4. Neurology Flashcards
CNIII controls most of the muscles of the eye. Which 2 does it not control?
Lateral Rectus
Superior Oblique
CNIII controls muscles of the eye. What is it’s other function?
Parasympathetic innervation of the pupil which keeps it constricted.
What is the classical clinical signs of a CNIII palsy?
Ipsilateral eye ‘down and out’ with fixed, dilated pupil.
(Only controlled by lateral rectus and superior oblique, and loss of parasympathetic innervation)
Causes of CNIII palsies (inner & outer fibre causes):
Inner (pupil remains normal):
Diabetes
High blood pressure
Inflammatory diseases
Outer (damage to sphincter pupillae/ciliary muscle / pupil affected):
Aneurysm
Herniation
Meningitis
Tumour
TBI
Where does the spinal cord terminate?
L1/2
(paediatrics = lower)
What is the scan of choice when there is clinical suspicion of CES?
Non-contrast CT of lumbosacral spine
Where is the primary motor cortex located in the brain?
Posterior frontal lobe
Which 3 systems are involved in motor control, and which is the most important?
Corticospinal (No1!)
Basal ganglia
Cerbellum
Patient with bulbar onset MND can have problems with sialorrhoea. Name 2 drugs that can help with this.
Hyoscine butylbromide
Glycopyrronium bromide
3 potential benefits of NIV (other than improved breathlessness) in MND patients.
Better sleep
Improve fatigue
Improve early morning headache
What scoring system is used to measure disease severity in MND, and how is it calculated?
ALSFRS-R score.
12 aspects of physical function, each scored 4-0 (4 normal, 0 no ability).
Medications relieve pain in 1/3 of patients with MND. Name a specific drug for each of the following 3 specific problems; muscle stiffness, muscle cramps and joint pains.
Stiffness = baclofen
Cramps = quinine
Joint pains = long acting NSAIDs
Is Future Care Planning legally binding in Scotland?
No
Is an Advance Directive legally binding in Scotland? What is it, and what can it NOT include?
It is a written statement of somebody’s wishes to refuse certain medical treatments e.g. IV Abx, NIV and gastrostomy tube feeding.
It cannot include a request for specific treatments, or for euthanasia.
State the 4 anticipatory drugs / drug class.
Hyoscine butylbromide
Midazolam
Levomepromazine
Opioids
What does CSCI stand for and what is it for?
Continuous subcutaneous infusion
More consistent symptom control
Give 3 bulbar features of MND.
Dysarthria
Tongue fasciculations
Dysphagia
Give 5 respiratory features of MND.
SOB on exertion
Daytime somnolence
Fatigue
Early morning headache
Orthopnoea
Give 3 cognitive features of MND (these are rare).
Emotional lability
Behavioural change
Fronto-temporal dementia
Give 6 limb features of MND.
Focal weakness
Falls / trips from foot drop
Loss of dexterity
Muscle wasting
No sensory symptoms
Muscle fasciculations
Give 4 neurological symptoms that would not be supportive of an MND diagnosis.
Bladder / bowel involvement
Improving symptoms
Prominent sensory symptoms
Double vision / ptosis
What would nerve conduction studies and electromyography show in MND?
Normal motor conduction on nerve studies (excludes neuropathy)
Electromyography would show reduced number of action potentials with increased amplitude
The diagnosis of MND is clinical, but what kind of scan is usually performed to rule out differentials, and what are they?
MRI
Cervical cord compression
Myelopathy
What is the typical distribution of upper and lower motor signs in ALS?
Upper limbs = lower signs e.g. muscle wasting esp small hand muscles, weakness
Lower limbs = upper signs e.g. spasticity, increased tone
What is the first line management for trigeminal neuralgia?
Carbamazepine
What should prompt a neurology referral when considering trigeminal neuralgia?
Failure to respond to treatment
Atypical features
Trigeminal neuralgia is a pain syndrome that causes severe pain. Is it bi or unilateral generally?
Unilateral
Define trigeminal neuralgia (4 point).
Unilateral disorder
Electric shock like pains
Sudden onset and termination
Pain remits for variable periods
Trigeminal neuralgia often is evoked by ‘trigger factors’. Give 3 examples of a trigger factor.
Washing
Shaving
Smoking
Brushing teeth
Trigger areas can also arise e.g. nasolabial folds
The vast majority of cases of trigeminal neuralgia are idiopathic, but can be due to a serious underlying cause in some cases. Give some red flag symptoms that would suggest this, and warrant a neurology referral.
Sensory changes
Only ophthalmic division involvement, or bilateral symptoms
Deafness / other ear problems
Optic neuritis
FHx of MS
Age onset < 40 years
Herpes simplex infection
What are the 3 divisions of the trigeminal nerve?
Ophthalmic
Maxillary
Mandibular
What age is the peak incidence of trigeminal neuralgia, and what is the distribution between sexes?
Age 60-70
F:M = 2:1
What is the age distribution in Myasthenia Gravis?
Women are affected younger, typically under 40
Men are affected older, typically over 60
What type of tumour is commonly associated with MG?
Thymoma
Which muscle groups are most affected in MG, and give some symptoms that arise due to this?
Proximal limb muscles; difficulty up stairs, standing up, lifting above head
Small muscles of head and neck; extraocular muscles causing diplopia, eyelids causing ptosis, swallowing difficulties and slurred speech
Give 3 tests that may be indicated when investigating for MG.
Antibody testing; Ach, MuSK, LRP4
CT/MRI for thymoma
Edrophonium test (cholinesterase enzyme blocker)
Give 4 management strategies for MG.
Pyridostigmine (Achesterase blocker)
Immunosuppression via prednisolone / azathioprine
Thymectomy
Rituximab as last line (mab against B cells)
What triggers a myasthenic crisis, and what is one of the most worrying symptoms?
Often triggered by intercurrent illness.
Respiratory muscle weakness can lead to respiratory failure.
Give 3 management options for a myasthenic crisis.
Iv Ig
Plasmapharesis
NIV or mechanical ventilation for respiratory support
4 good prognostic factors in Bell’s Palsy:
Improvement in symptoms in first 2 weeks
Partial > complete paralysis at onset
Younger patients do better
Initiation of steroids within 72 hours
Give 3 exacerbating factors of essential tremor:
Stress
Tiredness
Caffeine
Give 2 things that improve an essential tremor.
Rest
Alcohol
What inheritance pattern does essential tremor have?
Autosomal dominant
In Tourette’s syndrome do motor or vocal tics tend to develop first?
Motor then vocal
Which 2 tumour types can present with a bitemporal hemianopia, and what is the most common in adults vs children?
Pituitary adenoma most common in adults
Craniopharyngioma is more common in kids !! 75% present with GH deficiency as well
