Medicine - Neurology Flashcards
Recall some important initial investigations following a suspected TIA
BP
ECG
Carotid USS
Bloods to include cholesterol, lipids, glucose + clotting
What is the CHA2DS2VASc score used to estimate?
Risk of stroke in patients with atrial fibrillation
What scoring system predicts stroke risk following a TIA?
ABCD2
Recall the mainstay of immediate management for TIA, including some contraindications to this mainstay
Aspirin 300mg
Contraindicated if:
- >7 days since signs and symptoms
- Bleeding disorder/ on anti-coagulation
- Already on regular low-dose aspirin
Recall some cases in which you would admit someone following a TIA to investigate them further
> 1 TIA (‘crescendo’ TIA)
Severe carotid strenosis
Suspected cardioembolic source
Patient is on warfarin/DOAC
Patient has bleeding disorder
What should be the ongoing management for patients who have had a TIA? (1st and 2nd line)
1st line: 75mg clopidogrel OD + statin
2nd line: Aspirin + dypiridamole + statin
What is the indication for a carotid artery endarterectomy?
Stenosis >50% with <2w of signs/ symptoms
Define stroke
Rapid onset neurological deficit of a vascular origin that does not completely resolve within 24 hours
What % of strokes are ischaemic vs haemorrhagic?
Ischaemic = 80% (thrombotic/ embolic)
Haemorrhagic = 20% (intracerebral haeomorrhage, SAH)
What classification system is used for strokes, and how does it classify them?
Bamford classification
Based on initial presenting signs and symptoms
What are the 4 broad classifications of stroke under the Bamford classification?
Total anterior circulation stroke
Partial anterior circulation stroke
Posterior circulation stroke
Lacunar anterior circulation stroke
How does weakness compare in the legs vs arms in anterior vs middle cerebral artery infarcts?
Anterior cerebral artery: weakness in legs > arms
Middle cerebral artery: weakness in arms > legs
What are the 3 best forms of initial investigation in stroke?
Non-contrast CT
ECG
Carotid dopplers
Recall 2 scoring systems that can be used acutely in admission for stroke
NIHSS (max score 42)
ROSIER (professional version of FAST)
What is CT ASPECT?
Grading system used to assess early CT ischaemic changes following a stroke
What is the ‘penumbra’?
Area of hypoxic parenchyma following a stroke that is still salvageable
Describe the approach to imaging investigations in suspected subarachnoid haemorrhage
1st CT head
If this is negative –> LP to assess for xanthochromia (bilirubin in CSF)
Recall the general principles of management of subarachnoid haemorrhage
21 day course of nimodipine (CCB)
1st line: Coiling (IR procedure)
2nd line: Surgical clipping (requires craniotomy)
Recall the steps of managing an ischaemic stroke
- Exclude haemorrhagic stroke using CT
Then:
- If <4.5 hours –> thrombolysis (alteplase)
ALSO do a thrombectomy IF proximal anterior circulation
- If >4.5 hours –>
After 2 WEEKS:
1. 300mg aspirin PO OD + statin
If NO AF: add clopidogrel (aspirin 2nd line)
If AF: add Xa inhibitor (eg apixaban) (warfarin 2nd line)
Recall some aspects of management of stroke outside of immediate thrombolysis/ anti-coagulation
Control:
- Fluid management (hypo/hypervolaemia can both worsen symptoms)
- Glycaemic control (hyperglycaemia –> tissue acidosis, free radicals and increased BBB permeability)
- BP control - ONLY use if BP is dangerously high as hypotension so dangerous - eg hypertensive emergency + hypertensive encephalopathy/ cardiac failure/ nephropathy/ eclampsia or aortic dissection
- Cholesterol control (eg with statin)
- Feeding assesment and management
What is the Barthel index and how is it used?
Index of disability post-stroke
10 tasks scored on a scale of independence from 0 to 10 to give a total score out of 100
What is the typical frequency of tremor in Parkinson’s?
4-6 Hz
Recall 3 signs of Parkinson’s disease that might be seen in the eyes
Nystagmus (in MSA)
Vertigal gaze palsy (in PSP)
Saccades slow
Recall some autonomic nervous system symptoms of Parkinson’s
Postural hypotension (in MSA)
Urgency/ frequency (in MSA)
Constipation
Hypersalivation
Hyperhidrosis
ED
What is the glabellar tap?
Confirmatory test of Parkinson’s disease
If you tap the patient’s forehead, the eyes blink
Recall some symptoms of sleep disturbance that may be seen in Parkinson’s
Inability to turn
Restless legs
Early morning dystonia (drug wearing off)
Nocturia
OSA
Insomnia is BIG
Recall the names of 4 Parkinson PLUS syndromes
MSA - multiple systems atrophy
PSP - progressive supranuclear palsy
CBD (corticobasilar degeneration)
DLB (dementia with lewy bodies)
Recall some symptoms of multiple systems atrophy
Autonomic dysfunction
Cerebellar dysfunction
Rigidity > tremor
Recall some symptoms of progressive supranuclear palsy
Vertigal gaze palsy
Postural insability that leads to falls
Speech disturbance
Recall some symptoms of corticobasilar degeneration
Unilateral parkinsonianism
Aphasia
Astereognosis (–> alien limb phenomenon)
Recall some symptoms of dementia with lewy bodies
Visual hallucinations
Fluctuating cognition
Recall some differences between Parkinsonism and Parkinson’s
Parkinsonism: symmetrical, rapid progression, poor response to levodopa
Parkinson’s: asymmetrical, progressive nature, good response to levodopa
Recall some causes of Parkinsonism
VITAMIN CD
Vascular (strokes)
Idiopathic - nil
Trauma (eg dementia pugilistica)
Autoimmune (encephalitis)
Metabolic (eg neuroglycopaenic)
Infective (eg Syphilis, HIV, CJD)
Neoplasm - nil?
Congenital (eg Wilson’s)
Drugs (eg antipsychotics)
What is a DaTscan and what is it used for?
Dopamine Transporter Scan
Tracer binds to DA neurons to allow visualisation of substantia nigra
Used in Parkinson’s to exclude other causes of tremor eg BET
What are the 1st line medications used in Parkinson’s treatment?
Levodopa
MAO-B inhibitors (eg selegiline)
DA agonists (eg ropinarole)
Recall some side effects of levodopa
DOPAMINE
Dyskinesia
On/off phenomena
Psychosis
Arterial BP decrease
Mouth dryness
Insomnia
Nausea and vomiting
EDS
What is the drug of choice to treat nausea in Parkinson’s, and what nausea drug should be avoided in these patients?
Domperidone is best option
Metoclopramide should be avoided
What is the drug of choice to treat psychosis in Parkinson’s, and which antipsychotic should be avoided in these patients?
Best choice: quetiapine
Don’t use: haloperidol
What might COMT inhibitors be useful for in treating Parkinson’s?
Can be given as an adjunct to levodopa to increase compliance, but may increase side effects
In a tonic clonic seizure, how does the side the head turns to relate to the side of the seizure?
It’s the opposite side
For how long does a seizure have to last to be classed as status epilepticus?
> 5 mins
Recall the 4 steps of status epilepticus management
- Buccal midazolam/ IV lorazepam
- IV lorazepam
- IV phenytoin (or phenobarbital if already on phenytoin)
- Rapid sequence induction of anaesthesia using thiopental sodium
Recall 2 side effects of carbamazepine
Hyponatraemia
Rash
Recall 9 side effects of valproate
VALPROATE
Vomiting
Anorexia
Liver toxicity
Pancreatitis
Retention of weight
Oedema
Alopecia
Tetarogenicity
Enzyme inhibition
Which anti-epileptic drug can cause steven johnson syndrome?
Lamotrigene
What is the typical presentation of Alzheimer’s?
The four ‘A’s
Amnesia
Aphasia (Broca’s)
Agnosia (typically faces)
Apraxia (typically dressing)
Recall 3 examples of anti-cholineesterases
Donepezil
Galantamine
Rivastigmine
What is the mechanism of action of memantine?
NMDA (glutamate) receptor partial agonist
What is the first line medical management of Alzheimer’s disease?
If mild-moderate: anticholinesterases
If moderate-severe: memantine
Who are you legally required to inform if you make a diagnosis of any type of dementia?
DVLA
Insurers
What is the most important thing to check before prescribing anticholineesterases?
ECG
Recall 4 drugs that are absolute contraindications for prescribing anticholineesterases
NSAID
Anticholinergics (prevent ACh from binding)
Beta blockers
Muscle relaxants
Recall 3 features of an ECG that are relative contraindications to prescribing anticholineesterases
AV block
Sick sinus syndrome
Bradycardia
Recall 2 drugs that can be used in the prophylaxis of migraines
Propranolol
Topiramate
What are the key signs and symptoms of cluster headache?
Intense pain around eye that may cause watering, lasting 15 mins to 2 hours
What is the acute management of cluster headache?
100% oxygen
SC triptan
What drug can be used as prophylaxis for cluster headaches?
Verapamil
Recall some signs and symptoms of temporal arteritis
Headache
Jaw claudication
Tender scalp
Define multiple sclerosis
An autoimmune demyelinating disorder of the CNS characterised by multiple plaques of separate in time and space
What are the 4 subtypes of MS?
Relapsing remitting
Primary progressive
Secondary progressive
Progressive relapsing
Recall some key signs and symptoms of MS
Tingling
Optic neuritis
Ataxia
Spastic paraparesis eg shoulder paralysis
Recall some symptoms of optic neuritis in MS
CRAP
Central scomata
RAPD (relative afferent pupillary defect)
Acuity decreased
Pain on movement
In what ways is acuity affected by optic neuritis?
Decreased central and colour vision
What is RAPD?
Relative afferenr pupil defect
Pupils respond differently to light stimuli shone in one eye at a time
What are Lhermitte’s sign and Uhthoff’s sign?
Lhermitte’s sign: Neck flexion –> electric shocks in trunk and limbs
Uhthoff’s sign: temporary worsening of MS symptoms following an increase in temperature eg hot bath or exercise
What criteria are used for MS diagnosis?
Revised McDonald’s criteria
What sort of MRI is most useful in MS diagnosis?
Gadalonium-enhanced, T2 weighted
What would be seen on LP in MS?
IgG oliclonal bands
Recall 2 blood antibodies that might be seen in MS?
Anti-MBP (myelin basic protein)
NMO-IgG (neuromyelitis optica - only in Devic’s syndrome)
What is the main drug and dosage used to treat acute attacks of MS?
Methylprednisolone 1g IV/PO OD for 3 days
Recall some drugs that can be used in the management of chronic MS
DMARDs such as IFN-beta
Biologicals eg natalizumab and alemtuzumab (these are first line for RRMS)
Recall one drug that can be useful for fatigue in MS
Modafinil
Recall 2 drugs that can be used to manage in pain in MS
Amitriptyline
Gabapentin
What are the 1st and 2nd line options for medically managing spasticity in MS
1st line: baclofen + gabapentin
2nd line: dantrolene
What is the most useful drug to treat tremor in MS?
Clonazepam
Are sensory or motor signs at the onset of MS associated with a better prognosis?
Sensory signs at onset = better prognosis than motor signs at onset
What is the typical age of onset of myasthaenia gravis in women vs men?
Women: 20-30y
Men: 60-70y
Which autoimmune disorder is strongly associated with thymic hyperplasia?
Myasthaenia gravis
Recall 2 abnormalities on eye examination that could be seen in myasthaenia gravis
Diplopia
Ptosis
Recall some signs and symptoms of myasthaenia gravis
Muscle fatiguability is the main one
Also:
Extra-ocular muscle weakness
Proximal myopathy
Dysphagia
Recall some drugs that can exacerbate myasthaenia gravis
Beta-blockers
Lithium
Phenytoin
Numerous antibiotics
Penicillinamine
How is a myasthaenic crisis defined?
FVC <1L
Negative inspiratory force<20cmH2O
Need for ventilation
How should a myasthaenic crisis be managed?
Plasmapheresis, IV Ig, intubation
What is the most important investigation to do to investigate myasthaenia gravis?
Single fibre EMG
Recall 2 tests that can be used to assess fatiguability in myasthaenia gravis
Repetitive nerve stimulation
Serial pulmonary function testing
Recall 2 antibodies you might test for when investigating myasthaenia gravis
Anti-ACh-R
Anti-muscle-specific-receptor tyrosine kinase