Neuro Flashcards
What is the presentation of intracranial bleeds?
Sudden onset headache
Seizures
weakness
Vomiting
Reduced consciousness
What are subdural haemorrhages?
Occur between dura mater and arachnoid mater
CT: crescent shape and not limited by suture lines
More common in elderly or alcoholic patients
What are extradural haemorrhages?
Rupture of middle meningeal artery
CT: bi-convex shape and limited by suture lines
E.g. young patient with trauma and ongoing headache, period of improvement then decline
What is a subarachnoid haemorrhage?
Bleeding into the subarachnoid space where CSF is due to ruptured cerebral aneurysm
Thunderclap headache
Associated with cocaine and sickle cell anaemia
What is the management of an intracranial bleed?
Immediate CT head to establish diagnosis
Check FBC and clotting
Admit to specialist stroke unit
What are the tracts affected and presentation of Brown-Sequard syndrome (spinal cord hemisection)
Tracts:
- Lateral corticospinal tract
- dorsal columns
- Lateral spinothalamic tract
Features:
- ipsilateral spastic paresis below lesion
- ipsilateral loss of proprioception and vibration sensation
- Contralateral loss of pain and temp sensation
What are the tracts affected and presentation of subacute degeneration of the spinal cord (Vit B12 and E deficiency) and Friedrich’s ataxia?
Tracts:
- Lateral corticospinal tracts
- Dorsal columns
- Spinocerebellar tracts
Features:
- Bilateral spastic paresis
- Bilateral loss of proprioception and vibration sensation
- Bilateral limb ataxia
Friedrich’s ataxia also has intention tremor
What are the tracts affected and presentation of anterior spinal artery occlusion
- Lateral corticospinal tracts
- Lateral spinothalamic tracts
Features:
- Bilateral spastic paresis
- Bilateral loss of pain and temp sensation
What are the tracts affected and presentation of syringomyelia
Tracts:
- Ventral horns
- Lateral spinothalamic tract
Features:
- Flacid paresis (intrinsic hand muscles)
- Loss of pain and temp sensation
Define TIA
transient neurological dysfunction secondary to ischaemia without infarction.
What is the presentation of a stroke?
Asymmetrical: Sudden weakness of limbs Sudden facial weakness Sudden onset dysphasia Sudden onset visual or sensory loss
What is the management of stroke?
Admit patient to specialist stroke centre
Exclude hypoglycaemia
Immediate CT brain
Aspirin 300mg and continue for 2 weeks
Thrombolysis with alteplase
Thrombectomy (before 24hr)
What is the management of TIA?
Aspirin 300mg daily
Start secondary prevention measures
Seen within 24hr by stroke specialist
What is the gold standard imaging in stroke?
Diffusion-weighted MRI
What is the secondary prevention of stroke?
Clopidogrel 75mg/day
Atorvastatin 80mg but not started immediately
Carotid endarterectomy or stenting
Treat modifiable risk factors
What is vasovagal episodes?
Caused by a problem with the autonomic nervous system. When the vagus nerve receives a strong stimulation, it can stimulate the parasympathetic nervous system. This leads to hypoperfusion of the brain tissue causing patient to faint,
What are the causes of vasovagal syncope?
Primary:
Dehydration
Missed meals
Extended standing in a warm environment
Secondary: Hypoglycaemia Dehydration Anaemia Infection Anaphylaxis Arrhythmias
What is the difference between syncope and seizures?
Syncope:
Return of consciousness shortly after falling
No prolonged post-ictal period
Seizures:
Return of consciousness lasts more than 5 minutes
Prolonged post-ictal period
Describe the presentation of bell’s palsy?
Unilateral lower motor neurone facial nerve palsy:
- forehead affected
- drooping of eyelid
- loss of nasolabial fold
- loss of lacrimation
What is the prognosis of Bell’s palsy?
Majority of patients fully recover over several weeks but may take upto 12 months
1/3 are left with residual weakness
What is the management of Bell’s palsy?
If patient presents within 72 hours, consider prednisolone as either:
50mg for 10 days
60mg for 5 days followed by 5-day reducing regime of 10mg a day
Lubricating eye drops and tape
What is Ramsay-Hunt syndrome? Give the cause, presentation and treatment
Caused by varicella zoster virus.
Presents with unilateral lower motor neurone facial nerve palsy.
Painful vesicular rash in the ear canal, pinna and around the ear. Rash can extend to anterior 2/3 of tongue and hard palate
Treatment should be within 72 hours:
Prednisolone, aciclovir and lubricating eye drops.
What is cerebral palsy?
Permanent neurological problems resulting from damage to the brain at the time of birth. Not progressive.
What are the causes of cerebral palsy?
Antenatal:
Maternal infections
Trauma during pregnancy
Perinatal:
Birth asphyxia
Pre-term birth
Postnatal:
Meningitis
Severe neonatal jaundice
Head injury
What are the types of cerebral palsy?
Spastic (Pyramidal)
Dyskinetic (Extrapiramidal)
Ataxic
Mixed
What is the signs and symptoms of cerebral palsy?
Failure to meet milestones Increased or decreased tone Hand preference below 18mths Problems with coordination, speech and walking Feeding or swallowing problems Learning difficulties Upper motor neurone llesion signs
What is the difference between upper motor neurone and lower motor neurone lesion presentations?
UPN: Muscle bulk preserved Hypretonia Slightly reduced power Brisk reflexes
LMN: Reduced muscle bulk with fasciculation Hypotonia Dramatically reduced power Reduced reflexes
What is the management of cerebral palsy?
Cannot be cured
Physiotherapy and other MDT
Muscle relaxants
Anti-epileptic
Glycopyrronium bromide
What are the symptoms of cluster headaches?
Red, swollen and watering eye Pupil constriction Eyelid drooping Nasal discharge Facial sweating
What are the treatment options for cluster headaches?
ACUTE:
Triptans (e.g. sumatriptan 6mg IM)
High flow oxygen for 15-20mins
PROPHYLAXIS:
Verapamil
Lithium
Prednisolone (2-3wks)
What is multiple sclerosis?
Chronic and progressive condition that involves demyelination of the myelinated neurones in the CNS. Caused by an inflammatory process involving the activation of immune cells against the myelin.
What is the pathophysiology behind multiple sclerosis?
Schwann cells in PNS
Oligodendrocytes in CNS
MS typically only affects CNS (Oligodendrocytes)
What are the causes of Multiple sclerosis?
Multiple genes EBV Low vitamin D Smoking Obesity
What are the signs and symptoms of multiple sclerosis?
Optic neuritis Eye movement abnormalities Focal weakness Focal sensory symptoms Ataxia
What is relapsing-remitting MS?
Most common pattern at initial diagnosis.
Active: new symptoms are developing
Not active: no new symptoms
Worsening: overall worsening of disability over time
Not worsening: no worsening over time
What is secondary progressive MS?
Where there was relapsing-remitting disease at first but now there is progressive worsening of symptoms with incomplete remissions
What is primary progressive MS>
Where there is a worsening of disease and neurological symptoms from the point of diagnosis without initial relapses and remissions
What is the diagnosis of MS?
Made by neurologist based on clinical picture and symptoms suggesting lesions that change location over time.
Symptoms have to be progressive over 1 year period
What are the investigations in MS?
MRI scan with contrast
LP shows oligoclonal bands in CSF
CT for tinitus and other hearing problems
What is the presentation of optic neuritis?
Unilateral reduced vision developing over hours to days
Central scotoma
Pain on eye movements
Impaired colour vision
Relative afferent pupillary defect
What is the treatment for MS?
MDT
Methylprednisolone for relapses 500mg orally daily for 5 days
Symptomatic treatments
What is motor neurone disease?
Umbrella term for progressive, ultimately fatal condition where motor neurones stop functioning but sensory neurones are spared. E.g: ALS Progressive bulbar palsy Progressive muscular atrophy Primary lateral sclerosis
What is the presentation of motor neurone disease?
Late middle aged patient Insidious progressive weakness of muscles Weakness first noticed in upper limbs Increased fatigue when exercising Clumsiness Dysarthria
What is the diagnosis of motor neurone disease?
Clinical presentation and excluding other conditions
What is the management of motor neurone disease?
Riluzole can slow progression in ALS
Edaravone (only in US)
Non invasive ventilation
What is parkinson’s disease?
Progressive reduction of dopamine in the basal ganglia leading to disorders of movements. Asymmetrical symptoms with one side affected more than the other.
Triad:
Resting tremor
Rigidity
Bradyinesia
What is the diagnosis of Parkinson’s disease?
Clinically based on symptoms and examinations by a speciailst
What is the management of Parkinson’s disease?
No cure
Levodopa and bensarazide
or Levodopa and carbidopa
Dopamine agonists e.g. bromocryptine, pergolide and cabergoline
Monamine oxidase B-inhibitor. E.g. selegiline and rasagiline
What are the side effects of dopamine?
Dyskinesias. E.g.:
Dystonia, chorea, athetosis
What are the treatments for neuropathic pain?
- Amitriptyline
- Duloxetine
- Gabapentin
- Pregabalin
What is the treatment for trigeminal neuralgia?
Carbamazepine
If that doesn’t work then refer to specialist
Which cancers metastasise to the brain?
Lung
Breast
Renal cell carcinoma
Melanoma
What are the Gliomas and the different types?
Tumours of the glial cells
Astrocytoma (most common)
Oligodendroglioma
Ependymoma
What are meningiomas?
Tumours growing from the cells of the meninges. Usually benign however can lead to raised ICP
What are pituitary tumours?
Tend to be benign but can grow large enough to press on optic chiasm causing bitemporal hemianopia.
Can also cause hypopituitarism leading to: acromegaly hyperprolactinaemia cushing's disease thyrotoxicosis
What is an acoustic neuroma?
Also known as vestibular schwannoma
Tumours of the schwann cells surrounding the auditory nerve that innervates the inner ear.
They occur around cerebellopontine anglle
Classic symptoms are: hearing loss, tinnitus and balance problems
What are the features of a benign essential tremor?
Fine tremor Symmetrical More prominent on voluntary movement Worse when tired, stressed or after caffeine Improved by alcohol Absent during sleep
What medications can improve essential tremor?
Propranolol
Primidone
What is Huntington’s chorea?
Autosomal dominant genetic condition that causes progressive deterioration in the nervous system.
Trinucleotide repeat disorder that involved mutation in HTT gene on chromosome 4
What is genetic anticipation?
Feature of trinucleotide repeat disorders where successive generations have more repeats in the gene resulting in:
Earlier age of onset
Increased severity of disease
What is the presentation of Huntington’s Chorea?
Insidious progressive worsening of symptoms. Typically begins with cognitive, psychiatric or mood problems. Followed by:
Chorea
eye movement disorders
Speech difficulties
Swallowing difficulties
What is the diagnosis of huntington’s chorea?
Genetic testing
What is the management of huntington’s?
Symptomatic treatment
What is myaesthenia graves and what is it linked with having?
Autoimmune condition that causes muscle weakness that gets progressively worse with activity and improves with rest
Women under 40 and med over 60
Linked with having a thymoma
What is the pathophysiology of myaesthesia graves?
Acetylcholine receptor antibodies created by the immune system
Antibodies again MuSK
Antibodies against LRP4
What is the presentation of myaesthenia graves/
Diplopia Ptosis Weakness in facial movements Difficulty with swallowing Fatigue in jaw when chewing Slurred speech Progressive weakness with repetitive movements
What is the diagnosis of myaesthenia graves?
Testing for relevant antibodies:
ACh-R antibodies
MuSK antibodies
LRP4 antibodies
CT or MRI of the thymus to look for thymoma
Edrophonium test
What is the management of myaesthenia graves?
Reversible acetylcholinesterase inhibitors (pyridostigmine or neostrigmine)
Immunosuppression
Thymectomy
Monoclonal antibodies (Rituximab, Eculizumab)
What is cauda equina syndrome?
Rare but serious condition in which lumbosacral nerve roots that extend below the spinal cord are compressed
What are the possible presenting features of cauda equina syndrome?
Low back pain Bilateral sciatica Reduced sensation/pins and needles in perianal region Decreased anal tone Urinary dysfunction
What is the investigation and management of cauda equina syndrome?
Urgent MRI
Surgical decompression
What are the associations to tension headaches?
Stress Depression Alcohol Skipping meals Dehydration
What is the presentation of trigeminal neuralgia?
Intense facial pain that comes on spontaneously and last between seconds to hours.
Feels like electric shocks
Attacks worsen over time
What is the most common cause of encephalitis?
HSV 1 in children
HSV 2 in neonates
What is the presentation of encephalitis?
Altered consciousness Altered cognition unusual behaviour Acute onset of focal neurological symptoms Acute onset of focal seizures Fever
What is the diagnosis of encephalitis?
LP (or CT if contraindicated) MRI EEG Swabs HIV
What is the management of encephalitis?
IV aciclovir treats HSV and VZV
IV ganciclovir treats CMV
What are the most common bones to be affected by osteosarcoma?
Femur
Tibia
Humerus
What is the presentation of an osteosarcoma?
Persistent bone pain Worse at night time Bone swelling Palpable mass Restricted joint movements
What is the diagnosis of an osteosarcoma?
X-ray within 48hrs shows sun-burst appearance
Blood tests: high ALP
What is the management of a sarcoma?
Surgical resection of lesion with limb amputation and adjuvant chemo
Where does Ewing’s sarcoma typically affect?
Pelvis
Femur
Shoulder girdle
Ribs
What is hydrocephalus?
CSF build up within the brain and spinal cord either due to overproduction or a problem with draining and absorbing (arachnoid granulations)
What are the causes of hydrocephalus?
Most common: aqueductal stenosis. The cerebral aqueduct that connects the 3rd and 4th ventricle is stenosed so blocks normal flow of CSF
Other causes: Arachnoid cysts Arnold-chiari malformations Chromosomal abnormalities Congenital malformaitons
What is the presentation of hydrocephalus?
Babies: Bulging anterior fontanelle Poor feeding and vomiting Poor tone Sleepiness
What is the treatment for hydrocephalus/
Placing a ventriculoperitoneal shunt that drains CSF from ventricles into peritoneal cavity is used.
What is idiopathic intracranial hypertension?
Condition classically seen in young overweight females
What are the risk factors for idiopathic intracranial hypertension?
Obesity
Female sex
Pregnancy
Drugs (COCP, steroids, tetracyclines, Vit A and lithium)
What is the presentation of idiopathic intracranial hypertension?
Headache Blurred vision Papilloedema Enlarged blind spot 6th nerve palsy
What is the management of idiopathic intracranial hypertension?
Weight loss Diuretics (acetazolamide) Topiramate LP Surgery
What is the presentation of a migraine?
Pounding or throbbing in nature Usually unilateral Photophobia Phonophobia With/without aura N+V
What is a hemiplegic migraine?
Mimic stroke:
Sudden or gradual onset hemiplegia, ataxia and changes in consciousness
plus normal migraine symptoms
What is the acute management of migraines?
Paracetamol
Triptans
NSAIDs
Antiemetics
What is the prophylaxis for migraines?
Propranolol
Topiramate
Amitriptyline
What is charcot-marie-tooth disease?
Inherited disease that affects peripheral motor and sensory nerves. (usually autosomal dominant)
What is the presentation of charcot-marie-tooth?
High foot arches Distal muscle wasting Weakness in lower legs - loss of ankle dorsiflexion Weakness in hands Reduced tendon reflexes Reduced muscle tone Peripheral sensory loss
What are the causes of peripheral neuropathy?
Alcohol B12 deficiency Cancer and Chronic kidney disease Diabetes and Drugs (isoniazide, amiodarone and cisplatin) Every vasculitis
ABCDE
What is the management of charcot-marie-tooth?
Supportive
What is gullain-barre syndrome?
Acute paralytic polyneuropathy that affects the peripheral nervous system. Triggered by an infection i.e. campylobactor jejuni, CMV and EBV
What is the presentation of gullain-barre syndrome?
Symmetrical ascending weakness (starting at feet)
Reduced reflexes
Peripheral loss of sensation or neuropathic pain
May progress to cranial nerves and cause facial nerve weakness
What is the diagnosis of guillain-barre syndrome?
Brighton criteria
Nerve conduction studies
LP for high CSF
What is the management of Guillian-Barre syndrome?
IV immunoglobulins
Plasma exchange
Supportive care
VTE prophylaxis
What is neurofibromatosis?
Genetic condition that causes nerve tumours (neuromas) to develop throughout nervous system.
Type 1 is more common that type 2
What causes neurofibromatosis type 1?
NF1 gene is found on chromosome 17.
Codes for a tumour suppressor protein.
Autosomal dominant
What is the diagnostic criteria for neurofibromatosis type 1?
At least 2 of the 7 to indicate diagnosis. CRABBING:
Cafe-au-lait spots
Relative with NF1
Axillary or inguinal freckles
Bony dysplasia such as Bowing of a long bone
Iris hamartomas (yellow brown spots on iris)
Neurofibromas
Glioma of optic nerve
What are the investigations and management of neurofibromatosis type 1?
None needed for diagnosis but can do genetic testing, Xrays and other imaging to confirm or if unsure
No treatment for underlying disease - supportive
What is the cause of neurofibromatosis type 2?
NF2 gene found on chromosome 22 and codes for protein called merlin which is a tumour suppressor protein important for schwann cells.
Autosomal dominant
What is the presentation of neurofibromatosis type 2?
Acoustic neuromas - (hearing loss, tinnitus, balance problems)
What is the management of neurofibromatosis type 2?
Surgery to resect tumours
What is Wenicke’s encephalopathy?
Neuropsychiatric disorder caused by thiamine deficiency most commonly seen in alcoholics.
What is the presentation of Wernicke’s encephalopathy>
Opthalmoplegia/nystagmus
Ataxia
Confusion
What is the investigation and treatment of Wernicke’s encephalopathy?
Investigations:
Decreased red cell transketolase
MRI
Treatment is with urgent replacement of thiamine (B1)
What are some features of fronto-temporal dementia?
Lack of attention to personal hygiene Repetitive behaviour Hoarding/criminal behaviours New eating habits Lack of empathy Change in social behaviours
What is the treatment for subdural haemorrhages?
Burr hole drainage
What medication in alzheimers disease to help with sleep?
Trazadone
Which nerves control eye muscles?
Optic nerve does all except
SO4 and LR6
Superior oblique - Trochlear
Lateral rectus - Abducens
What is Creutzfelt-Jakob disease?
Rapidly progressive neurological condition caused by prion proteins.
What are the features of Creutzfelt-Jakob disease?
Dementia (rapid onset)
Myoclonus
What are the investigations in Creutzfelt-Jakob disease?
CSF normal
EEG: biphasic, high amplitude sharp waves
MRI: hyperintense signals in basal ganglia and thalamus
What is the presentation of coronary artery dissection?
Horner’s syndrome
Difference between Lambert eaton and Myasthenia gravis?
MG: fatigue with effort
LE: Easier with effort
What is first line for micro and amcroprolactinomas?
Cabergoline
What is the triad of presentation for cerebellar stroke?
Headache
Nausea/Vomiting
Ataxia
Which pathway blockage causes galactorrhoea?
Tuberoinfundibular pathway
When can you drive after a TIA or stroke?
4 weeks for cars
1 year for Lorry’s
Which test is abnormal during delirium regardless of the cause?
EEG shows diffuse slowing
Difference between vestibular migraine and vestibular neuronitis?
Migraine is recurrent whereas neuronitis is a single episode
Which type of dementia is most attributed to hallucinations?
Lewy body’s
Which heart condition does subarachnoid haemorrhage lead to?
Torsades de pointes
