PANCE Blueprint Neurology (7%)

Lessons

1. 2019 PANCE Neurologic System Content Blueprint

2. 2019 PANRE and Pilot Alternative to PANRE Neurologic System Content Blueprint
3. Neurology Comprehensive Exam (Members Only)

4. Neurologic System With Joe Gilboy PA-C (Video Lecture)

   18 mins
5. Neurology Flashcards (Members Only)
6. Closed head injuries (PEARLS)
   1. Concussion (ReelDx + Lecture)

      Grade 1: No LOC, post traumatic amnesia and other symptoms resolve in < 30 minutes

      • Athlete may return to sports if asymptomatic for one week

      Grade 2: + LOC , 1 minute or post-traumatic amnesia and other symptoms last > 30 minutes but < 1 week

      • Athlete may return to sports in 2 weeks if asymptomatic at rest and exertion for at least 7 days

      Grade 3: + LOC > 1 minute or post-traumatic amnesia and other symptoms last > 1 week

      • Athlete may return to sports in 1 month if asymptomatic at rest and exertion for 7 days

      Repeat concussions: if associated with either loss of consciousness or symptoms for more than 15 minutes may NOT to return to play sports for that season
   2. Postconcussion syndrome

      Cognitive and/or behavioral manifestations that may be present for a few days to weeks following concussion, including:

      • Chronic headaches, short-term memory difficulties, fatigue, difficulty sleeping, personality changes (irritability, mood swings), and sensitivity to light and noise
      • Postconcussive symptoms typically resolve in a few days to several weeks
   3. Traumatic brain injury

      Brain dysfunction caused by an outside force, usually a violent blow to the head

      • The Glasgow Coma Scale (GCS), the most commonly used system for classifying TBI severity, grades a person's level of consciousness on a scale of 3–15 based on verbal, motor, and eye-opening reactions to stimuli
      • Diagnose with MRI or CT
      • Treatment depends on the recovery stage of the patient

7. Cranial Nerve Palsies

   Olfactory nerve (CN I /sensory) - Responsible for smell

   • Anosmia, (inability to smell), hyposmia (reduced ability to smell), Dysomia, smells become mixed up

   Optic nerve (CN II/sensory) - Responsible for vision

   • Scotomas (blind spots) defect of vision in a defined area in one or both eyes. Optical neuropathologies show up as a partial or complete loss of vision

   Oculomotor nerve (CN III /motor) -  Controls most of the eye's movements, along with accommodation, eyelid opening, and pupillary constriction

   • Diplopia, ptosis, loss of accommodation
   • Pupillary involvement:
     • In compressive lesions, the pupil becomes dilated and non-reactive
     • In ischemic lesions (e.g., diabetes mellitus) the pupil is spared

   Trochlear nerve (CN IV/motor) - Controls the superior oblique extraocular muscle

   • Difficulty looking down, head tilt away from the side of the lesion
   • Jaw deviation towards the side of the lesion

   Trigeminal nerve (CN V/both)  - Responsible for facial movement, chewing, temperature, touch, pain

   • Absent corneal reflex, absent sensation in sensory distribution, weakness, and wasting of the muscles of mastication. Jaw deviation towards the side of the lesion

   Abducens nerve (CN VI/motor) - Eye movement. Controls the lateral rectus extraocular muscle

   • Horizontal diplopia

   Facial nerve (CN VII/both) - It's sensory functions include being responsible for taste from the anterior 2/3 of the tongue. It's motor functions include control of the muscles of facial expression, the stapedius muscle in the middle ear and closing of the eyelid

   • Bell's palsy, loss of blink reflex
   • Hyperacusis (when the stapedius is involved)

   Vestibulocochlear nerve (CN VIII/sensory) - It divides into the vestibular nerve which is responsible for balance/equilibrium and visual fixation during movement and the cochlear nerve which is responsible for hearing

   • Deafness, tinnitus, vertigo, dizziness, nausea, nystagmus, loss of balance and ataxia

   Glossopharyngeal nerve (CN IX/both) - Swallowing and taste sensation for the posterior 1/3 of the tongue, monitoring blood pressure, oxygen and carbon dioxide

   • loss of taste sensation to the posterior one-third of the tongue, and impaired swallowing

   Vagus nerve (CN X/both) - Heart rate regulation, respiratory drive regulation, palate elevation, swallowing and talking

   • Palate droop, dysphagia, deviation of the uvula away from the side of the lesion, loss of gag reflex (the sensory component of this reflex is mostly via CN IX)

   Accessory nerve (CN XI/motor) - Head-turning and shoulder shrugging via innervation of the sternocleidomastoid and trapezius muscles

   • Weakness with turning of the head, shoulder droop

   Hypoglossal nerve (CN XII/motor) - Tongue movement

   • Tongue deviation towards the side of the lesion

8. Encephalopathic disorders
9. Headaches (PEARLS)
   1. Brian Wallace PA-C Podcast: Headaches

      16 mins

      Brian Wallace PA-C
   2. Cluster headache (Lecture)

      Severe, unilateral, periorbital pain, lacrimation, and nasal congestion

      • More common in men (4:1). Treatment: 100% oxygen
   3. Migraine (ReelDx + Lecture)

      Unilateral (70%), throbbing, disabling pain, nausea, vomiting, photophobia

      • Classic: Aura and Common: No aura (80% of migraines)
      • Abortive: Triptans (do not use in ischemic heart disease), ergotamine (do not use in pregnant women)
   4. Tension headache (ReelDx + Lecture)

      Bilateral, non-throbbing, band-like or "vice like" pain

      • A tension-type headache is typically described as bilateral, mild to moderate, dull pain, whereas a migraine is typically pulsating; unilateral; and associated with nausea, vomiting, and photophobia or phonophobia.
      • Treatment: NSAIDs, Excedrin, muscle relaxer
10. Infectious Neurological Disorders (PEARLS)

    1. Brian Wallace PA-C Podcast: Infections and movement disorders

       23 mins

       Brian Wallace PA-C
    2. Encephalitis

       May present similar to meningitis but will see altered mental status, seizures, personality changes, exanthema. Encephalitis is clinically differentiated from meningitis by altered brain functioning.

       • Usually viral: Most common species: HSV or Immunocompromised: CMV
    3. Meningitis (ReelDx)

       Classic Triad: Fever, headache, stiff neck, petechiae (especially N. meningitidis)

       • Kernig's sign: knee extension causes pain in neck (Remember K = Kernig's and K = Knee)
       • Brudzinski's sign: leg raise when bend neck
       • CSF Finding: 
         • Bacterial: ↑ Protein ↓ Glucose (bacteria love to eat glucose)
           • there is a markedly increased opening pressure
         • Viral:  normal pressure, increased WBC (lymphocytes)
11. Movement Disorders (PEARLS)

    1. Brian Wallace PA-C Podcast: Parkinsons and Intracranial hemorrhages

       25 mins

       Brian Wallace PA-C
    2. Essential tremor (Lecture)

       Bilateral intention tremor of the hands, forearm, and/or head without resting component

       • Family history in 50-70% of patients, autosomal dominant inheritance. Elderly patients
       • Worse on intention. Hands and head.
       • Better with alcohol
       • Less likely to be unilateral
    3. Huntington Disease (Lecture)

       Inherited autosomal dominant neurodegenerative disease characterized by progressive motor and psychiatric dysfunction, dementia, and chorea (nonrepeating, complex, involuntary rhythmic movements that may appear purposeful)

       • Genetic testing: 40+ CAG repeats
    4. Parkinson disease (Lecture)

       Resting/pill rolling tremor, masked facies,  cogwheel (catching and releasing), bradykinesia, and shuffling gait

       • Decreased dopamine in substantia nigra. Lewy bodies.
    5. Tourette disorder (ReelDx)

       The defining feature which separates Tourette syndrome from other tic disorders is the presence of both motor and vocal tics.

       • Symptoms must have been present for > 1 year and age at onset must be < 18 years old.
       • Tic disorders are divided into 3 categories:
         • Tourette syndrome (Gilles de la Tourette syndrome): Both motor and vocal tics have been present for > 1 year.
         • Persistent (chronic) tic disorder: Single or multiple motor or vocal tics (but not both motor and vocal) have been present for > 1 yr.
         • Provisional tic disorder: Single or multiple motor and/or vocal tics have been present < 1 yr.
12. Neoplasms (benign and malignant)
13. Neurocognitive disorders (PEARLS)
    1. Delirium

       Acute, fluctuating mental status change caused by a medical condition

       • Delirium is rapid in onset, short term and reversible - Underlying organic cause: UTI, pneumonia, metabolic changes, CVA, MI, TBI, medications (anticholinergics, benzodiazepines, opioids). Treat underlying cause.
    2. Major/mild neurocognitive disorders

       Chronic, global, usually irreversible deterioration of cognition

       • Diagnosis is clinical - Mini-Mental Status Examination or Montreal Cognitive Assessment (MoCA)
       • Laboratory (TSH and B12) and imaging tests (MRI or CT) are usually used to identify treatable causes
       • Treatment is supportive. Cholinesterase inhibitors can sometimes temporarily improve cognitive function

       Alzheimer Disease

       • Most common type
       • Definitive diagnosis is on autopsy
         •  loss of brain cells, beta-amyloid plaques and neurofibrillary tangles
       • Physical exam: Abnormal clock drawing test
       • Treatment: anticholinesterase drugs (Tacrine, Donepezil)

       Vascular Disease

       • Multi-infarct
       • Treatment: Blood pressure control

       Frontotemporal lobar degeneration

       • Personality changes precede memory changes.

       Lewy Body Disease

       • Parkinsonian symptoms
14. Neuromuscular disorders (PEARLS)
    1. Cerebral palsy (ReelDx + Lecture)

       13 mins

       Prenatal injury perinatal hypoxia or ischemia, preterm baby

       • Hyperreflexia, rigidity, intellectual impairment, seizures

    2. Multiple sclerosis (ReelDx + Lecture)

       Autoimmune: Antibodies against myelin sheath: Often first finding: Retrobulbar optic neuritis. Other symptoms: numbness, tingling, balance disturbance, diplopia. MRI: Dawson fingers (white matter lesions). CSF: Elevated IgG, oligoclonal bands

       • Relapsing remitting MC 85% (symptoms come and go)
       • Secondary progressive (relapsing remitting progresses to steady decline)
       • Primary progressive (no remission, steady decline from onset)
       • Progressive relapsing (combination. Worse overtime with acute relapses. Most rare.)
    3. Myasthenia gravis (ReelDx + Lecture)

       Autoimmune attack of acetylcholine receptors at the neuromuscular junction results motor problems

       • Young women, older men. weakness in everyday activities like brushing hair, Proximal to distal weakness: eyes: ptosis usually first
       • Diagnose with Acetylcholine receptor antibodies, Tensilon test/edrophonium test- short acting anticholinesterase
15. Peripheral Nerve Disorders (PEARLS)
    1. Carpal Tunnel Syndrome

       Caused by a compression of the median nerve in the carpal tunnel

       • Pain with numbness and tingling into the hand, sometimes worse at night
       • + Phalen (pushing backs of hands together) and + Tinel test (tapping over nerve) 
       • EMG studies and nerve conduction studies
       • Treat with a volar splint, NSAIDs, corticosteroid injections, and carpal tunnel surgery in refractory cases
    2. Complex regional pain syndrome

       Non-dermatomal limb pain usually following a trauma or surgery. Upper or lower limbs pain, swelling, reduced range of motion, skin changes, and bone demineralization

       • Pain is disproportionate to the injury with continuing pain that is disproportionate to any inciting event
       • Sensory: hyperalgesia and/or allodynia
       • Vasomotor: skin, temperature, color asymmetry
       • Sudomotor/edema: edema, sweating changes, or sweating asymmetry
       • Motor/trophic: decreased range of motion or motor dysfunction and/or trophic changes (hair, nail, skin)
    3. Guillain-Barré syndrome (Lecture)

       Symmetrical ascending paralysis beginning in distal limbs, following Campylobacter jejuni infection, will often present after immunization

       • Weakness begins in lower extremities, treatment: admit, plasmapheresis or IVIG
       • Respiratory paralysis if no treatment. Good prognosis
    4. Peripheral neuropathies

       Symmetric distal sensory loss along with burning pain or weakness

       • Slow onset in stocking glove (hands and feet) pattern think Diabetes mellitus, uremia
       • Fast onset think drugs
       • Ascending think Guillain-Barre Syndrome
16. Seizure disorders (PEARLS)
    1. Focal Seizures (ReelDx)

       Partial (focal) seizures occur when this electrical activity remains in a limited area of the brain. The seizures can sometimes turn into generalized seizures, which affect the whole brain Focal seizures with retained awareness (consciousness maintained)

       • • This type of focal seizure was previously known as a simple partial seizure
         • No alteration in consciousness. Abnormal movements or sensations

       Focal seizures with a loss of awareness (consciousness impaired)

       • • This type of focal seizure may also be called a focal dyscognitive seizure (previously known as complex partial seizures)
         • Altered consciousness, automatisms (ie. lip-smacking)
         • Present with a postictal state (confusion and loss of memory) which differentiate them from absence seizures

       Treatment - phenytoin, and carbamazepine are drugs of choice

    2. Generalized seizures (ReelDx + Lecture)

       Generalized seizures: start midbrain or brainstem and spreads to both cortices.

       • Absence seizure (petit mal): Children. Blank stare.
         • Treatment: Valproic acid, ethosuximide (only for absence)
       • Tonic clonic/Generalized convulsive (Grand mal): Loss of consciousness, increased muscle tone (tonic), jerking muscles (clonic).
         •  Postictal phase- confusion after seizure.
         •  Treatment: Valproic acid, carbamazepine
       • Myoclonic: muscle jerking, but not the tonic phase, occurs in the morning
       • Tonic: extreme rigidity then immediate LOC, but not followed by a clonic phase
       • Atonic attack (drop attack): looks like syncope, sudden loss of muscle tone

       Additional types

       • Febrile Seizure: A convulsion associated with an elevated temperature greater than 38°, > 6 mos < 5 years, absence of central nervous system infection or inflammation
         • Febrile seizures that continue for more than five minutes should be treated with IV benzodiazepines (diazepam or lorazepam)
    3. Status epilepticus

       A nonstop seizure lasting greater than 5 minutes. There are two types:

       • Generalized convulsive status epilepticus involves at least one of the following:
         • Tonic-clonic seizure activity lasting > 5 to 10 min.
         • ≥ 2 seizures between which patients do not fully regain consciousness.
       • Nonconvulsive status epilepticus includes complex partial status epilepticus and absence status epilepticus. They often manifest as prolonged episodes of mental status changes. EEG may be required for diagnosis.
17. Vascular Disorders (PEARLS)

    1. Brian Wallace PA-C Podcast: Vascular disorders

       33 mins

       Brian Wallace PA-C
    2. Arteriovenous malformation

       Arteriovenous malformation is an abnormal connection between arteries and veins, bypassing the capillary system usually in the brain or spine, but also lungs

       • Brain: epilepsy, neurologic deficits, severe sudden onset headache indicates subarachnoid hemorrhage
       • Spine: sensory disturbances, muscle weakness, and paralysis
       • Lungs: Usually asymptomatic, may cause SOB or hemoptysis
       • The cause is poorly understood - may be congenital or genetic
       • Diagnosed by angiography (gold standard), CT scan or MRI
       • Treat all AVNs - radiosurgery or endovascular embolization
    3. Cerebral aneurysm

       Weak, bulging spot on the wall of a brain artery very much like a thin balloon or weak spot on an inner tube.

       • Usually found either incidentally or when a patient presents with subarachnoid hemorrhage.
       • Before a larger aneurysm ruptures, the individual may experience such symptoms as a sudden and unusually severe headache, nausea, vision impairment, vomiting, and loss of consciousness.
       • A key symptom of a ruptured aneurysm is a sudden, severe headache (the worst headache of my life).
       • Types include Saccular (Berry), Fusiform, dissecting, mycotic, and traumatic.
       • Ruptured saccular (berry) aneurysm accounts for approximately 75% of nontraumatic cases of SAH and has a mortality rate of 50%.
       • Noncontrast head CT is the initial investigational modality for suspected SAH.
         • Lumbar Puncture (LP) with evaluation of CSF reveals markedly elevated opening pressures and RBC in CSF. Xanthochromia (CSF protein > 150 mg/dL or serum bilirubin > 6 mg/dL) - if the blood has been in the CSF for over 2 hours.
         • Cerebral angiography (Gold Standard) should be done to evaluate the entire vasculature.
       • Surgical clipping or endovascular coiling is usually performed within the first 24 hours.
    4. Intracranial hemorrhage (ReelDx + Lecture)

       • Epidural Hematoma:  transient loss of consciousness from an injury, period of lucency, then neurologic deterioration. CT: lens-shaped, biconvex
       • Subdural Hematoma: elderly patient with a history of multiple falls who is now presenting with neurological symptom. May be chronic, taking days to weeks to develop symptoms. CT scan: Crescent shaped density in the brain
       • Subarachnoid hemorrhage: "explosive thunderclap" headache described as "the worst headache ever." Aneurysm or AVM rupture.
    5. Stroke (ReelDx + Lecture)

       Acute onset of focal neurologic deficits resulting from - diminished blood flow (ischemic stroke) or hemorrhage (hemorrhagic stroke).

       • Contralateral paralysis, motor function. Right-sided symptoms = left side stroke, Left-sided symptoms = right side stroke.
         • Carotid/Ophthalmic: Amaurosis fugax (monocular blind).
         • MCA:  Aphasia, neglect, hemiparesis, gaze preference, homonymous hemianopsia.
         • ACA:  Leg paresis, hemiplegia, urinary incontinence.
         • PCA: homonymous hemianopsia.
         • Basilar Artery: Coma, cranial nerve palsies, apnea, drop attach, vertigo.
         • Lacunar infarcts occur in areas supplied by small perforating vessels and result from atherosclerosis, hypertension, and diabetes: Silent, pure motor or sensory stroke, "Dysarthria-Clumsy hand syndrome", ataxic hemiparesis.
       • CT without contrast for acute presentation - important to diagnose as ischemic or hemorrhagic.
       • For occlusive disease treat with IV tPA if within 3-4.5 hours of symptom onset.
         • Can consider intra-arterial thrombolysis in select patients (major MCA occlusion) up to 6 hours after onset of symptoms.
         • For embolic disease and hypercoagulable states give warfarin/aspirin once the hemorrhagic stroke has been ruled out.
         • Endarterectomy if carotid > 70% occluded.
    6. Syncope (ReelDx)

       Sudden, brief loss of consciousness (LOC) with loss of postural tone followed by spontaneous revival.

       • The patient is motionless and limp and usually has cool extremities, a weak pulse, and shallow breathing. Sometimes brief involuntary muscle jerks occur, resembling a seizure.
       • Near-syncope is light-headedness and a sense of an impending faint without LOC. It is usually classified and discussed with syncope because the causes are the same.
    7. Transient ischemic attack

       An episode of neurologic dysfunction due to focal brain, retinal, or spinal cord ischemia without acute infarction

       • Large artery low flow TIA (stenosis) likely carotid stenosis causing short live (minutes) decrease in flow to the brain
       • Embolic TIA: emboli often form in the heart (afib)(septic emboli from endocarditis)
       • Clinical Manifestations:
         • Internal carotid artery: Amaurosis Fugax (monocular vision loss - temporary "lampshade down on one eye") weakness in the contralateral hand
         • ICA/MCA/ACA: Cerebral hemisphere dysfunction. Sudden headache, speech changes, confusion
         • PCA: somatosensory deficit.
         • Vertebrobasilar: brainstem/cerebral symptoms (gait and proprioception)
       • Diagnose by MRI (more sensitive) or CT, carotid doppler to look for stenosis, CT angiography, MR angiography
       • Carotid endarterectomy if internal or common carotid artery stenosis is > 70%.
       • Aspirin within 24 hours. Antiplatelet therapy (e.g., aspirin or clopidogrel or aspirin-dipyridamole) should be then initiated
18. Other Neurologic Disorders (PEARLS)

    1. Brian Wallace PA-C Podcast: Other Neurological Disorders

       80 mins

       Brian Wallace PA-C
    2. Altered level of consciousness (ReelDx)

       1. Eye opening:

       • 4- spontaneous
       • 3- voice
       •  2-pain
       • 1-none

       2. Verbal:

       • 5-oriented
       • 4-confused
       • 3-inappropriate words
       • 2-incomprehensible
       • 1-none

       3. Motor:

       • 6-obeys commands
       • 5-localizes pain
       • 4-withdraws
       • 3-abnormal flexion (decorticate)
       • 2-abnormal extension (decerebrate)
       • 1-none

       Scoring

       • Maximum score is 15 which has the best prognosis
       • Minimum score is 3 which has the worst prognosis
       • Less than 9 is a coma