Corrections - Neurology pt2 Flashcards
What is amaurosis fugax?
A form of stroke that affects the retinal/ophthalmic artery.
It means a ‘transient darkening’ –> a temporary loss of vision through one eye that returns to normal afterwards.
When should statins be started after stroke?
48 hours after stroke onset in patients not already taking a statin.
Management of AF post stroke?
1) following a stroke or TIA, exclude a haemorrhage before starting any anticoagulation or antiplatelet therapy
2) short-term: antiplatelet (i.e. aspirin 300mg) for 2 weeks
3) long-term: anticoagulation e.g. warfarin or a direct thrombin or factor Xa inhibitor
What artery is affected in lateral medullary syndrome (aka Wallenberg’s syndrome)?
PICA
Features of lateral medullary syndrome?
ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner’s
contralateral: limb sensory loss
What does a lacunar infarct involve?
involves perforating arteries around the internal capsule, thalamus and basal ganglia
How does a lacunar infarct present?
Presents with 1 of the following:
- unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
- pure sensory stroke.
- ataxic hemiparesis
How can MS be conclusively diagnosed?
‘MRI shows demyelinating lesions that are separated in space and time’.
MRI shows lesions at various stages, indicated by differing degrees of contrast enhancement and diffusion restriction, representing both old and active demyelination. To conclusively diagnose MS, it is necessary for these lesions to be present in multiple anatomical locations and to have occurred at different points in time.
Does the absence of oligoclonal bands in the CSF exclude a diagnosis of MS?
No
What test can be used to distinguish vestibular neuronitis from posterior circulation stroke?
The Head Impulse, Nystagmus, Test of Skew (HINTS) Examination.
What is the HINTS exam comprised of?
1) head impulse
2) evaluation nystagmus
3) test of skew
What is vestibular neuronitis?
Vestibular neuronitis is a cause of vertigo that often develops following a viral infection.
Features of vestibular neuronitis?
- recurrent vertigo attacks lasting hours or days
- nausea and vomiting may be present
- horizontal nystagmus is usually present
- no hearing loss or tinnitus
1st line medication for myoclonic seizures in males?
Sodium valproate
What type of nerve fibres transmit signals slowly and produce dull and diffuse pain sensations?
C fibres
What term describes an isolated patch of white hair on the head, eyebrows, eyelashes or beard, sometimes associated with tuberous sclerosis?
Poliosis
What surgical procedure may be used to treat myasthenia gravis?
Thymectomy
What is a thymectomy?
Surgical removal of the thymus gland, which has been shown to play a role in the development of myasthenia gravis.
What is the thymus gland?
A small organ that lies in the upper chest under the breastbone. It makes T lymphocytes.
What medication may be used to slow the progression of the disease and extend survival by several months in amyotrophic lateral sclerosis (ALS)?
Riluzole
What is the long-term antiplatelet treatment for secondary prevention after an ischaemic stroke?
What other secondary prevention medication will also be started?
Clopidogrel 75mg daily
Atorvastatin 20-80mg daily
What is the usual first-line prophylactic treatment for chronic or frequent tension headaches?
Amitriptyline
What cholinesterase inhibitor prolongs the action of acetylcholine and improves symptoms in myasthenia gravis?
Pyridostigmine
What type of cell are acoustic neuromas formed from?
Schwann cells
What type of medication blocks the action of enzymes that break down neurotransmitters, helping to increase the circulating dopamine in patients with Parkinson’s disease?
Monoamine oxidase B inhibitors
What type of seizure, usually seen in children, causes the patient to become blank, stare into space, and then abruptly return to normal?
What is the first-line medication for this type of seizure?
Absence seizure
Ethosuximide
What condition, typically starting at around six months of age, causes clusters of full-body spasms?
What is the characteristic EEG finding?
What treatments are used? (2)
Infantile spasms (West syndrome)
Hyperarrhythmia
ACTH & vigabatrin
What term describes increased resistance to the passive movement of a joint?
Rigidity
What type of receptor do triptans stimulate?
5-HT receptors (serotonin receptors)
What is Lhermitte’ sign?
The electric shock sensation that travels down the spine and into the limbs when flexing the neck, indicating demyelination in the dorsal column of the cervical spinal cord of a patient with multiple sclerosis.
What does Lhermitte’s sign indicate?
Demyelination in the dorsal column of the cervical spinal cord of a patient with MS.
What type of nerve fibres transmit signals fast and produce sharp and localised sensations?
A delta fibres
What is the most common idiopathic cause of lower motor neurone facial nerve palsy? (1)
What is the short-term treatment? (1)
Bell’s palsy
Prednisolone
What skin findings (other than neurofibromas) may be seen in neurofibromatosis type 1? (2)
Cafe au lait spots
Axillary or inguinal freckling
What medication may be used to prevent vasospasm in subarachnoid haemorrhage?
What is the mechanism of action of this drug?
Nimodipine
CCB
What may be seen in a cerebrospinal fluid sample from a patient with multiple sclerosis?
Oligoclonal bands
What type of migraine causes unilateral limb weakness?
Hemiplegic migraine
What tool gives a score based on the clinical features and duration to identify a stroke in A&E?
ROSIER tool (recognition of stroke in the emergency room)
What is the most important examination finding to check before starting triptans for migraines?
Why?
BP
HTN is a contraindication
What investigations may be used to support a diagnosis of Guillain-Barré syndrome? (2)
1) Nerve conduction studies (reduced signal through the nerves)
2) LP (increased protein in the CSF)
What is the initial antiplatelet treatment for patients with a confirmed ischaemic stroke?
Aspirin 300mg daily for 2 weeks (started after haemorrhage is excluded with CT)
What threshold is used for defining chronic versus acute pain?
> 3 months duration
What dose of IV morphine is approximately equivalent to 10mg of oral morphine?
5mg
What dose of oxycodone is approximately equivalent to 10mg of oral morphine?
6.6mg
What term refers to when pain is experienced with sensory inputs that do not normally cause pain (e.g., light touch)?
Allodynia
What type of tumour is strongly associated with myasthenia gravis?
Thymoma
What dose of tramadol is approximately equivalent to 10mg of oral morphine?
100mg
What type of medication is taken alongside levodopa and slows the breakdown of the levodopa in the brain, extending the effective duration of the levodopa?
COMT inhibitors (e.g. entacapone)
What type of medication is combined with levodopa to stop it from being metabolised in the body before it reaches the brain?
Give 2 examples
Peripheral decarboxylase inhibitors
Carbidopa & benserazide
What dopamine receptor-blocking antiemetic is suitable for patients with Parkinson’s disease?
Domperidone (doesn’t cross BBB)
What medication is used first-line to treat relapses of multiple sclerosis?
Methylprednisolone
What medications may be used to treat the symptoms of benign essential tremor? (2)
Propanolol
Primidone
What is the first line for prophylaxis of cluster headaches?
Verapamil
What class of medication is used first-line in the treatment of status epilepticus?
Give three examples, along with their typical route of administration.
Benzos
Lorazapam –> IV
Diazepam –> rectal
Midazolam –> buccal
What two features of Charcot-Marie-Tooth disease are immediately visible on inspection of the legs?
1) High foot arches (pes cavus)
2) Distal muscle wasting causing ‘inverted champagne bottle legs’
What are the most common antibodies found in patients with myasthenia gravis?
Acetylcholine receptor (AChR) antibodies
What is seen in a cerebrospinal fluid sample in a patient with a subarachnoid haemorrhage? (2)
Raised red cell count
Xanthochromia
What two conditions need to be excluded as an underlying cause in patients with an ischaemic stroke?
Carotid artery stenosis
AF
What type of benign tumour is associated with neurofibromatosis type 2?
Schwannoma
What signs may be seen on examination in a patient with lower motor neurone dysfunction?
Fasciculations
Hypotonia
Hyporeflexia
Muscle wasting
What are the causes of peripheral neuropathy? (8)
- Diabetes mellitus
- Drug induced e.g. amiodarone, isoniazid, cisplatin
- Vasculitis
- Alcohol
- B12 deficiency
- Cancer e.g. myeloma
- CKD
- Charcot-Marie tooth
What gait disturbance may be seen in Charcot-Marie-Tooth disease? (1)
High stepping gait (due to foot drop)
Which medication is used to treat the symptoms of Lambert-Eaton myasthenic syndrome?
Amifampridine
Mechanism of amifampridine in Lambert-Eaton?
Works by blocking voltage-gated potassium channels in the presynaptic membrane, which in turn prolongs the depolarisation of the cell membrane and assists calcium channels in carrying out their action.
What vitamin may be beneficial in treating migraines?
Who should avoid supplementing with this?
Vitamin B2 (riboflavin)
Patients who are pregnant or planning pregnancy
What types of cancer most often metastasise to the brain? (4)
Breast
Lung
Melanoma
Kidney
What term describes abnormal muscle tone, leading to abnormal postures?
Dystonia
What are the five branches of the facial nerve?
1) Temporal
2) Zygomatic
3) Buccal
4) Marginal mandibular
5) Cervical
What are the characteristic presenting features of Guillain-Barré syndrome? (2)
1) Symmetrical ascending muscle weakness
2) Reduced reflexes
What visual field defect is caused by optic neuritis?
Central scotoma
What is the first-line treatment for trigeminal neuralgia?
Carbamazepine
What are the two key features of Ramsay-Hunt syndrome? (2)
What pathogen causes the condition? (1)
1) Unilateral LMN facial nerve palsy
2) Painful vesicular rash around the ear on the affected side
VZV
What type of ischaemic stroke is typically associated with ataxia and vertigo?
Posterior circulation infarction
What condition is associated with bilateral acoustic neuromas?
Neurofibromatosis type 2
What type of benign tissue growth is associated with tuberous sclerosis? (1)
Hamartomas
What is the parasympathetic supply of the facial nerve? (2)
1) Submandibular and sublingual salivary glands
2) Lacrimal glands (stimulating tear production)
What groups of muscles tend to be most affected in myasthenia gravis? (2)
1) Proximal muscles of limbs
2) Small muscles of head and neck
What are the branches of the trigeminal nerve? (3)
1) Opthalmic (V1)
2) Maxillary (V2)
3) Mandibular (V3)
What questionnaire can be used to assess whether pain is neuropathic?
DN4 questionnaire
What is the mechanism of action of amantadine used to treat Parkinson’s disease? (1)
Glutamate antagonist
What are the usual first-line options for migraine prophylaxis? (3)
Propanolol
Topimarate
Amitryptiline
What are the main causes of unilateral upper motor neurone facial nerve palsy? (2)
1) Cerebrovascular accident (stroke)
2) Tumours
What is a notable long-term respiratory side effect of dopamine agonists, such as bromocriptine?
Pulmonary fibrosis
What group of medications are the only ones NICE recommend for chronic primary pain?
Antidepressants
What special test is used to support a diagnosis of myasthenia gravis?
Edrophonium test
What is the first-line medical treatment for Guillain-Barré syndrome?
IV immunoglobulins
What is the imaging investigation of choice in a suspected TIA?
Diffuse weighted MRI
What antibodies are associated with Lambert-Eaton myasthenic syndrome?
Voltage gated calcium channel (VGCC) antibodies
What is the main side effect of long-term use of levodopa?
Dyskinesia
What do antibodies target in patients with Guillain-Barré syndrome? (2)
Proteins on the myelin sheath or the nerve axon
What surgical options are available for treating a large extradural or subdural haematoma? (2)
Craniotomy
Burr holes
What is the first-line imaging investigation in patients with a suspected brain tumour?
MRI
What condition can cause features of Parkinsonism associated with autonomic dysfunction and cerebellar ataxia?
Multiple system atrophy
What structures does the facial nerve pass through on its way from the cerebellopontine angle to the face? (2)
Temporal bone
Parotid gland
What are the mechanisms of action of tramadol? (2)
Serotonin and norepinephrine reuptake inhibitor (SNRI)
Opioid receptor antagonist
What investigation is done at the same time as a LP in meningitis?
Why?
Blood glucose for comparison to the CSF glucose
