UWORLD

Main Division: Medicine

Sub Division: Neuro System Optha

Topic
Aminoglycoside Toxicity

FEATURES
Otoxicity (damage cochlear cells)
Oscillopsia (sensations of objects moving around visual field)
Esp Gentamycin can cause hair cell damage-->vestibuopaty
has abnormal head thrust
Anticholinergic toxicity
Hot as a hare, dry as a one, red as a beet, blind as a bat,
mad as a hatter (confusion). HA, tachy, constipaton, dizzy
Atropine, Parkinsons drugs:Benztropine, Trihexyphenidyl
antiplatelet/antithrombotic Tx: IV: altepase
Ischemic stroke:
A w/in 3-4.5h of symp, no CI
antiplatelet/antithrombotic Tx: ASA
Ischemic stroke:
B w/in 3-4.5h of symp, no CI
antiplatelet/antithrombotic Tx: ASA + dipyridamole/Clopidogrel
Ischemic stroke:
C stroke on ASA
antiplatelet/antithrombotic Tx: ASA + clopidogrel
Ischemic stroke:
D stroke on ASA + intracrania
larger artery atherosclerosis
antiplatelet/antithrombotic Tx:
Ischemic stroke:
E stike with evidence of Afib
B12 deficiency
Brain death

Cavenous sinus thrombosis

Cerebellar dysfunction

Long term anticoagulation (warfarin, dabigatran, rivaroxaban

Decreased b12 level, increacsed methylmalonic acid levels

Clinical diagnosis
absent cortical and brainstem functions
spinal cord may still work (reflexes)
HA, bilateral periorbital edema, CN III/IV/V/VI deficits
Common in Etoh users
Truncal ataxia, nystagmus, intention tremor, dysdiadochokinesia, hypotonia, pendular knee swing after DTR

TREATMENT

UWORLD
Main Division: Medicine

Sub Division: Neuro System Optha

CEvsCMvsSCC:
spinal cord compression

Gradual worsening back pain, worse at night

early: Symmetric LE weaking, hypo/absent DTR
Late: Bilateral babinsky, sensory, loss, absent rectal tone,
Urinary retention
Immediate neurological (surgical) evaluation
MRI and possibly high dose gluccocorticoids

CEvsCMvsSCC:
Cuada equina syndrome

Usually bilateral, severe radicular pain

saddle hypo/anesthesia
hyporeflexia/areflexia
Asym motor weakneses
late bowel & bladder dysfx
sudden severe back pain
Hyperreflexia
Perianal hypo/anesthesia Early onset & bladder dysfx
Sym motor weakness
Sym distal sensory neuropathy, stocking glove pattern
common agents: plantinum agents (ie cisplatin)
taxanes (ie Paxitaxel), vinca alkaloids (vinacristine)
halmark of prolonged sz, >5min seizure
MRI: cortical hyperintensity on diffusion weighted imaging
suggests infarction
Hyperdense (white)
Hypodense
Suggestive of brainstem compression
Hypertension, bradycardia, respiratory distress
CT: minute punctuate hemorrhages with blurring of
grey white interface but MRI more sensitive
Traumatic brain injury freq from traumatic deceleration -->
vegetative state
Magnetic (freezing): start and turn hesitation
Causes: frontal lobe degeration, hydrocephalus, dimentia
Ataxic: staggering wide base
Causes: Stroke, Drug/Etoh intox, B12 deficiency
Waddling
Short shuffling step, narrow-based,
stooped position, immobile arm movement
Cause: parkinsons

CEvsCMvsSCC:
Conus medullaris syndrome
Chemo induced
peripheral neuropathy
Cortical laminar necrosis

CT: radiology: Brain hmrge

CT: radiology: Brain Infarct
Cushing reflex
Diffuse axonal injury

Gait: Apraxia (frontal gait)

Gait: Cerebellar
Gait: Musclar dystrophy
Gait: Parkinsonian

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Main Division: Medicine
Gait: Sensory ataxia
Gait: Steppage

Gait: vestibular
Glioblastoma Multiforme
Heat Stroke

Idiopathic Intracranial HTN

(Pseudotumor cerebri)

Internuclear opthalmoplegia

Intracranial hypertension

Leision: Hemorrhage:
Basal Ganglia (putamen)
Leison: Hemorrhage:
Cerebellar

Sub Division: Neuro System Optha

Wide-based high-stepping gait
cause: peripheral nerves, doral root, post. Columns lesion
Foot drop, excessive knee & hip flex, slapping, falls
Causes: motor neuropathy (MC L5 radiculopathy
common peroneal nerve)
Unsteady, falling to one side
Acute labrynthtitis, meniere disease
CT/MRI: Butterfly appearance with central necrosis
heterogenous, serpiginous contrast enhancement
Acute confusion
Core body temp >40c
Coagulopathic bleeding
Tachycardia
Tx: ice cold bath
Increased ICP (Papilledema) in Alert pt
Obese, female, childbearing age with HA
Possible link to meds: GH, tetracyclins, hyper vit A, OCP
DX: LP: Nml CSF analysis with >250mmH20 pressure;
No focal neural deficit, may w/ diplopia, transient vision loss
Pulsatile tinnitus "wooshing", CN VI palsy
Characteristic of MS
Demyelination of MLF:
(Medial Longitudinal Fasiculus)
ipsilateral eye cant adduct on lateral gaze
Contralat eye has nystagmus
HA (worse at night), AMS, N/V, papilledema, focal neuro def
cushing reflex worrisome for brainstem compression
Homonymous hemianopsia
Gaze palsy
Contralateral hemiparesis & hemisensory loss
Usually NO hemiparesis
Ataxia
Neck stiffness
Facial weakness
Nystagmus
Occipital HA

Acetazolamide:(-) choroid
plexus carbonic anhydrase
Wt loss Stop offending agent
shunting or optic n. sheath
fenestration to prevent
blindness

UWORLD
Main Division: Medicine

Sub Division: Neuro System Optha

Leison: Hemorrhage:
Cerebral lobe

Fontal lobe: contralateral hemiparesis

Parietal lobe: contralateral hemisensory loss
Occipital lobe: homonymous hemiamopsia
Eyes deviate AWAY from hemiparesis High incidence of sz
Leison: Hemorrhage: Pons
Deep coma & total paralysis within minutes
PINPONT reactive putils
Leison: Hemorrhage: Thalamus Eyes deviate TOWARDS hemiparesis
Up-gaze palsy
Non-reactive miotic pupils
Contralateral hemipareis and hemisensory loss
Leison: Lacunar Infarct:
Pure motor hemiparesis
Internal capsule posterior limb Mild dysarthria (slurring)
Leison: Lacunar Infarct:
Dysarthric clumsy hand
Internal capsule genu
Leison: Lucunar Infarct:
Ataxia hemiplegic syndrome
Base of Pons
Weakness more in LE; incoordination of UE & LE
Lesion: Lacunar infarct
RF: old age, smoking, DM, HTN-->lipohyalinotic thickening
No cortical signs
Lesion: Lucunar infarct:
Pure sensory stroke
VPL and VPM in thalamus
Metoclopramide Side Effects
Metoclopramide is a dopamine agonist --> watch out for EPS Treat dystonia with
side effects
Benztropine
Dyphenhydramine
Multiple system Atropy
Parkinsonism + orthostatic hypotension, incontinence,
(Shy-Dragger syndrome)
impotence, or other autonomic dysfx
Myopathy:
Glucocorticoid induced
Neurofibromatosis 2 mutation

Painless proximal muscle weakness mostly in LE

ie difficulty getting up from chair
No inflammation, ESR & CK normal. Will stop with meds
AD, acoustic schwanoma bilateral, NF, caf au lait
Severe variant: wishart from non-sense mutation
Mild variant: gardner from missense
Silent of same sense make no change
MRI with gadolinium to see acoustic neuroma

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Main Division: Medicine
Ophta: subconjuntival hmrg

Optha: Amurosis Fugax

Optha: ant uveitis (irisitis)

Optha: endopthalmitis
Optha: episcleritis
Optha: herpes zoster
opthalmicus
Optha: keratitis: HSV

Optha: Ketatitis:
contact lens associated
Optha: Retinitis: Aids patient

Optha:Keratitis: viral
Restless leg syndrome

Sub Division: Neuro System Optha

caused by trauma or valsalva
well demarcated area of extravasated blood
most are benign and need no treatment
Painless, transient vision loss "curtain falls"
Impending stroke warning--> most like from retinal emboli in
ipsilateral atherocsclerotic carotid artery
Get US/duplex of neck; most emboli from carotid bifurcation
Cholesterol bodies (hollenherst bodies) may be seen
infection of uveal tracts
Pain, miosis, photophobia
Invasive infection of eye 2/2 disruption of external surface
Purulent haziness, hyopyon pus in anterior chamber
localized patchy red eye with mild pain
self limited, no cornea involvment, may be rltd to RA
Dendritic ulcers and vesicular rash in trigeminal distribution
tx w/in 72h with high dose acyclovir to prevent complication
Most common cause of corneal blindness
characteristics are vesicular and dendritic ulcers
epithelial scrapings show giant multinucleated cells
associated with outdoor workers, too much sun,
immunodeficiency, fever. TX antivirals (oral or topical)
Most cases from gram (-) pseudomonas & serratia
painful red eye, opacification, and ulceration of cornea
Treat with broadspectrum abx
VZV & HSV: pain, keratitis, uveitis
Fundoscopy: Peripheral pail lesions w central retinal necrosis
CMV: Painless, not usually assoc w keratitis on conjuntivitis
Fundoscopy: fluffy granular lesion around retinal vessels
Corneal infx related to HSV, VZV
vesicles, opacification, dendritic ulcers
urge to move legs w/ dysesthesias, exacerbated by
no movement, better with movement, worse at night
Tx: Dopamine agonist Pramiprexole, alpha 2 gama
ca channel ligands ie (gabapentin)

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Main Division: Medicine
Riley Day syndrome
Spinal epidural abscess

Stroke type:
Intracerebral hemorrhage

Stroke type:
Spontaneous SAH
Stroke type: Ischemic:
Embolic
Stroke type: Ischemic:
Thrombotic
Tick-borne paralysis
Ulnar nerve syndrome

Upper Thoracic Spinal Lesion

Vertigo cause:
Vestibular Neuritis
Vertigo cause: BPPV
Vertigo cause: Labrynthitis
Vertigo cause: Meniere

Sub Division: Neuro System Optha

Famila autonomia, AR, Ashkenazi Jews child
Orthostatic hypotension, gross dysfx of autonomic syndrome
Triad: Fever, focal back pain, neurological deficits
RF: IV drug use, immunocomp, infections spread from
contigous/distant source, spinal trauma or surgery
use MRI with gadolinium
Abx, surgical decompression, drainage
Hx uncontrolled HTN, illicit drug use, coagulopathy
Symptoms progress from minutes to hours
Focal neuro symp early ff by Inc ICP symp
(vomiting, headache, bradycardia, decreased alrerness)
Rupture of saccular berry or AVM
Severe HA at onset of neuro symp(vs intracerebral hmrg)
Menigeal symptoms; focal neural def uncommon
History of cardiac disease
Symptoms aburpt & maximal from the start
Multiple infacts within different vascular territories
Atheroslcerotic RF +/- TIA; LOOK for carotid bruit
Local insitu obx of artery; symptoms fluctuate, stuttering
progressing w periods of improvement
Rapidly progressive (hours) ascending paralysis
No fever, no autonomic dysfx, normal csf (vs GBS)a
Decreased sensationof 4th and 5th finger, weak grip due to
interosseous muscles
MC site entrapment: medial epicondylar grove (elbow)
Paraplegia, bladder & fecal incontinence
Absent sensation nipple down
Due to viral syndrome
NO hearing loss
Single severe episode of vertigo Patient falls to lesion
Recurrent brief episodes brought on by predictable moves
Epley maneuver
Dix-hallpike causes nystagmus
Dislodged otolith
N/V
Nystagmus
Hearing loss
Preceeded by a URI
Vertigo
Unilateral hearling loss (low freq)
Salt restriction
Tinnitus
Ear fullness
Thiazides

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Main Division: Medicine
Vitreous hemmorhage
Warfarin induced cerebral
hemorrhage
Wernicke's Encepholopathy

Sub Division: Neuro System Optha

Sudden loss of vision, onset of floaters, hard to visual fundus
MC cause: diabetic retinopathy
Reverse with IV vitamin K and prothrombin complexconcentrate. Fresh frozen plasma maybe used if no PCC
Thiamine (B1) def, seen with alcoholics
Encepholapthy, oculomotor defect, gait ataxia
Administer thiamine