● ALS

○ involves both
■ lower motor neurons
● anterior horn cells in the spinal cord
● brainstem neurons innervating the bulbar muscles
■ upper or corticospinal motor neurons
■ At onset = may involve selective loss of upper or lower motor neurons
○ Recent development of cramping
○ Volitional movements occur in morning
○ Ocular motility, sensory, bowel, bladder, and cognitive functions are preserved
○ Rx
■ Riluzole
● Headache
○ Instructed to make a headache diary for one week
○ Types
■ Cluster
● severe retroorbital pain, lacrimation, conjunctival injection,
rhinorrhea, sweating and pallor
● Rx
○ Initial
■ Triptans or 100 O2
■ Steroids
○ Prophylactic
■ verapamil
■ Migraine
● Rx
○ Best initial
■ Sumatriptan or ergotamine
○ Prophylactic
■ >/=4 headaches a month
● Beta blocker = propranolol
● Stroke
○ Ischemic
■ tPA
● Up to 4.5 hours after onset of symptoms
● After adminstration
○ Observation with frequent neuro checks in first 24 hours
○ Strict blood pressure management
■ <185/105
■ >140/90
■ IV drugs
■ IF contraindications to tPA
● Aspirin
 ● Permissive hypertension
○ Hypertension of up to 220/120 permitted in patients who
did NOT receive tPA
○ Prophylaxis
■ Assessment of swallowing function should be considered in all stroke
patients
■ DVT + PE
● common causes of morbidity and mortality
● Especially in dense hemiparesis
● Rx
○ Low-dose heparin or low-molecular-weight heparin
○ Discharge
■ Statins
● Lesion location
○ General
■ thalamus or cortex
● sensory loss
○ contralateral face + body
■ Cortical lesions
● specific findings
○ aphasia, neglect, or agraphesthesia
■ brainstem lesions
● Sensory loss/perception
○ ipsilateral face + contralateral body
○ Lateral medullary infarction
■ Intracranial vertebral artery
 ■
○ Medial medullary
■ Vertebral or anterior spinal artery

■
○
○ Medial mid-pontine
 ■ Contralateral ataxia
■ Contralateral hemiparesis of face, trunk, limbs

○
● Carotid stenosis
○ Rx
■ Drugs
● Antiplatelet agents
● Control of atherosclerotic risk factors
■ Carotid endarterectomy

●
● Spinal epidural abscess
 ○
● Seizures
○ Rx
■ Phenytoin
● Toxicity
○ Early signs
■ Nystagmus on far lateral gaze
○ blurred vision, diplopia, ataxia, slurred speech, dizziness,
drowsiness, lethargy, and decreased mentation
○ which progresses to coma
○ Reduce dose
● Vertigo
○
○ BPPV
■ Cause = semicircular canal dysfunction
■ NO hearing loss, tinnitus, ataxia
■ Dix-Hallpike maneuver
● vertigo and nystagmus are triggered as the patient quickly lies
back into a supine position with the head rotated 45 degrees
■ Rx
● canalith repositioning maneuver (Epley maneuver)
● Meclizine
○ Vestibular neuritis
■ No hearing loss or tinnititus
○ Labyrinthitis
■ Acute, self resolving
■ Vertigo, ​hearing loss​, tinnitus, self-limited
■ Meclizine + steroids
○ Meniere’s
■ Cause = increased volume and pressure of endolymph (endolymphatic
hydrops)
■ Rx
● Diuretics
● Salt restriction
● Unilateral VIII ablation - severe
○ Physical exam
■ Complete neurological exam
■ Romberg
■ Nystagmus
■ Dix
 ■ Gait
■ Hearing
■ weber/rinne
■ Ent
■ cv
○ Diagnostic workup
■ Cbc, vdrl/rpr, mri brain, dix-hallpike, audiogram, orthostatic vital signs,
ecetrolytes, electronystagmography
● Hearing loss

○
○ Prescbycusis
■ Tinnitus BILATERAL
● Vision loss
○ Retinal artery occlusion

■
■ which most commonly begins as an embolized plaque from the ipsilateral
carotid artery; a cardioembolic source
○ Retinal vein occlusion
■ Funduscopy
● dilated and tortuous veins
● leading to scattered and diffuse hemorrhages ("blood and
thunder"), disk swelling, and/or cotton wool spots
 ●
○ Acute angle closure glaucoma
○ Retinal detachment
■ light flashes, floaters, or a curtain across their visual field (usually starting
from the periphery rather than dropping vertically = RAO) that is not
transient
■ Funduscopic findings
● wrinkled or detached retina
○ Temporal arteritis
○ Hypertensive retinopathy
 ■
○ Workup
■ Fluorescein angiogram
■ Echo
■ Doppler us carotid
■ Intraocular tonometry
■ esr
■ Temporal artery biopsy
■ Cbc
● Visual field defects
○ Optical chiasm
■ Bitemporal hemianopsia
■ Causes
● Pituatary tumors
● Aca aneurysm
○ Optic tract
■ Ipsalateral nasal field
■ Contralateral temporal field
■ Homonymous hemianospsia
○ Hononygous hemianopia
■ Occipital lobe
■ Contralateral side
■ Contralateral posterior arter
● Internuclear Ophthalmoplegia
○ Symptoms
 ■ weakened adduction of the affected eye
■ nystagmus with abduction of the contralateral eye
■ diplopia with horizontal gaze
○ paramedian pontine reticular formation (PPRF) sends a signal to the abducens
nucleus
● Myesthenia gravis
○ Rx
■ Acute exacerbations of MS are treated with corticosteroids.
Beta-interferon or glatiramer acetate is used to
■ decrease the frequency of exacerbations in patients with
relapsing-remitting or secondary progressive form of
■ MS.
■
● Myopathy

○
● Dementia
○ Huntingtons
■ Symptoms
● Dementia
● Psych with personality changes
● chorea/movement disorder
■ Lesion location
 ● Caudate nucleus
■ Diagnosis
● Specific genetic testing
● AD
■ Treatment
● Tetrabenazine - movement
● Atypical antipsychotics
● Brain death

○
 ○
● Prevention
○ Aspiration in unconscious or dysphagia
■ Position upright supine
○ Patients with hypothermia or shock who receive blood transfusions are
predisposed to hypocalcemia because of their impaired ability to metabolize
citrate into lactate. In these patients (renal failure, hepatic failure, shock, lactic
acidosis) prophylactic administration of at least 10 cc of 10% calcium gluconate is
recommended for every 500 ml of packed red blood cells transfused
○