Neurology Clerkship – 2002
1. Trauma X-Rays ； Cervical spine, chest, and pelvis
2. Essential Tremor ； Tremor x 6 years, better with alcohol, treat with propranolol 3. Alzheimer Disease ； senile plaques, neurofibrillary tangles, no Lewy Bodies 4. Wernicke-Korsakoff ； not a direct consequence of alcohol
5. Parkinson’s Disease ； resting tremor, shuffling gait, cogwheel rigidity, Babinski is absent 6. Multiple Sclerosis ； periventricular demyelination, bowl and bladder problems, get an MRI of
the brain and spine
7. Cluster Headaches ； one-sided headache, occurs 1 to 3 times per day, causes tearing in one eye 8. Migraine Headaches ； strongest genetic component
9. Subarachnoid Hemorrhage ； 50 year old man comes to the ER with global headache,
meningeal signs, photophobia, worst headache of his life, a normal head CT (false negative), LP
shows blood (could also be an aneurysm – get MRA and/or angiography)
10. Occipital Headaches ； decreased pinprick over occipital scalp, “occipital neuralgia”
11. Absence Seizure ； kid with convulsions, staring spells, unresponsive, treat with VPA 12. Complex-Partial Seizure ； aura, fearful, unresponsive, post-ictal confusion
13. Juvenile Myoclonic epilepsy ； generalized multi-spike waves
14. 30% of epileptics have a normal EEG
15. Horner’s Syndrome ； ipsilateral ptosis, contralateral miosis, ipsilateral anhydrosis, associated
with Pancoast’s tumor
16. 50 year old man with bedwetting, thrashing, and a new onset seizure ； tumor, until proven
17. Brown-Sequard ； ipsilateral motor loss, ipsilateral vibratory and position sense loss,
contralateral loss of pain and temperature.
18. Bell’s Palsy ； peripheral VII lesion (ipsilateral facial ptosis), central VII lesion (ipsilateral
lower facial ptosis)
19. Myotonic Dystrophy ； genetic, difficulty with grip release, alopecia, ptosis, can’t hold puffed
cheeks, hypogonadism, Chr. 19
20. Huntington’s Chorea ； male, autosomal dominant, CAG repeats
21. Myasthenia Gravis ； young female with focal facial ptosis, fatigue, blurred vision (esp. after
use), cannot open eyes at the end of the day – do the Tenselon Test (Give edrophonium 2ml, then
3ml, then 5ml… positive if strength increases with each dose)
22. Guillain-Barre Syndrome ； parasthesia beginning in feet, SOB, decreased vital capacity, mild
distal weakness, “heavy legs”, areflexia, decreased position sense, otherwise healthy, follows GI
infection (campylobacter jejunii) or viral URI ---INCREASED CSF PROTEIN--- 23. Left MCA Stroke ； global aphasia, right hemiparesis, if A. fib is present, wait five days to
24. Subarachnoid Hemorrhage ； worst headache in your life, trauma is the most likely cause 25. Cervical X-ray must clear C1 to C7
26. Most common missed fracture on x-ray ； C2 involving the odontoid process
27. Back Pain History ； ask about bowel and bladder function, sex, did it keep them from work?,
mechanism of injury, rectal exam, treat uncomplicated pain with bedrest x 3 days and NSAIDS 28. Glaucoma ； visual acuity is not reduced, visual fields are reduced
29. Macular Degeneration ； wet vs. dry
30. Corneal Abrasion ； fluoroscein dye and slit lamp exam, pressure patch x 1 day 31. Intraocular pressure should be less than 21
32. Esotropia is “eyes inward” , Exotropia is “eyes outward”
33. Temporal Arteritis ； a.k.a. Giant Cell Arteritis, feel external carotid for lumpiness, diagnosis
requires external carotid biopsy, ESR is usually increased treat with steroids 34. Afferent Pupillary Defect ； lies behind the chiasm
35. Opthalmia Neonatorum ； don’t treat
36. Diabetic Retinopathy ； look for neovascularization, does not affect cup/disk ratio 37. Pink Eye ； treat with sulfacetamide
38. Headache/Pain that awakens one from sleep ； cancer until proven otherwise
39. Abnormal CT Bone ； 35% to 75% bone loss
40. Herniated Disc ； recurrent leg pain with cough or straining, ask about bowel/bladder function 41. Prostate cancer doesn’t go to the brain???
42. Melanoma has the highest incidence of metastasis to the brain 43. Pituitary Adenoma ； young woman, blurry vision, irregular periods, galactorrhea, most
commonly a prolactinoma
44. Epidural Hematoma ； most likely laceration of middle meningeal artery per trauma 45. Skull base fracture with otorrhea or nasal CSF leak ； pack nose or ear with gauze, give
antibiotics, 99% seal on their own
46. CSF electrolytes ； Na = 150, Cl = 120, K = 3, ATP is active
47. Causes of intracranial hemorrhage ； trauma, ruptured aneurysm, AVM, HTN, tumor,
anticoagulation, iatrogenic, infection
Neuro Test Facts
1. Subarachnoid Hemorrhage ； most common cause is trauma, most common spontaneous cause
is rupture of an aneurysm
2. Best study to localize an aneurysm ； angiogram
3. Subarachnoid Hemorrhage Diagnosis ； Try CT first, if negative, then do LP and look for
4. Metastases that bleed ； melanoma, renal cell carcinoma, choriocarcinoma 5. Trauma CT ； usually done without contrast
6. Occipital Neuralgia ； treat with amitriptyline (elavil)
7. Epidural Hematoma ； most common cause is trauma (to the middle meningeal artery, which
passes through the foramen spinosum), usually trauma followed by a lucid period, then problems,
lens shaped, can cause a midline shift
8. Subdural Hematoma ； rupture of bridging veins, often chronic, progressive, if acute then blood
is hyperintense (more so than chronic)
9. Fracture of C2 ； Jefferson Fracture
10. Fracture of C1 ； Hangman’s Fracture (through the pars portion of C2)
11. Overall incidence of Seizure Disorder ； 1%
12. Herpes Encephalitis ； loves the temporal lobe
13. Alkaline Burn of Eye ； immediately irrigate, then irrigate some more
14. Raccoon Eyes ； suggest orbital floor fracture
15. Strabismus ； ocular misalignment (esotropia vs. exotropia)
16. Forbe Albright ； prolactinoma
17. Most common site of HTN hemorrhage ； deep nuclei, internal capsule
18. Last suture in the head to close ； coronal at 30 years
; 42 y/o female s/p CABG, oral contraceptive use, 30 pack year history of cigarettes, increased
LDL…….. Which of these does not effect the risk of CVA? ； Female
; Which systemic tumor doesn’t metastasize to the brain? Prostate (loves the bone, lytic)
; 77 y/o female with history of bump on the head, with subsequent progressive aphasia and
decreased ambulation…..； Chronic Subdural Hematoma
; Blow to the head on a cold day, with resultant rhinorrhea….. This is a basilar skull fracture
(petrosal ridge) ； don’t treat (no ABX), just monitor and wait for spontaneous seal to develop
; What infection causes bleeding in the head? ； Herpes
; Glascow Coma Scale is graded from 3 to 15
; Trauma: Airway, Breathing, Circulation (ABCs)
o CT Scans: usually non-contrast; white = bone; black = air
1. Cervical Spine: AP and Lateral (make sure to include C1 through C7/T1
; Most commonly missed fracture on C-Spine: C2 (AKA “axis”)
; Most commonly fractured part of C2: odontoid
Specific Neurological Conditions
; Multiple Sclerosis
o Best test is MRI of brain and spine
o Periventricular calcifications and plaques
o Ask about bowel and bladder problems
; Amyotrophic Lateral Sclerosis (ALS; “Lou Gehrig’s Dz”): dz of motor neurons
o UMN and LMN signs: Atrophy and fasciculations in UEs initially (LMN dz). Mild
spasticity of LEs, increased DTRs (UMN dz)
o Degeneration of neurons in C-spine and medulla
; UMN signs: spasticity, increased DTRs, upward going toes (Babinski sign). Everything goes up in
Upper MN dz.
; LMN sings: flaccid paralysis, loss of DTRs, fasciculations, downward going toes ; Myasthenia Gravis (MG): an antibody is made to the neuromuscular junction and commonly
occurs in females.
o Signs: fatigue with repetitive use, ptosis, diploplia, dysarthria, NO atrophy or decreases in
o Dx: Tensilon test (injections of increasing doses of edrophonium. + test is increased
strength with increasing dosage).
; Gullian Barre: polyneuropathy of unknown cause vs. immune mediated. This is the acute onset of
a neuropathy with progressive proximal weakness that starts distally and moves proximally. It is
often secondary to a viral URI, immunizations, or surgery. Onset is 3 days to 5 weeks later.
o Signs: healthy individual, SOB, decreased VC, “funny” sensation in hands and feet,
trouble walking, heavy legs, areflexic, decreased proprioception.
o Pathophysiology: segmental demyelination, increased CSF protein without pleocytosis. ; Alzheimer’s Dz: #1 cause of dementia (multiple infarcts is the second).
o Pathophysiology: neurofibrially tangles, senile plaques, granulovacular degeneration,
decreased acetylcholine in the amygdala (estrogens and NSAIDS may help). ; Parkinson’s Disease: decreased dopamine in substantia nigra to striatum, basal ganglia. Lewy
bodies are present.
o Signs: early on, a decrease in arm swing with gait, increased tone in flexors and extensors,
resting tremor, “pill rolling” hand movements, shuffling gait, cogwheel rigidity,
bradykinesia, no babinski and no UMN signs.
; Essential tremor: a tremor for at least 6 years that improves with wine or alcohol. Treatment of
fine tremors is propranolol, EtOH, or primdone. Course tremors are best treated with valium. ; Huntington’s Chorea: chromosome #4, males, AD
; Forbes-Albright Syndrome: prolactinoma (pituitary adenoma).
o Sxs: HA, blurry vision, irregular periods, breast discharge
; Myotonic Dystrophy: chromosome 19
o Signs: atrophy of facial and neck muscles, weak soft voice, puffy cheeks, balding,
hypogonadism, ptosis, can’t release hands upon shaking.
; Bell’s Palsy: CN VII (facial)
o Peripheral Lesion: loss of unilateral face and forehead-weakness, can’t wrinkle forehead;
may present with pain behind the ear. Tx: 80% benign and will recovery within weeks to
months. Recommend covering the affected eye at night since you can’t close your eye.
Steroids have a questionable role.
o Central Lesion: forehead sparing.
; Wernicke-Korsakoff: effects of severe sustained thiamine depletion in the face of continued
caloric intake, it is not a direct result of EtOH consumption.
o Pathophysiology: axonal demyelination with neural loss, glial loss, endothelial thickening,
pretectal pericapillary hemorrhages; at higher levels the mamillary bodies, mediodorsal
thalamic nuclei, and scattered cortical regions suffer, especially the hippocampus.
o Signs: ocular palsies, ataxia, drowsy, dysarthric, loss of recent memory, confabulations. ; Horner’s Syndrome: sympathetic: ptosis, myosis, anhydrosis. Usually secondary to a pancoast
tumor of the lung.
; Carpal Tunnel: entrapment neuropathy of the median nerve
o Signs: pain and paresthesias of the hands/digits; Tinel’s sign; Phalen’s sign; pain is worse
at night and is relieved by shaking the hand.
o Tx: surgical section of the transverse carpal ligament.
; Stupor: a state of psychological unresponsiveness that can be interrupted only by vigorous and
sustained external stimulation (sternal rub)
; Coma: an eyes closed state of unarousable, sleeplike behavior in which patients lack any
recognizable evidence of awareness of inner thoughts or outer events.
o Metabolic Causes:
; Exogenous psychoactive drugs or poisons
; Anoxia or ischemia
; Mixed enceophalopathies, pathologic aging, systemic infections, etc…
; Hepatic, renal, pulmonary, or pancreatic insufficiency
; Meningitis, encephalitis
; Multifocal, small structural lesions, ie. Mets, emboli or thrombi
; Concussion and postictal states
; Ionic and electrolyte imbalances
; Nutritional def: thiamine
; Hx and Exam of Comatose Pt:
o Eval of motor and neuroophthalmogic signs plus an appraisal of the initial breathing
o Brain imaging
o Systemic studies of blood, urine, CSF, and others when indicated.
; Decorticate Rigidity (abnormal flexor response):
o This posture implies a destructive lesion of the corticospinal tracts within or very near the
cerebral hemispheres. When this is unilateral it is the posture of chronic spastic hemipleiga ; Decerebrate Rigidity (abnormal extensor response):
o This posture may occur spontaneously or only in response to external stimuli such as light,
noise, or pain. It is caused by a lesion in the diencephalon, midbrain, or pons. Although
severe metabolic disorders such as hypoxia or hypoglycemia may also produce it. ; Lesion of the medial longitudinal fasciculus (MLF):
o The MLF connects CN III to CN VI. Lesions cause internuclear ophthalmoplegia. With
this lesion, the eyes at rest may either be parallel or show a mild skew deviation but move
disjunctively on lateral gaze. During lateral gaze toward the side of the MLF lesion, the
ipsilateral eye abducts and shows nystagmus, the contralteral eye partly or completely fails rdto move nasally because of absence of ascending impulses to reach toe opposite 3 nucleus.
May be caused by infarct from vessel dz or by demyelinating dz.
; Pupillary Light Reflex:
o Afferent Limb: CN II
o Efferent Limb: CN III
o Ganglion cells of the retina project bilaterally to the pretectal nuclei; pretectal nuclei of the
midbrain projects to the EW nucleus of CNIII, which gives rise to the preganglionic
parasympathetic fibers, which synapse in the ciliary ganglion. The postganglionic
parasympathetic fibers innervate the sphincter of the muscles of the eye. ; Corneal Reflex:
o Afferent Limb: CNV
o Efferent Limb: CN VII
; Facial Nerve (CNVII):
o The lower part of the face normally is controlled by UMN only on one side of the cortex-
the opposite side
o The upper face is controlled by pathways form both sides of the cortex (lesion of the right
cortex ； can’t move Left lower face, but can move left upper face.
Spinal Cord Injuries (Bowel, Bladder, Rectal)
; Herniated Disc/Nucleus Pulposis: lateral leg pain with cough and sneeze; ask about retention and
incontinence. Tx: supportive, will get better with time. Donut to sit on. ; Back/Disc Pain: ask about bowel/bladder changes, sexual function. Do a rectal exam, palpate the
spine and look for paravertebral spasm. The discs start to degenerate around the age of 8.
o Tests: lumbar spine X-ray
o Tx: symptomatic with NSAIDS, bedrest for 2-3 days, then mobilize
; Brown-Sequard Syndrome (incomplete transection of the spinal cord). Patient was stabbed in the
left side of the back.
o Left leg: weakness, hyperreflexic, decreased proprioception, intact pain and temp
o Right Leg: decreased pain and temp, intact strength, reflexes, and proprioception.
o Check bulbocavernosus reflex and rectal sphincter tone
; Intraocular pressure: normally less than 20 mmHg
; Glaucoma: > 20 mmHg; no change in visual acuity
; Presbyopia: loose elasticity in the lens; you can’t see things close up
; Afferent Pupillary Defect (APD) (Marcus Gunn): damage to unilateral optic nerve ; Ophthalmia Neonatorium: no tx needed and will resolve spontaneously. ; Conjunctivitis: treatment is sulfacetamide
; Alkaline Burn: flush eyes with copious amounts of water
; Amblyopia: subnormal visual acuity in one or both eyes; won’t grow out of it
; Strabismus: abnormal ocular interaction or misalignment
; Orbital Fracture: sunken eyes, no roof involvement
; Diabetic Retinopathy: no cupped disc
; Macular Degeneration, corneal abrasion
; Esotropia: deviation to the inside
; Exotropia: deviation to the outside
; Epidural Hematoma: rupture of the middle meningeal artery (enters skull – Foramen spinosum).
1. Lateral Skull Fx, medical emergency because of the rapid bleeding
2. Sxs: progression from transient LOC to lucency then to coma.
3. Signs: fixed, blown pupil (secondary to uncal herniation and compression of CNIII
4. Tests: CT will show a lens shaped convex hyperdensity
; Subdural Hematoma: rupture of the bridging veins after head trauma (hx of fall). It is more
insidious, if acute the prognosis is dismal. Remember: geriatric patients can get these by simple
5. Signs: HA, change in MS within days to weeks. If chronic, it can present as a dementia
or aphasia. Contralateral hemiparesis (decreased ambulation).
6. Tests: CT will show a crescent shaped, concave hyperdensity. If it is chronic the fluid
will be darker, if acute the fluid is brighter.
; Subarachnoid Hemorrhage (SAH): most common cause is trauma. Most common cause of
spontaneous SAH is aneurysm rupture.
7. Signs: worst HA of life, HA everywhere, stiff neck, photophobia
8. Tests: CT, if normal (only 4% false negative), then proceed to LP to look for blood. If
you suspect an aneurysm then get an MRA (4 vessel angiogram).
; Basilar Skull Fx: CSF leak and otorrhea, rhinorrhea. There is no tx, give 4x4, 94% will
; Intracranial Hemorrhage (causes):
2. Ruptured aneurysm
3. A/V malformation
6. Anticoagulation therapy
8. infection (herpes)
; Herpes Virus: invades the temporal lobe and can cause bleeding in the head.
; Mets to the CNS that bleed: melanoma, renal cell carcinoma, choriocarcinoma
; Highest incidence of mets to CNS: melanoma (systemic tumor that doesn’t go to brain-prostate)
Case: 42 yo female that is s/p CABG, OCP use, 30 PYH, increased LDL. Which of the following does not affect risk of CVA: female.
Case: Patient with BP of 270/120 presents with sudden onset hemiplegia. Dx: HTN hemorrhage at the internal capsule. Tx is to reduce the BP to a premorbid state but don’t let it get too low.
Case: Global aphasia with right hemiparesis, lucency in right middle cerebral artery with ECG showing A. fib. Tx is to wait five days to heparinize.
Case: Female patient with HTN, dizziness, orthostatics, going for surgery on carotids and on Minipress (prazosin) as an anti-HTN medication.
Dx: side effect of medication Tx: give different medication
; Cluster HA: male with unilateral intense HA, occurring 1-3 times per day with watery eyes and
nose, Horner’s syndrome, eyelid edema and conjunctival injection.
o Tx: prophylaxis with Ca channel blocker, ergotamine, lithium, or prednisone.
; Migraine HA: genetic component
; Temporal Arteritis: usually > 55yoa, HA in temporal region, visual loss, increased ESR.
o Dx: temporal artery biopsy Tx: steroids
; Occipital Neuralgia: chronic occipital HA, sharp, decreased pinprick, otherwise nml
o Tx: amitriptyline
Case: Pt with HA waking him or her at night is cancer until proven otherwise. The work up includes an X-ray (need 35-75% bone loss to see anything) and CT may be abnml.
; Overall incidence of seizure disorder is about 1%.
; EEG: 30% of epileptics will have a normal EEG
; Complex-Partial Seizure: 16 yo with strange sensation, fearful, unresponsive, postictal confusion.
; Juvenile Myoclonic Epilepsy: generalized multi-spike waves
; Generalized Seizures: 12 yo male with convulsions, postictal staring and unresponsiveness. Tx is
; Seizure Treatments
o Partial: tegretol, dilantin, depakote
o Generalized: depakote
o Absence: zerontin (ethosuxamide) and depakote
Case: shaking arm after studying for test ； possible seizure ； ER for CT or MRI
Case: adult with bedwetting, thrashing, new onset seizure: tumor until proven otherwise. Get an MRI.
; CSF production is an active (ATP requiring) process with absorption being passive (gradient from
subarachonid space vs. sagittal sinus. Contents include Na of 150, K of 3.0 and Cl of 120.
; Last suture in the skull to close is the coronal
; If a victim is behind the steering wheel in an accident and you see them. The correct response for
the test is to drive on by.