TOP 100 SECRETS

These secrets are 100 of the top board alerts. They summarize
the concepts, principles, and most salient details of neurology .
1. The first step in treating patients with neurologic disease is to localize
the lesion.
2. Myopathies cause proximal symmetric weakness without sensory loss.
3. Neuromuscular junction diseases cause fatigability.
4. Peripheral neuropathies cause distal asymmetric weakness with
atrophy, fasciculations, sensory loss, and pain.
5. Radiculopathies cause radiating pain.
6. Spinal cord disease causes a triad of distal symmetric weakness,
sphincter problems, and a sensory level.
7. A unilateral lesion within the brain stem often causes “crossed
syndromes,” in which ipsilateral dysfunction of one or more cranial
nerves is accompanied by hemiparesis
and/or hemisensory loss on the contralateral body.
8. Cerebellar disease causes ataxia and an action tremor.
9. In the brain, cortical lesions may cause aphasia, seizures, and partial
hemiparesis (face and arm only), while subcortical lesions may cause
visual field cuts, dense numbness of primary sensory modalities, and
more complete hemiparesis (face, arm, and leg).
10. The brain is isolated from the rest of the body by the blood-brain
barrier.
11. Learning and memory are possible because repetitive input to a
synapse can cause
persistent changes in neuronal function (long-term potentiation).
12. Some of the most common and important neurologic diseases are
caused by
abnormalities in neurotransmitters: Alzheimer’s (acetylcholine), epilepsy
(g-aminobutyric acid, GABA), Parkinson’s (dopamine), migraine
(serotonin), and others.
13. Many genetic neurologic diseases have been shown to be caused by
expansion of
trinucleotide (triplet) repeat sequences.
14. Foot drop (weakness of the tibialis anterior muscle) can be caused
by lesions to the
common peroneal nerve or L5 nerve root.
15. If the facial nerve is damaged (such as from Bell’s palsy), the entire
side of the face is weak. If the cortical input to the facial nerve is
damaged (such as from a stroke), only the lower half of the face will be
weak.
16. A dilated or “blown” pupil implies compression of the third cranial
nerve. This is often due to a serious lesion such as an aneurysm or brain
herniation.
17. Collateral blood flow, often routed through the circle of Willis,
sometimes protects against damage from strokes.
18. Noncommunicating hydrocephalus is often a medical emergency
because the obstructed cerebrospinal fluid (CSF) will cause the
intracranial pressure to rise.
19. The diagnosis of myopathies often is based on serum creatine kinase
(CK) levels,
electromyography (EMG) findings, and muscle biopsy.
20. Myotonic dystrophy is the most common muscular dystrophy in
adults.
21. The possibility of respiratory failure is the most serious concern in
the management of most patients with myopathies or neuromuscular
junction diseases.
22. Drug toxicity should always be considered in the differential
diagnosis of many neurologic conditions.
23. Neuroleptic malignant syndrome is a true medical emergency with a
high mortality.
24. Patients with myasthenia gravis show a decremental response
(fatigue) with repetitive stimulation of their muscles.
25. Up to 40% of myasthenic patients experience a transient
exacerbation after starting
high-dose steroids, usually within 5 to 7 days.
26. Lambert-Eaton myasthenic syndrome (LEMS) resembles myasthenia
gravis with
autonomic dysfunction and arises from an autoimmune attack on
presynaptic
voltage-gated calcium channels.
27. Myotonia, a delayed relaxation after muscle contraction, is most
common in muscular dystrophies but can be seen in a host of other
conditions.
28. On an EMG, muscle disease shows full contraction of all muscles but
with short, small motor units.
29. On an EMG, nerve disease shows a dropout and reduction in muscle
contraction, with prolonged, large motor units. There may be
fibrillations and fasciculations.
30. The most common causes of peripheral neuropathy are diabetes and
alcoholism.
31. The most common motor neuropathy is Guillain-Barre´ syndrome.
32. Nerve biopsy is seldom necessary for the diagnosis of peripheral
neuropathy.
33. The most often overlooked cause of peripheral neuropathy is
genetic.
34. The spinal fluid of patients with Guillain-Barre´ syndrome has high
protein but low (normal) cell counts.
35. The most common motor neuron disease is amyotrophic lateral
sclerosis (ALS).
36. Indications for surgery in patients with radiculopathies are
intractable pain, progressive motor weakness or sensory deficits, or
symptoms refractory to a reasonable degree of nonoperative therapy.
37. Neurogenic claudication (pseudoclaudication) presents typically as
bilateral, asymmetric, lower extremity pain that is provoked by walking
(occasionally standing) and relieved by rest.
38. Sudden damage to the spinal cord can cause spinal shock, which
results in temporary flaccid paralysis, hyporeflexia, sensory loss, and
loss of bladder tone.
39. Occlusion of the artery of Adamkiewicz may result in anterior spinal
artery syndrome, causing bilateral weakness, loss of pain and
temperature, and hyperreflexia below the
lesion with preserved dorsal column functions (position and vibration).
40. Cauda equina syndrome is a neurosurgical emergency that presents
with weakness and sensory loss in the lower extremities, prominent
radicular pain, saddle anesthesia, and
urinary incontinence.
41. Symptoms of brain stem ischemia are usually multiple, and isolated
findings (such as vertigo or diplopia) are more often caused by
peripheral lesions affecting individual cranial nerves.
42. Me´nie`re’s disease presents with the symptomatic triad of episodic
vertigo, tinnitus, and hearing loss. It is caused by an increased amount
of endolymph in the scala media.
Pathologically, hair cells degenerate in the macula and vestibule.
43. The blood supply of the brain stem is derived from the
vertebrobasilar system of the posterior circulation.
44. There are only two causes of coma: a process affecting the reticular
activating system in the brain stem or a process affecting both cerebral
hemispheres simultaneously.
45. Posterior fossa neoplasms account for 50% of the total number of
neoplasms in children. In adults, they are much rarer.
46. Lesions of the cerebellar hemisphere impair movement on the
ipsilateral side of the body because of a double-crossing of the
pathways.
47. Loss of pigmented dopaminergic neurons in the substantia nigra is
the pathologic
hallmark of Parkinson’s disease.
48. Sinemet (levodopa) remains the most valuable therapy for
Parkinson’s disease.
49. Essential tremor is the most common cause of tremor.
50. Torticollis is the most common form of focal dystonia.
51. Botulinum toxin is the treatment of choice for most focal dystonias.
52. Tardive dyskinesia is a serious side effect of many neuroleptic drugs.
53. Cardinal symptoms of autonomic insufficiency include orthostatic
hypotension, bowel and bladder dysfunction, impotence, and sweating
abnormalities.
54. Diabetic neuropathy is one of the most common causes of autonomic
dysfunction.
55. Syncope is seldom a neurologic problem; loss of consciousness is
almost always due to cardiovascular disease.
56. Traditionally, the diagnosis of multiple sclerosis requires two
separate symptoms at two different times, or lesions disseminated in
time and space.
57. Faulty interpretation of magnetic resonance imaging (MRI) scans is
the most common error in misdiagnosing multiple sclerosis.
58. No treatment has yet been shown to prevent ultimate disability in
multiple sclerosis.
59. Dementia must be differentiated from delirium and depression.
60. Dementia is a category, not a diagnosis. The clinician must
determine the cause of dementia.
61. Seizures that persist or recur without regaining consciousness are
called status epilepticus. To avoid permanent brain damage, these
should be stopped within 1 hour of onset.
62. Alzheimer’s disease and other dementias are treatable. Both
cognitive and behavioral symptoms can be treated, and long-term
therapy may slow decline and help maintain function.
63. Vascular dementia cannot be diagnosed by MRI or computed
tomography (CT) scan alone. It also requires a clinical picture of cerebral
ischemia.
64. A common cause of excessive daytime sleepiness is obstructive sleep
apnea syndrome.
65. A patient’s own assessment of his sleep quantity and quality is often
unreliable.
Polysomnographic evaluation (sleep laboratory testing) is the only
reliable means for
obtaining objective information regarding a suspected sleep
disturbance.
66. The classic tetrad of narcolepsy is excessive daytime sleepiness,
cataplexy, sleep
paralysis, and hypnagogic hallucinations.
67. Gliomas are the most common primary brain tumors.
68. Astrocytomas are the most common spinal cord tumors.
69. Metastatic brain tumors are 10 times more common than primary
brain tumors.
70. Cancer that metastasizes to the spine usually causes pain, a sensory
level, paraplegia, and sphincter disturbances. It is usually treated by
radiation therapy.
71. Many cancer patients die in pain because physicians fail to treat pain
appropriately.
72. Dysarthria is a defect in the way speech sounds, which can arise
from many causes, whereas aphasia is a defect in the use of language
and results from damage to the dominant (usually left) cerebral cortex.
73. Antibiotics should be given immediately to patients with meningitis
and not delayed while other tests are performed.
74. Mad cow disease is a variant of Creutzfeldt-Jakob disease caused by
a prion—a protein that does not require DNA or RNA to replicate and
produce infection.
75. Herpes simplex, the most common sporadic encephalitis, often
produces focal neurologic damage and must be aggressively treated
with acyclovir.
76. Patients with acquired immunodeficiency syndrome (AIDS) may
develop problems from the virus itself, the drugs used to treat it, or
opportunistic infections.
77. Most patients with a headache due to a serious underlying illness
have an abnormal physical examination. The sudden onset of “the worst
headache of my life” should raise concern about an intracranial
hemorrhage.
78. The use of narcotic analgesics for treatment of headaches should be
strongly discouraged.
79. The first-choice drugs for acute migraine therapy are the triptans.
80. The best treatment for tension headache is usually amitriptyline plus
a nonsteroidal
anti-inflammatory drug (NSAID).
81. Temporal arteritis should be considered in any elderly patient with
new headaches.
82. The normal adult electroencephalogram (EEG), relaxed with eyes
closed, is characterized by 9 to 11 cycles/sec activity in the back of the
brain (occipital lobes) and is called the alpha rhythm.
83. Each different stage of sleep has a highly characteristic EEG pattern.
84. In most jurisdictions, a patient is considered to have died if he meets
the criteria for brain death, even if his vital signs (e.g., pulse, blood
pressure) are otherwise normal.
85. Strokes can be thrombotic, embolic, lacunar, or hemorrhagic.
86. The clinical features, etiology, and treatment of strokes are different
depending on whether they involve the anterior circulation (carotid
arteries) or posterior circulation (vertebral
basilar arteries).
87. The most important modifiable risk factors for stroke are
hypertension, smoking, heart disease, hyperlipidemia, and
hyperhomocysteinemia. Other modifiable risk factors include diabetes,
alcohol consumption, drugs of abuse, oral contraceptives, and obesity.
88. When administered properly, tissue plasminogen activator (tPA) is a
beneficial therapy for acute ischemic stroke.
89. The role of anticoagulation in cerebrovascular disease is the
prevention of stroke in
patients at high risk for cardiac emboli.
90. The best way to prevent strokes is to control the risk factors.
91. Surgery is superior to medical therapy in symptomatic stroke
patients with a 70% stenosis or more in their internal carotid arteries.
92. The most important complications of subarachnoid hemorrhage are
rebleeding,
vasospastic ischemia, hydrocephalus, seizures, and syndrome of
inappropriate antidiuretic hormone secretion (SIADH).
93. Accurate seizure classification guides appropriate antiepileptic
therapy. Each type of seizures requires its own specific anticonvulsant
drug.
94. All partial seizures should be evaluated with an MRI scan.
95. A significant change in antiepileptic drug levels should alert you to
either noncompliance or a new drug interaction. Noncompliance is
probably the most common cause of status epilepticus.
96. The most common cause of antiepileptic drug treatment failure is
drug side effects.
97. Patients whose seizures are refractory to two appropriate
antiepileptic drugs should be evaluated at an epilepsy center for
definitive diagnosis and surgical evaluation.
98. The most common cause of aphasia in adults is stroke.
99. Broca’s aphasia is impaired comprehension, repetition, naming, and
speech output due to a left frontal lobe lesion; Wernicke’s aphasia is
fluent speech full of nonsense words and phrases due to a left temporal
lobe lesion.
The drug most often recommended by neurologists is .100
.acetaminophen

SOURCE: NEUROLOGY SECRETS .5th.edition