Dr.
HY Neuro
Stroke (top 3 causes of death after MI and cancer)
● 2 Greatest RF for stroke: Age and HTN
● TIA: stroke Sx < 24 hour and Sx resolve w/in 24 hr; reversible bc no actual infarction
(clot resolves or there’s collateral circulation)
○ Amaurosis fugax - ophthalmic artery emboli - transient curtain-like blindness
● Ischemic strokes (85% of strokes)
○ Tx: TPA within first 3 hours of onset (can’t use w hemorrhagic), but if post 3
hours: aspirin
● Hemorrhagic strokes
○ Causes: trauma, ruptured berry aneurysm, arterialvenous malformation
○ Subarachnoid hemorrhage: thunderclap headache (worst headache of their life)
■ Sx of intracranial pressure (papilladema, nausea, projectile vomiting,
headache)
■ Stroke Sx with headache, nausea and vomiting -> increased ICP ->
hemorrhagic stroke
● Tx to lower ICP: 1. Hyperventilate (vasoconstriction ->
regulate CO2 in tissues) 2. Mannitol 3. Elevate head of bed
■ Berry aneurysm (MCC subarachnoid hem) is associated with AD
polycystic kidney disease (ADPKD)
● Tx: surgical clipping
■ Dx: CT head w.out contrast, but if not clear then -> Lumbar Puncture
showing xanthochromia (RBCs in it)
● Lacunar strokes: in deep subcortical (basal ganglia, internal capsule, or thalamus)
○ MCC: HTN -> arterial sclerosis -> poor perfusion -> over time with healing ->
lacunes -> lacunar stroke
○ Pure sensory stroke: infarction of thalamus (VPL)
○ Pure motor stroke: infarction of internal capsule (upper and lower motor neuron
fibers converge here)
■ UE and LE paralysis; complete hemiparesis
● Workup for all strokes:
○ First step: Head CT without contrast
■ Only time CT without contrast: kidney stones and for stroke (bc contrast is
white and so is blood)
○ Find source of stroke:
■ Carotid doppler: check for stenosis from atherosclerotic disease,
predisposes to thrombosis
■ Echo: check for wall motion abnormalities because can predispose to
thrombus -> emboli due to stasis promoting hypercoagulability
● Virchow’s triad: 1. Stasis 2. Endothelial damage 3.
Hypercoagulable state
■ EKG: because AFib (irregular R-R intervals with no clear P waves) atria
isn’t contracting well, so more prone to thrombosis
● If AFib -> CHA2DS2VAS score; <2: aspirin, 2 or more: warfarin
● CHA2DS2VAS (all 1 point except *): CHF/LV dysfunction, HTN,
Age 75 or more* (2 points), DM, stroke/TIA/thrombo-embolism* (2
points), vascular disease, age 65-74, sex (female)
● Usually happen in the MCA
○ Middle parts of brain by longitudinal fissure controls lower extremities
■ ACA supplies
○ Outer parts control upper extremities
■ MCA supplies
○ Left MCA supplies language areas of the brain
■ With left MCA stroke: language deficit, right arm weakness and sensory
loss; UMN deficit (hyperreflexia)
Language
Broca’s
● In left inferior frontal lobe
● Broca’s (expressive) aphasia: can understand, can’t put it into words
Wernicke’s
● In temporal lobe
● Wenicke’s aphasia: Word Salad; Can’t understand what you’re saying, but can speak
real words they just don’t make sense
Anatomy
Left Hemisphere (Dominant)
● Controls language (aphasia)
Right Parietal Hemisphere
● Causes hemineglect
Treatments
● Carotid stenosis (>70%) and Symptomatic (syncope, TIA): Tx with carotid
endarterectomy
○ If < 70%: Tx with aspirin
● Hypertensive emergency Tx: 1) nitroprusside 2) labetalol 3) hydralazine
● To Dx Tourette’s need a motor and phonic tic for at least 1 year
○ Tx: clonidine, guanafacine, or 2nd gen antipsychotic
● Essential tremor (familial intention tremor): worsens with movement, better at rest,
usually have a fam Hx and usually goes away with drinking alcohol
○ Tx: beta blocker
● Friedreich’s (GAA) ataxia: scoliosis, HOCM, dorsal column problems
○ HOCM: IV septum is thickened bc poor outflow -> poor perfusion to the brain ->
syncope (young athletes)
Delirium
● MCC in elderly: infection, poly pharmacemia (benzos or antimuscarinics)
○ Ex: elderly with UTI or taking benzos, showing periods of waxing and waning of
consciousness (sleepiness then agitated then sleepy….)
■ Dementia they’re constantly out of it
○ Sundowning: worse at night
○ Tx when agitated: haloperidol
Conditions
● Multiple sclerosis: central nervous system autoimmune disease
○ Affects upper motor neurons (spastic paralysis, urinary
incontinence, blindness that all come and go)
○ Sx spread out through space and time
○ MC in young female caucasian in her 20s with history of
blindness that was transient and now has spastic paralysis
and urinary incontinence
○ Charcot’s Triad of MS (SIIN): scanning speech, internuclear
opthalmoplegia, intention tremor, nystagmus
○ Dx: MRI see periventricular plaques; LP: oligoclonal bands
(IgG antibodies specific for MS)
○ Tx: 1) disease-modifying - interferon 2) acute flare - steroids
● Guillain barre: peripheral nervous system autoimmune disease
○ Pt who had a URI or severe infectious diarrhea (campylobacter) and then get
weakness and ascending paralysis
○ Tx: IVIG or plasmapheresis
● Myasthenia gravis: ACh antibodies attacking NMJ
○ MC: Young female
○ Sx: ptosis, weakness of head, problems swallowing,
weakness that gets worse throughout the day
○ Deep tendon reflexes normal
○ Dx: edrophonium test Ach-esterase inhibitor, relieves Sx
temporarily
■ After diagnosing, do CT of thorax bc often
associated with a thymoma that produced the
antibodies
○ Tx: pyridostigmine
● Lambert Eaton
○ Sx get better with muscle use
● Duchenne muscular dystrophy (X-linked recessive)
○ Missing dystrophin
○ Sx: Gowers sign - use hands on legs to stand up
○ MC in 5 y old
● Beckers muscular dystrophy
○ MC in 18-20 y old
● Tuberous sclerosis
○ Sx: ASHLEAF
(L- ashleaf, R-shagreen)
facial angiofibroma
● Sturge weber syndrome
○ Sx: port wine stains and intellectual disability
● Von hippel lindau
○ Sx: renal cell carcinoma, pheochromocytoma, cavernous hemangiomas of the
brain
● Arnold chiari malformation type 2
○ Myelomeningocele, tonsillar herniation, syrinx (fluid-filled cyst in central canal
of SC that puts pressure on spinothalamic neurons) usually in cervical spine
■ Loss of pain and temperature along arms
b/l (cape-like distribution)
● Brown sequard
○ Usually caused by stab wound that hits side of the
spinal cord (transaction of one part of SC)
○ Sx: ipsilateral paralysis (CS tract), ipsilateral loss of
pressure, proprioception, vibration and touch (DC
tract), and contralateral pain and temperature
○ Ex: stabbed on right -> loss of motor and touch on
right, but loss pain/temp on left
● Polio: damage to anterior horn cells (corticospinal tract
synapses here)
○ Only affects LMN (fasciculations, flaccid paralysis, hyporeflexia)
■ Note: UMN injury would have spastic paralysis (stiff) and
hyperreflexia
■ MS = UMN, Guillain and Polio = LMN
● Amyotropic lateral sclerosis (lou gehrig): ALS is UMN and LMN
○ Ex. flaccid paralysis with hyperreflexia
Spinal tracts
● Corticospinal tract (descending, 2 neuron): motor control
○ Starts in cortex -> internal capsule -> deccusates at pyramids (around medulla)
and crosses to other side -> travels down SC -> synapses at lamina 9 at anterior
horn (LMN)
● Dorsal column tract (ascending, 3 neuron): senses pressure, proprioception, vibration,
and touch
○ 1st motor neuron comes at SC and travel up dorsal column of SC (fasciculus
gracils for lower extremities, cuneatus for upper extremities) -> synapses on
nucleus gracilis or cuneatus around medulla level and crosses -> up to thalamus
where VPL is -> cortex
● Spinothalamic tract (ascending): senses pain and temperature
○ Feeds into SC through posterior horn of SC and synapses then crosses at that
level -> comes up through contralateral side and synapses again in VPL -> cortex
Syncope/Dizzy Conditions
● Benign paroxysmal positional vertigo (BPPV)
○ Sx: when they lie down or move head sudednly, have room spinning sensation
and nausea; positionally dependent
○ Dx: dix-hallpike test: turn head to look for nystagmus
○ Tx: meclizine
● Causes: vasovagal, orthostatic hypo, AS, seizures, arrhythmias
○ Need good history to Dx
● Vasovagal syncope (MCC of syncope)
○ Patho: have increased sympathetic tone or BP -> perfuse carotid sinuses, but
reflex doesn’t work well and vagal response to increased pressure in carotid
sinus is too strong -> Strong sympathetic tone followed by strong
parasympathetic tone
■ Tachy and HTN from stressor then have bradycardia and hypotension ->
syncope
○ Have a prodrome (feel not well before fainting - diaphoresis, headache, not
feeling well)
○ MC in someone standing a long time or experiencing emotional stressor
● Orthostastic hypotension
○ MC in volume depleted (dehydrated) and when suddenly stand the venous return
is slow to come back, slow brain perfusion -> syncope
● Aortic stenosis
○ Syncope with exertion
● Seizures
○ Wake up confused (postictal confusion), urinary incontinence, tongue biting, and
convulsions
○ Complex partial seizure vs absence difference: absence don’t have postictal
confusion, if confused after then complex partial
■ Both have lip smacking and staring into space
■ Tx: ethosuximide
● Arrhythmia
○ MC in older person who fainted out of nowhere even when sitting, but were fine
when they woke up
Ear Problems
● Menier’s disease:
○ Problem with pressure in endolymph
○ Sx: tinnitus, vertigo, and hearing loss
● Labyrinthitis: viral infection prior to hearing loss
Dementia
● Lewy body dementia: hallucinations then memory loss or parkinsonian symptoms
● Parkinsons also has lewy body
○ Slow shuffling gait with pill rolling tremor and dull-like facies
○ Tx: carbidopa levodopa
● Alzheimer's: memory loss then hallucinations
○ Acetylcholinesterase inhibitors: galantamine, donepezil, rivastigmine,
memantine
■ Grandma doesn’t remember meman
● Tic Douloureux: trigeminal neuralgia
○ When brushing teeth or chewing feel electricity around V3 dermatome, even wind
will cause intense pain
○ Tx: carbamazepine (sodium channel blocker)
● Tabes doralis: damage just to dorsal columns
○ Secondary to tertiary syphilis
○ Painless chancre, rash on palms and soles, condyloma lata, neurosyhpilis (tabes
dorsalis, syphili aortitis, gummas)
○ Tx: penicillin
● Subacute combined degeneration: 2ary to B12 deficiency
○ Macrocytic anemia, megaloblastic anemia with hypersegmented neutrophils,
dorsal column and corticospinal tract problems (UMN injuries)
