Medicine- neurology Flashcards
Cerebellar signs
Disdiadochokinesia
Ataxia
Nystagmus
Intention tremor
Scanning/ staccato/ slurred speech
Hypotonia
LMN signs
Flaccid paresis
Hypotonia
Hyporeflexia
Atrophy
Fasciculations
UMN signs
Hyperreflexia
Positive Babinski sign (extensor plantar response)
Spasticity
No muscle weakness (early on)
Pyramidal pattern of weakness
Contraindications to lumbar puncture
- Mass lesion causing increased ICP (risk of cerebral herniation)
- Infection over LP site/suspected epidural abscess
- Low platelets (<50,000) or anticoagulated
- Uncooperative patient
- Confirmed/suspected spinal trauma or congenital spinal abnormalities
CNIII palsy signs
Ptosis
Pupil down and out
Pupil dilation
What EEG findings are associated with absence seizures?
3 Hz spike and slow wave activity on EEG
EEG findings suggestive of epilepsy
Abnormal spikes Polyspike discharges, Spike-wave complexes
Definition of status epilepticus
Medical emergency involving unremitting seizure or successive seizures without return to baseline state of >5 min
Vit B12 deficiency signs
Macrocytic anemia, pallor, SOB, fatigue, chest pain, palpitations
- Confusion or change in mental status (if advanced)
- Decreased vibration sense
- Distal numbness and paresthesia
- Weakness with UMN findings
- Diarrhea, anorexia
Name the disorder
Visual hallucinations
Parkinsonism
Fluctuating cognition
Lewy body dementia
Lewy Body dementia is associated with what kind of response to neuroleptics?
Severe sensitivity (rigidity, neuroleptic malignant syndrome, extrapyramidal symptoms)
Canadian CT head rules: high risk (5)
High risk (for neurosurgical interventions)
GCS score <15 at two hours after injury
Suspected open or depressed skull fracture
Any sign of basal skull fracture (haemotympanum, “panda” eyes, cerebrospinal fluid otorrhoea, Battle’s sign).
Vomiting more than once
Age≥65 years
Canadian CT head rules: medium risk (2)
Medium risk (for brain injury on CT) * Persistent retrograde amnesia of greater than 30 minutes Dangerous mechanism of injury (pedestrian struck by vehicle, ejection from vehicle, fall from greater than three feet or five stairs)
Canadian CT head rules exclusion criteria
Exclusion criteria
anticoagulant medication or bleeding disorder
age <16 years seizure
Major neuropathological findings in Parkinsons (2)
- Loss of pigmented dopaminergic neurons in the substantiata nigra
- Lewy bodies
PD investigations (2)
PET SPECT
Serum ceruloplasmin is a screening test for what?
Wilson disease
Cluster headache characteristics
Unilateral Pain in orbital or supra-orbital region
Assoc w nasal congestion or conjunctival injection
The genetic basis of Huntintgons Disease
expansion of a CAG repeat encoding a polyglutamine tract in the N terminus of the protein product called Huntingtin
Signs of raised intracranial pressure
Headache
Reduced LOC
Papillodema
Reduced HR
Hypertension
Respiratory depression
Maybe apparent VI palsy (paralysis of lateral gaze)
Tonometry measures what?
Intraocular pressure. Used for diagnosis of glaucoma.
Optic chiasm lesion results in what?
Bitemporal hemianopsia
What does ALS not affect?
Bowel + bladder function
Sensation
Mental function
Eye muscles
What is the relationship between smoking and Parkinsons disease?
It lowers risk
Typical presentation of myasthenia gravis
Fatgued Muscle weakness Improvement with rest Diplopia
What (pathologically) causes the symptoms of Guillan-Barre syndrome?
Loss of myelin
Dementia, gait instability + urinary incontinence suggests what?
Normal pressure hydrocephalus These symptoms are Adam’s triad (or Hakim’s triad); ‘wet, whacky + wobbly’
What is The Miller Fisher test?
High-volume lumbar puncture (LP) with removal of 30–50 ml of CSF.
Gait and cognitive function are typically tested just before and within 2–3 hours after the LP to assess for signs of symptomatic improvement.
First line treatment of normal pressure hydrocephalus
Shunting is the first-line treatment. The most common type used to treat NPH is ventriculoperitoneal (VP) shunts
Presentation of Cauda Equina Syndrome
- Severe back pain
- Saddle anesthesia ie S3 to S5 dermatomes, including the perineum, external genitalia and anus; or more descriptively, numbness or “pins-and-needles” sensations of the groin and inner thighs
- Bladder and bowel dysfunction, caused by decreased tone of the urinary and anal sphincters.
- Sciatica-type pain on one side or both sides, although pain may be wholly absent
- Weakness of the muscles of the lower legs (often paraplegia)
- Achilles (ankle) reflex absent on both sides.
- Sexual dysfunction
- Absent anal reflex and bulbocavernosus reflex
- Gait disturbance
Typical cause of Cauda Equina Syndrome
Herniated lumbar disc below L2
Neuropathic pain criteria (4)
- Distribution of pain that is neuroanatomically plausible
- Hx suggesting disease or lesion of somatosensory system
- A Dx test confirming a lesion or disease that can explain neuropathic pain
- Neg or pos symptoms confined to the innervation territory of the damaged nervous structure
First line treatments for cluster headaches
The evidence-based acute treatments for cluster headaches are 1. subcutaneous sumatriptan 2. intranasal sumatriptan and zolmitriptan 3. high-flow oxygen via a non-rebreather mask 4. in episodic cluster alone, non-invasive vagus nerve stimulation (nVNS).
Diplopia on upward gaze
Myasthenia Gravis
Myasthenia Gravis is associated with what pathology?
Thymomas
Charcot Marie Tooth mode of inheritance
Autosomal dominant
Classical features of Charcot Marie Tooth syndrome
High foot arches (pes cavus)
Distal muscle wasting causing “inverted champagne bottle legs”
Weakness in the lower legs, particularly loss of ankle dorsiflexion
Weakness in the hands
Reduced tendon reflexes
Reduced muscle tone
Peripheral sensory loss
A neurological disorder associated with genetic anticipation
Huntingtons disease Huntington’s chorea displays something called genetic “anticipation”. Anticipation is a feature of trinucleotide repeat disorders. This is where successive generations have more repeats in the gene, resulting in: Earlier age of onset Increased severity of disease
UMN facial nerve palsy is associated with what pathology? How can you distinguish between UMN and LMN facial nerve palsy?
Usually a stroke UMN - the forehead is spared
Treatment for Bell’s palsy if you present within 72h
Prednisone
Vesicular rash near the ear and LMN facial nerve palsy
Ramsay Hunt Syndrome
Cause of Ramsay Hunt syndrome
Varicella zoster virus
Rx Ramsay Hunt syndrome
Treatment should ideally be initiated within 72 hours. Treatment is with: Prednisolone Aciclovir Patients also require lubricating eye drops.
Benign intentional tremor does what with intentional movement?
Gets worse
Postural headache worse on standing, lying or bending over- think what?
Raised ICP
Sudden onset occipital headache
Subarachnoid
First line Rx trigeminal neuralgia
Carbamazepine
A virus implicated in multiple sclerosis
EBV
CSF findings in multiple sclerosis
Oligoclonal bands
Key features of optic neuritis
Central scotoma. This is an enlarged blind spot.
Pain on eye movement
Impaired colour vision
Relative afferent pupillary defect
Note ON is the presenting feature of MS in 20% of cases and 50% of MS pts will get it.
Typical presentation Guillain Barre syndrome
Symmetrical ascending weakness (starting at the feet and moving up body)
Reduced reflexes
There may be peripheral loss of sensation or neuropathic pain
It may progress to the cranial nerves and cause facial nerve weakness
Bilateral acoustic neuromas almost always indicate what?
Neurofibromatosis II
Inheritance of neurofibromatosis I + II
Autosomal dominant
Diagnostic criteria for neurofibromatosis I
Need 2 of 7:
C – Café-au-lait spots (6 or more) measuring ≥ 5mm in children or ≥ 15mm in adults
R – Relative with NF1
A – Axillary or inguinal freckles
BB – Bony dysplasia such as Bowing of a long bone or sphenoid wing dysplasia
I – Iris hamartomas (Lisch nodules) (2 or more) are yellow brown spots on the iris
N – Neurofibromas (2 or more) or 1 plexiform neurofibroma
G – Glioma of the optic nerve
Complications of NF1
Migraines
Epilepsy
Renal artery stenosis causing hypertension
Learning and behavioural problems (e.g. ADHD)
Scoliosis of the spine
Vision loss (secondary to optic nerve gliomas)
Malignant peripheral nerve sheath tumours
Gastrointestinal stromal tumour (a type of sarcoma)
Brain tumours
Spinal cord tumours with associated neurology (e.g. paraplegia)
Increased risk of cancer (e.g. breast cancer)
Leukaemia
Skin signs of tuberous sclerosis
- Ash leaf spots are depigmented areas of skin shaped like an ash leaf
- Shagreen patches are thickened, dimpled, pigmented patches of skin
- Angiofibromas are small skin coloured or pigmented papules that occur over the nose and cheeks
- Subungual fibromata are fibromas growing from the nail bed. They are usually circular painless lumps that grow slowly and displace the nail
- Cafe-au-lait spots are light brown “coffee and milk” coloured flat pigmented lesions on the skin
- Poliosis is an isolated patch of white hair on the head, eyebrows, eyelashes or beard
CSF findings in GBS
High protein
Periodic synchronous bi- or triphasic sharp wave complexes on EEG
Creutzfeldt-Jacob disease
Classical presentation of CJD
Rapid progressive mental deterioration and myoclonus
First line agents for migraine prophylaxis
Amitryptiline
Venlafaxine
Propanolol
Topiramate
Which AED causes kidney stones?
Topiramate
Trigeminal neuralgia occurs in young people with which disorder?
MS
Treating MS relapses
Relapses can be treated with steroids. NICE recommend methylprednisolone: 500mg orally daily for 5 days 1g intravenously daily for 3–5 days where oral treatment has failed previously or where relapses are severe
A drug to slow the progression of ALS
Riluzole
What is Natazulimab? What has it been associated with?
A synthetic monoclonal antibody used to treat relapsing/ remitting MS.
Associated with progressive multifocal leukoencephalopathy
First line therapy for Grand Mal seizures
Valproic acid
Action of valproic acid
Increases GABA by altering properties of voltage gated sodium channels
Migraine triggers
Caffeine withdrawal
Chocolate
Sleep deprivation
Tyramines (red wine, ripe cheese)
Nitrites (processed meats)
Most common neurological manifestation of vitamin B12 deficiency
Subacute degeneration of the cord
Polyneuropathy + dilated cardiomyopathy
Thiamine deficiency
Effacement of the supra cellar cistern on non-contrast CT is associated with what?
Subarachnoid haemorrhage
Subarachnoid haemorrhage risk factors
Trauma
Berry aneurysm (+polycystic kidney disease)
Female gender
Hypertension
Connective tissue disease (eg Ehlers Danlos)
A major complication of subarachnoid haemorrhage + prophylactic treatment
Cerebral vasospasm Triple H therapy + calcium channel blockers
Diagnostic test for myasthenia gravis
The Tensilon test
Using Edrophonium 10mg
Rx for benign essential tremor (2)
Propranolol (a non-selective beta blocker) Primidone (a barbiturate anti-epileptic medication)
Classical presentation of tuberous sclerosis
classical presentation is a child presenting with epilepsy found to have skin features of tuberous sclerosis
Factors thought to be implicated in multiple sclerosis
Multiple genes Epstein–Barr virus (EBV) Low vitamin D Smoking Obesity
What is Lhermitte’s sign?
Lhermitte’s sign in MS is an electric shock sensation which travels down the spine and into the limbs when flexing the neck.
It indicates disease in the cervical spinal cord in the dorsal column. It is caused by stretching the demyelinated dorsal column.
Diagnosis of multiple sclerosis
MRI scans can demonstrate typical lesions Lumbar puncture can detect “oligoclonal bands” in the cerebrospinal fluid (CSF)
What % of ppl with optic neuritis develop MS?
Around 50% of patients with a single episode of optic neuritis will go on to develop MS over the next 15 years
Management of spasticity in MS
Baclofen, gabapentin and physiotherapy
Biggest source of brain mets
Lung Breast Skin Kidney GI tract
Lisch nodules (iris hamartomas)
Neurofibromatosis
CNIII palsy
Charcot Marie Tooth
Shagreen patch
Tuberous sclerosis
Ash leaf spots
Tuberous sclerosis
Ramsay Hunt Syndrome
Normal pressure hydrocephalus
Entry point for lumbar puncture
L3-L4 or L4-L5
