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What is Bell palsy? Acute idiopathic unilateral facial nerve (CN VII) paralysis - most common cause of facial paralysis
What are the clinical features of Bell palsy?
Sudden unilateral facial weakness, inability to close eye, loss of forehead wrinkles, droop of mouth, loss of nasolabial fold
How is Bell palsy differentiated from stroke?
Bell palsy: affects forehead (cannot wrinkle forehead); Stroke: forehead spared (can wrinkle forehead) due to bilateral innervation
What is the treatment for Bell palsy? Prednisone 60-80mg daily x 7-10 days (within 72 hours of onset), eye protection (artificial tears, eye patch at night)
What is the role of antivirals in Bell palsy?
Valacyclovir may be added to corticosteroids for severe cases, though evidence is mixed - not used alone
What is the prognosis of Bell palsy? 70-80% complete recovery within 3 months, earlier treatment improves outcomes
What complication should be prevented in Bell palsy?
Corneal abrasion/ulceration due to inability to close eye - requires lubrication and protective measures
What is a cerebral aneurysm? Abnormal focal dilation of cerebral artery wall, typically at bifurcations in Circle of Willis - risk of rupture causing SAH
What are the risk factors for cerebral aneurysm?
Hypertension, smoking, family history, polycystic kidney disease, Ehlers-Danlos syndrome, coarctation of aorta
What is the classic presentation of ruptured cerebral aneurysm?
Sudden "thunderclap" headache (worst headache of life), nuchal rigidity, photophobia, loss of consciousness
What is the initial diagnostic test for suspected SAH?
Non-contrast head CT - shows blood in subarachnoid space in 95% if done within 24 hours
What test is performed if CT is negative but SAH suspected?
Lumbar puncture - look for xanthochromia (yellow CSF from RBC breakdown) and elevated RBC count
What imaging confirms aneurysm location?
CT angiography or catheter angiography - used for surgical/endovascular planning
What is the definitive treatment for cerebral aneurysm?
Surgical clipping or endovascular coiling to prevent rebleeding - prevent vasospasm with nimodipine
What is a cerebrovascular accident (stroke)?
Acute neurologic deficit from interruption of blood supply to brain - ischemic (87%) or hemorrhagic (13%)
What is the preventive treatment for cluster headaches?
Verapamil (first-line), lithium, topiramate - started during cluster period
What defines coma? State of unconsciousness with no response to verbal or painful stimuli - eyes remain closed
What is the Glasgow Coma Scale and its components?
15-point scale: Eye opening (4), Verbal response (5), Motor response (6) - score ≤8 indicates severe brain injury
What is the initial management of coma? Use mnemonic DONT
Dextrose (check glucose), Oxygen, Naloxone (if opioid suspected), Thiamine (before glucose in alcoholics)
What imaging is essential in evaluating coma?
Non-contrast head CT to rule out hemorrhage, mass lesion, herniation
What are common reversible causes of coma?
Hypoglycemia, drug overdose, hepatic encephalopathy, uremia, infection, seizure (postictal state)
What is Complex Regional Pain Syndrome (CRPS)?
Chronic neuropathic pain syndrome with autonomic and inflammatory features disproportionate to inciting event
What are the clinical features of CRPS?
Severe burning pain, allodynia, temperature/color changes, edema, sweating abnormalities, motor dysfunction
What are the two types of CRPS? Type I (reflex sympathetic dystrophy): no definable nerve lesion; Type II (causalgia): identifiable nerve injury
What is the treatment approach for CRPS?
Multimodal: physical therapy (most important), gabapentin/pregabalin, NSAIDs, sympathetic nerve blocks, psychological support
What is a concussion? Mild traumatic brain injury causing temporary neurologic dysfunction without structural brain injury on imaging
What are the symptoms of concussion?
Headache, confusion, amnesia (retrograde/anterograde), dizziness, nausea, balance problems, sensitivity to light/noise
What are red flags requiring head CT after head trauma?
Loss of consciousness >5 minutes, severe headache, repeated vomiting, seizure, focal neurologic deficits, declining mental status
What is the management of concussion?
Physical and cognitive rest initially, gradual return to activities, no contact sports until symptom-free
What is post-concussion syndrome? Persistent symptoms >3 months after concussion - headache, dizziness, cognitive difficulties, mood changes
What is delirium? Acute confusional state with fluctuating consciousness, inattention, and disorganized thinking - hours to days onset
How is delirium differentiated from dementia?
Delirium: acute onset, fluctuating course, altered consciousness; Dementia: chronic, progressive, consciousness intact
What are the three types of delirium? Hyperactive (agitated), Hypoactive (lethargic), Mixed - hypoactive often missed
What is encephalitis? Inflammation of brain parenchyma causing altered mental status, fever, seizures - often viral etiology
What is the most common cause of sporadic encephalitis?
Herpes simplex virus-1 (HSV-1) - most common and treatable cause
What are the classic features of HSV encephalitis?
Fever, altered mental status, seizures, focal neurologic deficits, temporal lobe involvement on MRI
What CSF findings suggest viral encephalitis?
Lymphocytic pleocytosis (10-500 WBC), elevated protein, normal glucose, PCR positive for virus
What is the empiric treatment for suspected encephalitis?
IV acyclovir 10mg/kg q8h immediately - do not wait for confirmatory testing
What imaging findings suggest HSV encephalitis?
MRI shows temporal lobe enhancement, hemorrhage, or edema (CT may be normal early)
What is essential tremor? Most common movement disorder - bilateral postural/action tremor without other neurologic signs
What are the characteristics of essential tremor?
Bilateral hand tremor (worse with action), may affect head/voice, improves with alcohol, worsens with stress
How is essential tremor differentiated from Parkinson tremor?
Essential: action/postural tremor, bilateral, no bradykinesia; Parkinson: resting tremor, asymmetric, bradykinesia present
What is the first-line treatment for essential tremor?
Propranolol 60-320mg daily or primidone 50- 750mg daily
What is giant cell arteritis (temporal arteritis)?
Vasculitis of large/medium arteries affecting those >50 years - risk of irreversible vision loss
What are the classic symptoms of giant cell arteritis?
New headache, temporal artery tenderness, jaw claudication, vision changes, scalp tenderness
What serious complication must be prevented?
Permanent vision loss from anterior ischemic optic neuropathy - occurs in 15-20% if untreated
What laboratory finding is characteristic?
Markedly elevated ESR (often >50, typically >100) and elevated CRP
What is the definitive diagnostic test? Temporal artery biopsy showing giant cells, intimal thickening, fragmented internal elastic lamina
What is the treatment for giant cell arteritis?
High-dose prednisone 40-60mg daily immediately
- do not wait for biopsy results
What condition is associated with giant cell arteritis?
Polymyalgia rheumatica (50% association) - proximal muscle pain and stiffness
What is Guillain-Barré syndrome (GBS)?
Acute inflammatory demyelinating polyneuropathy causing ascending paralysis - often follows infection
What infections commonly precede GBS?
Campylobacter jejuni (most common), CMV, EBV, Mycoplasma, Zika virus
What are the classic features of GBS? Ascending symmetric weakness, areflexia, paresthesias, respiratory muscle weakness (monitor FVC)
What are the most common intracranial tumors in adults?
Metastases (most common overall), glioblastoma multiforme (most common primary), meningioma
What are the most common intracranial tumors in children?
Pilocytic astrocytoma, medulloblastoma, ependymoma
What are the classic presenting symptoms of brain tumors?
Headache (worse in morning, with Valsalva), seizures (new-onset), focal neurologic deficits, papilledema
What imaging is used to evaluate suspected brain tumor?
MRI with gadolinium contrast (best) - shows mass, edema, enhancement pattern
What is glioblastoma multiforme? Most aggressive primary brain tumor (grade IV astrocytoma) - poor prognosis, median survival 12- 15 months
What imaging finding is characteristic of glioblastoma?
"Butterfly" pattern crossing corpus callosum, ring- enhancing lesion with central necrosis
What is meningitis? Inflammation of meninges - bacterial (medical emergency), viral (most common), or fungal
What are the classic signs of meningitis?
Fever, headache, nuchal rigidity, photophobia, altered mental status
What are Kernig and Brudzinski signs?
Kernig: resistance/pain with knee extension when hip flexed; Brudzinski: hip flexion when neck flexed
- suggest meningeal irritation
What are the most common bacterial causes by age?
Neonates: GBS, E. coli; Children/adults: S. pneumoniae, N. meningitidis; Elderly: S. pneumoniae, Listeria
What CSF findings indicate bacterial meningitis?
Elevated WBC (>1000, PMN predominant), elevated protein (>200), low glucose (<40 or <40% serum), positive Gram stain/culture
What is the empiric treatment for bacterial meningitis?
Adults: vancomycin + ceftriaxone; >50 years or immunocompromised: add ampicillin (for Listeria)
When should dexamethasone be given in meningitis?
Before or with first antibiotic dose for suspected pneumococcal meningitis - reduces mortality and complications
What are migraine headaches? Recurrent moderate-to-severe headaches with associated symptoms - unilateral, pulsating, 4- hours duration
What are the diagnostic criteria for migraine?
≥5 attacks of 4-72 hours with 2 of: unilateral, pulsating, moderate-severe intensity, worsened by activity PLUS nausea/vomiting or photophobia/phonophobia
What is migraine with aura? Migraine preceded by reversible visual, sensory, or speech symptoms lasting 5-60 minutes
What medications are used for acute migraine treatment?
Mild: NSAIDs, acetaminophen; Moderate-severe: triptans (sumatriptan), antiemetics (metoclopramide)
What are contraindications to triptans?
Coronary artery disease, uncontrolled hypertension, hemiplegic migraine, basilar migraine
