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A MMSE score of less than 24 points is suggestive of dementia (total maximum is
30).
Alzheimer's Disease
Neuroimaging may demonstrate atrophy which is more prominent in the temporal and parietal
lobes in patients. CT scan shows generalized/diffuse cortical atrophy. The typical first
symptoms are subtle memory loss, language difficulties and apraxia, followed by impaired
judgment and personality changes.
There is selective loss of cholinergic neurons.
Tx: cholinesterase inhibitor (donepezil (Aricept), galantamine (Razadyne), galantamine ER
(Razadyne ER), and rivastigmine).
Frontotemporal Dementia
Similar to Alzheimer's, however he age of onset is earlier (usually at 40-60 years).
Initially less disorientation and memory loss, but more personality changes and loss of social
restraints.
Central retinal artery occlusion Is a monocular painless acute vision loss. “Curtain falling”
Funduscopic examination is often normal but may show embolic plaques and retinal whitening
(due to ischemia).
Painless, sudden (sometimes subacute) vision loss (or haze) can be seen In
central retinal vein occlusion, likely from venous thrombosis. It can progress to an
ischemic form that can be painful. Funduscopy usually reveals dilated and tortuous veins
leading to scattered and diffuse hemorrhages ("blood and thunder"), disk swelling, and/or
cotton wool spots.
Detached retina typically have light flashes, floaters, or a curtain across their visual field.
NPH:
Gait impairment is the most prominent clinical feature of NPH and appears early in its course.
The gait is broad-based and shuffling.
Gait impairment is the most prominent early clinical feature of
normal-pressure hydrocephalus but is a later finding in Alzheimer's dementia.
Infarction of the medial vermis of the cerebellum can cause severe vertigo
and nystagmus. Lateral cerebellar infarction causes dizziness, ataxia, weakness, and a
tendency to sway toward the side off the lesion.
Anterior cord syndrome is commonly associated with burst fracture of the vertebra and is
characterized by total loss of motor function below the level of lesion with loss of pain and
temperature on both sides below the lesion with intact proprioception.
Optic neuritis (acute vision loss, pain, afferent pupillary defect) most
commonly occurs in women age <50 and is often an initial presentation of multiple
sclerosis. Optic neuritis is rarely associated with nausea/vomiting.
In temporal arteritis, the erythrocyte sedimentation rate (ESR) is usually >50 mm/h. This
patient's
mildly elevated ESR may be due to her urinary tract infection.
Seizures (UWorld):
Evaluation of a first-time seizure:
Metabolic (eg, hypoglycemia, electrolyte disturbances) and toxic (eg, amphetamine use,
benzodiazepine/alcohol withdrawal) causes.
Basic laboratory tests typically include serum electrolytes, glucose, calcium, magnesium,
complete blood count, renal function tests, liver function tests, and a toxicology screen.
***If any of these are missing in the question, then this is the next step. THEN do CT &
EEG.
- Unprovoked, first seizure (CBC, electrolytes, EKG all normal): Get Computed
tomography (CT) scan of the brain without contrast is as initial imaging study.
**Important: get neuroimaging before you do EEG (which is next step)
Helps to exclude acute neurologic problems (eg, intracranial or subarachnoid bleed) that might
require urgent intervention.
**MRI is more sensitive than CT in identifying most structural causes of epilepsy and is the
neuroimaging modality of choice in elective situations.
EEG is useful for risk-stratifying patients after a first-time seizure once metabolic and toxic
etiologies have been excluded.
Brain that has seized for >5 minutes is at increased risk of developing permanent injury due to
excitatory cytotoxicity.
- Cortical laminar necrosis is the hallmark of prolonged seizures and can lead to
persistent neurologic deficits and recurrent seizures.
Q60: