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More neurological conditions Flashcards

1
Q

what are the major categories of neurological disease and how can you differentiate them

A
  • infectious
  • traumatic
  • congenital/genetic
  • vascular
  • degenerative
  • toxic
  • metabolic (acquired/inherited)
  • neoplastic
  • inflammatory/immune

Degenerative disease – slow - yrs

Vascular and trauma are fast

Inflammatory/autoimmune/neoplastic – subacute – mo

demographic

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2
Q

where is the problem if you have UMN signs

A

From cortex to subcortex to pyramidal decussation to spinal cord

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3
Q

distinguishing factors for facial weakness

A

UMN = forehead sparing - bihemispheric innervation of both nuclei for the frontalis muscle

Bell’s - eye cant open properly, white of eye seen when try and open it

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4
Q

where does the facial nerve sit

A

in the pons

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5
Q

summarise the visual pathway

A

doesn’t go through the brainstem, it goes above it

optic nerve -> optic chiasm -> radiation -> occipital lobe

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6
Q
A

Area of hypodensity = infarct

Middle cerebral artery

L middle cerebral artery territory infarct.

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7
Q

aphasia

A

expressive - cant produce the word they want to produce.

Receptive – cant understand what other people are saying to them ie cant follow commands

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8
Q

dx

A

MND

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9
Q

what is MND

A

degenerative condition - anterior horn cells and upper motor neurons in spinal cord = mixed UMN and LMN signs

cause unknown

10% familial

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10
Q

epidemiology of MND

A

inciddence 2-4/100000

50-70yrs (can be any adult age)

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11
Q

presentation of MND

A

insidious onset (nearly always missed)

motor nerves only affected - UMN and LMN (can be just one initially, other features develop with time)

progressive

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12
Q

amyotrophic lateral sclerosis

A

typical presentation of MND (60%)

one limb initially - foot drop, clumsy weak hand

some wasting

fasiculations, brisk reflexes, extensor plantar responses

no sensory signs

progression over weeks/mo

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13
Q

bulbar MND

A

dysarthria and dysphagia - 30% of cases

bulbar and pseudobulbar sx

dysarthria -> tongue wasting

fasiculation

brisk jaw jerk

weakness of neck muscles

may be limb sx

progression more rapid than ALS

Px = 2yrs until death

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14
Q

where are the cranial nerves

A

At top of spinal cord have the medulla (bulbar) – in here have the CN 12 11 10 and 9

Pons – 5 7 6 8

Midbrain – 3 and 4

Above that – optic nerve and visual pathway and olfactory pathway.

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15
Q

difference between bulbar and pseudobulbar

A

bulbar - function in mouth and oropharynx eg dysarthria/dysphagia, absent gag reflex, tongue fasiculations, absence of jaw jerk

pseudobulbar - UMN bulber problem = dysarthria/dysphagia spastic tongue, exaggerated gag reflex

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16
Q

other MND presentations

A

primary lateral sclerosis - 5% - pure UMN onset

progressive muscular atrophy - 5% - pure LMN onset - flail limb appearance

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17
Q

Dx of MND

A

clinical - look for fasiculations

EMG/NCS - chronic nerve root denervation

imaging (MRI) - exlude other causes eg cervical/lumbar degenerative changes and myelopathy - cervical/thoracic/lumbar spine (brain sometimes)

exclude:

benign fasiculation syndrome

bulbar - cerebrovascular disease

multifocal motor neuropathy

hereditory spastic paraplegia

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18
Q

Mx of MND

A

no cure

riluzole - glutamate antagonist - extend LE (3-5mo)

palliative

nutrition

soft diet - excessive secretions/salvation

opiates/benzodiazepines

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19
Q

dx

A

MS

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20
Q

definition of MS

A

evidence of damage to the CNS that is disseminated in time and space

damage occurs at different dates and to different parts of the CNS

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21
Q

pathophysiology of MS

A

immune mediated

  • T cell trigger attacks on myelin in CNS (inc optic nerve)
  • scarring caused by inflammatory attacks at multiple sites in CNS
  • plaques visible on MRI and autopsy

genetic predisposition with environmental triggers

  • 20% MS sufferes have blood relative with MS
  • low vit D, ENBV, smoking, extremes of latitude, obesity in adolescence
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22
Q

MS sx and signs

A

vary between people

  • fatigue
  • visual problem
  • bladder and/or bowel dysfunction
  • sexual dysfunction
  • emotional disturbances - depression, mood swings
  • cognitive difficulties - memory, attention, processing
  • sensory changes - tingling, numbness
  • pain - neurological, musculoskeletal
  • spaticity
  • gait, balance, and coordination problems
  • speech/swallowing problems
  • tremor (if cerebellar effected)
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23
Q

presentation of MS

A

Some presentations short lived – weeks/mo – vision loss/numbness – patient doesn’t report, battle between immune response and recovery.

Some get single episode of inflammation and some more progressive

loss of vision in 1 eye, with painful eye movements (optic neuritis)

double vision - brainstem syndromes

sensory disturbance or weakness, spastic parapesis, weakness and gait, increased tone and clonus, hyperreflexia -spinal cord lesion, transverse myelitis

balance related problems or clumsiness - cerebellar

altered sensation travelling down back when bend neck forward - Lhermitte’s syndrome

24
Q

Dx of MS

A

clinical

PMHx and Ex

evidence of damage disseminated in time and space

McDonalds critera - more reliant on MRI appearances of plaques

  • MRI - hyperdense plaques - Pathognomonic in corpus collosum
  • LP - in CSF see abnormal Ig present, or immune response in the CSF
  • visual evoke potentials - optic nerve slowed down by loss of myelin
25
clinical course of MS
in young adults \<40yrs 4 patterns of disease: * relapsing remitting - most common, gets better but return to worse baseline * primary progressive - worse Px * secondary progresive * progressive-relapsing remitting MS
26
Mx of MS
neurology annual review MDT look for incection in relapse - IV or PO steroids disease modifying drugs eg B interferon when not in relapse as prophylaxis
27
dx of parkinson's
clinical
28
summarise parkinson's
idiopathic substantia nigra degeneration -\> dopamine deficiency in striatum/basal ganglia -\> motor sx = abnormality of movement, not loss basal ganglia fasicilitates movement normally - extrapyramidal tract dopaminergic therapy relieves motor sx
29
3 cardinal sx of parkinson's
tremor - high frequency **resting tremor** (5movements/sec) - pinrolling (finger and thumb), or supination-pronation rigidity - different from increase in tone/spasticity in UMN. In spasticity – tone more notable in particular dirn. Parkinsons – **leadpipe rigidity – equal in both directions.** *Cogwheel rigidity – tremor superimposed on the tone.* **Bradykinesia** – don’t blink very often, paucity of movement, gait. Get them to tap fingers and see if it is slow
30
features of parkinsons
Freeze when mobilise Shuffling hait Poor arm swing on one side Poor posture Problem swallowing postural hypotension, bowel and urinary function Hypophonia Need 2/3 of bradykinesia, tremor, rigidity
31
causes of parkinsonism
parkinson disease - idiopathic or genetic parkinson-plus degenerations drug induced parkinsonism vascular parkinsonism brain trauma CNS infection
32
parkinson-plus degenerations
progressive supranuclear palsy - impaired gaze (cant look down), balance and dysarthria multiple system atrophy - autonomic issues, urinary problems and orthostatic hypotension
33
drug induced parkinsonism
anti-dopaminergics drugs that reduce dopamine transmission - antipsychotics/antiemetics: * resperidone * haloperiodol * metoclopramide
34
ways to differentiate Parkinson's disease from other causes of parkinsonism
asymmetrical findings no atypical features - eye fine, automomic shlouldnt be the predominant sx not on/had neuroleptics responds to L Dopa
35
Mx of Parkinson's disease
L-dopa (with carbidopa) - most effective and best tolerated dopamine agonists - ropinirole, pramiplexole MAO-B inhibitors, anti-cholinergics, amantadine have modest benefits drugs are for sx relief, not neuroprotective/neurotoxic response to L dopa is best diagnostic test for PD
36
L-Dopa SE
non-motor: * nausea * orthostasis * sleepiness * hallucinations dyskinesias
37
Mx of PD as disease progresses
more motor complications as disease progresses - including dyskinesias and on-off fluctuations drug resistant motor sx - impaired balance with falls non-motor sx - dementia and hallucinations
38
**hemiplegic** ## Footnote typical of pyramidal weakness from stroke or UMN problem Corticospinal tract affected – reflex arc exaggerated and out of control – spasticity in pyramidal pattern Everything flexed in upper limb and **extend in lower limb** **swing leg out to prevent the foot drop** Hemiplegic stroke – extended position and arcs outward
39
highstepping gait
foot drop - lift foot high so dont rip
40
stomping gait
sensory problem – have to stomp so you get vibration – peripheral neuropathy
41
Hoffman's sign
42
antalagic gait
painful leg - compensate by lifting leg up a bit
43
L occipital lobe = R sided homonymous hemianopia
44
sx to check for with visual field defects
clarify field of vision loss in transient sx any positove phenomona any associated sx
45
dx
MS – internuclear ophthalmoplegia (INO) – brainstem and medial longitudinal fasiculus – associated with MS. R eye didn’t adduct, L eye looked like it had nystagmus. Relate to the midbrain and pons – plaque occur in MS
46
BPPV Very short lived period of vertigo, related with head movement. Manouvre – Dix-Hallpike gold standard test Epley manouvre to make them feel better
47
fatiguability Myasthenia gravis Eye becomes misaligned with other eye = squint – fatiguability Diplopia in evening And speech in consultation
48
summarise myasthenia gravis
autoimmune synapto-pathy affecting NMJ of skeletal muscle affecys ocular, face and swallowing sx and signs worse with use - fatiguability NCS and Ab testing - AChR and MUSK Ab test CXR - thyoma, ice test
49
Mx for myasthenia gravis
ACh inhibitors immunosuppresssion plasmapharesis and IVIG surgery? thymectomy
50
R middle cerebral artery stroke
51
**Cerebral met** Think about the mode of onset SAH – all or nothing event – thunderclap headache TIA – resolves in \<24hrs Cerebral infarct – wouldn't progress – over mo language would get better.
52
R brainstem: ## Footnote Not cervical spine because face problem – and tracks above this Not occipital – because would be vision of R of both eyes R motor cortex – L sided face weakness Have crossed signs here – face not equating to the body Very typical for brainstem - Nucleus on one side, then pyramidal decussation
53
spinal cord
54
T10
55
GBS Ascending motor radiculopathy Peripheral = areflexia
56
Contact the stroke team – do scan where pt get treatment
57
L cerebellum – cerebellum is ipsilateral innervation – L sided coordination.

DPD (38 decks)

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