Pronator drift: upper motor neuron disease or pyramidal/corticospinal tract disease

Romberg: proprioception (dorsal column medial leminiscus)

Basal ganglia: Parkinson like; tremor, rigidity, bradykinesia, choreiform
Cerebellar: ataxia, intentional tremor, impaired rapid alternating movement, trouble
balance with eyes open when trying Romberg
Gait
- Cerebellar: ataxia, staggering, wide based
- Frontal gait: magnetic/freezing, start/turn hesitation (dementia, frontal lobe
degeneration)
- Parkinson: short steps, narrow, shuffling
- Steppage: foot drop; motor neuropathy
- Vestibular: unsteady, falling to one side

Lateral cerebellar hemisphere: ipsilateral ataxia

Lateral medullary infarct (PICA or vertebral a.): dysphagia, dysarthria, hoarseness,
vertigo, nystagmus, ipsilateral face pain and temp loss, contralateral trunk and
limbs, Horners
Medial medullary infarct (vertebral or anterior spinal a): hypoglossal hemiplegia;
tongue deviated to side of lesion
Lateral mid pontine: weakness of mastication, diminished jerk reflex, trigeminal
ipsilateral sensory loss
Medial mid pontine infarction: ataxia, hemiparesis of face, trunk, limbs
ACA: leg weakness, sensory loss, urinary incontinence
Vertebrobasilar insufficiency or basilar migraine: LOSS OF CONSCIOUSNESS

Strongest association with ischemic and hemorrhagic stroke: HYPERTENSION

Intracerebral/parenchymal hemorrhage: headache; hypertension, amyloid
angiopathy (lobar hemorrhage; occipital homonymous hemianopsia), AVM (children
or without risk factors)
- Warfarin associated: high INR; therapy prothrombin complex, fresh frozen
plasma, vitamin K
- Usually in basal ganglia (putamen, caudate, thalamus, pons (pinpoint pupils,
coma disrupt RAS), cerebellum): contralateral hemiparesis, hemisensory and
eyes deviate to side of lesion (frontal eye field in internal capsule)
Subarachnoid hemorrhage: thunderclap headache; meningeal signs of n/v and
photophobia, neck stiffness; berry (saccular) aneurysm; CT without contrast star of
death; high echogencity of brainstem and basal cisterns; if CT negative get LP for
xanthochromia and high opening pressure
- High RBC, no xanthochromia, decreased RBC in later tubes: bloody tap
- High RBC, xanthochromia, continuous RBC in later tubes: SAH or HSV
encephalitis
- Complications after coiling/clipping
o 1 day: rebleeding
o 3 days: vasospasm; CT angio detects; nimodipine
o SIADH: hyponatremia, seizures, hydrocephalus
- Mycotic aneurysm can cause; HIV pt or IV drug abuse; poss endocarditis
Subdural hematoma: rupture of bridging veins (old age, alcoholism, kids abuse);
concave/crescent crosses suture line
Epidural hematoma: meningeal a rupture; biconvex pattern does not cross suture
line; pass out then fine then goes into coma
Diffuse axonal injury
- Multiple punctate hemorrhage and blurring of grey-white junction
- After MVA; lose consciousness instantaneously and become vegetative state
Cardioembolic stroke:
- a fib (ischemic hemorrhage at gray white junction usually multiple)
- bacterial endocarditis valvular vegetation septic emboli; IV antibiotics, blood
cultures, do not
use tPA/heparin/antiplatelet
o Valvular insufficiency, abscess, mycotic aneurysm, renal infarct or
glomerulonephritis, vertebral osteomyelitis
o IV drug abuse, fever, cardiac murmur

Lacunar stroke: internal capsule; pure motor hemiparesis (lenticulostriae off MCA);
weakness of contralateral face/arm/legs (lipohyalinosis)
- Pure sensory stroke: thalamus VPL (PCA- thalamoperforators); burning pain
with light touch or sensory loss
Carotid a. dissection: head/neck pain; ipsilateral Horner (damage to sympathetic
fibers)
TIA
- Amaurosis fugax: painless rapid transient monocular vision loss;
atherosclerotic emboli from ipsilateral carotid a; get a duplex US of neck;
funduscopic exam shows embolic plaques and retinal whitening
Vertebrobasilar insufficiency
- Reduced blood flow in posterior circulation (emboli, thrombi, arterial
dissection)
- Vertigo, dysarthria, diplopia, numbness
Head on collision
- Contusion frontal and occipital causes uncal herniation and temporal
hemorrhage
- Also cribriform shearing- loss of taste and anosmia
Cushing reflex: hypertension, bradycardia, respiratory depression (brain
compression usually brainstem)

Right parietal cortex: hemi neglect of left side

Dominant frontal lobe stroke: MCA territory; Brocas (non fluent, cant repeat, can
follow commands/understand); expressive aphasia; right hemiparesis (face, upper
limb)
Wernicke: fluent, cant repeat, cant understand/commands; right superior visual field
defect; superior temporal lobe
Conduction: fluent, can understand, cant repeat
Mixed transcortical: no fluent, no comprehension, can repeat
Temporal lobe: pie in the sky; Meyers loop; contralateral homonymous superior
quadrantanopia
Parietal lobe: dorsal optic radiation; contralateral homonymous inferior quadran
Occipital cortex: PCA occlusion; macular sparing b/c of MCA; contralateral
hemianopia with macular sparing
Scotoma: macular degeneration or optic neuritis
Lateral geniculate nucleus in thalamus: contralateral homonymous hemianopsia
Edinger Westphal nucleus lesion: ipsilateral fixed, dilated, nonreactive to light or
accommodation pupil

Anterior spinal cord syndrome (injury to anterior spinal a)

- Loss of pain and temperature sensation (spinothalamic tract); loss of
sensation 1-2 levels below
- Also bilateral hemiparesis (lateral corticospinal- injury below)
- Intact bilateral proprioception, vibration sensation, light touch (posterior
spinal artery)
Central cord syndrome
- Decreased sensation and motor function in arms with sparing of legs
- Maybe bladder dysfunction
Synringomyelia
 - Fluid filled cavity in spinal cord; associated with Chiari 1
- Loss of pain/temperature (cape like); areflexia in upper, weakness,
hyperrelexia in lower extremities (motor + pain/temp issues)
- Preserved vibration/proprioception
Cervical myelopathy
- Usually due to spondylosis (degeneration- canal narrowing- spinal cord
compression)
- Gain instability, weakness in upper extremities, upper motor neuron and
lower motor neuron signs
- MRI of cervical spine or CT myelogram
- Tx: immobilization and surgical decompression
Cauda equina (spinal nerve root)- lower motor neuron sign
- Radicular pain, saddle anesthesia, asymmetric motor weakness, hyporeflexia,
late onset bowel/bladder
- LP at level of L3/L4 or L4/L5
- MRI, IV steroids, neurosurg
Conus medullaris- upper + lower motor neuron sign
- Severe back pain, perianal anesthesia, symmetric motor weakness,
hyperreflexia, early bowel/bladder
- Conus usually at L1
- MRI, IV steroids, neurosurg
Acute spinal cord compression
- Accident, tumor, infection abscess
- Pain worse in recumbent and night; symmetric LE weakness; absent DTR;
babinski positive; decreased rectal sphincter tone; sensory loss
- MRI, IV steroids, neurosurg consult
Lumbar spinal stenosis
- Due to degenerative joint disease: disc herniation or osteophytes impinging
on spinal cord and roots
- Flexion improves the symptoms (walking uphill, pushing cart)
- Neuropathic claudication (leg symptoms worse with walking)
- MRI Spine if red flags like UMN, cauda/conus, fever, cancer,
immunosuppression otherwise conservative like NSAIDS
Brown Sequad (hemisection of spinal cord)
- Contralateral pain and temperature loss (usually lost 1-2 below level of injury)
o Hemisection at T8 causes loss at T10
- Ipsilateral proprioception, vibration, light touch and motor function
B12 deficiency
- Subacute combined degeneration: loss of proprioception/vibration causing
ataxia; spastic weakness with hyperreflexia
 - Macrocytic anemia with hypersegmented neutrophils
- B12 levels, serum methylmalonic acid and homocysteine high, CBC
B1 thiamine deficiency
- Wernicke: confusion, ataxia (wide gait), horizontal nystagmus; treated with
thiamine
- Korsakoff: anterograde amnesia, psychosis, severe memory impairment,
delusional; nonreversible
- GIVE THIAMINE first then glucose; pt condition worsens with glucose or fluids
with glucose
- Korsakoff: memory loss
Chronic alcoholism
- Cerebellar dysfunction: ataxia, nystagmus, intentional tremor, impaired rapid
alternating movements (dysdiadochokinesia)
- Day 1: seizures!!!
- Day 2-3: delirium tremens
CJD
- rapidly progressive dementia; startle myoclonus; cerebellar dys; akinetic
mutism
- periodic sharp waves on EEG
- positive 14-3-3 CSF; cortical ribboning
- brain biopsy findings (gold standard) & demonstrated PRNP gene
Amyotrophic lateral sclerosis
- hyperreflexia, spasticity (upper); weakness, fasciculation, muscle atrophy
(lower)
- Loss of anterior motor horn cells (lower motor cells), degeneration of
corticospinal tract, loss of motor nuclei in brainstem
- Tx: riluzole (glutamate blocker)
Parkinson disease
- alpha synuclein accumulation in substantia nigra pars compacta
- rest tremor (pill rolling 4-6 Hz), rigidity, bradykinesia, shuffling/hypokinetic
gait, small handwrite, soft speech (hypophonia), postural instability (loss of
balance with turning/stopping), mask like face
- Parkinsons psychosis/hallucinations: try decreasing or stopping Parkinson
meds or add new generation antipsychotic like quetiapine
- Tx: trihexyphenidyl (anticholinergic) if just tremor (watch out for acute
glaucoma closure)
- Side effects
o Levo/carbidopa: hallucinations, confusion early and then later
involuntary movement, choreiform dyskinesia
Alzheimer disease
- Early, short term memory loss
 - Language deficits and spatial disorientation
- Later personality changes
- Acetylcholinesterase inhibitors: donepezil, galantamine, rivastigmine
- Then try mamantine (NMDA antagonist)
Lewy body dementia
- parkinsonism, waxing/waning alert, VISUAL HALLUCINATION, cognitive
impairment
- worsens with anti psychotic tx
Picks disease (frontotemporal dementia)
- personality changes; dementia; apathy, disinhibition, compulsive
- frontotemporal atrophy on MRI
Vascular dementia
- stepwise decline
- MRI: cerebral infarction
AIDS dementia
- MRI: cortical and subcortical atrophy; ventricular enlargement
Pseudodementia
- Depression related cognitive impairment; reversible; highly likely to have
Alzheimers later
- Cognitive impairment, feeling worthless, sleep disturbance, low energy, slow
speech/though/movement
Delirium
- Infection, toxin, metabolic
- Waxing-waning, acute, nursing home,
- Tx: antipsychotic like haloperidol or atypical like risperidone
Multiple sclerosis
- space and time; urinary incontinence, optic neuritis, bilateral trigeminal
neuralgia
- transverse myelitis: motor/sensory loss below lesion; bowel/bladder
dysfunction; flaccid paralysis then spastic; bilateral MLF deficit-internuclear
opthalmoplegia (each eye cannot adduct but looking to nose both can
adduct)
- Lhermitte sign (electric shock down spine), Uhthoff phenomenon (heat
sensitivity)
- Acute MS: IV methylprednisone (plasmapheresis if refractory to steroids)
- Maintenance: interferon beta, glatiramer for relapsing-remitting or secondary
- MRI: T2 periventricular, infratentorial, spinal cord, juxtacortical white plaques
- CSF: oligoclonal IgG bands
- Pain: gabapentin, muscle spasticity: baclofen, urinary incontinence:
oxybutynin
Huntingtons disease
- AD; writhing, choreiform movements (facial grimace, ataxia, tongue
protrusion), mood disturbance depression, dementia, sudden jerky movement
- Caudate atrophy
- Anticipation: earlier and more severe
- Tx: antipsychotic
Myasthenia gravis
- Proximal muscle weakness worse later in day: diplopia, ptosis, dysphagia,
dysarthria, resp muscl crisis
- Damage at neuromuscular junction
- Dx: edrophonium test, ice pack test at bedside, AcHR Ab or anti-MuSK, CT
chest for thymoma
- Tx: acetylcholinesterase inhibitors (pyridostigmine), immunotherapy (steroids
or azathioprine), thymectomy
- Crisis: oropharyngeal weakness, resp insufficiency
o Intubation
o Steroids + plasmapheresis or IVIG

Lambert Eaton
- Symmetric proximal muscle weakness; decreased deep tendon reflex; DOES
NOT affect bulbar or eyes; increased strength with repetitive movements
- Autoantibodies against voltage gated Ca channels
- Small cell lung cancer
- Tx: 3,4 diaminopyridine, guanidine (increase Ach levels)
Myopathies
- Polymyositis, statin induced etc
- Proximal muscle weakness with muscle pain/tenderness
- Elevated creatine kinase
Polymylagia rheumatic
- Pain and STIFFNESS in shoulder/pelvis
- High ESR (normal CK)
- Steroids
Inflammatory myopathies/dermatomyositis
- Muscle pain, skin rash, arthritis, purple red rash around eyes-heliotrope rash,
red discoloration over finger joints-gottron papule
- Proximal muscle weakness: hip, shoulders
- High ESR and CK
- Screen for cancer
Statin induced myopathy
- Muscle pain; rhabdo
- High CK (normal ESR)
Glucocoritcoid induced myopathy
- Proximal muscle weakness (no pain)
- Normal CK and ESR
Hypothyroid myopathy
- Muscle pain, cramps, delayed relaxation of DTR
- High CK

Guillain-Barre
- Rapid ascending paralysis after infection (campylobacter); absent reflex,
paresthesia, demyelinating
- Spirometry: measure FVC to assess pulm function and prevent resp failure
- CSF: albuniocytologic dissociation (high protein, normal cell count)
Tick borne paralysis
- Progressive ascending paralysis; decreased reflex; facial weakness; erythema
chronic migrans
- Meticulous search for tick and remove it
- Ceftriaxone for lyme
Bacterial meningitis
- Fever, nuchal rigidity
Neurosymphillis
- Impaired vibration and positional and ataxia, absent LE reflex, Argyll
Robertson pupil (whore accommodates but does not react), personality
changes, urinary incontinence
- Positive CSF VDRL, unstable Romberg
- IV penicillin
Progressive multifocal leukoencephalopathy
- JC virus; demyelination; immunocompromised (AIDS, transplant)
- Multifocal neuro deficits

Normal pressure hydrocephalus

- wobbly (gait), wet (incontinence), wacky (dementia)
- due to decreased CSF absorption
- dilated ventricles on MRI
Idiopathic intracranial hypertension (pseudotumor cerebri)
- Female, fat, fertile, forty; tetracycline, vitamin A meds like isotretinoin
- Headaches worse at night and with waking up, transient vision loss, diplopia
- Papilledema, peripheral visual defect, CN VI palsy, whooshing/tinnitus in ear
 - LP: high opening pressure; get MRI to look for lesion
- Tx: acetazolamide or furosemide (inhibits choroid plexus carbonic
anhydrase), LP puncture, VP shunt, optic nerve fenestration to prevent
blindness

Cerebellar hemisphere: dysdiadochokinesia (difficulty rapid alternating movement),

dysmetria, limb ataxia, intentional tremor
- vermis: ipsilateral ataxia, nystagmus

Locked in syndrome: quadriplegia; cant speak or swallow; blink voluntary

Brain death: only deep tendon reflexes might be present (spinal works only); absent
cortical and brainstem

Peripheral
- Sensorineural hearing loss: inner ear, cochlea, auditory nerve
o Meniere dx, presbycusis, acoustic neuroma, cerebrovascular ischemia
o Presbycusis: high frequency sensorineural hearing loss; bilateral
tinnitus
o Meniere: excessive endolymph; ear fullness, tinnitus, sensorineural HL
o Acoustic neuroma: unilateral tinnitus, sensorineural HL, vertigo
- Conductive: limit sound from entering inner ear
o Otitis media/externa; cholesteatoma, trauma, cerumen, tympanic
membrane perforation
o Cholesteatoma: keratinizing squamous epithelium destroys ossicles;
white plaque on tympanic membrane
o Otosclerorsis: sclerosis of ossicles; normal otoscopic exam

Peripheral vs central vertigo

- Peripheral: horizontal (+/-vertical or torsional), <1 min duration, walking
preserved, has hearing loss or tinnitus
o BPPV, Meniere, Vestibular neuritis, Acoustic neuroma
o Perilymphatic fistula: history of trauma such as flying airplane, scuba
diving, vigorous Valsalva, fall/concussion; n/v and vertigo
o Labyrinthitis (involves cochlea): brief vertigo attacks + hearing loss of
tinnitus; Tx prednisone (HSV/viral)
o Vestibular neuronitis (no cochlea): vertigo, NO hearing loss or tinnitus;
after URI
o Meniere: hearing loss, vertigo, tinnitus; tx HCTZ
o Acoustic neuroma: can also compress CN VII or V
- Central: purely vertical or torsional, >1 min, unstable posture, neuro signs
o Stroke, MS, migraine, CNS tumor, cerebellar infarction
- If risk factors for stroke (HLD, HTN, DM), new onset headache or neuro
deficits, get non contrast CT
 - Tx: meclizine, promethazine, dimenhydrinate
Aminoglycoside ototoxicity
- Sensorineural hearing loss, oscillopsia (objects moving around in visual field),
abnormal head thrust (rapid head movement away from target pts eyes
move away and then come back to target with saccade)
- Furosemide also causes sensorineural hearing loss
Metastasis
- Lungs, breast, melanoma
- Gray white junction/watershed zone; well circumscribed; vasogenic edema
- Multifocal and spherical
- Steroids to reduce edema
Glioblastoma multiforme
- Nausea, vomiting, headaches worsen with changes in position, papilledema
with increased intracranial pressure (frontal lobe- behavior and personality
changes)
- CT/MRI: butterfly; central necrosis
Primary CNS Lymphoma
- HIV patient; EBV DNA positive in CSF
- MRI: ring enhancing solitary periventricular mass
- HIV pt: worry about primary CNS lymphoma or mets Kaposi sarcoma
Sellar mass
- Pituitary adenoma, craniopharyngioma (most common in kids)
- Bitemporal hemianopsia (compress optic chiasm), headache, hormonal
deficiency (decreased libido)
- MRI; surgery or radiotherapy
Cerebellar tumor
- Ipsilateral ataxia (fall toward side of tumor), nystagmus, positive Romberg
( even with eyes open)
Solitary brain metastasis: surgical resection
Multiple brain metastasis: whole brain radiation
Brain abscess
- Fever, acute symptoms, seizures
- Single abscess: usually from direct extension (otitis media, sinusitis, dental
inf)
o Usually viridans strep or staph aureus
- MRI: ring enhancing lesion with central necrosis
Spinal abscess
 - Sensation loss, upper motor neuron lesions findings below the lesion,
decreased motor strength
- Fever, sepsis, meningitis
Toxoplasmosis
- Fever, HA, AMS, seizures
- Prophylaxis TMP SMX in HIV pts
- MRI: multiple ring enhancing lesion in basal ganglia
- Tx: pyrimethamine, sulfasadizine
Neurocysticercosis
- Taenia solium; new onset seizure
- Imaging: cysts are various stages; calcified granuloma, hypodense lesions
Seizures
- Epilepticus >5 min; worry about cortical laminar necrosis
- First unprovoked seizure: CT without contrast (r/o hemorrhage)
- First time seizure work up: CBC, CMP, glucose, Mg, renal/liver function test,
urine drug toxicology, CT, EEG
- Discontinuing seizure meds after seizure free >2 years is reasonable; do a
slow taper
- Phenytoin: fetal hydantoin syndrome (nail/digit hypoplasia, cardiac defect,
orofacial cleft)
- Levetiracetam (keppra): seizure prophylaxis; levels go into effect right away
- Lamotrigine: chronic management; takes time for levels to build up
- Valproate/divalproex: neural tube defects
Restless leg syndrome
- Urge to move legs with crawling sensation
- DOPAMINE AGONIST (PRAMIPREXOLE, ROPIRENOLE) or GABAPENTIN
Cavernous sinus thrombosis
- Headache, periorbital edema, CN III, IV, V or VI deficit (EOM restricted,
increased or decreased sensation in V1/V2/V3)
- IV heparin? Antibiotics if infectious
Foodborn botulism
- C botulism: inhibits presynaptic Ach release at NMJ
- Canned foods or aged seafood
- Acute bilateral cranial neuropathy (blurred vision, diplopia, facial weakness,
dysarthria, dysphagia)
- Descending symmetric muscle weakness (might need to intubate)
- Serum analysis for toxin
- Tx equine serum heptavalent botulinum antitoxin
Wilsons disease
- Neuro + liver
 o Neuropsych: tremor, rigidity, paranoia
- Atrophy of lenticular nucleus (basal ganglia)
- Low serum ceruloplasmin, high copper urine excretion, Kayser Fleischer rings
on slit exam

Vasovagal syncope: emotional distress, standing, pain; nausea/warmth/diaphoresis

and then LOC
Situational syncope: cough, pee, poop
Orthostatic hypotension: postural with standing
Aortic stenosis, HOCM: syncope with exertion
Arrhythmia: hx of cardiac dx; pass out quickly without prodrome
Seizure: post ictal state (disorientation, confusion)

Multiple system atrophy/Shy Drager

- Parkinsonism + autonomic symptoms (orthostatic hypotension, bowel bladder
issues, salivation, lacrimation, impotence etc)

Essential tremor
- Action tremor; hands, head, arm, legs; usually bilateral; improves with EtOH
- Tx: beta blockers, primidone (anticonvulsant), clonazepam, small EtOH
Cancer pain
- Mild-mod: ibuprofen, NSAIDS
- Then try short acting opioids
- Then long acting opioid, fentanyl patch, oxycodone

Bells palsy (peripheral facial palsy)

- Upper and lower face affected; cant raise eyebrow, close eye or smile
- Also might have loss of taste of ant 2/3 of tongue, hyperacusis (CN 7 in ear-
increased sensitivity), decreased tearing
Central facial palsy
- Only lower face affected; cant smile
L5 radiculopathy or peroneal neuropathy
- Unilateral foot drop; lot of hip and knee flexion with walking
Lumbar disc herniation
 - Most common in L4-L5 (L5) and L5-S1 (S1)
- L5-S1 (S1): loss of Achilles, sensory paresthesia of lateral foot; lower back
pain radiating to posterior leg
- NSAIDS first and imaging if red flags like UMN, cauda/conus, fever,
immunosuppression, cancer
Ulnar n (elbow injury)
- Interosseous and lumbricals of hand
- Claw deformity, impaired extension of last 2 ulnar digits (wont straighten)
- Median n injury: first three fingers cant flex
Arnold Chiari: tonsil below foramen magnum; associated with spina bifida; causes
ataxia as cerebellum extends down
Dandy Walker: unapparent tonsil or sitting more cephalad; unfused cerebellar
elements in midline; cyst in posterior fossa
Olfactory hallucinations: mesial TEMPORAL lobe; hippocampus
Monoclonal gammopathy: proteinmic neuropathy with stocking sensory loss (if bad
then areflexia and motor loss)
Restlesss leg syndrome: exercise; dopamine agonist (pramipexole, ropinirole, L-
dopa), gabapentin, clonazepam
Niacin deficiency: corn diet; dermatitis, diarrhea, dementia (short and long term
memory)
Lead: ataxia, tremor, psychomotor retardation, peripheral neuropathy, abd pain,
constipation, anemia, basophilic stippling, linear discoloration gingival lines; tx
penicillamine
Mercury: ataxia, tremor, personality change (Mad Hatter)
Arsenic: anemia, transverse white lines in nails, hallucinations
Manganese: similar to Parkinson (shuffling gait, tremor, cogwheel rigidity, inaudible
speech); affects brainstem nuclei
Methyl alcohol: acute scotoma;
Organophosphate: cholinesterase inhibitor- salivation, lacrimation, urination,
diarrhea; treatment focused on blocking action of Ach- atropine

Red glass test: diplopia; two images b/c eyes are not moving together; most likely
CN VI deficit; can also be CN III or IV deficit
Lack of red eye reflex: congenital cataract or retinoblastoma
CMV retinitis: HIV pt; ganciclovir
Papillitis: inflammation of optic nerve; significant visual loss
Papilledema: not much visual loss
Tunnel vision: conversion disorder or malingering; same size visual field even as test
screen is moved further away
Concentric constriction in neurosyphillis: area seen enlarges as test screen is moved
away but visual field is still smaller than normal field
Optic neuritis: swinging flashlight test; optic atrophy; dilation of eye with light
swinging back and forth
HTN: segmental narrowing of arterioles, AV nicking
Diabetes: microaneurysm
Trauma: superior oblique muscle most at risk because its most anterior; CN IV
Compression of CN III: impaired pupillary constriction
Vascular damage of CN III (diabetes): impaired movement; down and out eye
MLF: incomplete adduction ipsilateral to MLF lesion (left MLF=left eye cant move
medially)
Ischemic optic neuropathy/anterior ischemic optic neuropathy: acute monocular
blindness; painless loss of vision; affected visual field is inferior and central; pale
optic disc; associated with infarction or MS
Pituitary tumor: bitemporal hemianopsia
MS: vision loss in one eye
Occipital lobe: contralateral homonymous hemianopsia (macular sparing
sometimes0
Temporal lobe: superior homonymous quadrantanopsia (Meyer Loop; PITS)
Parietal lobe: superior optic radiation; inferior homonymous quadrantanopsia

SAH
- coiling superior to clipping

- clipping only in first 2 days or 2 weeks after

Reduce vasospasm (cause worsening symptoms): Triple H Therapy (hypertensive,

hypervolemia, hemodilution) + nimodipine

- evaluate using transcranial doppler (elevated MCA velocity) and conventional

angiography

Patent foramen ovale: paradoxical embolism in pts with cryptogenic stroke (no
cause found)

Post stroke find reason: MRI, angiography, carotid doppler, EKG, echo and labs (lipid,
homocysteine, protein C, protein S, antithrombin III, anticardiolipin, lupus
anticoagulant, factor V leiden, prothrombin and toxicology screen)

New onset seizure in adults: MRI for space occupying lesion and then EEG; potential
anticonvulsant and driving restriction

Complex: alteration or loss of consciousness

Juvenile myoclonic epilepsy: early morning after awakeing myoclonic seizure (jerks)
and followed by tonic clonic if sleep deprived or EtOH ingestion

Complex partial seizure (most common in adult): mesial temporal sclerosis

Valproate: neural tube defects

Syncope:

- vasovagal (lightheaded, dimmed vision/hearing, sweating, nausea, increased HR;

strong emotions, micturition, defecation)

- orthostatic (standing up; hot day exertion; autonomic failure due to DM, amyloid,
syphilis, spinal cord etc; use stockings or avoid hypovolemia/salt imbalance,
increase salt in diet, try fludrocortison)

- cardiogenic (suddenly without warning; arrhythmias; exertional aortic stenosis or

HOCM)

- seizure (urinary incontinence, tongue biting, confusion after)

Pesudoseizure:

- tonic clonic activity but wide awake and aware of surrounding (inconsistent level of
consciousness); bilateral seizure activity without confusion or uncosnciousness is
rarely organic (arms legs shaking but able to talk)
- conversion disorder: resembles seizure but is due to psychological cause; no EEG
characteristics; pt is not consciously producing the symptoms; is a mental illness

- malingering: intentional production of symptoms due to external incetives; not a

mental illness

- evaluate with EEG and video to rule out seizures

Migraine

- unilateral; throbbing; photo/phonophobia; visual aura (classic); n/v; triggers

- contraindication for triptan: CAD or HTN (even hemiplegia or blindness as aura in

migraine attack)

- abortive: triptan, nsaids, acetaminophen, metoclopramide/prochlorperazine, egots

- prevention: beta blocker, topiramate, divalproex sodium, TCA

Acute glaucoma

- sudden eye pain, n/v, after dark setting or use of anticholinergic drugs; elevated
IOP; red eyes; light sensitivity

Meniere disease: vertigo, tinnitus, hearing loss (low frequency lost first)
Vertigo: salicylates, aminoglycosides
Dorsal spinal root: sensory deficit
Ventral spinal root: weakness and wasting
Dorsal column medial lemniscus: decussate in medulla; 2 nd neuron in thalamus
Spinothalamic: decussates right away in spine; 2 nd neuron in thalamus; pain/temp
loss 1-2 levels below lesion
Corticospinal tract: decussates in medulla in pyramids
Anterior artery: artery of Adamkiewicz (arteria radicularis magna); loss of pinprick,
flaccid paresis, preservation of proprioception; enters at level T10-L1
- Spinal cord infarct usually affects this one b/c there is just one main artery
Long thoracic nerve: serratus anterior; damage causes winging of scapula
Hemisection/Brown-Sequard: contralateral pain/temp, ipsilateral position/vibration,
ipsilateral weakness
UMN: spastic tone, weakness, hyperreflexia
LMN: flaccid paralysis, fibrillations, fasciulations, hyporeflexia, weakness, muscle
wasting
Schistosoma: granulomas and egg emboli in CNS (mansoni in south America;
japonicum in Asia)
C6: thumb
C7: index and middle finger
C8: ring and pinky finger
Brachial plexus injury: C5-T1 affected
Cervical nerve root: tingling b/c of sensation; and muscle weakness
Posterior cord gives rise to radial n; lateral and medial cord gives rise to median n;
medial rise to ulnar n
Peroneal n: foot drop, dorsiflexion, eversion; avoid sitting with crossed legs
- Superficial peroneal/fibular dermatome: dorsum of foot
- Deep peroneal/fibular: webspace between big and 2 nd toe
Tibial n: Inverts, plantar flexes; cant stand on TIPtoes
Sciatic: both peroneal and tibial
Uncal herniation: ipsilateral CN III; contralateral hemiplegia
Hypertensive encephalopathy: 220/120, end organ damage
- Use IV nitroprusside, labetalol, nitroglycerine
Shoulder dislocation: injure axillary n
- Cant abduct from 15 to 90; loss of sensation of lateral upper arm
Cervical spondylotic myelopathy
- Degenerative changes: compression of spinal cord
- Neck stiffness, electric shock going down arm or neck, weak hands, leg
stiffness, arm pain, neck stiffness, hyperreflexia, atrophy of hand muscle,
sensory loss
Detrusor hyperreflexia: urge like incontinence; unable to reach bathroom
Acute cerebellar ataxia: after a viral illness like VZV, flue, EBG; truncal ataxia (cant
sit or stand unsupported), gait problems, nystagmus; get CT to rule out
hemorrhage/tumor
lateral medullary: PICA; dysphagia

lateral pontine; AICA; facial involvement

infantile spasm: hypsarrythmia

lennox gastaut: slow spike wave
absence: 3Hz spike wave

awake eyes open: Beta (highest frequency, lowest amplitude)

awake eyes closed: Alpha (8-13 Hz)
N1: theta (4-7 Hz)
N2: K complexes and spindles
N3: delta (low freq, high amp; 0.5-2 Hz)
REM: Beta
at night, BATS Drink Blood

cjd:periodic spike wave 1-2hz; 14 3 3 protein in csf

alheimers:generalized slowing

Neuroleptic malignant syndrome: fever, rigidity, dysautonomia; after antipsychotic

(haloperidol, risperidone), antiemetic (promethazine, metoclopromaide);
myoglobinuria, high CPK; Tx dantrolene, benzos, dopamine agonist (bromocriptine)
Malignant hyperthermia: fever, rigidity; after using halothane or succinylcholine
Acute dystonia: after haloperidol and other antipsychotics
- Muscle spasms, stiff neck
- Tx: anticholin (benztropine), benzos, antihistamine with anticholinergic
Pancoast tumor: compression of superior cervical plexus above T1 in superior
sulcus: Horners (ptosis, miosis, anhidrosis)
Superior vena cava syndrome: enlarged neck veins, erythema, swelling; usually
small cell CA
Thoracic outlet syndrome: cervical root compression causing neck, shoulder, arm
pain; upper extremity muscle atrophy; compression of veins like subclavian;
compression of artery like subclavian causing pallor and coldness
Subclavian steal syndrome/stenosis: difference in blood pressure, numbness/tingling
in fingers, vertigo, lightheaded as the arm steals blood from the brain
Erb palsy: C5-C6; Watiers tip (internal rotation, adduction, finger flexion)
Kumpke: C8-T1; claw hand (decreased extension of 4 and 5)
Lumbar spinal stenosis: pain going down leg
Diabetic radiculopathy: mononeuropathy- one loss only; sensory loss in T12
Leprosy: patches of sensory loss; thickened peripheral nerves
Muscle phosphorylase deficiency (McArdle disease): muscle cramps after exertion;
dark urine
Low back pain radiating down back: first use ibuprofen
Tic disorder: tx a2 agonist like clonidine, antipsychotic like risperidone
Demyelination: decreased velocity
Axonal: decreased amplitude
Acute intermittent porphyria
- Abdominal crisis, psychosis, acute neuropathy
- Increased urine aminolevulinic acid and porphorobilinogen
Spinal muscular atrophy
- LMN signs only: atrophy and fasiculations