NEUROLOGY TiKi TaKa

_____________________
. HEMORRHAGE -> HYPER-dense areas on CT. (WHITE).
. INFARCTIONS -> HYPO-dense areas on CT. (BLACK).
. GAITS IN NEUROLOGY:
_____________________
1. FESTINATING ----> PARKINSONISM:
___________________________________
(Mask face - bradykinesia - resting tremor - rigidity).
. N.B. PARKINSONISM's gait -> FESTINATING = HYPOKINETIC = SHUFFLING.
2. HIGH STEPPAGE --> TABES DORSALIS:
_____________________________________
(Neuro$ - Loss of proprioception - +ve Romberg sign).
3. SEMI-CIRCLE ----> STROKE HEMIPLEGIA:
_______________________________________
(Adducted affected arm & Extended affected leg).
4. WADDLING -------> MUSCULAR DYSTROPHY:
_________________________________________
(Weakness of gluteal muscles).
5. WIDE BASED & SHUFFLING -> NORMAL PRSSURE HYDROCEPHALUS:
___________________________________________________________
(Urine incontinence & dementia).
6. IPSILATERAL ATAXIA -> CEREBELLAR ATAXIA:
____________________________________________
The pt tends to fall towards the side of the lesion,
(Nystagmus-Hypotonia-Dysarthria-Loss of coordination-Dysdiadokokinesia).
7. SPASTIC ----> UMNL UPPER MOTOR NEURON LESION:
_________________________________________________
(Spinal cord injury or cerebral palsy).
8. STAGGERING -> VESTIBULAR ATAXIA:
____________________________________
(Ass. with nausea & vomiting).
. TREMORS IN NEUROLOGY:
_______________________
1. RESTING TREMORS (PARKINSON):
________________________________

*
*
*
*
*

At rest - improves e' activity.

High frequency tremors 5-7 Hz.
Ass. e' rigidity & bradykinesia.
Pill rolling quality.
NOT ivolving the entire head.

2. ESSENTIAL TREMORS:
______________________
* Familial in up to 50 % of cases.
* Starts with fine movement in the upper extremity.
* Worst at the end of the goal directed activity (e.g. reaching a pen).
* Involving the entire head.
3. CEREBELLAR TREMORS:
_______________________
* Intension tremors.
* low fequency 3-4 Hz.
* Affect the extremity & the Whole head.
* Nystagmus & ataxia are present.
. TRIGEMINAL NEURALGIA:
_______________________
. Paroxysmal, LIGHTENING PAIN on the face.
. Severe intense burning or electric shock like.
. Tx: CARBAMAZEPINE.
. CEREBELLAR TUMORS:
____________________
. Ipsi-lateral ataxia (The pt. falls towards the side of the lesion).
. Ipsi-lateral muscular hypotonia.
. Titubation (Forward & backward movement of the trunk).
. Nystagmus.
. Intention tremors.
. Dysdiadokokinesia (Difficulty in performing rapid & alternating movements).
. INTRA-CRANIAL HEMORRHAGE:
___________________________
. HYPERTENSION is the most imp. risk factor.
. Focal neurological signs develop suddenly & gradually worsen over mins to hours.
. The degree of symptoms is not maximal at onset (# SAH or embolic stroke).
. Symptoms start during normal activity (may be ppt by sex).
. Site of INTRA-CRANIAL HEMORRHAGE ------> NEUROLOGICAL FINDINGS:
_________________________________________________________________
1- BASAL GANGLIA (PUTAMEN):
___________________________
* Hemi-plegia, hemi-sensory loss.
* Homonymous hemianopsia, gaze palsy.
* Stupor & coma.

2- "T"HALAMUS:
______________
* Hemi-paresis, hemi-sensory loss.
* Eyes deviate "T"owards hemiparesis.
* UP-GAZE palsy.
* (Non-reactive) miotic pupils.
3- CEREBELLUM:
______________
* NO hemiparesis.
* GAIT ATAXIA.
* OCCIPITAL HEADACHE (+nausea & vomiting).
* Gaze palsy (6th CN. paralysis)
* Facial weakness.
4- "P"ONS:
__________
* COMPLETE PARAPLEGIA.
* Followed by deep coma in a few mins.
* (REACTIVE) "P"IN POINT PUPILS.
5- CEREBRAL:
____________
* May be associated with seizures.
* Eyes deviate AWAY from the hemi-paresis.
. GUILLAIN BARRE' $YNDROME:
___________________________
. Acute idiopathic polyneuropathy.
. Ascending paralysis (i.e. affects LL 1st then involve the rest of the ms upwards!).
. Preceided by infection or vaccination.
. weakness in both legs then ascends to involve the arms, respiratory ms & face.
. Reflexes are diminished or symptoms.
. Distal paresthesia may occur.
. Dx: CSF ANALYSIS -> HIGH PROTEIN CONCENTRATION with NORMAL CELL COUNT.
. ++ PROTEIN & NORMAL (WBCs - RBCs - GLUCOSE) !
. i.e. CYTO-ALBUMINOUS DISSOCIATION.
. Tx: Supportive care, IVIG (Intravenous immunoglobulins) & plasmapharesis.
. GB$ may lead to respiratory failure.
. LUNG VITAL CAPACITY is the best way to monitor the respiratory function.
. N.B. TICK BORNE PARALYSIS:
____________________________
. Progressive ascending paralysis.
. Over hours - days.
. NO fever.
. Normal sensations.
. Normal CSF analysis.

. Meticulous search & removal of the tick results in improvement & complete
recovery.
# PARA-NEOPLASTIC $YNDROMES !
_____________________________
.1. MYASTHENIA GRAVIS:
______________________
. Female 18 - 25 ys.
. NEURO-MUSCULAR JUNCTION DISEASE.
. Muscle weakness after a period of muscle use.
. Dysarthria - Dysphagia.
. Drooping eyelids (Ptosis) - Diplopia (Double vision). {Extraocular ms
involvement}.
. Generalized weakness may develop (trunks - arms - legs). {Bulbar ms
involvement}.
. RESOLUTION OF MUSCULAR WEAKNESS with REST is the HALLMARK of Myasthenia
gravis.
. Dx: CT SCAN CHEST is MANDATORY to exclude THYMOMA.
. Tx: Oral ANTI-CHOLINESTERASES e.g. PYRIDOSTIGMINE & NEOSTIGMINE.
. Immunosuppressive agents & thymectomy may induce remission.
. MYASTHENIC CRISIS may occur resulting in severe weakness of the respiratory
muscles.
. Tx with ENDOTRACHEAL INTUBATION & withdrawal of anti-cholinesterases.
.2. LAMBERT EATON $YNDROME:
___________________________
. H/O of cancer mostly LUNG CANCER (Heavy smoking - weight loss - malaise - lung
mass).
. Small cell carcinoma.
. Proximal ms weakness.
. Auto-antibodies directed against the voltage gated calcium channels,
. leading to -- Acetylcholine release with proximal ms weakness.
. Dx: Electro-physiological studies.
. Tx: Plasmapharesis & immunosuppressive therapy.
. N.B. MYASTHENIA GRAVIS:
_________________________
. Auto-antibodies against the (post)-synaptic receptors.
. INTACT deep tendon reflexes.
. N.B. LAMBERT-EATON $:
________________________
. Auto-antibodies against the (pre) - synaptic receptors.
. LOSS of deep tendon reflexes.
.3. DERMATOMYOSITIS/POLYMYOSITIS:
___________________________________
. MUSCLE FIBER INJURY.
. Symmetric & more proximal ms weakness.

. Ass. ILD, esophageal dysmotility, Raynaud's phenomenon & polyarthritis.

. SKIN FINDINGS (Gottron's papules & Heliotrope rash).
. N.B. STEROID INDUCED MYOPATHY:
________________________________
. Due to ttt with HIGH doses of steroids over a prolonged period of time.
. ex: ttt of Temporal arteritis with high dose steroids.
. Proximal muscle weakness (LL before UL).
. No pain.
. Difficulty getting up from a chair - climbing stairs or brushing hair.
. Muscle power improves after discontinuation of the drug.
. SUB-ARACHNOID HEMORRHAGE:
___________________________
. Caused by rupture of arterial saccular "Berry" aneyrysm.
. Sudden severe headache (WORST HEADACHE EVER).
. Meningeal irritation may occur (Neck stiffness).
. Dx -> NON CONTRAST HEAD CT.
. Dx -> is imp. to rule out SAH.
. Dx -> Xanthochromia in CSF confirms the diagnosis.
. Dx -> CT cerebral Angiography is imp. to identify the bleeding source.
. Tx -> Coiling or restenting (Endovascular therapy).
. Tx -> Nimodipine (CCB) to -- the vasospasm.
. Complications:
. ______________
. 1 - Re-bleeding (1st 24 hours).
. 2 - Vasospasm (after 3 days).
. 3 - Hydrocephalus (++ ICT).
. 4 - Seizures.
. 5 - HYPO-NATREMIA (--Na due to SIADH).
. NEURO-FIBROMATOSIS TYPE 2:
____________________________
. YOUNG pt.
. S.C. neurofibromas + Cafe' au lait spots + Bilateral acoustic neuromas (Deafness).
. Family H/O.
. Autosomal dominant dis. caused by a mutation in chromosome 22.
. NON-SENSE or frame shift mutations are the cause.
. N.B. Silent (Same sense) mutations don't affect the structure of the protein.
. Dx: MRI with GADOLINIUM.
. PRONATOR DRIFT:
_________________
. It denotes UMNL.
. When the pt. closes his eyes & extends his arms with the palms up,
. The affected arm will tend to pronate.
. Bec. UMNL causes weakness in supination with dominance of the pronator
muscles.
. ESSENTIAL TREMOR:

___________________
. ACTION tremor.
. Absence of other neurological signs.
. Suppressed at rest (# parkinsonism).
. Noticed when the pt. attempts a task that requires fine motor movement !
. Tx: BB (Propranolol) is the 1st line of ttt.
. Primidone may be used (Anti-convulsant which may ppt acute intermittent
Porphyria,
. manifested as abdominal pain, neurologic & psychiatric abnormalities.
. MULTIPLE SCLEROSIS:
_____________________
. Affects women in child bearing peiod (15-50 ys).
. Multiple neurological deficits that can't be explained by single lesion.
. "PATCHY" neurological manifestations.
. Optic neuritis (painful loss of vision) & diplopia.
. Sensory symptoms -> Numbness & paresthesia.
. Motor symptoms -> Paraparesis & spasticity.
. Bowel/bladder dysfunction.
. "UHTHOFF phenomenon" Exacerbated by hot weather or exercise !
. "LHERMITTE's sign" Electric shock-like sensation down the spine on flexion of the
neck.
. INTER-NUCLEAR OPHTHALMOPLEGIA (INO) is characteristic:
_______________________________________________________
* On attempted left gaze, the left eye abducts & exhibits horizontal jerk nystagmus,
* but the right eye remains stationary.
* On attempted right gaze, the right eye abducts & exhibits horizontal jerk
nystagmus,
* but the left eye remains stationary.
* caused by demyelination of the MEDIAL LONGITUDINAL FASCICULUS.
. Dx: BRAIN MRI with & without GADOLINIUM.
. MRI:Multiple bilatreal asymmetric hyperintense lesions in periventricular white
matter.
. CSF analysis: OLIGOCLONAL IgG bands - Normal pressure.
. Tx of acute exacerbation -----> HIGH DOSE IV GLUCOCORTICOIDS.
. Tx to prevent future attacks -> B-interferon or Glatiramer acetate.
. N.B. YOUNG FEMALE with BILATERAL TRIGEMINAL NEURALGIA = MS.
. AMYOTROPHIC LATERAL SCLEROSIS:
________________________________
. UPPER + LOWER motor neuron lesions.
. UMNL (Spasticity - bulbar symptoms - exagerrated deep tendon reflexes).
. LMNL (Fasciculations, wasting).
. Tx: RILUZOLE (Glutamate inhibitor) - Steroids are WRONGGGGGGGGGGGGGGG !
. CARPAL TUNNEL $YNDROME = MEDIAN NERVE ENTRAPPMENT $YNDROME:
_____________________________________________________________
. At WRIST !
. Numbness & pain in the palm.
. Thenar eminence atrophy.

. Paresthesia of the 1st three & a half digits

. ULNAR NERVE ENTRAPMENT $YNDROME:
___________________________________
. -- sensation over the 4th & 5th fingers with weak grip.
. due to involvement of the interosseus muscles of the hand.
. entrapment at the medial epicondylar groove.
. Leaning on the elbows while working at a desk or table is the typical scenario.
. VESTIBULO-TOXICITY by AMINO-GLYCOSIDES:
_________________________________________
. Gentamycin & Amikacin.
. Vertigo & gait imbalance.
. due to damage of the motion sensitive hair cells in the inner ear.
. TORTICOLLIS:
______________
. Example of FOCAL DYSTONIA.
. Dystonia -> Sustained ms contraction.
. Focal -> Affecting one muscle.
. Involuntary head turning & fixation to one side.
. Hypertrophy of the opposite side sterno-cleido-mastoid ms.
. It is a common side effect of Anti-psychotic drugs.
. UN-PROVOKED FIRST SEIZURE -> HEAD CT WITHOUT CONTRAST is the 1st initial
step done:
_____________________________________________________________________________________
. To exclude intracranial or subarachnoid bleeding requiring urgent intervention.
. MRI is the best diagnostic modality in elective situations for seizures cases.
. LIMB ISCHEMIA:
________________
. Mostly due to migration of arterial emboli from the heart.
. The emboli source may be Af or recent MI.
. 5 Ps (Pain - Pallor - Paresthesia - Pulselessness & Paralysis).
. Tx: IV HEPARIN BOLUS followed by continous heparin infusion.
. Referral for emergency vascular surgery.
. METOCLOPRAMIDE:
_________________
. It is a pro-kinetic agent used to treat nausea , vomiting & gastro-paresis.
. Pts sh'd be monitored closely for the development of drug induced extrapyramidal syms.
. Ex: Tardive dyskinesia - Dystonic reactions & prkinsonism.
. Manifested by stiff painful neck.
_____________________________________________________________________________________
____
_____________________________________________________________________________________
____

# MAIN CAUSES OF STROKE:

_________________________
. 1 . ISCHEMIC THROMBOTIC:
__________________________
-> H/O of previous TIAs (Transient ischemic attacks).
-> Atherosclerotic risk factors (Uncotrolled HTN & DM).
-> Local in-situ obstruction of an artery.
-> Symptoms may progress or regress with time.
. 2 . ISCHEMIC EMBOLIC:
_______________________
-> H/O of cardiac disease (Af, endocarditis or carotid atherosclerosis "Bruit").
-> Onset of symptoms is ABRUPT & usually MAXIMAL at the start.
-> Multiple infarcts within different territiories.
-> NO headache or impaired consciousness.
. 3 . HEMORRHAGIC:
__________________
-> H/O of uncontrolled HTN, co-agulopathy, illicit drug use e.g amphetamines &
cocaine.
-> Sudden development of focal neurological signs.
-> Followed by ++ ICT symptoms (vomiting & headache).
-> Worsens gradually over mins to hours.
-> Symptoms may start with normal activity.
-> Hypertension is the most imp. risk factor.
. 4 . SPONTANEOUS SUB-ARCHNOID HEMORRHAGE:
__________________________________________
-> Rupture of an arterial saccular berry aneurysm or AV malformation.
-> Sudden dramatic onset of severe headache (WORST HEADACHE EVER).
-> Meningeal irritation e.g. neck stiffness.
-> Focal deficits are uncommon.
# The 1st step in STROKE management is NON CONTRAST HEAD CT.
_____________________________________________________________
# TOPOGRAPHY of the lesions in stroke pts (ACCORDING TO THE AFFECTED
ARTERY):
______________________________________________________________________________
* POSTERIOR LIMB OF INTERNAL CAPSULE (LACUNAR INFARCT):
________________________________________________________
. Motor impairment without any higher cortical dysfunction.
. No visual field abnormalities.
* MIDDLE CEREBRAL ARTERY OCCLUSION:
____________________________________
. Contralateral hemiplegia.

.
.
.
.
.

Contralateral hemianesthesia.
Conjugate eye deviation toward the side of stroke.
Homonymous hemianopia.
Aphasia (dominant hemisphere).
Hemi-neglect (Non dominant hemisphere).

* ANTRIOR CEREBRAL ARTERY OCCLUSION:

_____________________________________
. Contralateral weakness that predominantly affects the LLs.
. Abulia (loss of willing).
. Akinetic mutism.
. Emotional disturbances.
. Deviation of head & eyes towards the side of the lesion.
. Sphincter incontinence.
* VERTEBRO-BASILAR SYSTEM LESION (BRAIN STEM):
_______________________________________________
. Alternate $ with contralateral hemiplegia & ipsilateral CN involvement.
# Presentations according to the AFFECTED LOBE:
________________________________________________
. DOMINANT FRONTAL LOBE STROKE:
_______________________________
. Expressive (BROCA's) aphasia.
. Contralateral hemiparesis (due to involvement of the primary motor cortex).
. Contralateral apraxia (due to involvement of the supplementary motor cortex).
. DOMINANT PARIETAL LOBE STROKE:
________________________________
. Contralateral sensory loss (pain, vibration, agraphesthesia & astereognosis).
. Contralateral inferior homonymous quadrantanopsia (Superior optic radiation
lesion).
. DOMINANT TEMPORAL LOBE STROKE:
________________________________
. APHASIAS due to ARCUATE FASCICULUS involvement.
. Reception aphasia (Affect comprehension).
. Anomic aphasia (inability to speak nouns).
. Conductive aphasia (Repitition)
. Contralateral inferior homonymous quadrantanopsia (Superior optic radiation
lesion).
# PRESENTATION ACCORDING TO TEH AFFECTED PART OF THE BRAIN:
____________________________________________________________
.1. BRAIN STEM LESIONS:
________________________
. involve the cranial nerves.
. sensory loss of one half of the face & contralateral half of the body.

.2. THALAMUS LESIONS:

______________________
. Hemi-sensory loss with severe dysesthesia (THALAMIC PAIN PHENOMENON).
.3. CORTICAL LESIONS:
______________________
. sensory loss of one half of the face & ipsilateral half of the body.
. Aphasia - Neglect - Abnormal graphesthesia or stereognosis.
.4. MEDIAL MEDULLARY $YNDROME:
_______________________________
. Due to occlusion of the vertebral artery or one of its branches.
. Contralateral paralysis of the arm & leg.
. Contralateral loss of tactile, vibratory & position sensation.
. Ipsilateral Tongue deviation.
# THE MOST COMMON RISK FACTOR OF STROKE IS HYPERTENSION.
_________________________________________________________
# LACUNAR STROKES:
___________________
. Most common site is in the POSTERIOR LIMB OF THE INTERNAL CAPSULE.
. Most common cause is HYPERTENSION & DM.
. Lipo-hyalinotic thickening of the small vessels.
. Micro-atheromas.
. LIMITED neurological deficit.
. Pure motor or sensory stroke - Ataxic hemiparesis - Dysarthria with clumsy hand
$.
. May be missed on CT due to their small size.
1. PURE MOTOR HEMIPARESIS:
__________________________
. Lacunar infarct in the POSTERIOR LIMB OF THE INTERNAL CAPSULE.
. Unilateral motor deficit (face, arm & to a lesser extent leg).
. Mild dysarthria (Slurred speech).
. NO sensory, visual or higher cortical dysfunction.
2. PURE SENSORY STROKE:
_______________________
. Lacunar infarct in the ventro-postero-lateral of the THALAMUS.
. Unilateral numbness, paresthesia.
. Hemisensory deficit in the face, arm, trunk & leg.
3. ATAXIC HEMIPARESIS:
______________________
. Lacunar infarct in the ANTERIOR LIMB OF THE INTERNAL CAPSULE.
. Weakness more prominent in LL extremity.
. Ipsi-lateral arm & leg incoordination.

4. DYSARTHRIA CLUMSY HAND $YNDROME:

___________________________________
. Lacunar stroke at the basis pontis.
. Hand weakness, mild motor aphasia.
. NO sensory deficits.
# STROKE MANAGEMENT:
_____________________
1- NON contrast head CT to rule out hemorrhagic stroke.
2- Ischemic stroke -> Give fibrinolytic therapy (if the pt comes within 3-4 hs of
onset).
3- Make sure that the pt. has no contraindications to the fibrinolysins.
4- If there is contraindication -> Give Antiplatelets (ASPIRIN).
. Clinical presentation "ischemic stroke case" -> Anti-platelet/Anti-thrombotic
therapy:
_____________________________________________________________________________________
___
. Presenting within 3 - 4.5 hs of symptoms onset with no cont'ds -> I.V. Alteplase.
. Stroke with no prior anti-platelet therapy -> Aspirin.
. Stroke on Aspirin therapy ->(Aspirin + dipyridamole) OR (Clopidogrel).
. Stroke on Aspirin therapy + intracranial large art. sclerosis -> Aspirin +
Clopidogrel.
. Stroke with evidence of atrial fibrillation -> LONG TERM ANTICOAGULATION e.g.
WARFARIN.
# THROMBOLYTICS = TISSUE PLASMINOGEN ACTIVATOR (t-PA) = ALTEPLASE:
___________________________________________________________________
# THROMBOLYTICS INDICATIONS & CONTRAINDICATIONS:
_________________________________________________
# THROMBOLYTICS INDICATIONS:
_____________________________
.1. Non hemorrhagic ischemic stroke.
.2. Symptoms onset < 3 - 4.5 hours before treatment initiation.
# THROMBOLYTICS CONTRA-INDICATIONS:
____________________________________
.1. Stroke or head trauma in the past 3 months.
.2. H/O of intracranial hemorrhage.
.3. Major surgery in the past 2 weeks.
.4. GI,GU or active bleeding in the past 3 weeks.
.5. Seizure at the onset of stroke.
.6. SBP > 185 mmHg or DBP > 110 mmHg.
.7. Platelets < 100000/mm3 , Glucose < 50 mg/dl , INR > 1.7.
_____________________________________________________________________________________
_____

_____________________________________________________________________________________
_____
. HEMI-NEGLECT $YNDROME = LESION in the (RIGHT PARIETAL LOBE CORTEX):
_____________________________________________________________________
. Lesion of the RIGHT (NON)-dominant hemi-sphere.
. which is responsible for spatial organization.
. So, In this disease, The pt ignores the left side of a space.
. Responds only to the stimuli coming from the RIGHT side.
. Pt may shave only the Right side of their face.
. Comb the Right side of his hair.
. Ignore the subject located in the left side of a space.
. Dx: Ask the pt to fill in the numbers o a clock !
. EXERTIONAL HEAT STROKE:
_________________________
. Severe exertion under direct sun light.
. Acute confusion, hyperthermia, tachycardia & persistent epistaxis.
. Due to FAILURE OF THERMO-REGULATORY CENTER to maintain a euthermic state.
. Core temperature > 40 with altered mental status.
. Factory workers, Military recruits exposed to hot humid environment.
. Complications: Rhabdomyolysis - RF - ARDS - Coagulopathic bleeding.
. Tx -> EVAPORATION COOLING (NOT immersion in cold water xxx).
. MALIGNANT HYPERTHERMIA:
_________________________
. Genetically susceptible pt during anesthesia.
. Ass. with halothane & succinyl choline.
. Uncotrolled efflux of calcium from the sarcoplasmic reticulum.
. CAVERNOUS SINUS THROMBOSIS:
_____________________________
. Un-controlled infection of the skin, sinuses & orbit may spread to he cavernous
sinus.
. Bec. the facial / ophthalmic venous system is valveless !
. Cav. sinus inflammation may lead to cav. sinus thrombosis & intracranial
hypertension.
. HEADACHE (INTOLERABLE) is the most common symptom.
. Vomiting is common due to ++ ICT.
. Fundoscopy will reveal papilledema.
. Binocular palsies, periorbital edema with hypo/hperesthesia.
. Dx: MRI.
. Tx: Broad spectrum Antibiotics.
. RESTLESS LEG $YNDROME:
________________________
. Uncomfortable "Crawling" sensation or urge to move the legs.
. Discomfort which worsens in the evening or during sleep.
. Discomfort which worsens at rest.
. Discomfort alleviated by movement of the affected limb.

. Tx : Dopaminergic agonists e.g. L-dopa.

. WERNICKE's ENCEPHALOPATHY:
____________________________
. Alcoholic pt.
. Altered mental status + Gait instability + Nystagmus + Conjugate gaze palsy.
. Due to Vit. B "1" defeciency 2ry to long term alcohol use.
. Triad of ecephalopathy, oculomotor dysfunction & gait ataxia is diagnostic.
. DECUBITUS ULCER:
__________________
. H/O of old pt in a care giver facility.
. Continued pressure on a bony prominence for a long period.
. Ischemic necrosis of the overlying ms, S.C. tissue & skin.
. Preveted by repositioning of the pt every 2-4 hours.
. LEVO-DOPA / CARBI-DOPA Side effects:
_____________________________________
. Dopamine precursors.
. Most common side effect is HALLUCINATIONS.
. Others: Dizziness, Headaches & agitation.
. Involuntary movements may occur.
. TRI-HEXY-PHENIDYL side effects ( VERY IMPORTANT .. ASKED TWICE in UW):
________________________________________________________________________
. It is an Anti-cholinergic drugs used for ttt of Parkinsonism.
. Red as beet, dry as bone, hot as hare, blind as bat, mad as hatter & full as a flask.
. Red as beet
: Flushing.
. Dry as bone
: Anhydrosis - dry mouth.
. Hot as hare
: Hyperthermia.
. Blind as bat : Mydriasis - vision changes.
. Mad as hatter : Delirium - cofusion.
. Full as a flask : Urine retention - constipation.
# DEMENTIAS:
_____________
.1. FRONTO-TEMPORAL DEMENTIA (Pick's disease):
______________________________________________
. Personality changes (euphoria - disinhibition - apathy).
. Compulsive behavior (peculiar eating habits - hyperorality).
. Impaired memory.
. Family H/O of the disease is common.
.2. LEWY BODIES DEMENTIA:
_______________________
. Fluctuating cognitive impairment.
. Bizarre visual hallucinations.
.3. ALZHEIMER's DISEASE:

______________________
. Progressive dementia.
. Age, female gender, +ve family H/O, head trauma are common risk factors.
. Subtle memory loss, language difficulties & apraxia.
. Impaired judgement & personality changes.
. N.B. HYPOTHYROIDISM is an imp. cause of reversible changes in memory &
mentation:
___________________________________________________________________________________
. Accompanied by systemic changes e.g. weight gain, fatigue, hoarseness &
constipation.
.4. HUNTINGTON's DISEASE:
_________________________
. Triad of mood disturbances + Choreiform movements + Dementia.
. Due to ATROPHY of the CAUDATE NUCLEUS.
. Autosomal dominant (Gene defect on chromosome 4).
. Affects both sexes equally.
. Family H/O of the disease is present.
. Age 30 - 50 ys.
. Mood disturbances (Depression & apathy).
. Choreiform movements (facial grimacing, ataxia, dystonia, tongue protrusion).
. Writhing movements of the extremeties.
.5. CREUTZFELDT - JAKOB DISEASE:
______________________________
. Age 50 - 70 ys.
. It is a spongiform encephalopathy caused by a prion.
. Rapidly progressive dementia & myoclonus.
. EEG -> SHARP TRI-PHASIC SYNCHRONOUS DISCHARGES.
. Pts die within one year of onset.
.6. NORMAL PRESSURE HYDROCEPHALUS:
________________________________
. Triad of Urine incontinence + Abnormal gait + Dementia.
. Gait -> Broad based & shuffling
. ++ in ventricular size without persistent ++ in ICT.
. Symptoms due to distortion of the periventricular brain matter.
. The cause is -- CSF ABSORPTION.
. Dx: CT or MRI -> ENLARGED VENTRICLES.
. Dx: LP -> NORMAL OPENING PRESSURE.
. Tx: VENTRICULO-PERITONEAL SHUNT.
.7. PSEUDO-DEMENTIA:
____________________
. Major depressive episode may present as pseudo-dementia.
. Elderly pts who r severely depressed may present with memory loss.
. H/O of emotional situation with the pt. (e.g. Pt's son moving out !).
. Symptoms coincides with the emotional situation.
. Tx -> Anti-depressants e.g. SSRIs (SLECTIVE SEROTONIN RE-UPTAK INHIBITORS).

.N.B. NORMAL AGING:

___________________
. Tiredness.
. occasional forgetfulness.
. occasional word finding difficulty
. Trouble falling asleep.
. Absence of functional impairments.
. Normal performance on mental status examination.
. BRAIN DEATH:
_______________
. Irreversible cessation of the brain activities.
. Absent cortical & brain stem functions.
. Absent corneal reflex.
. Absent gag reflex.
. Absent oculovestibular rflex.
. FIXED DILATED PUPILS.
. No spontaneous breathing when the ventillator is off for 10 mins.
. Spinal cord may be still functioning, so, DEEP TENDON REFLEXES may be STILL
PRESENT.
. MUST BE CONFIRMED BY TWO PHYSICIANS.
. SHY DRAGER $YNDROME:
______________________
. MULTIPLE SYSTEM ATROPHY.
. PARKINSONISM pt.
+ Autonomic dysfunction (postural hypotension - bowel&bladder loss of controlimpotence).
+ Widespread neurological signs (cerebellar, pyramidal or lower motor neuron).
. Chronic alcohol abuse -> Cerebellar damage:
_____________________________________________
. loss of co-ordiated movement.
. Ataxia.
. Broad based gait.
. Dysmetria.
. Intention tremors.
. Dysdiadokokinesia.
. Nystagmus.
. Ms hypotonia (pendular knee reflex).
. BELL's PALSY:
_______________
. Facial 7th cranial nerve peripheral neuropathy.
. Sudden onset of unilateral facial paralysis.
. Inability to close the eye on the affected side.
. Inability to raise the eye brow on the affected side.
. Drooping of the mouth corner with disappearnce of the nasolabial fold,
. so, the mouth is drawn to the spared side.

. Diminished tearing.
. Hyperacusis.
. Loss of taste sensation over the anterior 2/3s of the tongue.
. If the lesion in the CNS occuring above the facial nucleus,
. it will typically CONTRALATERAL LOWER FACIAL WEAKNESS SPARING THE
FOREHEAD.
. AMAUROSIS FUGAX:
__________________
. Painless loss of vision.
. Cholesterol particles may be seen in the eye.
. It is a warning sign of impending stroke.
. An underlying embolic disease is most always present.
. Emboli occur at the carotid bifurcation.
. Dx: NECK DUPLEX ULTRA$OUND.
. SUB-DURAL HEMATOMA:
_____________________
. Due to BLUNT or shearing trauma tearing the BRIDGING VEINS.
. causing them to slowly bleed into the subdural space.
. Headache & gradual loss of consciousness occur gradually.
. More common in older pts & alcoholics due to brain atrophy & vessel fragility.
. NON contrast head CT -> WHITE CRESCENT..
. Mass effect with mid line shift may be seen.
. Emergent neurosurgical consultation for hematoma evacuation is necessary.
. EPI-DURAL HEMATOMA:
_____________________
. Trauma to the TEPORAL bone.
. Injury to the MIDDLE MENINGEAL ARTERY.
. Non contrast head CT -> BICONVEX HEMATOMA.
. SYRINGOMYELIA = CORD CAVITATION:
__________________________________
. Idiopathic Cavitary expansion of the spinal cord.
. Affets the upper limbs in a CAPE like distribution.
. Areflexic weakness in the upper extremeties.
. Dissociated anesthesia (Loss of pain & temperature with intact position &
vibration).
. A cord cavity is present !
. Lower cervical or upper thoracic are the most common affected sites.
. DIABETIC NEUROPATHY:
______________________
. Symmetric peripheral polyneuropathy, mononeuropathy or autonomic neuropathy.
. Mononeuropathies either cranial or somatic.
. CN 3 (Oculomotor) is the most common affected.
. The cause of neuropathy is ISCHEMIC.
. Somatic & parasympathetic fibers in CN 3 have separate blood supplies.
. So .. Only somatic fibers are affected while the parasympathetic fibers are intact.

. Manifested by PTOSIS & DOWN & OUT GAZE.

. Accomodation & light reflex are intact.
. SPINAL CORD COMPRESSION:
__________________________
. isolated, symmetric, lower extremity symptoms.
. Loss of sensations & signs of upper motor neuron lesion.
. Weakness without fasciculations, hyperreflexia & +ve Babinski sign.
. Possible etiologies: (Disk herniation - Epidural absess & malignancy).
. It is a medical emergency !
. Dx: MRI Spine .. NOT CT !!
. ALZHEIMER's DISEASE:
______________________
* It is the most common cause of dementia.
* NO disturbance in consciousness.
* Age group > 60.
* EARLY FINDINGS:
__________________
. Anterograde memory loss (immediate recall affected, distant memory preserved).
. Visuospatial deficits (lost in own neighborhood).
. Language difficulties (difficulty finding words).
. Cognitive impairment with progressive decline.
* LATE FINDINGS:
_________________
. Neuropsychiatric (hallucinations & wandering).
. Dyspraxia (difficulty performing learned motor tasks).
. Lack of insight regarding deficits.
. Non-cognitive neurological deficits (pyramidal & extra-pyramidal motor,
myoclonus).
. Urinary incontinence.
* Dx: CT -> Diffuse cortical & subcortical atrophy,
which is disappropriately greater in the temporal & parietal lobes.
. GLIOBLASTOMA MULTIFORME (GBM) = HIGH GRADE ASTROCYTOMA:
_________________________________________________________
. Symptoms of ++ ICT (Nausea-vomiting-headache worsening with change in
position).
. ++ ICT = Space occupying lesion.
. Personality changes & strange behavior (Due to involvement of the frontal lobe).
. Dx: CT or MRI -> BUTTERFLY appearance with central necrosis,
. with HETEROGENOUS SERPIGINOUS CONTRAST ENHANCEMENT.
. CRANIOPHARYNGIOMA = Hypopituitarism signs + Headaches + Bitemporal
blindness:
_______________________________________________________________________________
. Benign tumors arising from Rathke's pouch.

.
.
.
.
.
.
.
.
.
.
.

Bimodal age distribution i.e. children & 55-65 ys age group.

It is located above sella turcica.
Consists of multiple cysts filled with oily fluid.
Presents with symptoms of hypothyroidism.
In children (Retarded growth due to -- GH & TSH).
In adults (Sexual dysfunction).
Women may present with amenorrhea.
It compresses the optic chiasma -> BITEMPORAL BLINDNESS.
Headaches occur due to ++ ICT.
Dx: MRI or CT.
Tx: Surgery or radiotherapy.

. CAUDA EQUINA $YNDROME:

________________________
. Compression of the spinal nerve roots.
. Causes (Tumor - Herniated disk - Abscess - Trauma).
. Low bk pain.
. Bowel & bladder dysfunction.
. Saddle anesthesia.
. Sciatica.
. Lower extremity sensory & motor loss.
. Dx: Emergent MRI.
# HIV associated lesions on MRI:
________________________________
.1. PRIMARY CNS LYMPHOMA:
_________________________
. Solitary.
. {WEAKLY} ring enhancing peri-ventricular mass.
. Altered mental status.
. Associated EBV DNA in the CSF.
.2. TOXOPLASMOSIS:
__________________
. Multiple.
. {Ring - enhancing} spherical lesions in the basal ganglia.
. +ve serology is not specific !
. TMP-SMX is preventive.
.3. PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY:
_______________________________________________
. {Non - enhancing}.
. No mass effects.
. Opportunistic viral infection (JC virus).
.4. AIDS DEMENTIA COMPLEX:
__________________________
. Cortical & sub-cortical atrophy.
. 2ry ventricular enlargement.

.5. ABSCESS:
____________
. Solitary.
. {Ring enhancing}.
. Isolated, round with smooth borders.
. H/O of known extra-cranial infections.
. Fluid collection in the maxillary sinus.
. The most common causative organisms are AEROBIC & ANAEROBIC
STREPTOCOCCI & BACTEROIDES.
# CAROTID ARTERY STENOSIS:
__________________________
. May progress to embolic stroke or TIAs.
. May be silent with no symptoms.
. Symptomatic -> sudden onset of focal neuro. syms ipsilateral to the blocked
artery.
. Dx: NECK DUPLEX U/$.
. Tx: CEA or CAS.
. CAROTID END ARTERECTOMY (CEA) is recommended if:
_________________________________________________
. * Symptomatic pts with carotid stenosis 70 - 99 %.
. * Low surgical risk.
. * Good 5 year predicted survival.
. * Surgically accessible carotid lesion.
. CAROTID ANGIOPLASTY WITH STENTING (CAS) is recommended if:
___________________________________________________________
. * High surgical risk.
. * Poor 5 year predicted survival.
. * Lesion not amenable to surgery.
# IMPORTANT CRANIAL NERVES & THEIR FUNCTIONS:
_____________________________________________
* OPTIC NERVE (CN 2):
_____________________
. VISION.
* OCULOMOTOR (CN 3):
____________________
. Eye movement (Most).
. Adduction with medial rectus.
. Elevation with superior rectus.
. Depression with inferior rectus.
. Eye lid opening.
. Pupil constriction.
* TRIGEMINAL (CN 5):
____________________
. Three branches with both motor & sensory fibers.

. The 1st branch is called the Ophthalmic nerve,

. It carries sensory fibers to the scalp, forehead, upper eyelid, cornea & nose.
* FACIAL (CN 7):
________________
. Facial movement.
. Taste in the anterior 2/3s of the tongue.
. Lacrimation.
. Salivation.
. Eye closing.
* VAGUS (CN 10):
________________
. Swallowing.
. Palate elevation.
. Monitoring baro & chemo receptors of the aortic arch.
. IMPAIRED DAILY FUNCTIONING:
_____________________________
. is essential to distinguish between dementia & normal aging.
. Pts with dementia have functional impairment.
. Normal aging is not ass. with impairment.
. ACUTE GLAUCOMA:
_________________
. Occurs when a pre-existing narrow anterior chamber angle is closed,
. in response to pupillary dilatation from medications or another stimiulus.
. PPt by direct bright light e.g. watching TV.
. ++ IOP may lead to nausea & vomiting & tearing pain.
. Complain of seeing halos around light.
. Damage of the optic nerve is common & may lead to visual loss.
. Sudden onset of photophobia, eye pain, headache & nausea.
. Palpation -> very hard eye.
. NON REACTIVE MID DILATED PUPIL.
. Dx: TONOMETRY.
# HEADACHES:
____________
.1. MIGRAINE HEADACHE:
_______________________
. Unilateral.
. Pulsating quality.
. Attacks last from 4 - 72 hs.
. Photophobia.
. Common in younger females.
. AURA of neurological syms preceiding headache.
. Tx: TRIPTANS (Efficient only before the start of the attack) + NSAIDs.
. I.V. Anti-emetics e.g. (PRO-CHLOR-PERAZINE) or Metoclopramide {SEVERE
VOMITING CASES}.

.2. CLUSTER HEADACHE:

______________________
. Intense unilateral retro-orbital pain.
. Starts suddenly (usually at night).
. More common in men.
. Redness of the ipsilateral eye.
. Tearing eye pain.
. Stuffed or runny nose.
. Ipsilateral Horner's $.
. Attacks occur in clusers.
. Prophylaxis is the key to management (Verapamil - Lithium - Ergotamine).
. Tx of acute attack -> 100 % OXYGEN & S.C. Sumatriptan.
.3. BENIGN IDIOPATHIC INTACRANIAL HYPERTENSION = PSEUDOTUMOR CEREBRI:
______________________________________________________________________
. Over-weight female in the child bearing period.
. H/O of OCPs intake or hypervitaminosis A.
. Headache - transient loss of vision - pulastaile tinnitus - diplopia.
. Ex: papilledema - peripheral visual defects.
. Dx: MRI & LP (CSF opening pressure > 250 mmHg with NORMAL analysis).
. Tx: Stop the offending medications, weight loss & Acetazolamide.
. ACETAZOLAMIDE +/- FUROSEMIDE is the 1st line therapy.
. Acetazolamide -> inhibits choroid plexus carbonic anhydrase -> -- CSF production.
. Most common complication is BLINDNESS !
. Shunting or optic nerve sheath fenestration is done to prevent blindness.
.4. SUB-ARACHNOID HEMORRHAGE:
______________________________
. WORST HEADACHE EVER !!
.
. BROWN SEQUARD $YNDROME:
_________________________
. Damage to the lateral spinothalamic tract.
. Causing contra-lateral loss of pain & temperature sensation,
. beginning two levels below the level of the lesion.
. N.B. The spino-thalamic tract crosses on very early in the spinal cord !
. so .. A lesion of the Rt-sided spino-thalamic tract at T10,
. will result in a Lt-sided loss of pain & temperature sensation beginning at T12.
. L5 RADICULOPATHY -> Foot drop -> Compensated by HIGH STEPPAGE GAIT:
_____________________________________________________________________
. Foot drop due to failure of the foot dorsiflexion.
. caused by trauma to the common peroneal nerve
. or one of the spinal roots contributing to it (L4 - S2).
. To compensate, HIGH STEPPAGE GAIT is done.
. Pts have to overly flex the hip & knee to bring the foot forward.
. The toes of the affected foot may drag on the ground.
. caused by peripheral neuropathy.

. Foot drop may be congenital (Charcot - Marie - Tooth disease).

. HERPES ENCEPHALITIS:
______________________
. Caused by HSV-1.
. Mainly affects the TEMPORAL lobe of the brain.
. Acute onset < 1 week duration.
. Altered mentation - focal neuro. deficits - hemiparesis - dysphasia - aphasia ataxia.
. May present with seizures !
. FEVER is present in 90 % of cases.
. CSF analysis -> LYMPHOCYTIC PLEOCYTOSIS.
. .............-> ++ RBCs (Hemorrhagic destruction of the temporal lobes).
. .............-> ++ Ptn level.
. .............-> -- Glucose level
. Dx : HSV POLYMERASE CHAIN REACTION IS THE GOLD STANDARD.
. Tx : IV ACYCLOVIR.
. ETHICAL PROBLEM:
__________________
. REGARDLESS OF H/O OF DRUG ABUSE,,
. Pts with acute severe pain sh'd receive the same standard of pain management !!
. IV MORPHINE is the best ttt for acute severe pain.
. Physicians sh'd NEVER undertreat pain even if there is a risk for abuse.
. SITE OF THE LESION ----> DEFICIT:
___________________________________
. UPPER THORACIC SPINAL CORD ---> Paraplegia - Bladder & fecal incontinence,
. ............................... + Absent sensation from the (NIPPLE) downwards.
. LOWER THORACIC SPINAL CORD ---> Absent sensation from the (UMBILICUS)
downwards.
. PARKINSON DISEASE = TREMORS + RIGIDITY + BRADYKINESIA:
________________________________________________________
. Neurodegenerative disorder.
. Caused by accumulation of alpha synuclein within the neurons of SUBSTANCIA
NEGRA.
. The most common presenting symptom is asymmetric resting tremor in the upper
extremity.
.1 * TREMOR:
___________
. A resting 4 to 6 Hz tremor with a pill-rolling quality.
. Frequently first manifests in one hand.
. May slowly generalize to involve the other side of the body & the lower extremity.
.2 * RIGIDITY:
______________
. Baseline ++ resistance to passive movement (Lead pipe or cog wheel).

.3 * BRADYKINESIA:
__________________
. Difficulty initiating movements as when starting to walk or rising from a chair.
. Narrow based, shuffling gait with short strides without arm swing (FESTINATING).
. Micrographia (Small hand writing).
. Hypomimia (-- facial expression).
. Hypophonia (soft speech).
.4 * POSTURAL INSTABILITY:
__________________________
. Flexed axial posture.
. Loss of balance during turning or stopping.
. Loss of balance when pushed slightly.
. Frequent falls.
. NO SPECIAL TEST FOR EXACT DIAGNOSIS.
. ONLY PHYSICAL EXAMINATION CAN LEAD TO THE Dx.
. STATUS EPILEPTICUS:
_____________________
. Single seizure lasting > 30 mins.
. H/O of seizure disorder with no compliance to anti-convulsant therapy.
. A brain seizing > 5 mins is at ++ risk of permanent injury : CORTICAL LAMINAR
NECROSIS.
. Tx -> BENZODIAZEPINE -> IV DIAZEPAM.
. Failed -> ADD FOSPHENOTOIN.
. Failed -> ADD PHENOBARBITAL.
. Failed -> ADD SUCCINYL CHOLINE.
. DELIRIUM:
___________
. Acute confusion state.
. Reduced oe fluctuating level of consciousness.
. Inability to sustain attention.
. Anxiety, agitation & hallucinations.
. Common ppt factors (infections: UTI).
. Polypharmacy, medication side effects, volume depletion & electrolyte imbalance.
. SERUM ELECTROLYTES & URINALYSIS sh'd be done to detect the cause.
. Tx-> Typical & atypical anti-psychotics (HALOPERIDOL).
. Benzodiazepines (Lorazepam) are not recommended in old age.
. ONCE MORE: DIFFERENT CEREBRAL ARTERY OCCLUSIONS & THEIR EFFECTS:
__________________________________________________________________
* MIDDLE cerebral artery occlusion:
____________________________________
. Contralateral motor & sensory deficits.
. More pronounced in the {upper limb} than the lower limb.
. Homonymous hemianopia.
. If the dominant lobe (LEFT) is involved ------> APHASIA.

. If the NON dominant lobe (RIGHT) is involved -> HEMI NEGLECT $.

* ANTERIOR cerebral artery occlusion:
______________________________________
. Contralateral motor & sensory deficits.
. More pronounced in the {lower limb} than the upper limb.
. Urinary incontinence.
. Gait apraxia.
* POSTERIOR cerebral artery occlusion:
_______________________________________
. Homonymous hemianopia.
. Alexia without agraphia (dominant hemisphere).
. Visual hallucinations (cortex).
. Sensory symptoms (Thalamus).
. INTRACRANIAL HYPERTENSION:
____________________________
. ++ intra-cranial pressure > 20 mmHg.
. Causes: Trauma - space occupying lesion - hydrocephalus - impaired CSF outflow.
. Symptoms: Diffuse headache worse in the morning - Nausea & vomiting.
. Vision changes - papilledema - cranial nerve deficis.
. Somnolence - cofusion - Unsteadiness.
. Cushing's reflex: Hypertension & bradycardia.
. Dx: CT or MRI.
. CEREBRAL HEMORRHAGE due to EXCESS ANTI-COAGULATION:
_____________________________________________________
. Anti-coagulation therapy is the most common bleeding disorded causing brain
hemorrhage.
. So .. Pts on anti-coagulants (e.g. Warfarin) sh'd be monitored regularly with INR.
. Risk of bleeding ++ with INR ++ !
. Correction of excess anti-coagulation is dependent upon the INR value:
. INR < 5 , NO significant bleeding -> Omit next Warfarin dose.
. INR 5-9 , NO significant bleeding -> Stop Warfarin temporarily.
. INR > 9 ---------------------------> Stop Warfarin, Give oral Vit. K.
. SERIOUS INTRA-CRANIAL BLEEDING -> FRESH FROZEN PLASMA (FFP).
. FFP reverses the actio of warfarin , works immediately & lasts for few hours.
. HYPOKALEMIA -> WEAKNESS, FATIGUE & MUSCLE CRAMPS:
___________________________________________________
. Electrolyte disturbance with K < 2.5 mEq/L.
. Flaccid paralysis, hyporeflexia, tetany, rhabdomyolysis & arrhythmia may occur.
. ECG -> BROAD FLAT T-waves, U waves & pre-mature ventricular beats.
. Af, Torsades de points & VF may occur.
. H/O of K wasting diuretic is common (Hydrochlorothiazide).
. Other causes -> Diarrhea - vomiting - anorexia - hyperaldosterinism.
. Symptoms resolve with K supplementation.
. TAKE CARE: Differentiate bet IIH & NPH:

_________________________________________
. NORMAL PRESSURE HYDROCEPHALUS = Triad of Urine incontinence + Abnormal
gait + Dementia.
_____________________________________________________________________________________
____
. BENIGN IDIOPATHIC INTACRANIAL HYPERTENSION = PSEUDOTUMOR CEREBRI:
___________________________________________________________________
. Over-weight female in the child bearing period.
. H/O of OCPs intake or hypervitaminosis A.
. Headache - transient loss of vision - pulastaile tinnitus - diplopia.
. Dx: MRI & LP (CSF opening pressure > 250 mmHg with NORMAL analysis).
=========================
. KEY-WORDS to RE-MEMBER:
=========================
. OLIGO-CLONAL BANDS -> MS.
. CYTO-ALBUMINOUS DISSOCIATION -> GB$.
. HEMORRHAGE -> HYPER-dense areas on CT. (WHITE).
. INFARCTIONS -> HYPO-dense areas on CT. (BLACK).
.
.
.
.
.
.
.
.
.

GAITS
FESTINATING = HYPOKINETIC = SHUFFLING -> PARKINSONISM.
HIGH STEPPAGE -------------------------> TABES DORSALIS or L5 Radiculopathy.
SEMI-CIRCLE ---------------------------> STROKE HEMIPLEGIA.
WADDLING ------------------------------> MUSCULAR DYSTROPHY.
WIDE BASED & SHUFFLING ----------------> NORMAL PRSSURE HYDROCEPHALUS.
IPSILATERAL ATAXIA --------------------> CEREBELLAR ATAXIA.
SPASTIC -------------------------------> UMNL UPPER MOTOR NEURON LESION:
STAGGERING ----------------------------> VESTIBULAR ATAXIA.

. TREMORS
. RESTING TREMORS (PARKINSON)-> At rest,imp. e' activity,High frequency tremors
5-7 Hz.
. ESSENTIAL TREMORS-> Worst at the end of the goal directed activity (reaching a
pen).
. CEREBELLAR TREMORS -> Intension tremors - low fequency 3-4 Hz - Nystagmus &
ataxia.
. TRIGEMINAL NEURALGIA: LIGHTENING PAIN on the face - electric shock - Tx:
CARBAMAZEPINE.
. GUILLAIN BARRE'$: Ascending paralysis - Pre.by infection - CYTOALBUMINOUS
DISSOCIATION.

. TICK BORNE PARALYSIS: Ascending paralysi - NO fever - Normal CSF - Tx: Tick
removal.
. MYASTHENIA GRAVIS: Ptosis,Diplopia RESOLUTION OF MUSCULAR WEAKNESS
WITH REST.
. LAMBERT EATON $YNDROME: LUNG CANCER H/O, Auto-Abs against voltage gated
Ca channels.
. N.B. MYASTHENIA GRAVIS: AutoAbs against (post)synaptic recs - INTACT DTRs.
. N.B. LAMBERT-EATON $: AutoAbs against (pre)synaptic receptors - LOST DTRs.
. DERMATOMYOSITIS: Sym. prox. ms weakness - SKIN (Gottron's papules &
Heliotrope rash).
. STEROID INDUCED MYOPATHY: Prox. ms weakness (LL before UL) - No pain.
. SUB-ARACHNOID HEMORRHAGE: Rupture of "Berry" aneyrysm - WORST
HEADACHE EVER.
. NEURO-FIBROMATOSIS "2": S.C. neurofibromas + Cafe' au lait spots + acoustic
neuromas.
. PRONATOR DRIFT = UMNL.
. ESSENTIAL TREMOR: Tx: BB "Propranolol".
. MULTIPLE SCLEROSIS
. MULTIPLE SCLEROSIS
. MULTIPLE SCLEROSIS
. MULTIPLE SCLEROSIS
. MULTIPLE SCLEROSIS
GLUCOCORTICOIDS.
. MULTIPLE SCLEROSIS
acetate.
. MULTIPLE SCLEROSIS

=
=
=
=
=

Optic neuritis (painful loss of vision) & diplopia.

INTER-NUCLEAR OPHTHALMOPLEGIA (INO).
Dx: BRAIN MRI with & without GADOLINIUM.
CSF analysis: OLIGOCLONAL IgG bands - Normal pressure.
Tx of acute exacerbation -----> HIGH DOSE IV

= prevent future attacks -> B-interferon or Glatiramer

= YOUNG FEMALE with BILATERAL TRIGEMINAL NEURALGIA.

. AMYOTROPHIC LATERAL SCLEROSIS: UPPER + LOWER motor neuron lesions.

. CT$: MEDIAN N. - At WRIST - Thenar eminence atrophy - Paresthesia 1st 3.5
fingers
. ULNAR N. ENT. $: paresthesia of 4th & 5th fingers - ent.at medial epicondylar
groove.
. VESTIBULO-TOXICITY by AMINOGLYCOSIDES: Gentamycin-Amikacin - Vertigo & gait
imbalance.
. TORTICOLLIS: Example of FOCAL DYSTONIA.

. UN-PROVOKED FIRST SEIZURE -> HEAD CT WITHOUT CONTRAST is the 1st initial
step done.
. LIMB ISCHEMIA: 5 Ps (Pain - Pallor - Paresthesia - Pulselessness & Paralysis).
. METOCLOPRAMIDE: Side effect Dystonia - Manifested by stiff painful neck.
. HEMI-NEGLECT $YNDROME: RIGHT PARIETAL LOBE CORTEX lesion - (NON)dominant hemi-sphere.
. EXERTIONAL HEAT STROKE: Tx -> EVAPORATION COOLING (NOT immersion in cold
water xxx).
. CAVERNOUS SINUS THROMBOSIS: Dx: MRI - Tx: Broad spectrum Antibiotics.
. RESTLESS LEG $YNDROME: "Crawling" sensation - Tx : Dopaminergic agonists e.g.
L-dopa.
. WERNICKE's ENCEPHALOPATHY: ecephalopathy,oculomotor dysf. & gait ataxia.(-Vit B1).
. DECUBITUS ULCER: Preveted by repositioning of the pt every 2-4 hours.
. LEVO-DOPA / CARBI-DOPA Side effects: Most common side effect is
HALLUCINATIONS.
. TRI-HEXY-PHENIDYL:
Red as beet, dry as bone, hot as hare, blind as bat, mad as hatter & full as a flask.
. DEMENTIAS
. FRONTO-TEMPORAL : Personality changes (euphoria - disinhibition - apathy).
. LEWY BODIES DEMENTIA: Bizarre visual hallucinations.
. ALZHEIMER's DISEASE: Progressive dementia - Impaired judgement & personality
changes.
. HUNTINGTON's DISEASE: Triad of mood disturbances + Choreiform movements +
Dementia.
. CREUTZFELDT - JAKOB DISEASE: EEG -> SHARP TRI-PHASIC SYNCHRONOUS
DISCHARGES.
. NORMAL PRESSURE HYDROCEPHALUS: Triad of Urine incontinence + Abnormal
gait + Dementia.
. PSEUDO-DEMENTIA: Tx -> SSRIs.
. NORMAL AGING: Absence of functional impairments.
. BRAIN DEATH: DTRs may be STILL PRESENT - MUST BE CONFIRMED BY TWO
PHYSICIANS.
. SHY DRAGER $YNDROME: MULTIPLE SYSTEM ATROPHY - PARKINSON pt. + bladder
loss of control.
. Chronic alcohol abuse -> Cerebellar damage.

. BELL's PALSY: Facial 7th cranial nerve peripheral neuropathy.

. AMAUROSIS FUGAX: BLACK CURTAIN FALLING - impending stroke - NECK DUPLEX
ULTRA$OUND.
. SUB-DURAL HEMATOMA: Tearing the BRIDGING VEINS .. CT -> WHITE CRESCENT.
. EPI-DURAL HEMATOMA: Injury to the MIDDLE MENINGEAL ARTERY .. CT ->
BICONVEX HEMATOMA.
. SYRINGOMYELIA: CAPE like - Loss of pain & temperature with intact position &
vibration.
. SPINAL CORD COMPRESSION: It is a medical emergency - Dx: MRI Spine.
. ALZHEIMER's DISEASE: CT -> Diffuse cortical & subcortical atrophy.
. GLIOBLASTOMA MULTIFORM: BUTTERFLY appearance with central necrosis on VT
or MRI.
. CRANIOPHARYNGIOMA = Hypopituitarism signs + Headaches + Bitemporal
blindness.
. CAUDA EQUINA $YNDROME: LBP - bladder dys. - Saddle anesthesia - Dx: Emergent
MRI.
. HIV associated lesions on MRI:
. PRIMARY CNS LYMPHOMA: Solitary - {WEAKLY} ring enhancing - Ass. EBV DNA.
. TOXOPLASMOSIS: Multiple - {Ring - enhancing} spherical - TMP-SMX is preventive.
. PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY: {Non - enhancing} - No
mass effects.
. ABSCESS: Solitary - {Ring enhancing} - caused by ANEROBES
. CAROTID ARTERY STENOSIS: NECK DUPLEX U/$.- CAROTID END ARTERECTOMY if
stenosis 70-99 %.
. ACUTE GLAUCOMA: Palpation -> very hard eye - NON REACTIVE MID DILATED
PUPIL.
. HEADACHES
. MIGRAINE HEADACHE: female Unilateral Pulsating, AURA of neuro syms preceiding
headache.
. CLUSTER HEADACHE: unilateral 5tearing retro-orbital pain .. Tx -> 100 % OXYGEN.
. PSEUDOTUMOR CEREBRI: Obese female- Vit A - OCPs - Most common complication
is BLINDNESS
. SUB-ARACHNOID HEMORRHAGE: WORST HEADACHE EVER !!

. BROWN SEQUARD $YNDROME: contra-lateral loss of pain & temperature

sensation,
. BROWN SEQUARD $YNDROME: beginning two levels below the level of the lesion.
. L5 RADICULOPATHY -> Foot drop -> Compensated by HIGH STEPPAGE GAIT:
. HERPES ENCEPHALITIS: CSF analysis -> LYMPHOCYTIC PLEOCYTOSIS - Tx : IV
ACYCLOVIR.
. PARKINSON DISEASE = TREMORS + RIGIDITY + BRADYKINESIA.
. DELIRIUM: Tx -> Typical & atypical anti-psychotics (HALOPERIDOL).
. ABSENCE seizures -> ETHOSUXIMIDE.
Dr. Wael Tawfic Mohamed
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