Neuro Flashcards
What is the Rosier score?
The ROSIER scale was effective in the initial differentiation of acute stroke from stroke mimics in the ER. Introduction of the instrument improved the appropriateness of referrals to the stroke team. The benefits of early assessment and hyperacute treatment of stroke patients with thrombolysis within the first 3 h is well known.
What is the Banford score?
Score for TACS (total anterior circilationm stroke)
PACS (partial)
Posterior ciculatoon
Lacunar
What type of dementia is associated with motor neurone disease?
Frontotemporal dementia is associated with motor neurone disease
What is the criteria for the Banford score?
What are signs of MND?
Motor neuron disease is associated with normal motor conduction on nerve conduction studies
What is the Oxford classification of stroke?
The Oxford Stroke Classification (also known as the Bamford Classification) classifies strokes based on the initial symptoms. A summary is as follows:
The following criteria should be assessed:
- unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphasia
Total anterior circulation infarcts (TACI, c. 15%)
involves middle and anterior cerebral arteries
all 3 of the above criteria are present
Partial anterior circulation infarcts (PACI, c. 25%)
involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
2 of the above criteria are present
Lacunar infarcts (LACI, c. 25%)
involves perforating arteries around the internal capsule, thalamus and basal ganglia
presents with 1 of the following:
- unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
- pure sensory stroke.
- ataxic hemiparesis
Posterior circulation infarcts (POCI, c. 25%)
involves vertebrobasilar arteries
presents with 1 of the following:
- cerebellar or brainstem syndromes
- loss of consciousness
- isolated homonymous hemianopia
What is the Oxford classifcation of stroke?
What is the treatment for post-hepatic neuralgia?
This lady has developed post-herpetic neuralgia. NICE recommend using amitriptyline, duloxetine, gabapentin or pregabalin first-line.ot
What are the signs of UMN disease symptoms?
Hyperreflexia
Hypertonia
Positive bainski
No faciculations
What is a good way of remembering LMN symptoms?
DWARF
Decreased tone/ reflexes
Weakness with wasting
Atrophy
Reflexes diminished
Fascilations
Spacicity
What is a way you can distinguish between a brain and spinal cord lesion?
Brain will have a unilateral presentation and spinal cord bilateral
What are the different parts of the peripheral nervous system?
Anterior horn cell
Nerve roots
Plexus
Neurones
NMJ
Muscle
What is a sign of muscle damage?
Proximal myopathy
What is a sign of nerve root damage?
Parasthesia
What is a disease of the anterior horn cells?
Motor neurones disease
What is motor neurones disease characterised by?
Upper and lower motor neurone symptoms
What is the most common myelopathy?
Cervical myelopathy or spondylitis which is arthritis
What are the features of cervical myelopathy?
Upper motor neuron signs—weakness, spasticity, clumsiness, altered tonus, hyperreflexia and pathological reflexes, including Hoffmann’s sign and inverted plantar reflex (positive Babinski sign)
Lower motor neuron signs—weakness, clumsiness in the muscle group innervated at the level of spinal cord compromise, muscle atrophy, hyporeflexia, muscle hypotonicity or flaccidity, fasciculations
Sensory deficits
Bowel/bladder symptoms and sexual dysfunction
How is cervical myelopathy diagnosed?
What is the differece between PACS and TACS?
TACS is total anterior cerebral stroke and refers to a stroke affecting the anterior and middle cerebrum.
PACS is partial anterior cerebral stroke and refers to the middle or anterior cerebrum.
Its part of the Banford score.
For TACS 3/3 or for PACS 2/3: (HUH)
- Homonymous heminopia
- Unilateral weakness
- Higher level function loss
What is a lacunar stroke?
Pure motor
Pure sensory
Mixed sensory motor
What is amurosis furax?
A temporary loss of vision
What are the different types of tremor?
Active
Postural
Intention
Kinetic
Isometric tremor
What is unique about essential tremor?
How do you treat essential tremor?
Primidone
Beta blockers like propanolol
Deep brain stimulation
Tremors are quite responsive to alcohol (remember akchol stop these tremors unlike DT)
What are the differences between Parkinsons and Essential Tremor?
Bilateral
Higher frequency
Action tremor
Voice
In the family
Calligraphy
Alcohol
(BAVICA)
Compare Parkinsons with Essential tremor>
What are the four types of trigeminal autonic cephalagias?
Hemi, Continuing to sink a clusters of parots
Hemicranual continua,
SUNCT
Cluster headaches
Paroxysmal hemicrania
What condition causes mixed UMN and LMN disease?
Amyotrophic lateral sclerosis (ALS) is a type of motor neurone disease (MND). Degeneration of neurones in the motor cortex and in the ventral spinal cord produces mixed UMN and LMN signs. There are no associated sensory deficits.
What are the migraine rules?
- Better lying flat/ down
- Episodic
- Associated symptoms i.e. migraine with aura
What are the stages of migraine?
Predrome phase –> Aura –> Headache –> Post drome
What are some associated features of migraine?
Macrosomatagnosia
Distortion of reality
Seeing lights
What are some treatments for migraine?
Treatment 1. Lifestyle (Detox, no caffeine, look for triggers, boring life) 2. Rescue treatment – NSAIDS and antiemetic (not opioids) and Triptan 3. Prophylaxis – beta blocker, topiramate, candesartan, valproate tricyclic, SS or SNRI 4. BOTOX
CGRP blockade Acute treatment – antagonists • Antogepant • Rimegepant • Ubrogepants Prophylaxis – antibodies • Fremaezumab • Galcenizumab • Erenumab • Eptinezumab
What are the rules for a tension headache?
.Medication overuse? 2.“Cervicogenic headache” 3.“Need glasses” 4.Consider migraine
How do you treat a tension headache?
1.Detox 2.Physiotherapy 3.Tricyclic Antidepressant - Nortriptyline 4.SSRI
Name the trigeminal autonomic cephalalgia diseases.
SUNCT –
Paroxysmal Hemicrania
- Cluster headache –
- Hemicrania Continua -
How do you treat the trigeminal autonomic cephalgias?
SUNCT – Lamotrigine (Rash) • Paroxysmal Hemicrania – Indometacin (Kidney injury, Ulcer) • Cluster headache – Verapamil (Heart block – can be delayed) • Hemicrania Continua - Indometacin
What is trigeminal neuralgia and how is it treated?
Trigeminal Neuralgia • Rules 1. One branch of trigeminal nerve 2. Stabbing pain 3. Triggered (Cold wind, eating/drinking, touch sensitive) 4. Need to detox to get clear picture • Treatment 1. Carbamazepine 2. Maximum Carbamazepine – refer to neurosurgery 3. Oxycarbamazepine 4. Another AED
What is hemicrania continua?
Hemicrania continua is a headache disorder. It causes constant pain in one side of the face and head. Unlike other headache disorders, environmental or lifestyle factors don’t trigger hemicranial headaches. People may also have migraine-like symptoms, such as nausea or sensitivity to light. Most people can take medications to manage the pain. Treated with indomethin
What is paroxymal hemicrania?
Paroxysmal hemicrania is a rare but treatable primary headache disorder, meaning that it’s not caused by another condition. The name paroxysmal hemicrania describes the hallmark features of this headache: Paroxysmal means sudden recurrence or attack Hemicrania means one-side of the head (unilateral or side-locked)
What is malignant hypertension?
Rapid rise in BP that causes end organ damage.
What is the rule for epilepsy and the DVLA?
First seizure - 1 month
Epilepsy - seizure free 6 months
What are some causes of raised intracranial pressure?
Increased arterial blood pressure – Maliganant hypertension, Pre-eclampsia, hypercapnia (Obstructive sleep apnoea) • Increased CSF pressure – Obstruction to flow (intraventricular mass, meningitis), Failure of reabsorption (meningitis), Overproduction (idiopathic intracranial hypertension) • Increased brain pressure – Space occupying lesion (blood, cancer, infection) • Increased venous blood pressure – Cerebral venous sinus thrombosis • Meningeal inflammation – infection, autoimmune, cancer
What is temporal arteritis and how is it diagnosed and treated?
Rules 1. Extremely rare below 60 2. ESR and/or CRP raised • Management (from a neurology perspective) 1. Refer immediately to rheumatology 2. Steroids 3. U/S of temporal artery and biopsy within a week
What are the risk factors for stroke?
Ischaemic heart disease
Hypertension
Atrial fibrillation
Hypercholesterolaemia
Diabetes
Previous stroke or TIA
Smoking
Excessive alcohol intake
Hypercoagulable disease (e.g. sickle cell anaemia, polycythemia vera)
Prosthetic heart valves
Carotid stenosis
Poor ventricular function
Migraine with aura
Combined oral contraceptive pill
Family history of stroke in first-degree relatives
What are 3 key things to consider when a patient comes in with a susepected stroke?
Is it stroke - CT / MRI
Precipitating factors
Treatments
What is a cause of central diabetes insipidus?
Traumatic head injury and subsequent intracranial haemorrhage. This is a central cause of DI which leads to the underproduction of ADH. As a result, central DI responds to desmopressin (an ADH analogue) treatment.
What is autonomic dysreflexia?
What are the treeatments for essential tremor?
The mainstay of treatment is beta-blockers • Primidone can be used if tolerated • AIprazolam
What are the types of tremor?
Postural- occur when a limb is held against gravity Kinetic - occur with goal directed voluntary movements of the affected body part Isometric- sustained muscle contraction against a fixed object.
What is the frequency of PD tremor?
4-6 hz
How can tremors be organised?
- Resting or active (postural, isometric, kinetic)
- Anatomical
- Frequency
What are the different frequencies for headaches?
•Low frequency (<4 Hz) cerebellar tremor (<5 Hz). •Medium frequency (4-7 Hz) eg PD tremor (4-6Hz) •High frequency (≥8 Hz) eg physiological tremor (8-12 Hz)
What are the features of essential tremor?
Commonest tremor disorder
Mid-to-late life but sometimes appears during adolescence
AD inheritance pattern
Bilateral symmetrical
Can also affect the jaw, voice, head, leg
s Affects activities such as holding objects, writing, pouring drinks
Improves with alcohol. Disappears during sleep
Aggravated by stress, anxiety, fatigue, extremes of temperature
What are some of the conditions similar to Parkinsons?
Vascular
Drug induced - neuroleptics, valproate
Parkinsons +
What is another name for orthostatic tremor?
Shaky leg tremor
High frequency 8-13hz
How is orthostastic tremor treated?
Rx-Clonazepam valproate, gabapentin, primidone, DBS
What is dystonic tremor?
Can occur at rest, posture or be kinetic Can be suppressed by sensory tricks (geste antagoniste) Irregular jerky rhythm and amplitude Task or position specific Treatment Clonazepam, baclofen, and anticholinergics (trihexyphenidyl). Botulinum toxin injections Vim DBS for medically refractory cases
What tremor is 3-4 hz?
Holmes tremor
What is a cerebellar tremor?
Irregular, often of a high amplitude, postural and action tremors. Low frequency <5 Hz (3-5 Hz). Can affect the head, trunk and limbs.
Name some low frequency tremor?
What is the difference between ET and PD?
What is MS?
A condition discussed by Jean Martin Charcot resulting in brain atrophy and focal demyelination of white and grey.
Normally emerges in the 3rd and 4th decade of life.
Main symptoms can include sensory and visual disturbance, motor impairment, bladder and bowel problems, fatigue, pain, cognitive deficits
Light chains and oligobands found in CNS.
CIS, relapsing remitting, secondary, primary
MRI
Problem with VEPs and SSEPs - visual evoked potentials and sematosensory evoked potentials
What are some of the treatments associated with MS?
What are the types of MS from most relapsing to least?
Can Rachel Save Pupils
CIS, relapsing, secondary, primary
What are the types of syncope?
What is Uhtoff phemomena?
These ‘Uhthoff’s phenomena’, which are a feature of multiple sclerosis (MS) and other demyelinating diseases, can be triggered by factors including the perimenstrual period, exercise, infection, fever, exposure to high ambient temperatures, and psychological stress
What is Lhermitte’s sign?
Lightning like sensation
What is a bulbar palsy?
This is caused by dysfunction in cranial nerves 9-12 from their origin in the medullary nuclei to their termination in the muscles supplying the tongue and the muscles coordinating speech and swallow. It is a ‘lower motor neurone’ lesion of the bulbar cranial nerves.
Loss of CN 9-12 is called a ________________
Bulbar palsy
Hot potato speech is example of a _____________
Pseudobulbar palsy
Coin shaped brain tumour and hyponatremia is indicative of?
Small (kulchitsky cell) metastasis
Which drug is first line for girls with epilepsy?
Lmaotrigine
What therapy is preferred for carotidstenosis?
Endarectomy is better than thrombolysis with stenting as recurrence is too risky (Mount Sainai)
What are the features of multiple systems atrophy? Shy Drager
parkinsonism
autonomic disturbance erectile dysfunction: often an early feature; postural hypotension’ atonic bladder
cerebellar signs
What are the clinical features of TIA?
The clinical features are similar to those of a stroke, i.e. sudden onset, focal neurological deficit but, rather than persisting, the features resolve, typically within 1 hour.
Possible features include
unilateral weakness or sensory loss.
aphasia or dysarthria
ataxia, vertigo, or loss of balance
visual problems
sudden transient loss of vision in one eye (amaurosis fugax)
diplopia
homonymous hemianopia
Features of Parkinsons disease?
Shuffling gait
Masked facies
Akinesia
Rigidity
Tremor
What drug is given in status epilepticus after someone has had a benzodiazepine like buccal midazolam or lorazepam?
Give a phenytoin infusion
What drugs increase the risk of IIH?
COMART – ciclosporin, oral contraceptives, mineralocorticoids, amiodarone, retinoic acid, tetracyclines .
Suggest some risk factors for IIH?
Risk factors
obesity
female sex
pregnancy
drugs*
combined oral contraceptive pill
steroids
tetracyclines
vitamin A
lithium
How is MS diagnosed via imaging?
MRI with contrast to pick up demyelinating lesions
What are the features of Miller Fisher GBS?
ophthalmoplegia, areflexia and ataxia.
For acute ischaemic stroke, when might a 24 hour extension be done?
For thrombectomy in acute ischaemic stroke, an extended target time of 6-24 hours may be considered if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
How is myaesthenic crisis managed?
Emergency is treated with plasmaphoresis and IVG.
What are the stages of treatment for status epillepticus?
1Buccal midazolam/ IV lorazepam
2IV lorazepam
3IV phenytoin (phenobarbital if already on regular phenytoin)
4Rapid sequence induction of anaesthesia using thiopental sodium
