Ax Neurology Flashcards
What’s hemineglect/ unilateral spatial neglect/ unilateral inattention.
One sided ( often left sided) spatial disorientation afar pathological event in the contralateral hemisphere , classically Right posterior parietal cortex.
Features- fails to entirely attend to other side, not shaving the face ( as if that side doesn’t exist) , lifting other arm instead of that, collides on surroundings, ( NOT ONLY SENSORY MOTOR, but also PERCEPTUAL, VISUOSPATIAL, BEHAVIORAL changes )
Causes- contralateral PARIETAL LOBE PATHOLOGY is the likely cause.
Features of frontal Cortex deficit
Speech and behavior problems
Primitive reflexes( grasping, sucking)
Altered mental status
Impaired judgement
CONTRALATERAL WEAKNESS ( greater in legs than arms)
Gait apraxia
Temporal cortex lesions features
Features LESS NOTICABLE by others-
Language and speech problems
Forgetfulness
Visual disturbances
Left parietal lobe problems causing-
Right side hemineglect
Occipital lobe lesions causing-
Contralateral homonymous hemianopia
Cortical blindness
Visual agnosia ( not eecongnizing familiar objects)
Impaired memory
Altered mental status
Definition of drug induced Parkinsonism
Bilateral and symmetrical Parkinsonism without tremors at rest.
What’s atypical Parkinsonism and what are their features
Syndromes characterized by some features of Parkinsonism plus additional features.
CF- falls in the early disease, poor response to levadopa, symmetry at the disease onset, rapid disease progression.
Usually little or no tremors, relatively early speech and balance difficulty and little or no response to doperminergic meds.
Rules Regarding Huntington disease testing
Generic testing ( CRITERIAS) for >18Y OR OLDER who have atleast ONE BLOOD RELATIVE with definite diagnosis.
In Gillick competence rule - if child who CAN HANDLE THE SITUATION but LESS THAN 18Y, can be referred to generic unit for genetic counseling OR can be informed that such screening CAN BE DONE AT THE AGE OF 18. (Less than 13y shouldn’t be referred for genetic counseling.)
Generic testing not done due to parents request.
If guidelines are unclear for decision making - court order can be requested.
Features of huntingtons diseases
Involuntary muscle movements affecting face ,hand,limbs( irregular and jerky)
Slurred speech and swallowing problems
Disruption of thought process.
Unsteadiness and falls
Memory loss
Depression and anxiety
Develops slowly over 15-20 years.
Diff between posterior communicating artery aneurysms and midbrain infarcts causing 3rd nerve palsy
Only PCA infarcts palsy -PUPILS AFFECTED.
Pupils intact in midbrain infarcts and diabetic palsy.
Causes of 3rd nerve palsy
- Ischemia (diabetic and midbrain infarcts)
- Aneurysms of PCA, internal carotid artery and basilar artery.
- Trauma
- Infection
Features of Bell’s palsy
- Acute onset unilateral upper or lower facial paralysis
- Posterior auricular pin
- Decrease tearing
- Hyperacusis
- Taste disturbance
What’s subacute combined degeneration of spinal cord
Due to vit B12 deficiency.
CF
1. Distal paresthesia and weakness of extremities.
2. Followed by spastic paresis and ataxia( Romberg positive)
3. Deficit of proprioception.
4. pyramidal signs ( plantar extension and hyperreflexia)
5. Recent memory loss, reduced attention, depression, hypomania, hallucinations.
6. Sensory could be affected.
Testing and management of subacute DOSC
Serum Vitamin b12 levels
Rx- vitamin B12
What’s re pyramidal and extra pyramidal signs
Features of Horners Xn
Ptosis
Miosis
Ipsilateral loss of sweating
Features of optic nerve lesion
Causes monocular visual loss
1. Impaired pupil light reflex
2. Central vision loss ( scotoma) in the visual field exam
3. Colour blindness out of proportion to acuity loss.
What’s normal MMSE
Above 24 rules out cognitive impairment
What’s haloperidol and it’s effect on Parkinsonism
Haloperidol is a first gen antipsychotic ( acts on inhibition of dopamine receptors )
In Parkinsonism dopamine depletion by basal ganaglia occurs.
So haloperidol results in worsening of extrapyramidal symptoms of Parkinson’s.
Which antipsychotics doesn’t produce dose dependent extrapyramidal effects in Parkinsonism
Aripiprazole
Clozapine
Quetiapine
Sensory distribution of the tongue
Function of non dominant parietal lobe? And damage causes?
Three dimensional manipulation
Causes constructional apraxia( drawing of intersecting pentagon is impaired)
Areas of cognitive function tested in MMSE
Orientation
Registration
Attention And Calculation
Recall
Language
Immediate anti platelet therapy for patient with STROKE OR TIA ( after excluding hemorrhagic stroke by CT scan )
Aspirin + clopidogrel recommended for a SHORT TERM COURSE only.
Warfarin is the preferred anticoagulant in stroke with AF.
Endarterectomy - if asymptomatic and more than 60% OR asymptomatic and more than 50%
For this patient - endarterectomy within 2 weeks to prevent further strokes.
Episodic vertigo , right sided hearing loss, double vision and simultaneous numbness of left limbs.. suggestive of
Difference between mineire disease and VBI
What are distinct characteristics of vertebrobasilar strokes
These will differentiate VB strokes from hemispheric strokes caused by lesions of anterior , middle cerebral and internal carotid artery
PICA syndrome features
Features of SAH
Features of subdural hematoma
Features of epidural hematoma
What’s the biggest preventable RF in strokes
Hypertension
Unless contraindicated by symptomatic hypotension , all patients should receive anti hypertensives after stroke/TIA
( ACE-I And diuretics together or alone are more beneficial)
What’s the window for thrombolytic therapy in stroke
Within 4.5 hours of symptom onset
What’s the most imp step in managing strokes/TIA
Antiplatelet therapy ( for prevention of further ischemic cerebrovascular accidents)
Dual therapy is the initial pharmacological management - aspirin + clopidogrel for ONLY 3 WEEKS.
When to do theombolytic therapy in stroke
In carefully selected patients with ischemic stroke and TIA —> thrombolytic therapy can be given ( rTPA)
Antiplatelet should ebatarted immediately. And if theombolysis done antiplatelet started after 24hours.
Causes of transient visual loss
Among emboli conclusions causing TIA Retinal ischemia common with emboli originating from CAROTID STENOSIS rather than THE HEART.
Indication for CEA
If asymptomatic 60% or more stenosis
If symptomatic 50% or more
What are more likely features of a brain tumor
Early morning nagging type headache
Associated vomiting WITHOUT nausea
Highly suggestive of a space occupying brain lesion
Types of headaches
- Scape occupying lesion- nagging early morning headache with vomiting without nausea.
- Migraine - throbbing in nature, nausea, aggregated by head movement
- Cluster headache- unilateral, deep severe pain around of behind the eyes or in the temple, tearing ,runny nose, eye congestion, ptosis are seen. Agitated.
- Sinusitis - nagging around maxillary or frontal sinuses.
- Tension headache- common type no nausea , in evening hours.
What’s the commonest visual disturbance in carotid artery stenosis
Amaurosis fugax- unilateral vision loss ( curtain coming down on their eyes )
Sudden reduction of vision and retroorbital pain in a Young patient suggestive of
Optic neuritis.
MRI brain is always the INITIAL IX.
Most DIAGNOSTIC accuracy with VISUAL EVOKED POTENTIAL( VEP )
Why do temporal artery biopsy
For temporal arteritis / GCA
( scalp tenderness, jaw claudication, vision loss but common in >50yo elderly )
Features of optic neuritis
Demyelinating inflammation of optic nerve ( associated with MS)
CF-
In young adults
RAPID developing
Impairment of vision in one or (less commonly) both eyes.
Dyschromatopsia-change in Colour perception
Retro orbital ocular pain with eye movement.
Commonest intraocular malignancy adults
Uveal melanoma
What are aura in migraine
Visual, auditory or taste changes
Migraine vs tansion headache
Confirmatory test for endometriosis
Laparoscopy
Commonest cause of chronic pelvic pain in developed countries
Endometriosis
Usual delay in diagnosis of endometriosis
8-10 YEARS
In endometriosis what increases fertility
Medical - only relieves symptoms
Surgical - improves fertility as well
Symptoms of endometriosis
How to manage a large uterine fibroid in a women expecting pregnancy
GnRH agonist are most effective medical therapy for uterine myomas.—-> most women will improve and SIZE WILL BE REDUCED after 3 months of therapy ——> then Myomectomy follows
OOCP or progesterone will regulate abnormal uterine bleeding but won’t help in leiomyomas.
How to manage asymptomatic ovarian cysts in PREMENOPAUSAL WOMEN
What’s the interaction between OCP and antiepileptics
Antiepileptics reduce EFFICACY of OCP and progesterone only pills and implanon..
So DOSE INCREMENT is needed.
What are best options- Mirena , DepoProvera
What’s the alternative for COC if that causes hypertension
Replace with PROGESTERONE ONLY PILL
What’s in pristinor 2 and how to take them
Contains progesterone only method ( Levenegestrol 750mcgs)
One tab within 72 hours and the other within 12 hours
But TAKING THEM TOGETHER IS MORE EFFECTIVE AND LESS ADVERSE EFFECTS.
If given before 8-10 days of menstruation - breakthrough bleeding within a few days is possible. But if given mid cycle vaginal bleeding unlikely
SOL/ brain tumor features
Early morning headache
Worsens on bending forward, sneezing and coughing.
Projectile vomiting.
Focal neurological signs
Tension headache in what time
Worsens towards evening
Adequately respond to analgesics
Prolonged analgesics use , no alarming features and ALMOST EVERYDAY MORNING headache ??
Drug rebound headache ( medications overuse headache)
Absent seizure ?
L5S1 nerve root compression symptoms
Weak ankle dorsiflexion, foot drop (L5)
Decreased plantar flexion (S1)
Decreased reflexes bcos its lower motor type
UMN lesion of brainstem origin features
UMN features
And also bulbar Signs- slurred speech, dysphagia specially for liquids , facial involvement.
Features of spinal canal stenosis
UMN and LMN mixed picture
CHRONIC PAIN
Causes UMN features and the level of stenosis and LMN features below that.
What’s the commonest MND
ALS
ALS features
ALS features
Clinical diagnosis
But for initial workup- EMG and NCS done
Foot dermatomes
How to differentiate L5 radiculopathy and CPN compression
They presents similarly
But L5 has associated Lower back pain and aggravated by walking and relieved by rest ( opposite is seen in CPN COMPRESSION)
Tests - L5 radiculopathy will reproduce the pain for SLRT and SLUMP test.
Radial nerve injury causes
Involves on wrist extension, MCP extension , thumb extension and ABDUCTION
So nerve injury affects them
Post menopausal ovarian cyst management
Radial nerve sensory
What causes deltoid area loss of sensation
Axillary nerve damage
By humoral neck fractures ( not shaft)
Sciatic nerve innovation
At popliteal fossa divides into 2 branches - tibial and common perineal.
Sciatic nerve injury causes hamstring muscle weakness and all the muscles weakness below that.
Most specifically WEAK ANKLE REFLEX.
S1 nerve root compression features
Pain down the posterior aspect of the leg
Weakness of PLANTAR FLEXION
Weakness of leg extension and toe flexion.
LOSS OF ANKLE REFLEX.
Tibial nerve injury feature
Supplies the posterior compartment.
(ankle plantar flexors )
So WEAK PLANTAR FLEXION and weak ANKLE REFLEX.
Weak or absent PLANTAR REFLEX.
Weakness of plantar flexion and inversion. Which nerve?
Plantar flexion by posterior compartment muscles- by tibial nerve
Inversion by tibialis anterior ( by deep perineal nerve) and tibialis posterior ( tibial nerve)
So could be either DPN or TN.
Features of L4 radiculopathy
Weak knee reflex
Partially impaired ankle inversion.
Which muscles affected by CPN injury
Brachial plexus branches
Two types of vertigo and how to differentiate
Central vertigo / true vertigo ( due to CNS pathology ) - spinning or moving sensation
Peripheral vertigo ( due to peripheral component like vestibular system, not true vertigo) - no spinning sensation. Only dizziness. Causes -anxiety
Cerebral degeneration features
Ataxia
Gait abnormalities ( weakness, unsteadiness)
Recurrent acute attacks of vertigo, nausea and vomiting , without tinnitus or hearing impairment in otherwise healthy adult …?
BPPV (COMMONEST CAUSE of vertigo in clinical practice)
Brief episodes ( a few seconds)
Nystagmus
Triggered by rapid changes of head position.
Diagnosis of BPPV
Dix Hallpike maneuver
How to treat BPPV
Benign condition and reassuance can be done
Epley maneuvre , vestibular rehabilitation and watchful waiting.
What are the 3 cancers which metastasize to brain
Lung (21%)
Breast (9%)
Melanomas (40%)
Is acute BP lowering safe for stroke patients ?
No.. it could result in brain hypoperfusion.
Management of migraine in children ?
Stepwise mx
PCM alone of with NSAIDS( ibuprofen)
Next - sumatriptan
prevention. - propranolol
In optic neuritis MRI will show demyelination features if ____ is associated.
Multiple sclerosis.
What’s hypsarrhythmia?
Aka infantile spams / west syndrome.
What’s benign Rolandic epilepsy
What’s babinski sign and what does it indicate
It indicated UMN lesion.
UMN and LMN features in same areas of body and intact sensation..what’s the diagnosis
MND - ALS COMMONLY
Common preceding infection for GBS?
Gastroenteritis with compylobacter
How to investigate for GBS
Confirmatory test is CSF analysis by LP ( albuminocytogenic dissociation)
But NCS and EMG studies are also accurate and provides prognostic value.
What are treatment of choice for GBS
Plasma exchange and IVIg ( same efficacy but plasma exchange has more adverse effects )
Role of steroids in treatment of GBS
No role
What are types of reflex syncope
Root problem is neurogenic not cardiogenic.
What’s syringomyelia
Development of fluid filled cavity ( syrinx) within the spinal cord.
Syrinx compressing anterior horn damages motor neurons.
What muscles innervated by anterior interosseous nerve?
What’s the specific feature of sciatic nerve injury
Weak or absent ankle reflex
