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 - lun

g 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 extra-pyramidal 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 control-impotence). + 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 = Optic neuritis (painful loss of vision) & diplopia. . MULTIPLE SCLEROSIS = INTER-NUCLEAR OPHTHALMOPLEGIA (INO). . MULTIPLE SCLEROSIS = Dx: BRAIN MRI with & without GADOLINIUM. . MULTIPLE SCLEROSIS = CSF analysis: OLIGOCLONAL IgG bands - Normal pressure. . MULTIPLE SCLEROSIS = Tx of acute exacerbation -----> HIGH DOSE IV GLUCOCORTICOIDS. . MULTIPLE SCLEROSIS = prevent future attacks -> B-interferon or Glatiramer acetate. . MULTIPLE SCLEROSIS = 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 _________________________