NERVOUS SYSTEM KEYNOTES

1. Inadvertent retraction or transection of the hypoglossal nerve

causes tongue deviation to the site of injury.
2. The facial nerve can be damaged after it exits from the
stylomastoid foramen and courses along the inferior portion of the
ear.
3. Carbidopa blocks DOPA decarboxylase and, therefore, prevents
conversion of L-DOPA to dopamine in the liver and peripheral
blood.
4. The use of carbidopa also decreases many of the unpleasant
adverse effects that occur due to the peripheral effects of
dopamine (eg, nausea/vomiting, postural hypotension,
tachyarrhythmias).
5. PSG evaluates the quality of sleep, and the recorded tracings of
physiologic variables can assist in the diagnosis of obstructive sleep
apnea, periodic limb movements, and narcolepsy.
6. Subtherapeutic drug levels are a common cause of breakthrough
seizures in children with known epilepsy.
7. Up to 80% of patients recovering from an acute episode of WE
show signs of KS, including significant retrograde and
anterograde amnesia, often with confabulation.
8. The internal capsule is composed largely of the corticospinal
tract, which brings information from the primary motor cortex to
the lower motor neurons in the spinal cord. Damage to this area
typically results in contralateral hemiparesis or hemiplegia.
9. c/o unilateral facial nerve palsy, hepatomegaly, and
lymphadenopathy raise suspicion for extrapulmonary
sarcoidosis.
10. Brain death is the irreversible absence of cerebral and brain
stem function.
11. Traumatic brain injury (TBI) of any severity can lead to (a few
hours to days later) postconcussive syndrome, which is
characterized by headache, confusion, amnesia, difficulty in
concentrating or with multitasking, vertigo, mood alteration, sleep
disturbance, and anxiety. These symptoms typically resolve with
symptomatic treatment within a few weeks to months following
TBI; however, some patients may have persistent symptoms lasting
>6 months.
12. ECG to diagnose arrhythmia (eg, atrial fibrillation) that may
result in the formation of an intracardiac thrombus.
13. Patients with acute ischemic stroke should undergo evaluation
to determine the underlying stroke etiology, guide therapy, and
minimize the risk for future events. This evaluation should include
advanced head imaging (eg, MRI), noninvasive neurovascular
imaging (eg, CT angiography, carotid duplex ultrasonography),
ECG monitoring, and echocardiography.
14. Keep BP <180/105 mm Hg to ↓ risk of hemorrhagic
transformation.
15. Blood pressure is kept <180/105 mm Hg using intravenous
antihypertensive agents to decrease the risk of hemorrhagic
transformation.
16. A transthoracic or transesophageal echocardiogram with a
bubble study (which can detect a PFO or ASD) will reveal such an
intracardiac shunt.
17. Paradoxical emboli are those that originate in the venous
system and enter the arterial system via an intracardiac shunt.
They are a more common cause of stroke in the young than in the
elderly. They can be diagnosed with an echocardiogram and
bubble study.
18. 20% of patients with Fronto-temporal dementia, develop a
motor neuron disease with both upper (eg, hyperreflexia) and
lower (eg, fasciculations) motor neuron signs similar to those
seen in amyotrophic lateral sclerosis. Early personality and
behavior changes are more characteristic of FTD.
19. Creutzfeldt-Jakob disease presents with neuropsychiatric signs,
upper motor neuron and extrapyramidal signs, startle myoclonus,
then akinetic mutism.
20. Sleep disturbance and motor impairment are features of
dementia with Lewy bodies; however, these patients often have
visual hallucinations and fluctuating attention or alertness.
21. The cardinal feature of Huntington disease is chorea
accompanied by prominent psychiatric sequalae (eg, depression,
psychosis, suicide) and abnormal eye movements (eg, abnormal
saccade) prior to slow cognitive decline.
22. Patients who are pregnant or postpartum have an increased
risk of Bell palsy, a peripheral neuropathy involving the facial nerve
(CN VII). It should be treated with glucocorticoids with or without
acyclovir, and patients have an excellent prognosis for full recovery
over weeks to a few months.
23. The presence of distal symmetric polyneuropathy (in the classic
"stocking-glove" pattern) and history of erectile dysfunction are
suggestive of significant diabetic neuropathy.
24. The cremasteric reflex corresponds to the L1-L2 level of the
spinal cord. This reflex can be diminished or lost secondary to
diabetic autonomic neuropathy.
25. Anal sphincter is S2-S4.
26. Thrombolysis is contraindicated when a patient's blood
pressure is >185/110 mm Hg because uncontrolled hypertension
increases the risk for hemorrhagic conversion and may
decrease the effectiveness of alteplase. So start with iv anti-
hypertensives.
27. Dopaminergic receptor agonists (bromocriptine and
cabergoline) are the first-line treatment for prolactinomas,
including large prolactinomas.
28. Subacute combined degeneration (SCD) is a myelopathy
characterized by both posterior spinal column disease and lateral
corticospinal tract disease, the latter of which causes spastic
paresis and hyperreflexia.
29. Folic acid deficiency usually does not cause neurologic
symptoms.
30. Late neurosyphilis can present with tabes dorsalis (sensory
ataxia and lancinating pains) and Argyll Robertson pupils
(constriction with accommodation but not with light).
31. The sympathetic nervous system (SNS) inhibits gastrointestinal
muscular contraction. The parasympathetic nervous system
primarily promotes motility.
32. A positive Babinski sign is normal until age 2.
33. Chronic phenytoin therapy reduces the effectiveness of all oral
contraceptive pills through induction of their hepatic metabolism.
34. Vasovagal syncope is often associated with a prodrome of
tunnel vision, diaphoresis, nausea, and pallor.
35. Syncope can be divided into two broad categories:
cardiovascular and noncardiovascular. Cardiovascular causes
include arrhythmia and blood flow obstruction (i.e. aortic stenosis).
Noncardiovascular causes are extensive including: vasovagal,
carotid sinus hypersensitivity, orthostasis, seizures, TIA.
36. White blood cell (WBC) count can be adjusted with a ratio of 1
WBC to every 1,000 RBCs to help differentiate traumatic LP from
meningitis.
37. Spinal epidural abscess, a bacterial infection of the epidural
space, typically arises in the setting of bacteremia from intravenous
drug use or distant infection. Manifestations include fever, focal
back pain, and progressive neurologic deficits.
38. A TIA—defined as a transient episode of neurologic dysfunction
caused by ischemia but without acute infarction—is considered a
neurologic emergency because it signals an acutely increased
risk of stroke (eg, up to 5% within the first 48 hr, up to 12%
within the first 30 days).
39. Compression of the median nerve as it passes between the 2
heads of the pronator teres (ie, pronator teres syndrome) can cause
pain and numbness in the first 3 digits but typically also causes
symptoms in the lateral palm and thenar eminence due to
involvement of the palmar cutaneous branch.
40. American Academy of Neurology (AAN) currently recommends
screening for hypothyroidism, vitamin B12 deficiency, and
depression as part of the initial evaluation of all patients with
suspected dementia.
41. Hypothyroidism in elderly patients may present with impaired
cognition and is often associated with hyponatremia and
macrocytosis.
42. Acute dystonic reactions are extrapyramidal symptoms that can
occur as a result of treatment with dopamine antagonists (eg,
antipsychotics, prochlorperazine, metoclopramide).
These extrapyramidal effects include dystonia, akathisia
(restlessness), and parkinsonism.
43. Diphenhydramine and benztropine are the drugs of choice
for the immediate treatment of prochlorperazine-induced acute
dystonia due to their anticholinergic effects.
44. Some patients receiving tPA may also be candidates for
mechanical thrombectomy if CT angiography demonstrates a large
vessel occlusion (LVO), but an LVO is not present in this patient.
45. c/o Acute ischaemic stroke - give tPA if patient has presented
within 4.5hours. anti platelet therapy is witheld for 24hours. then
find the cause of stroke. if its embolic then start long term
anticoagulation therapy 48 hours later rather than antiplatelets.
46. c/o bilateral polyspike
& slow wave activity - s/o Juvenile myoclonic epilepsy. Rx valproic
acid.
47. During adolescence, the classic presentation involves
myoclonic seizures (ie, jerks) of the arms within the first hour of
waking that can be aggravated by sleep deprivation and alcohol
intake.
48. Corticotropin (ACTH) and vigabatrin are the gold-standard
treatments for infantile spasms.
49. Valproate - Dose dependent thrombocytopenia, pancreatitis,
neural tube defects & hepatotoxicity.
50. Hyponatremia - ass with carbamazepine and oxcarbazepine.
51. Meningovascular syphilis can present with stroke due to
intracranial arteritis. Can affect frontal lobe.
52. Most perioperative strokes are ischemic (vs hemorrhagic) and
are caused by an embolism, thrombosis, or hypotensive episode
(eg, watershed infarction). Do CT scan without contrast to detect
hemorrhage.
53. c/o headaches, papilledema, and abducens nerve (CN VI) palsy,
findings concerning for idiopathic intracranial hypertension
(IIH). Seen with obese women.
54. Diagnosis of IIH is with neuroimaging (to exclude mass lesions)
followed by lumbar puncture that shows an elevated opening
pressure (>250 mm H2O).
55. Idiopathic Parkinson disease is a clinical diagnosis that requires
the presence of motor parkinsonism (bradykinesia plus either
tremor or rigidity).
56. Ultrasound of the head is used primarily to grade
intraventricular hemorrhage in preterm infants.
57. Stroke patients, particularly those with dysarthria, are at risk
for oropharyngeal dysphagia and aspiration. In the setting of acute
stroke, patients should be given nothing by mouth, including
medications, until a rapid bedside dysphagia screening can be
performed.
58. Patients with hemiparesis are at greatest risk (up to 75% of
DVTs are on the hemiparetic side), and risk is highest 2-7 days
following stroke.
59. If u suspect stroke, check timeline. If within 4.5 hours,
administer thrombolytics. If >4.5 hours, do CT head to find
thrombus, if present do mechanical thrombectomy, if not, then do
immedicate bedside dysplagia screening and give oral antiplatelets
if cleared. If > 24 hours, give antiplatelets and also find the source
of embolism. Majority might have DVT on hemiparesis side, so give
prophylactic lose dose heparin within 48 hours of admission.
60. If thrombolytics are administered, give IV anti-hypertensives to
control BP and keep BP below 185/110mmHg below administration,
and below 180/105 after administration within 24hours.
61. Meningitis should be suspected in patients with nuchal rigidity,
headache, bulging fontanelle, and/or prolonged altered mental
status.
62. Patients with Cataplexy can be treated with a serotonin-
norepinephrine reuptake inhibitor (eg, venlafaxine) or selective
serotonin reuptake inhibitor, and a tricyclic
antidepressant, Sodium oxybate and stimulants.
63. Status epilepticus has been defined as a single continuous
seizure for >30 minutes or multiple seizures occurring in a short
period with no return to baseline mental status.
64. Forehead muscle sparing is suggestive of an intracranial (eg,
central facial) lesion.
65. Although cases of reversible dementia are rare (ie, <1%),
clinicians must rule out reversible causes prior to making a
diagnosis of a specific dementia syndrome. The initial laboratory
workup should include TSH, complete blood count, complete
metabolic panel, and vitamin B12 levels.
66. Acetylcholinesterase inhibitors (eg, donepezil, rivastigmine,
galantamine) are first-line pharmacotherapy for dementia-
related cognitive impairment.
67. Patients who take analgesics (eg, acetaminophen) for
headaches >10 days/month for >3 months can develop a secondary
headache disorder due to medication overuse.
68. c/o unilateral, orbital headaches of short duration associated
with autonomic symptoms, suggesting cluster headache.
69. Temporal arteritis is a vasculitis often associated with
unilateral headache, vision change, and jaw claudication.
70. First-line therapy for acute management of cluster headache is
100% oxygen inhalation. Verapamil is considered the agent of
choice for the prevention of episodic and chronic cluster
headaches.
71. CMZ - Trigeminal neuralgia; Indomethacin - Acute t/t of tension
type or migraine headache; Propanolol - Migraine headache
prevention; Sumatriptan - acute treatment of cluster headaches.
72. A normal oculovestibular response is characterized by a
transient, conjugate, slow deviation of gaze to the side of the
stimulus (brainstem-mediated), followed by saccadic correction to
the midline (cortical correction). Also seen with psychogenic coma.
73. Rapidly progressive weakness of the lower extremities
following an upper respiratory infection, accompanied by sensory
loss and urinary retention, is characteristic for transverse myelitis.

74. SLR positive - Herniated IV Disk.

75. IV drug abuse or treatment with anticoagulants - Epidural
abscess or an acute subdural hemorrhage.
76. ALS with prominent corticospinal involvement is characterized
by hyperactivity of muscle-stretch reflexes (tendon jerks) and
frequent spastic resistance to passive movements of the affected
limbs. Ocular motility, sensory, bowel, bladder, and cognitive
functions are preserved, even with advanced disease.
77. Binswanger's disease is a type of vascular dementia that
involves white matter infarcts. Patients with this disease usually
present with apathy, agitation, and bilateral corticospinal or bulbar
signs.
78. c/o intracranial hypertension have been classically described to
have bradycardia, hypertension and respiratory depression
(Cushing's triad).
79. Damage to the dominant parietal lobe, especially the inferior
parietal lobe, presents as Gerstmann syndrome - Acalculia,
agraphia, finger agnosia & right/left confusion.
80. Nondominant parietal lobe lesions present with constructional
and dressing apraxia.
81. Patients with diaphragmatic paralysis typically present with
shortness of breath that is worse in the supine position.
82. One helpful clue on physical examination suggestive of
diaphragmatic paralysis is paradoxical abdominal wall retraction
during inspiration when the patient is lying supine, which occurs
because the diaphragm is not contracting.
83. c/o optic neuritis, which typically presents with monocular
visual loss accompanied by eye pain that worsens with eye
movement.
84. Acute multiple sclerosis exacerbation is treated with
corticosteroids. Patients with optic neuritis should receive
intravenous corticosteroids as oral agents may be associated with
an increased risk of recurrence. Plasmapheresis can be used in
refractory cases.
85. Beta-interferon or glatiramer can decrease the frequency of
exacerbations and reduce the development of brain lesions in
patients with relapsing-remitting multiple sclerosis.
86. Pregnant women with MS have a modest increase in cesarean
section and assisted delivery (eg, vacuum, forceps) rates compared
to those without MS.
87. Benztropine is an anticholinergic medication that can treat
drug-induced dystonia.
88. First-line treatment for severe spasticity includes oral baclofen
or tizanidine.
89. Idiopathic intracranial hypertension primarily occurs in obese
women of childbearing age and is usually associated with severe,
throbbing, unilateral headache, papilledema, and vision changes
(eg, diplopia, blurriness).
90. Tension headaches are typically non-throbbing, bilateral, and
band-like.
91. Severe & sudden onset of headache different from previous
pattern or described as "worst headache of my life" - SAH.

Noncontrast CT scan of the head is preferred for diagnosis, followed by lumbar puncture to
evaluate for xanthochromia if the CT scan is negative and concern for SAH persists.
92. Patients with symptomatic carotid artery disease who have high-grade (eg, 70%-99%)
stenosis and a life expectancy ≥5 years should undergo carotid endarterectomy (CEA) to
reduce future risk of stroke.
93. Lower-grade (<70%) lesions may be managed either medically (eg, aspirin, statins,
antihypertensives) or surgically, depending on the degree of stenosis and sex of the patient.
94. Patent foramen ovale closure is recommended for patients with embolic-appearing
cryptogenic strokes.
95. GBS patients are at high risk of respiratory failure and require frequent monitoring of tidal
volume and negative inspiratory force to assess respiratory status.
[Link] myelitis is typically treated with high-dose glucocorticoids.
97. Guillain-Barré syndrome is treated with plasma exchange or intravenous immunoglobulin
to speed recovery and reduce risk of respiratory failure.
98. Patients with spina bifida carry an increased risk of having a child with spina bifida.
99. Spina bifida occulta associated with neurogenic bladder.
100. Acoustic neuromas result from the proliferation of Schwann cells (schwannomas) seen
with neurofibromas.
101. Step wise decline seen in Vascular dementia.
102. Dementia with leqy bodies - Fluctuating cognition, Visual hallucinations, Parkinsonism
and, REM sleep behavious disorder.
103. The classic triad of normal-pressure hydrocephalus (NPH) consists of cognitive
impairment, urinary incontinence, and abnormal gait. NPH has dilated ventricles.
104. The use of antipsychotics in DLB may be associated with a significant worsening of
confusion, parkinsonism, or autonomic dysfunction.
105. Premature infants are at risk for cerebral palsy, which often presents as hypertonia
(spasticity & scissoring of legs), hyperreflexia (eg, sustained clonus), and delayed motor
milestones. MRI of the brain evaluates for a potential etiology.
106. In children age <2, high-risk features include altered mental status, loss of
consciousness, severe mechanism of injury, nonfrontal scalp hematoma, and palpable skull
fracture.
107. IIH is most common in obese premenopausal women, but is also thought to occur
secondary to endocrine disorders (e.g., hypoparathyroidism, hypothyroidism, adrenal
insufficiency, Cushing disease) and the usage of some medications (e.g., isotretinoin, all-
trans-retinoic acid, minocycline, tetracycline, cimetidine, corticosteroids, danazol, tamoxifen,
levothyroxine, lithium, nitrofurantoin).
108. The pathophysiology of IIH involves increased intracranial venous pressure due to
impaired resorption of cerebrospinal fluid (CSF) by the arachnoid granulations and CSF
lymphatic drainage sites. Acetazolamide, the first-line treatment for symptomatic IIH, works
by inhibiting choroid plexus carbonic anhydrase, thereby decreasing CSF production by the
choroid plexus.
109. Although more than 40 species of ticks can cause tick paralysis, most cases in North
America are due to Dermacentor andersoni (Rocky Mountain wood tick) and D variabilis
(American dog tick).
110. Tick paralysis - Manifestations typically arise after 4-7 days of tick attachment and
include rapidly progressive gait ataxia and ascending paralysis. Neurologic examination
usually reveals absent deep tendon reflexes and normal sensation.
111. MRI spine with contrast detects spinal epidural abscess.
112. Epidural abscess presents with fever, focal spinal tenderness/back pain, and neurologic
dysfunction.
113. Patients with mild but potentially disabling symptoms of acute ischemic stroke should be
considered for treatment with thrombolytics.
114. The constellation of unilateral headache and partial left-sided Horner syndrome
indicates left carotid artery dissection until proven otherwise. Diagnosis by CT
angiography.
115. Patients with medial medullary syndrome develop contralateral hemiparalysis and
ipsilateral CN XII palsy (tongue deviation toward the lesion).
116. A lateral medullary infarct (Wallenberg syndrome) leads to vertigo/nystagmus
(vestibular nucleus), loss of pain/temperature sensation in the ipsilateral face (trigeminal) and
contralateral body (spinothalamic), bulbar weakness (lower cranial nerves), and ipsilateral
Horner syndrome (descending sympathetic).
117. Neurologic impairment is the leading cause of death in patients with tuberous sclerosis
complex. Uncontrollable seizures, aspiration pneumonia, and obstructive hydrocephalus can
result from progressive central nervous system involvement.
118. Renal involvement (obstructive renal angiomyolipoma, renal failure) is the second most
common cause of death in TSC after neurologic involvement. 119. Central pontine
myelinolysis is a dreaded complication of an overly rapid correction of plasma
hypotonicity. It classically presents with paralysis of all extremities and the lower
cranial nerves. Cerebral function and upper cranial nerve function are typically
spared; therefore, patients remain conscious and are able to communicate via blinking
and vertical eye movements.
120. Pituitary apoplexy (ie, pituitary hemorrhage or infarction, usually in a large
adenoma) presents with headache and cranial nerve compressive symptoms (eg,
ophthalmoplegia, hemianopsia). CT scan of the head is usually obtained initially;
MRI is highly sensitive and specific.
121. Carbamazepine use has been associated with hyponatremia and SIADH. Because
of some mild anticholinergic effects, there is a risk of glaucoma, urinary retention or
constipation.
122. Acetylcholine receptor (AChR) antibody assay is positive in most patients
with MG; some patients with MG have antibodies directed at muscle-specific kinase
(MuSK) or low-density lipoprotein receptor–related protein (LRP4). Nerve
conduction studies can show classic findings (decremental response to repeated
stimulation) that can also help confirm the diagnosis if AChR testing is negative.
123. Acetylcholinesterase inhibitors are the first-line treatment for myasthenia gravis;
they work by decreasing the breakdown of acetylcholine at the synaptic cleft. Dosing
is titrated to clinical effect.
124. Agranulocytosis has been reported with ethosuximide.
125. Patients with fever, back pain, and acute neurologic deficits should be evaluated
with emergency MRI for spinal epidural abscess, especially when risk factors (eg,
diabetes mellitus) are present. More commonly seen with Parkinsonism.
126. Several clinical prerequisites must be met before formal brain death testing:

 Neuroimaging consistent with a devastating brain condition (eg, anoxic brain injury,
herniation)
 Absence of confounding factors causing encephalopathy (eg, sedation, metabolic
derangements)
 Absence of drug intoxication (explaining ongoing CNS depression)
 Absence of hypothermia and hypotension (compromising brain metabolism or
perfusion).
127. EEG showing burst-suppression pattern (eg, isoelectric
periods punctuated by high amplitude activity) is consistent with
deep coma or anesthesia.
128. Brain death testing can be interpreted only in the absence of
confounding factors contributing to central nervous system
depression such as metabolic derangements, sedation, and drug
intoxication.
129. Lumbar drainage of cerebrospinal fluid in NPH with pre and
post assessment of gait and cognition is helpful in predicting the
effectiveness of ventriculoperitoneal shunting.
130. The "Get Up and Go" test is commonly used to assess
postural stability in elderly patients annually who have history of
falls.
131. Intracranial hypertension can be precipitated by excessive
vitamin A and its derivatives (eg, isotretinoin) and presents with
headaches, pulsatile tinnitus, vision changes, and papilledema.
132. c/o recurrent episodes of sustained, forceful contraction of the
right muscles of mastication, resulting in painful jaw movement
into an abnormal position. This is consistent with oromandibular
dystonia, a form of focal dystonia. Injections of botulinum toxin to
weaken (not fully paralyze) the orbicularis oculi muscle can lead to
significant symptomatic relief.
133. Impaired bile excretion can occur with extrahepatic
cholestasis (eg, choledocholithiasis, malignant obstruction, biliary
stricture) or intrahepatic cholestasis (eg, primary biliary cirrhosis,
primary sclerosing cholangitis).
134. Impaired hepatic conjugation is observed in patients with
Gilbert syndrome.
135. Patients with brain death have absence of reflexes associated
with cortical and brainstem function (pupillary, oculocephalic,
oculovestibular [caloric], cough, corneal, gag, sucking, swallowing,
and extensor posturing).
136. Absence of a respiratory response (in a typical observation
period of 8−10 minutes) with a PaCO2 >60 mm Hg (or >20 mm Hg
from baseline) and a final arterial pH of <7.28 are considered a
positive apnea test.
137. The greater the D2 receptor antagonism, the greater the
likelihood for inducing parkinsonism. Risperidone antipsychotic will
cause more harm than olanzapine; Drug induced parkinsonism.
138. Posterior communicating artery (PCOM) aneurysms
(~20% of aneurysms) are classically associated with oculomotor
nerve (CN III) palsy (eg, diplopia, ptosis, anisocoria) due to the
proximity of the PCOM to CN III.
139. A tumor of the pineal gland characteristically causes
Parinaud's syndrome, which is characterized by the loss of
pupillary reaction, vertical gaze paralysis, the loss of optokinetic
nystagmus, and ataxia. Some pineal tumors are germinomas and
secrete HCG, which can cause precocious puberty in prepubertal
males. 140. Frontal lobe tumors can be associated with Foster
Kennedy syndrome (optic atrophy on the side of the tumor and
papilledema on the contralateral side).