NEURO Flashcards
1
Q
Peak incidence in 20-40s, common in pregnancy
acute, unilateral idiopathic facial paralysis
usually have preceding pain/tinging around the post-auricular region
forehead affected
altered taste
dry eyes
hyperacusis (loud sounds)
A
bell’s palsy
2
Q
management of bell’s palsy
A
present with 72hrs = oral prednisolone
can provide eye patch/symptomatic relief
if no improvement in 3 weeks = ENT referral
3
Q
which cranial nerve is affected in bell’s palsy
A
facial nerve - CN 7
4
Q
initial pain in bag or legs
progressive, symmetrical weakness in all of the limbs
classically ascending from (legs upwards)
reduced/absence reflexes
hx of gastroenteritis
CN involvement sometimes or urinary retention
A
guillian-barre syndrome
5
Q
what Ix done in guillian barre syndrome?
A
LP = elevated protein
nerve conduction studies
6
Q
management of guillian barre syndrome
A
admit to neuro critical care
IVIG or plasmaphresis
pain control using gabapentin or opiates
7
Q
motor sensory and optic symptoms seperated by time and space
tingling, paresthesia and numbness
optic neuritis - worse on eye movement
balance difficulties
commonly in females 20-40yrs
A
Multiple sclerosis
8
Q
Ix for MS
A
MRI = multiple areas of focal demyelination in the brain and plaques LP = oligoclonal bands
9
Q
management of acute MS attack
A
high dose methylprednisolone for 5 days
10
Q
management of MS
A
b-interferon injections
glatiramer acetate, natalizumab and fingolimoid
supportive measures
11
Q
brisk tendon reflexes and hypertonia
A
MS spasticity
12
Q
MS spasticity management
A
baclofen and gabapentin
13
Q
more insidious progression of limb weakness, in the symmetrical ascending pattern in all limbs
A
Chronic inflammatory demyelinating polyneuropathy (CIDP)
14
Q
management of CIDP
A
long term immunosuppression
15
Q
burning feet
tingling and numbness
feet affected first - but all peripheries affected
stocking/glove distribution
A
diabetic peripheral neuropathy
16
Q
Ix for diabetic neuropathy
A
nerve conduction studies
17
Q
management of diabetic neuropathy
A
anticonvulsants = gabapentin/pregabalin
antidepressants = SNRI/Tricyclics
tramadol/weak opioid - but addiction risk
lidocaine patches/topical cream
supplements and therapies
exercise, weigth loss and diet
18
Q
postural tremor - worse outstretched
improved by alcohol and rest
impaired use of spoon/fork
A
essential tremor
19
Q
management of essential tremor
A
propranolol first line
can use primidone
20
Q
pill-rolling tremor cogwheeling rigidity bradykinesia depression/dementia micrographia shuffling gait - leads to balance difficulties
A
parkinson’s disease
21
Q
any Ix for PD?
A
usually clinical diagnosis
SPECT can be used if hard to distinguish from essential tremor
22
Q
management of PD
A
First line = levodopa,
dopamine agonists = bromocriptine and ropinirole
MOA-B inhibitors = selegine
COMT inhibitors = entacapone
cycling meds as can build tolerance
severe cases - surgical = deep brain stimulation
23
Q
postural instability and falls
impairment of vertical gaze
bradykinesia
cognitive impairment
A
progressive supranuclear palsy
24
Q
parkinsonism
autonomic disturbance = erectile dysfunction and postural hypotension
A
multisystem atrophy
25
progressive cognitive impairment/fluctuating cognition, visual hallucinations
lewy body dementia
26
management of lewy body dementia
acetylcholinesterase inhibitors = rivastigmine and donepezil
27
35 years +
chorea = involuntary movements
dystonia
saccadic eye movements
huntington's disease
28
what will HD pts need investigated?
genetic testing for CAG trinucleotide expansion
29
management of huntingtons
previously incurable, new arising tx
30
rapid onset of dementia
myoclonus/twitching
all areas of the neurological system affected = gait, sensation, memory, strength, speech and visual losses
in younger pts may have anxiety, withdrawal, dysphonia
Creutzfeldt-jakob disease
31
Creutzfeldt-jakob disease cause
prion proteins
32
Creutzfeldt-jakob disease Ix
CSF normal, hyperintense signals in MRI
33
common in females
unilateral severe throbbing heachache - up to 72hrs
nausea and vomiting
photosensitivity
phonophobia
can be precipitated by aura (usually visual)
can be menstrual related
migraine
34
what is needed for diagnosis
5 attacks of the symptoms
35
management for migraines
first line = oral triptan & NSAIDs - nasal triptan in younger patients
metoclopramide + propranolol = preferred in child bearing age / first not tolerated
menstrual migraine = frovatriptan or zolmitriptan
36
headache = tight-band around the head/pressure
episodic
few other associated symptoms
tension headache
37
management of tension headaches
first line = aspirin, paracetamol, NSAIDs
prophylaxis = acupuncture/low dose amitriptyline
38
headache with intense sharp pain around an eye
unilateral redness, lacrimation and lid swelling around affected eye
rhinorrhea
restless patient
same time each day, can feel it coming on
cluster headache
39
management of cluster headache
acute = 100% oxygen and SC triptan
prophylaxis = verapamil (bridging prednisolone when initiating)
40
```
loss of consciousness
nausea/vomiting
confusion
smell of alcohol
difficulty walking
```
may have injured head via high-impact trauma
otherwise may present more insidiously
subdural haemorrhage
41
investigations for SDH
CT head = crescent shaped feathered fluid, midline shift/mass effect
42
management of SDH
neurosurgical intervention = decompressive craniotomy or burr holes
43
```
caused by trauma to the side of the head - not necessarily high impact trauma
LOC
focal neurological deficit
tympanic tap
lucid interval after trauma
```
epidural haemorrhage
44
which artery is affected in EDH
middle meningeal artery
45
investigations for EDH
CT - biconcave collection of blood (suture view)
46
management for EDH
craniotomy and evacuation haematoma
47
Headache: typically sudden-onset/thunderclap, severe and occipital
Nausea and vomiting
Meningism (photophobia, neck stiffness)
Coma
Seizures
Sudden death
ECG changes including ST elevation may be seen
subarachnoid haemorrhage
48
Ix for SAH
CT = hyperdensitiy/brighter in the basal cisterns, sulci
| LP within 12hrs = xanthochromia + raised opening pressure
49
management of SAH
immediate neurosurgery referral - usually treated with coil
| nimodipine 21days given to prevent vasospasms
50
main cause of SAH
intracranial aneurysms/ saccular ‘berry’ aneurysms)
| linked to Polycystic kidney and Ehler-Danlos
51
```
headaches
seizures
impaired consciousness/confusion
CN lesions = unilateral deafness, diplopia, pulsatile tinnitus
focal neuro signs
papiloedema
```
cavernous sinus thrombosis
52
Ix for cavernous sinus thrombosis
CT/MRI venograms
53
management cavernous venous thrombosis
heparin/warfarin
54
```
headaches - similar to raised ICP
seizures
impaired consciousness/confusion
CN lesions = unilateral deafness, diplopia, pulsatile tinnitus
focal neuro signs
```
venous sinus thrombosis
55
```
muscle fatigue after repetition of movements
facial weakness
proximal arm weakness
ptosis
diplopia
```
myasthenia gravis
56
Ix for MG?
electromyography and serologic testing for Ach antibodies
57
management for MG?
1. long acting acetylcholinesterase inhibitors - pyridostigmine and mestinon
2. prednisolone and azathioprine/cyclosporin
sometimes thymectomy (remove thymus)
58
all-over muscle weakness that may cause double vision or a wobbly walk.
respiratory depression - breathing and talking difficulties- subcostal recession
commonly due to use of B-blocker
MG crisis
59
MG crisis management
IVIG + plasmapheresis
60
abnormal tone in early infancy
delayed motor milestones
abnormal gait
feeding difficulties
cerebral palsy
61
management of cerebral palsy
oral diazepam, baclofen and botulinum toxin A = treat spasticity
anticonvulsants
analgesia
62
transient loss of consciousness, rapid onset
short duration
spontaneous complete recovery
syncope
63
investigations needed for syncope
ECG = check, prolonged QT
glucose level
electrolytes, FBC
64
causes of syncope
reflex/vasovagal = can be triggered from emotion/pain/stress or due to coughing/urinating
orthostatic = volume depletion, autonomic failure, drugs,
cardiac = arrhythmias or MI, PE
65
management of syncope
treat if underlying cause identified
optimise glucose + hydration
review medications
close follow up
66
progressive headaches
signs of raised ICP = N/V, headache worse on lying down
aggravated by valsalva
brain/CNS tumour
67
CNS/brain tumour Ix
MRI scan
68
management of CNS/brain tumour
usually surgery (reduces ICP even if not fully resectable)
69
global functional alteration of mental status
changes to memory,
changes to mood
difficulties thinking
acute encephalitis
70
confusion, memory loss or mood changes
| repeated blows to the head/ repeated concussions
chronic encephalitis
71
management of chronic encephalitis
supportive = helmets, avoid risky activities, allowing time for full recovery from concussion
72
```
patients present with weakness in arms or legs
usually asymmetric
weakness of facial muscles - difficulty speaking, swallowing, chewing or coughing
fasiculations/twitching
stiffness
weight loss
muscle atrophy
worsening fatigue
```
Amyotrophic lateral sclerosis
73
Amyotrophic lateral sclerosis investigations needed?
usually clinical
| nerve conduction studies can be done to exclude neuropathy
74
management of ALS?
riluzole/rilutek
symptomatic tx
PT, OT, speech+language therapy
75
pain/pins and needles in thumb, index, middle finger
unusually the symptoms may 'ascend' proximally
patient shakes his hand to obtain relief
symptoms classically at night
muscle wasting at thenar eminence
+ve tinels and phalen's test
carpal tunnel syndrome
76
investigations for carpal tunnel syndrom
electrophysiology - prolongs APs
77
management of carpal tunnel syndrome
corticosteroid injection
wrist splints at night
surgical decompression
78
which nerve is affected in wrist drop
radial nerve
79
which nerve is affected in foot drop
```
peroneal nerve (L4, L5, S1, S2)
sometimes L5 radiculopathy results in foot drop
```
80
a single seizure lasting >5 minutes,
OR
>= 2 seizures within a 5-minute period without the person returning to normal between them
status epilepticus
| medical emergency - hypoxic state
81
management of status epilepticus
ABC = airway adjunct, oxygen, check blood glucose
glucose if BM low and thiamine & Mg2+ if alcoholic
phenytoin or phenoarbital infusion
first line = benzodiazepines = diazepam/lorazepam
can repeat once after 10-20mins
no response in 45mins = general anesthesia
82
acute treatment of seizures
benzodiazepine first line = lorazepam/diazepam
83
recurrent seizures
epilepsy
84
Ix after first seizure
electroencephalogram (EEG) and neuroimaging (usually a MRI).
85
long term epilepsy management
generalised seizure = sodium valproate
focal seizures = carbamazepine
other tx options include = lamotrigine, levetiracetam
86
seizure with isolated motor symptoms which may spread across one side of the body
may have some sensory changes
simple partial seizure
87
seizure where patient has aura (nausea, fear olfactory hallucinations) followed by impaired responsiveness - stereotyped motor movements
complex partial seizure
88
```
progressive memory loss despite alertness
inability to solve problems
language difficulties
wandering/inattention
personality changes
symptoms worse at night/sundowning
```
alzheimer's disease
89
Diagnosis of alzheimer's
usually clinical
| Neuropsychiatric testing useful
90
widespread cerebral atrophy
| neurofibrillary tangles
alzheimer's disease
91
management of alzheimer's
first line = acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine)
second line = memantine (an NMDA receptor antagonist)
other mx options include:
- activities promoting wellbeing
- CBT
- highly structured routines
92
```
motor weakness
speech problems (dysphasia)
swallowing problems
visual field defects (homonymous hemianopia)
balance problems
>24hrs
```
Stroke
93
what indicates a haemorrhagic stroke ?
decrease in the level of consciousness:
headache is also much more common
nausea and vomiting is also common
seizures
94
assessment/Ix of stroke
FAST
ROSIER score - exclude hypoglycaemia first! = A stroke is likely if > 0.
non contrast CT = first line radiological investigation for suspected stroke
95
management of stroke
Acute ischaemic stroke
Thrombolysis with should only be given if:
it is administered within 4.5 hours of onset of stroke symptoms
make sure haemorrhage has been definitively excluded
secondary prevention
clopidogrel
if contraindicated/not tolerated = aspirin plus MR dipyridamole
96
```
Unilateral weakness or sensory loss.
Dysphasia.
Ataxia, vertigo, or incoordination.
Syncope.
Sudden transient loss of vision in one eye (amaurosis fugax).
Homonymous hemianopia.
Cranial nerve defects.
<24hrs
```
TIA
97
management of TIA
Aspirin 300mg and refer for specialist assessment
further management/ prevention
clopidogrel
if contraindicated/not tolerated = aspirin plus MR dipyridamole
98
```
headache
vomiting
reduced levels of consciousness
papilloedema
Cushing's triad = widening pulse pressure + bradycardia + irregular breathing
```
raised ICP/pseudotumor cerebri
99
investigate raised ICP/pseudotumor cerebri
CT
| LP - opening pressure
100
management of raised ICP/pseudotumor cerebri
head elevation to 30º
IV mannitol may be used as an osmotic diuretic
controlled hyperventilation
removal of CNS - shunting/serial LPs
if due to tumour = Na+ restriction -> Carbonic anhydrase inhibitor (such as acetazolamide) to decrease rate of production of CSF
Diuretics are second line therapy
101
```
headache
jaw claudication
visual disturbances
= amaurosis fugax
blurring
double vision
tender palpable temporal artery
```
temporal arteritis
102
Ix for temporal arteriris
raised inflammatory marker = CRP/ESR
diagnostic = temporal artery biopsy
CK & EMG normal
103
management of temporal arteritis
urgent high dose of prednisolone if no visual loss
if visual loss = IV methylprednisolone
urgent ophthalmology review = same-day
(sometimes bisphosphonates & low-dose aspirin given)
104
fever, headache, psychiatric symptoms, seizures, vomiting
focal features e.g. aphasia
peripheral lesions (e.g. cold sores)
encephalitis
105
Ix for encephalitis
CSF = lymphocytosis, elevated protein
| PCR for HSV
106
management for encephalitis
IV acyclovir started in all suspected cases
| (HSV responsible for 95% of cases
107
```
headache
fever
nausea/vomiting
photophobia
drowsiness
seizures
neck stiffness
purpuric rash
```
meningitis
108
cloudy appearance , low glucose, high protein and high WBCs
bacterial meningitis
109
clear/slightly cloudy
high glucose
protein normal
raised WBC
viral meningitis
110
slightly cloudy, fibrin web, low glucose, high protein, elevated WBC
Tuberculous meningitis
111
management of meningitis
IV antibiotics, usually to include ceftriaxone/cefotaxime + amoxicillin
ampicilin added in >50yrs
IV dexamethasone
prophylaxis offered to patient contacts
112
HLA-B27 positive
middle aged man
diarrhoea, weight loss
large-joint arthralgia
lymphadenopathy
skin: hyperpigmentation and photosensitivity
whipple's disease
113
Ic for whipple's
jejunal biospy PAS granules
114
management of Whipple's
co-trimoxazole for a year
