

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? Microinfarcts infarction in HTN/DM patients
? Stuttering course
? Often CT scan negative
? Prognosis better than with cortical strokes
5 Types

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? Pure motor hemiparesis: pons, internal capsule
? Pure sensory: thalamus
? Dysarthria-hemiparesis: pons, internal capsule
? Ataxia-hemiparesis: pons, internal capsule
? Mixed sensorimotor: hemiparesis with ipsilateral

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sensory complaints
84

---

Lacunar Syndromes (2)
85

---

Ischemic Stroke Treatment (1)

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? Watch for stroke mimics
? Todd's post-seizure paralysis / mass lesions /
metabolic abnormalities (low glucose) / vascular
disorders / infection / complex migraine / dural sinus
thrombosis / Bel 's palsy

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? Early CT to rule-out bleed
? ASA if no bleed and no TPA
? Lower BP only if very, very high
? HTN in stroke is transient and cerebroprotective
? Insulin if hyperglycemic

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? Avoid hypotonic fluids ? linked to cerebral
edema
86

---

Ischemic Stroke Treatment (2)
? Consider tPA

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? Ischemic stroke (CT without blood)
? Measurable neuro deficits
? Not rapidly improving (TIA?)
? Symptoms onset to drug treatment < 4.5 hours
? BP below 185/110

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? No other contraindications (bleeding risk)
? Treat tPA ICB with FFP or cyroprecipitate
87

---

Neurology Trivia (1)
? Uncal herniation: Ipsilateral fixed, dilated pupil,

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contralateral hemiparesis
? Cushing reflex: BP up, HR down (late sign of
elevated ICP, sign of impending herniation)
? Intracerebral stroke: Gaze toward side of lesion
? Seizure disorder: Gaze away from seizure focus

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? Brainstem stroke: Gaze away from side of lesion
? Ophthalmoplegic migraine: Cranial nerve palsy (III,
IV, VI), mydriasis, diplopia, strabismus
? Headache upon awakening: Hypoxia (COPD), mass,
glaucoma, cluster headache, pseudotumor cerebri

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(idiopathic intracranial hypertension)
88

---

What's going on here?
89

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---

Neurology Trivia (2)
? Myopathy: Proximal weakness > distal, reflexes
and sensation normal
? Peripheral neuropathy: Distal weakness >
proximal, decreased reflexes

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? Unexplained syncope: Consider vertebral artery
ischemia
? Phenytoin (Dilantin) is contraindicated in 2? and
3? AVB
? Pontine hemorrhage: Pinpoint pupils (interruption

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of sympathetic outflow + unopposed
parasympathetic activity)
90

---

Neurology Trivia (3)
? Reflex Sympathetic Dystrophy

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? Complex Regional Pain Syndrome
? Initiating noxious event or immobilization
? Pain (burning) or hyperalgesia out of proportion
? Skin edema, changes in blood flow, abnormal
sudormotor activity (sweating changes)

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? X-ray may show osteoporosis
? Treatment: Ganglion block, Bier block, TCAs,
gabapentin, clonidine, terazosin, opiates
91

---

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Psychiatry
92

---

Psych - General
? Commonly involve alcohol and drugs
? Sometimes have a pure medical etiology

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? Mental status exam: OMIHAT
Orientation
Memory
Intel ect
Hal ucinations

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Affect
Thought
93

---

Functional Disorder vs.
Organic Disorder

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? Functional
? Organic
?Age 15-40 years
?Onset <12 or >50
?Gradual onset

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?Acute onset,
?Clear sensorium
fluctuating course
?Auditory
?Disoriented

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hal ucinations
?Visual and tactile
?Oriented
hal ucinations
?Flat affect

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?Abnormal vital signs
?Normal PE
?Pupil size, nystagmus
?History of substance
abuse

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94

---

Amnesia
? Impairment of memory
? Acute thiamine deficiency causes Wernicke's
encephalopathy, which can lead to Korsakoff's

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psychosis (amnesia and confabulation)
? Transient global amnesia: Inability to form new
memories, lasts 6-24 hours, etiology unclear,
prognosis good
? Traumatic amnesia: Post-traumatic,

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anterograde or retrograde
Anorexia Nervosa
? Amenorrhea
? Obsessed with control
? Adolescent females ? Normochromic anemia

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? Weight loss
? Significant mortality
? Distorted body image 95

---

Antisocial Personality
? Most common personality disorder seen in ED

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? Common complications: Substance abuse,
multiple divorces, trauma, poor medical
compliance
? Disrespect for rights of others, law
? History of conduct disorder as

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child or teen
? Impulsive behavior, no remorse
? Inability to meet daily obligations and
responsibilities
? Severity decreases after age 30

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96

---

Borderline Personality Disorder
? Chronic emotional lability, intense and
unstable relationships, impulsiveness
? Self-destructive behavior

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? Frequent suicide threats, gestures
? Brief micropsychosis
97

---

Histrionic Personality Disorder
? Emotional, dramatic, extroverted, attention-

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seeking behavior
? Seductive, impulsive behavior is
common
? Suicide gestures are common
? No micropsychosis

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Narcissistic Personality Disorder
? Exaggerated sense of abilities and
achievement, self-importance
? Unrealistic ambitions
98

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Anxiety Disorders
? Anxiety with occupational / social dysfunction
? Common, age <45
? Motor tension
? Autonomic hyperactivity

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? Increased vigilance
? Rule out organic causes (OTC medications, drugs,
caffeine)
Post-traumatic stress disorder: Continued anxiety
fol owing a traumatic event, substance abuse

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Panic attack: Recurring episodes of fear (impending doom) without
identified stimulus
Obsessive - compulsive disorder: Repetitive acts or
ritualistic behavior to relieve anxiety
Phobias: Unfounded fears that arouse a state of panic

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99

---

Bipolar Disorder
? Onset in third decade
? Genetic predisposition
? Mood changes, "flight of ideas," hyperactivity

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? Rapid, pressured speech, grandiose
behavior
? Inability to sleep, concentrate or control
impulses
? Flamboyant dress, inappropriate behavior

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? Rule out toxic, metabolic and CNS disorders
? Antipsychotics for acute treatment
? Lithium is treatment of choice (takes a week
for therapeutic onset)
100

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Bulimia Nervosa
? Poor impulse control, fasting
? "Binge-purge" cycle
? Weight normal or increased
? Adolescents

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? Increased drug and alcohol abuse, sexual
promiscuity
Catatonia
? Rigidity, mutism, grimacing, stupor
? DDX: Psych, drugs, CNS, metabolic

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? Risk for dehydration (check labs, tox screen)
? Rule out neuroleptic malignant syndrome
101

---

Delirium
? Clouding of consciousness

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? Severity fluctuates
? Confusion
? Acute, deteriorating course
? Visual hal ucinations
? Abnormal vital signs

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? Rule out
?Electrolyte imbalance
?Hypoxia
?Hepatic failure
?Drug use

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?CNS lesions
102

---

Dementia
? Decreased cognitive functioning
? Decreased memory, judgment, personality

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? Gradual onset
? No clouding of consciousness
? Acute worsening of dementia
?Rule out superimposed medical il ness
Alzheimer's: Age > 65, no focal findings, no

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trauma or stroke, CT shows cortical atrophy
? Multi-infarct dementia
?Focal findings
?CT: lacunar infarcts
103

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Depression
? Poor appetite
? Insomnia
? Loss of interest
? Loss of energy

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? Feelings of worthlessness
? Psychomotor retardation
? Loss of attention span
? Suicidal ideation
? Lifetime suicide risk is 15%

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104

---

Somatoform Disorders
? Somatization
? Repetitive concerns (physical/medical/sexual)
? Numerous physical symptoms with no findings

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? Hypochondriasis
? Physical symptoms disproportionate
? Conviction that one is sick
? Preoccupation with body
? Pursuit of medical care

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? Conversion reaction
? No organic basis; symptoms must include neurologic
complaints
? Inappropriate indifference
105

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Malingering
? Voluntary simulation of disease
? Exaggerated physical symptoms
? Motivated by external incentives
? Frequently associated with litigation

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? Marked disparity of symptoms with objective
findings
? Lack of cooperation with evaluation
? Often antisocial behavior or substance abuse
106

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Munchausen Syndrome
? Repeated fabrication of disease symptoms for the
purpose of gaining medical attention
? Voluntary
? Hospitalization is primary objective

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? Common in healthcare workers
? Demand invasive tests and procedures
? Angry at discharge
? Distinguished from malingering by wil ingness to
undergo painful procedures

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? By proxy: parent, usual y mother, exaggerates,
fabricates or induces medical complaints for their pre-
school child
107

---

Neuroleptic Agents

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Extrapyramidal symptoms
? Dystonia, akathisia (restlessness), tardive
dyskinesia (may be permanent)
Anticholinergic:
? Delirium, fever, dry mouth, erythema, mydriasis

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Alpha blockade:
? Hypotension, syncope
QT prolongation
? Both typical and atypical antipsychotics have been
associated with an increased risk of sudden death

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? Thioridazine (Mel aril) has the highest incidence
108

---

Neuroleptic Malignant Syndrome
? Caused by antipsychotics (not dose related)
? Typical y onset is within two weeks of starting

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? Cause = Decreased dopamine levels and
increased sympathoadrenal activity
? Manifestations
? Fever
? Encephalopathy

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? Vital sign instability
? Elevated CPK
? Rigidity of muscles, "lead pipe" rigidity,
bradykinesia
? Dantrolene or bromocriptine treatment

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109

---

Serotonin Syndrome
? Caused by antidepressants, opioids, CNS stimulants,
triptans, herbs
? Results in excess central and peripheral serotonin

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activity (a neurotransmitter)
? Symptoms:
? Cognitive ? confusion, hypomania, agitation,
hal ucinations, headache, coma
? Autonomic ? shiver, sweat, fever, BP up, HR up, nausea,

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diarrhea
? Somatic ? myoclonus, tremor, hyperreflexia
? No specific lab abnormalities / no CPK
? Rapid onset / responds to serotonin blockers
(chlorpromazine, cyproheptadine)

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? Libby Zion = meperidine + phenelzine
110
11
0

---

Schizophrenia

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? Age of onset 15 to 35 years
? Common in homeless population
? Diagnosis requires symptoms > 6 months
? Delusions, auditory hal ucinations, flat affect
? Disorganized thought processes, bizarre or

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eccentric behavior
? Poor social interactions, poor appearance
111
111

---

Suicide

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? Females attempt more often
? Males succeed more often
? Familial
? Depression is a major risk factor
? Other risk factors: Psychosis, alcohol / drug

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dependence, previous attempts, living alone
? Widowed men at greatest risk
? Detain patient until suicide risk assessment is
complete
? More often in Spring

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112
11
2

---

Involuntary Psychiatric Civil
Commitment

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? Laws vary from state to state
? Can be authorized by court or licensed
physician
? Patient is dangerous to self or others
? Legal risk greater for not committing potential y

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dangerous patient
? Chronic psychosis is not sufficient to commit
113
11
3

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---

Psych Trivia (1)
? Delirium tremens
?Waxing and waning
?Visual and tactile hal ucinations
?Autonomic dysfunction

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?Altered mental status
? Parkinsonism
?Difficulty with balance
?Short- stepped shuffling gait
?Pil -rol ing tremor, masked facies

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?"Cog-wheel" rigidity
114
11
4

---

Psych Trivia (2)

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? Attention deficit hyperactivity disorder (ADHD)
?Inappropriate degree of gross motor activity
?Treatment: methylphenidate, Dexedrine
? Tourette syndrome: Motor and vocal tics
? Night terrors

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?Last 15 minutes
?Screams
?Incoherent speech
?Amnesia
? Pica: Ingestion of non-nutritional substances

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115
11
5

---

NEURO PSYCH QUESTIONS
11 11

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6 6
11
6

---

Which is a sign of depression?
A. Pressured speech

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B. Polydipsia
C. Hearing voices
D. Thought broadcasting
E. Loss of interest in previous activities
NE 1

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---

A 45 year old female presented to the
emergency department reporting
numbness of the left arm and leg. No
medical explanation can be found. Which
best describes her disorder?

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A. Somatization
B. Conversion disorder
C. Psychogenic pain
D. Hypochondriasis
E. Bipolar affective disorder

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NE 2

---

Which of the following is true with
regard to suicide?
A. Males attempt more often
B. Females succeed more often

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C. Widowed men at greatest risk
D. Depression and drug dependence are not
major risk factors
E. Most suicides occur in the winter
NE 3

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---

Which of the following is true of
patients with Munchausen's
syndrome?
A. The individual's acts are involuntary
B. Hospitalization is the patient's primary

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objective
C. They usual y are not healthcare workers
D. They try to avoid invasive tests or procedures
E. They seek narcotic pain medications
NE 4

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---

Which of the following is the most
important consideration in the
differential diagnosis for vertigo?
A. Benign positional vertigo
B. Vertebro-basilar insufficiency

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C. Labyrinthitis
D. Vestibular neuronitis
E. Meniere's
NE 5

---

A 15 y/o female presents following syncope.

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Examination: well-developed, dry mucous
membranes, dental enamel loss. UHCG = neg,
Na+ 130, CO2 = 15, Glc = 52. What is the most
likely diagnosis?
A. Psychogenic polydipsia

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B. Diabetic ketoacidosis
C. Bulimia nervosa
D. Methanol intoxication
E. Anorexia nervosa
NE 6

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---

Which of the following would
be consistent with an organic, as
opposed to functional, cause of acute
psychosis?
A. Age less than 40

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B. Auditory hal ucinations
C. Visual hal ucinations
D. Gradual onset
E. Normal mental status
NE 7

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---

A patient is found to be comatose
with a BP of 260/160 and pinpoint
pupils. Which of the following best
describes this patient's ICH?
A. Thalamic hemorrhage

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B. Pontine hemorrhage
C. Cerebel ar hemorrhage
D. Intracerebral occipital hematoma
E. Intraventricular hemorrhage
NE 8

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---

A patient presents with paralysis involving his
face and arm greater than his leg on the right
side, with sensory findings in the same
distribution. Examination reveals visual field
cuts of the right temporal and left nasal fields.

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This would be most consistent with:
A. Left anterior cerebral artery stroke
B. Left middle cerebral artery stroke
C. Right posterior cerebral artery stroke
D. Left basilar artery stroke

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E. Right anterior cerebral artery stroke
NE 9

---

A patient presents with acute left-sided
hemiparesis involving the lower limb greater
than the upper limb. Sensory deficits have the

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same distribution as the motor deficits. He also
complains of difficulty walking. The most likely
diagnosis is:
A. Right anterior cerebral artery stroke
B. Right middle cerebral artery stroke

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C. Right posterior cerebral artery stroke
D. Left basilar artery stroke
E. Left anterior cerebral artery stroke
NE 10

---

The cauda equina syndrome is

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characterized by which of the
following?
A. It is synonymous with conus medul aris
syndrome
B. Upper motor neuron findings with

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hyperreflexia
C. Compression of peripheral nerve roots S2-S5
D. Saddle anesthesia is present but rectal tone
is preserved
E. Sensory deficits only

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NE 11

---

A 4 y/o is evaluated following a "shaking"
episode. The episode lasted several minutes and
the child now appears normal. He has mild URI
symptoms. Examination reveals a temp of 39.5,

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no meningismus, and he is playful. What is the
most appropriate next step?
A. Perform a lumbar puncture
B. Administer acetaminophen and observe the
patient

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C. Provide Cipro to the ED staff
D. Obtain a CBC, 2 blood cultures and a cath u/a
E. Administer Ceftriaxone 50mg/kg IVPB
NE 12

---

A 40 y/o patient presents with severe headache,

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nausea and vomiting for 24 hours. He reports he
has "never felt anything like it before." His CT
was negative. Which of the following is true?
A. Subarachnoid hemorrhage has been ruled out
with a negative CT at 24 hours.

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B. A negative LP would rule out SAH
C. Xanthochromia wil always be present in SAH
D. MRA is the next most appropriate study/test
E. The patient should be discharged for an
outpatient evaluation

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NE 13

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Which of the following is true of
myasthenia gravis?
A. Myasthenic crisis may lead to respiratory
arrest if untreated

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B. Distal limb weakness is greater than proximal
limb weakness
C. Most have an associated thymoma
D. The tensilon test is associated with SVT and
ventricular dysrhythmias

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E. More common in males than females
NE 14

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A 32 y/o overweight, female patient presents
with chronic severe headaches. CT is negative
and LP is negative except for a markedly

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increased opening pressure. Which of the
following are complications of her condition?
A. Acute monocular blindness
B. Cerebel ar ataxia
C. Homonymous hemianopia

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D. Severe headaches after LP
E. Sixth nerve palsy
NE 15

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Which of the following is most
effective for the treatment of an acute

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migraine headache?
A. Amitriptyline
B. Prochlorperazine
C. Metoprolol
D. Verapamil

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E. Ketorolac
NE 16

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A recommended treatment for bacterial
meningitis in a 10 day old should cover
the following organisms:

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A. Listeria, staph, H. flu
B. Group B strep, enterococcus, chlamydia
C. E. coli, klebsiel a, pseudomonas
D. Listeria, group B strep, E. coli
E. GC, Listeria, E. coli

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NE 17

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Which of the following is consistent
with syringomyelia
A. Usual y involves the lumbar spinal cord
B. Loss of pain and temperature sensation usual y

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occurs in the feet
C. Is associated with migraines
D. Is defined as an expanding central cavity in the
spinal cord
E. CT scan is the most appropriate diagnostic study

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NE 18

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A patient with a peripheral facial
nerve palsy generally:
A. Has anhidrosis
B. Can't move the frontalis muscle

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C. Has decreased sensation on the affected side
D. Has decreased masseter muscle strength
E. Has ptosis
NE 19

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Peripheral CN VII palsy is associated

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with which of the follow entities?
A. Lyme disease
B. CVA
C. Herpetic whitlow
D. Erysipelas

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E. Viral parotitis
NE 20

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Neuro Psych Answer Key
1. E
11.C

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2. B
12.B
3. C
13.B
4. B

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14.A
5. B
15.E
6. C
16.B

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7. C
17.D
8. B
18.D
9. B

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19.B
10. A
20.A

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