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Phase 2a Concise > Neuro > Flashcards

Neuro Flashcards

1
Q

Brain tumours

A

Can be primary / secondary (10x more common)

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2
Q

Brain tumours patho

A 
Primary
Majority are gliomas
astrocytoma (85-90%)
oligodendroglioma (5%)
Also ependymomas, meningiomas, neurofibromas (Schwannomas), craniopharyngiomas
Secondary
Non-small cell lung (most common)
Small cell lung
breast
melanoma
renal cell
GI

Tumours act as space-occupying lesion, increase ICP. Initially, no symptoms, then sharp rise in ICP, symptoms, risk of coning, midline shift

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3
Q

Brain tumours Px

A

3 cardinal symptoms:

Symptoms of raised ICP
headache (increased by coughing, straining), drowsiness, vomiting, papilloedema (optic disc swelling), retinal oedema, haemorrhages

Progressive neurological deficit
Focal - motor (ataxia), sensory, speech, visual, deafness, memory, personality change
Depends on part of brain affected:

Temporal - dysphasia, amnesia
Frontal - hemiparesis, personality change, Broca’s dysphasia
Parietal - hemisensory loss, reduction in 2-point discrimination, dysphasia, astereognosis (cannot recognise object from touch alone)
Occipital - contralateral visual defects
Cerebellum - DANISH - dysdiadochokinesis (impaired rapidly alternating movt), ataxia/gait, nystagmus, intention tremor, slurred speech, hypotonia

Epilepsy
focal seizures more common with tumours

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4
Q

Brain tumour DDx

A

other causes of space-occupying lesion - abscess, haematoma, aneurysm, cyst

stroke

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5
Q

Brain tumour Ix

A

CT/MRI

Bloods - FBC, U+W, LFTs, B12 etc

Biopsy - via skull burr hole

LP CONTRAINDICATED - withdrawing CSF may provoke immediate coning

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6
Q

Brain tumour Mx

A 
Surgery to remove mass
Chemotherapy, radiotherapy
Oral dexamethasone
Anticonvulsants - oral carbamazepine
Palliative care
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7
Q

Brain tumour Cx

A

acute haemorrhage into tumour, blockage of CSF outflow - hydrocephalus, coning, Cx of radiotherapy

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8
Q

Cauda equina syndrome

A

compression of cauda equina (~L1), caused by:

disc prolapse, tumour, infection, bleeding, trauma

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9
Q

Cauda equina syndrome Px

A

signs
loss of anal tone on PR
loss of anal wink reflex
loss of sensation around saddle region

symptoms
urinary retention, overflow incontinence
bilateral leg pain
impotence
loss of power in legs, gait disturbance
numbness, paraesthesia
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10
Q

Cauda equina syndrome DDx

A

difference with this and lesions higher up in cord - leg weakness is flaccid and areflexic, not spastic and hyperreflexic

conus medullaris syndrome, mechanical back pain, fracture, tumour, spinal cord compression

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11
Q

Cauda equina syndrome Ix

A

PR examination

lumbar spine MRI

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12
Q

Cauda equina syndrome Mx

A

emergency lumbar decompression

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13
Q

Dementia

A

syndrome caused by a number of brain disorders, which cause memory loss, decline in cognition, difficulties with ADL

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14
Q

Dementia causes

A

Alzheimer’s - degeneration of cerebral cortex, cortical atrophy, neurofibrillary tangles, amyloid plaque formation, reduced ACh production

Vascular - brain damage from cerebrovascular disease - stroke, multi-infarct

Dementia with Lewy bodies - deposition of abnormal proteins, has features of Parkinsonism

Frontotemporal dementia - specific degeneration of frontal and temporal lobes of the brain

Mixed dementia
Parkinson’s disease
Potentially treatable - substance misuse, hypothyroidism

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15
Q

Dementia Px

A

Cognitive impairment - difficulties with memory, language, attention, thinking

Psychiatric/behavioural disturbances - changes in personality, emotional control, social behaviour

Difficulties with ADL - driving, shopping, eating, dressing

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16
Q

Dementia Ix

A 
Clinical dx
Screen for cognitive impairment - MMSE
Medication review to exclude drug cause
Identify depression, look for reversible/organic causes
MRI, functional imaging (eg PET)
EEG - in suspected delirium, FTP
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17
Q

Dementia Mx

A

AChE inhibitor - rivastigmine
Anti-glutaminergic tx - memantine (NMDA antagonist)
Challenging behaviour - trazadone/lorazepam
SSRI for depression - citalopram

Non-pharmacological - eg aromatherapy, animal assisted therapy, massage, music

Palliative care

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18
Q

Depression

A

low mood +/- loss of interest and pleasure in most activities

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19
Q

Depression patho

A

associated diseases
dysthymia (chronic depressive state 2+yrs), eating disorders, substance misuse, other psychiatric conditions, various medical conditions

causes
anxiety, alcohol abuse, substance misuse, Parkinson’s, MS, endocrine, medication

RFs
female, past history of depression, significant physical illness, other mental health problems, psychosocial issues

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20
Q

Depression Px

A 
Persistent sadness/low mood
Loss of interest in most activities
fatigue, loss of energy
worthless, excessive/inappropriate guilt
recurrent thoughts of death, suicidal thoughts, suicide attempts
diminished ability to think
insomnia
changes in appetite, wt loss
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21
Q

Depression DDx

A

bipolar disorder, schizophrenia, dementia, seasonal affective disorder, bereavement, organic cause (eg hypothyroidism), drugs

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22
Q

Depression Ix

A

Assessment - PHQ-9, HAD scale, Beck’s Depression Inventory

Assess suicide risk

Past psychiatric history

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23
Q

Depression Mx

A

Mental health team - crisis team, IAPT

CBT, counselling

SSRIs - fluoxetine, sertraline, citalopram

TCAs - amitriptyline, amoxapine

Electroconvulsive therapy (ECT)

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24
Q

Depression Cx

A

Impaired QoL, social difficulties, suicide

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25
Q

Encephalitis

A

infection and inflammation of the brain parenchyma

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26
Q

Encephalitis causes

A

Viral - HSV 1, 2, VSV, CMV, HIV, mumps, measles

Bacterial meningitis, TB, malaria

RFs - extremes of age, immunocompromised, history of travel / animal bite

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27
Q

Encephalitis Px

A

fever + headache + altered mental status

Fever, headaches, myalgia, fatigue, nausea

Personality and behavioural changes, decreased consciousness, confusion, drowsiness

Hemiparesis, dysphasia, seizures, raised ICP, coning, coma

May have signs of meningitis

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28
Q

Encephalitis DDx

A

meningitis, stroke, brain tumour

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29
Q

Encephalitis Ix

A 
MRI
Contrast-enhanced CT
EEG
LP - CSF elevated lymphocytes, viral detection by PCR
Blood and CSF serology
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30
Q

Encephalitis Mx

A

Antiviral - acyclovir

Antiseizure - primidone, phenytoin

If meningitis suspected - benzylpenicillin

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31
Q

Epilepsy

A

recurrent tendency to spontaneous intermittent abnormal electrical activity, manifesting in seizures

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32
Q

Epileptic seizure

A

paroxysmal event caused by excessive hypersynchronous neuronal discharges

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33
Q

Convulsions

A

motor signs of electrical discharges

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34
Q

Elements of a seizure

A

Prodrome - change in mood/behaviour before seizure, might not occur

Aura - deja vu, strange gut feeling, strange smells, flashing lights, part of seizure where patient is aware, implies focal seizure, but not necessarily, from temporal lobe

Post-ictal - after, headache, confusion, myalgia, sore tongue, dysphasia if seizure in temporal lobe

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35
Q

Types of seizures

A

Focal (partial) seizures - small area, one hemisphere
- SIMPLE - without consciousness impairment, focal motor, sensory, autonomic or psychic symptoms, no post-ictal

  • COMPLEX - with conscious impairment, most commonly from temporal lobe, post-ictal confusion
  • SECONDARY GENERALISED - bilateral, convulsive seizure, starts locally, spreads widely

Generalised seizures - widespread electrical discharge in both hemispheres
- ABSENCE SEIZURES - brief pauses (eg stops mid sentence), presents in childhood

  • TONIC-CLONIC - loss of consciousness, limbs stiffen (tonic), jerk (clonic), post-ictal confusion, drowsiness
  • MYOCLONIC - sudden jerk of limb, face, trunk
  • ATONIC (AKINETIC) - sudden loss of muscle tone, fall, no LOC
  • INFANTILE SPASMS - seizure in baby
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36
Q

Epilepsy causes

A 
idiopathic
cerebrovascular disease
trauma
cranial surgery
neurodegenerative diseases
brain neoplasm
genetic diseases
drugs
metabolic medical disorders - electrolytes
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37
Q

Epilepsy RFs

A

FHx, premature babies small for age, childhood febrile convulsions, abnormal blood vessels in brain, Alzheimers/dementia, drugs, alcohol withdrawal, stroke, trauma

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38
Q

Epilepsy Px

A 
PRIMARY GENERALISED
Generalised tonic-clonic (grand-mal)
no aura
LOC
tonic - stiff
clonic - jerk
eyes open, tongue bitten
incontinent
post-ictal - drowsy, confusion, coma

Absence (petit mal)
childhood
stops activity, stares, turns pale, carries on as normal

Myoclonic
sudden isolated jerk of limb, face, trunk

Tonic seizure
sudden sustained increased tone, stiffness, no jerking, characteristic cry/grunt

Atonic (akinetic)
sudden loss of muscle tone, cessation of movt, fall

PARTIAL/FOCAL
Simple partial
No LOC or memory, focal motor, sensory, autonomic or psychic symptoms, no post-ictal symptoms

Complex partial
LOC, memory, commonly temporal (understanding speech, memory, emotion), post-ictal confusion

Secondary generalisation
Starts focally, becomes widespread, typically convulsive

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39
Q

Epilepsy Px different lobes

A 
Temporal lobe (memory, emotion, speech understanding)
aura - deja vu, funny smells
anxiety, out-of-body experience, automatisms (lip smacking, chewing, fiddling)
Frontal lobe (motor and thought processing)
motor features, Jacksonian march (seizure 'marches' up/down motor homonculus starting in face/thumb)
Post-ictal Todd's paralysis - paralysis of limbs
Parietal lobe (interprets sensations)
sensory disturbances - tingling, numbness
Occipital lobe (vision)
visual phenomena - spots, lines, flashes
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40
Q

Epilepsy DDx

A

postural syncope, cardiac arrhythmia, TIA, migraine, hyperventilation, hypoglycaemia, panic attacks, non-epileptic seizure

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41
Q

Epilepsy Ix

A

For clinical Dx: >2 unprovoked seizures >24hrs apart

EEG
MRI
CT head
Bloods - rule out metabolic causes, find comorbidities
Genetic testing - juvenile myoclonic epilepsy

Rule out provoking causes - trauma, stroke, haemorrhage, increased ICP, alcohol/benzo withdrawal, infection, drugs

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42
Q

Epilepsy Mx

A

Emergency
ABCDE
Check glucose
Prolonged/repeated - benzos: diazepam/lorazepam
IV phenytoin loading (anti-seizure)
If still fitting - anaesthetic and ventilation

Medication - all AEDs (anti-epileptic drugs)

Primary generalised
Tonic clonic (grand mal) - sodium valproate, lamotrigine, carbamazepine

Absence (petit mal) - sodium valproate, ethosuximide, lamotrigine

Partial/focal
carbamazepine, sodium valproate, lamotrigine

Neurosurgical tx - resection, vagal nerve stimulation

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43
Q

Epilepsy Cx

A

Status epilepticus - continuous seizures

Sudden unexpected death epilepsy (SUDEP)

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44
Q

Extradural/epidural haemorrhage

A

Collection of blood between dura mater and bone

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45
Q

EDH patho

A

traumatic head injury, fracture of temporal/parietal bone, laceration of middle meningeal artery

also due to any tear in dural venous sinus

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46
Q

EDH Px

A

Head injury
Brief LOC / drowsiness
Lucid interval - time between injury and decrease in consciousness, while haematoma is small
Severe headache, N+V, confusion, seizures - rising ICP
Hemiparesis, brisk reflexes
Ipsilateral pupil dilates, coma deepens, bilateral limb weakness, deep/irregular breathing - brainstem compression
Decreased GCS, coning
Bradycardia and BP increase - late signs

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47
Q

EDH DDx

A

Epilepsy, carotid dissection, CO poisoning, SDH, SAH, meningitis, intoxication

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48
Q

EDH Ix

A

Head CT - hyperdense haematoma, biconcave / lens shaped adjacent to skull (blood forms more rounded shape compared to sickle-shaped SDH as the tough dural attachments to skull keep it localised)
Skull xray - may be normal, fracture lines

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49
Q

EDH Mx

A

ABCDE

IV mannitol - if increased ICP

Neurosurgery - clot evacuation +/- ligation of bleeding vessel

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50
Q

Subdural haemorrhage

A

blood between dura and arachnoid layers

can be acute, subacute, chronic

Simple / complicated (underlying parenchymal injury)

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51
Q

SDH patho

A

Commonly following rupture of bridging vein between cortex and venous sinus
Bleed from damaged cortical artery (branches of ACA, MCA, PCA)
Clotting disorders

At risk - infants, elderly, alcoholism, on anticoagulants

Cerebral atrophy in elderly and alcoholism - tension on veins

Trauma, bleeding from bridging veins between cortex and venous sinuses, bleed forms haematoma, reduces pressure and bleeding stops, later when haematoma breaks down, insoluble proteins -> soluble, increase in osmotic pressure, water sucked into haematoma, enlarges, ICP rises

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52
Q

SDH Px

A

Days/weeks/months between injury and symptoms
Lucid interval

signs
increased ICP
seizures
localising neurological symptoms (unequal pupils, hemiparesis) - occur late
Stupor (decreased consciousness), coma, coning

symptoms
fluctuating level of consciousness
slowing, sleepiness, headache, personality change, unsteadiness

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53
Q

SDH DDx

A

stroke, dementia, CNS masses, EDH, SAH

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54
Q

SDH Ix

A

Head CT - sickle-shaped collection of blood, one hemisphere, hyperdense crescent-shaped

MRI for subacute, smaller

Bloods - FBC, U+E, LFT, thrombocytopenia, coagulation screen

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55
Q

SDH Mx

A

ABCDE

Reverse clotting abnormalities

Neurosurgery - irrigation/evacuation via burr hole craniotomy

IV mannitol

Address cause of trauma, eg falls, abuse

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56
Q

SDH Cx

A

coning, raised ICP, seizures, coma

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57
Q

Subarachnoid haemorrhage

A

bleed between subarachnoid and pia

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58
Q

SAH causes

A

Berry aneurysm rupture (80%), results in tissue ischaemia, raised ICP, pressure on brain (bleed acts as space-occupying lesion)

Arteriovenous malformations (15%)- vascular development malformation

Others - encephalitis, vasculitis, tumour, idiopathic

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59
Q

SAH RFs

A

HTN, known aneurysm, FHx, diseases that predispose to aneurysm (PKD, Ehlers Danlos syndrome, coarctation of aorta), smoking, bleeding disorders, post-menopausal decreased oestrogen

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60
Q

SAH Px

A

signs
neck stiffness
Kernig’s - unable to extend patient’s legs at knee when thigh is flexed
Brudzinski’s - when patient neck flexed by doctor, patient will flex hips and knees
retinal, subhyaloid, vitreous bleeds
Papilloedema
Focal neurology - eg pupil changes, CN3 palsy
Later deficits
BP increase as reflex to haemorrhage

symptoms
thunderclap headache
vomiting
collapse
seizures
coma/drowsiness
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61
Q

SAH DDx

A

meningitis, migraine, intracerebral bleed, cortical vein thrombosis, other causes of stroke

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62
Q

SAH Ix

A

Head CT - star-shaped lesions due to blood filling gyri patterns

CT angiography - see aneurysm

LP - bloody CSF, then becomes xanthochromic (yellow) due to bilirubin from Hb breakdown

ECG - QT prolongation, Q waves, dysrhythmias, ST elevation

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63
Q

SAH Mx

A

IV fluids

Nimodipine - CCB, reduces vasospasm

Surgery - endovascular coiling / surgical clipping, stents

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64
Q

SAH Cx

A

Rebleeding, cerebral ischaemia, hydrocephalus (tx ventricular/lumbar drain), hyponatraemia

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65
Q

Guillain-Barre syndrome

A

autoimmune condition - acute inflammatory demyelinating ascending polyneuropathy (symmetrical) affecting PNS / Schwann cells

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66
Q

GBS patho

A

usually triggered by infection (eg campylobacter, CMV, VZV, HIV, EBV) - resp/GI infection

auto-AB mediated nerve cell damage - damage to Schwann cells, demyelination, reduction in peripheral nerve conduction

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67
Q

GBS Px

A

Symmetrical ascending muscle weakness, paralysis
Proximal muscles more affected, then trunk, resp muscles, cranial nerves later
Pain
Sensory signs may be absent
Paraesthesia
Reflexes lost
Hypotonia
Autonomic features - sweating, raised pulse, BP changes, arrhythmias
Progressive for 4wks then recovery

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68
Q

GBS DDx

A

Other causes of acute paralysis

Brain - stroke, encephalitis
Spinal cord - compression, poliomyelitis
Peripheral nerve - vasculitis, lead poisoning
NMJ - MG, botulism
Muscle - hypokalaemia, polymyositis
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69
Q

GBS Ix

A

Usually clinical Dx

Nerve conduction studies (NCS) - slowing of conduction

LP - CSF raised protein, normal WCC

Spirometry - monitor FVC, if deceases, go to ITU

Maybe AB screen electrolytes, ECG abnormalities

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70
Q

GBS Mx

A

ITU and ventilate if FVC <80%

IVIg (IV immunoglobulin)

Plasma exchange

Pain relief for neuropathic pain

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71
Q

Headaches

A 
Primary
Tension - most common, pain like hand squeezing head
Cluster - pain around one eye
Sinus - pain behind forehead/cheekbones
Migraine - pain, nausea, visual changes

Secondary
Could be GCA, trigeminal neuralgia, medication overuse

Red flags for headache
HIV, immunosuppressed
Fever
Thunderclap headache
Seizure
Suspected meningitis, encephalitis
Red eye? acute glaucoma
Headache + new focal neurology, eg papilloedema
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72
Q

Migraine

A

Recurrent throbbing headache often preceded by aura, associated with N+V, visual changes

May be caused by changes in brainstem and its interactions with trigeminal nerve, or brain chemical imbalance

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73
Q

Migraine triggers - CHOCOLATE

A 
Chocolate
Hangovers
Orgasms
Cheese
Oral contraceptives
Lie ins
Alcohol
Tumult - loud noise
Exercise
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74
Q

Migraine Px

A

Prodrome - yawning, cravings, mood/sleep changes

May have aura

Unilateral, pulsing, pain in head
Aggravated by routine physical activity
N+V, photophobia, phonophobia (sound sensitive)
Visual disturbances
Paraesthesia
POUND
Pulsating
Onset over 4-72hrs
Unilateral
Neurological signs, eg photophobia
Disabling – patient often wants to be in a dark room
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75
Q

Migraine Ix

A

Clinical dx

Examine - eyes, BP, head and neck

Exclude other causes - CRP, ESR, red flags, maybe LP if indicated

76
Q

Migraine Mx

A

Reduce triggers - dietary factors

NSAIDs, ibuprofen, naproxen
Aspirin, paracetamol
+/- antiemetic - prochlorperazine
Triptans - sumatriptan

Prevention
BB (propranolol), TCA (amitriptyline), anti-convulsant (topiramate)

77
Q

Tension headache

A

most common primary headache, no organic cause

78
Q

Tension headache RFs

A

stress, sleep deprivation, bad posture, hunger, eye strain, anxiety, noise

79
Q

Tension headache Px

A

Bilateral, pressing/tight, non-pulsatile, like a tight band
Pressure behind eyes
no vomiting, no sensitivity to head movt, no aura

80
Q

Tension headache Ix

A

Clinical dx

81
Q

Tension headache Mx

A

Reassure, exercise, avoid triggers
Stress relief - massage, acupuncture

Aspirin, paracetamol, ibuprofen

82
Q

Cluster headache

A

most disabling primary headache, in/around eye

83
Q

Cluster headache Px

A 
Abrupt onset
Excruciating pain around one eye, temple/forehead
Unilateral
Eye may be watery, bloodshot, facial flushing, rhinorrhoea (blocked nose), miosis (excessive pupil constriction) +/- ptosis
Pain rises to crescendo
Often nocturnal
\+/- vomiting
episodic
84
Q

Cluster headache Ix

A

Clinical Dx

85
Q

Cluster headache Mx

A

O2
Triptan - sumatriptan

Prevention - CCB (verapamil), prednisolone may help

86
Q

Chickenpox

A

caused by varicella-zoster virus

87
Q

Chickenpox patho

A

transmitted by resp droplets
invades resp mucosa, replicates in lymph nodes, infects skin epithelial cells

Cx can occur in - immunocompromised, older, steroid use, malignancy, pregnancy (danger to neonates, mother can get pneumonia)

88
Q

Chickenpox Px

A

Prodrome (1-2 days) - fever, malaise, headaches, abdo pain

Rash - pruritic, erythematous macules -> vesicles, crust in 48hrs

89
Q

Chickenpox DDx

A

generalised herpes zoster or simplex, dermatitis herpetiformis, impetigo, contact dermatitis

90
Q

Chickenpox Ix

A

Clinical dx
PCR
Investigate Cx - CXR, LP

91
Q

Chickenpox Mx

A

Fluids, avoid scratching
Paracetamol
Self-limiting
Acyclovir if at risk of Cx

92
Q

Chickenpox Cx

A

secondary infections of lesions
viral pneumonia
encephalitis
other CNS complications, other infections

93
Q

Shingles

A

Herpes zoster - reactivation of VZV

94
Q

Shingles patho

A

VZV remains latent in sensory ganglia, reactivated, in dorsal root, travels down affected root in dermatomal distribution

RFs - elderly, immunocompromised

95
Q

Shingles Px

A

Pre-eruptive phase
burning, itching, paraesthesia in one dermatome
malaise, myalgia, headache, fever, maybe lymphadenopathy

eruptive phase
rash - papules, vesicles in one dermatome
neuritic pain
paraesthesia
does not cross midline

chronic phase
Post-herpetic neuralgia (PHN) - persistent pain >30d after acute infection

96
Q

Shingles Ix

A

Clinical dx

97
Q

Shingles Mx

A

Antivirals - acyclovir

Topical AB for tx of secondary bacterial infection

Analgesia, ibuprofen

PHN Tx - TCA (amitriptyline), anti-epileptic (gabapentin), anticonvulsant (carbamazepine)

Vaccine at 70yo to prevent reactivation

98
Q

Shingles Cx

A

Ophthalmic - can affect sight

PHN

99
Q

Huntington’s disease

A

neurodegenerative disorder characterised by lack of the inhibitory NT GABA

causes chorea - jerky, semi-purposeful movts, may interfere with voluntary movts

100
Q

HD patho

A

autosomal dominant, repeated expression of CAG on chromosome 4, mutation in huntingtin gene

cerebral atrophy, loss of neurons in caudate nucleus, putamen, decreased ACh and GABA synthesis, decreased inhibition of dopamine release, excessive thalamic stimulation, excessive movts

Corpus striatum loss

101
Q

HD Px

A

Prodromal - mild psychotic and behavioural symptoms

Chorea - relentlessly progressive, jerky, explosive, rigid involuntary movts, stop when sleeping

Dysarthria, dysphagia, abnormal eye movts

Aggression, addictive behaviour, apathy, self-neglect, depression/anxiety

Dementia
Seizures

102
Q

HD DDx

A

other causes of chorea - SLE, stroke of basal ganglia

103
Q

HD Ix

A

Clinical Dx

Genetic testing - many CAG repeats

CT/MRI - caudate nucleus atrophy, increased frontal horn size of lateral ventricles

104
Q

HD Mx

A

Counselling, genetic counselling

Symptomatic Mx of chorea
Benzodiazepines - attach to GABA receptors
Sulpiride - neuroleptic, depresses nerve function
Tetrabenazine - dopamine depleting agent

SSRI for depression
Antipsychotic - haloperidol (neuroleptic)
Risperidone to tx aggression

105
Q

Meningitis

A

inflammation of the meninges

106
Q

Meningitis patho

A

Bacterial
group B strep, listeria, E coli, H.influenzae, N.meningitidis, S.pneumoniae, TB, G- (Klebsiella, pseudomonas, enterobacter), staph…

N.meningitidis - transmitted by droplet spread, can lead to meningococcal septicaemia (bacteria invades blood, petechial rash, sepsis)

Aseptic meningitis - CSF has cells, but no bacterial cultures
Viral (most common), fungal, parasites

Non-infective meningitis
malignant cells, chemical, medication, sarcoidosis, SLE

107
Q

Meningitis Px

A

Fever, headache, neck stiffness
Leg pains, cold hand+feet, abnormal skin colour
Photophobia
Reduced GCS, coma
Seizures, focal CNS signs, petechial rash (stays red when glass pressed)
Shock, papilloedema, vomiting

Kernig’s - pain + resistance on passive knee extension with hip fully flexed
Brudzinski’s - passive flexion of neck causes patient to raise knees/hips
Opisthotonos - spasm of muscles causing backwards arching of head, neck, spine

108
Q

Meningitis DDx

A

malaria, encephalitis (altered mental state is predominant symptom), septicaemia, dengue, tetanus, SAH

109
Q

Meningitis Ix

A

Blood culture (before LP and any tx)

Bloods - FBC, U+E, CRP, glucose

LP - to MC&S

  • Bacteria - polymorphs, raised protein, low glucose, turbid/yellow colour
  • TB - lymphocytes, raised protein, low/normal gluc
  • Virus - lymphocytes, normal/high protein, normal gluc

CT head

Throat swabs

Serum PCR for virus

110
Q

Meningitis Mx

A

ABs - IV ceftriaxone/cefotaxime, add amoxicillin if >60yo or immunocompromised
Chloramphenicol if allergic to beta lactams

Dexamethasone for meningism, seizures, ICP

Maybe IV vancomycin for return travellers

Prophylaxis for contacts - oral ciprofloxacin/oral rifampicin

AB for specific org

111
Q

Meningitis Cx

A

Meningococcal septicaemia - IV benzylpenicillin / IV cefotaxime

Septic shock, DIC, coma, cerebral oedema, raised ICP

112
Q

Motor neuron disease

A

cluster of neurodegenerative diseases - destruction of motor neurons

loss of neurons in motor cortex, cranial nerve nuclei, anterior horn cells

113
Q

MND patho

A

Usually sporadic, possibly oxidative stress from abnormality of mitochondrial function
5% have familial SOD1 mutation

Amyotrophic lateral sclerosis (ALS)
Most common (<80%)
Loss of motor neurons in motor cortex and anterior horn of cord (UMN + LMN)

Progressive bulbar palsy (PBP)
10-20%
CN9-12 (LMN)

Progressive muscular atrophy (PMA)
<10%
Anterior horn lesion (LMN)
Affects distal muscle groups before proximal

Primary lateral sclerosis (PLS)
Loss of bets cells in motor cortex (UMN)
Spastic leg weakness, pseudobulbar palsy, no cognitive decline

114
Q

MND Px

A

ALS - UMN+LMN
Weakness, LMN wasting/fasciculations - usually one limb
Cramps
Split hand sign - thenar wasting, thumb side of hand seems adrift
Wrist and foot drop
UMN signs - brisk reflexes, positive Babinski, spasticity

PMA - LMN
Everything goes down
Muscle tone reduced - flaccid
Muscle wasting
Fasciculation
Reflexes depressed/absent
Usually starts in one limb, gradually spreads
Affects distal muscles before proximal

PBP - LMN
Dysarthria, dysphagia, nasal regurgitation of fluids, choking
LMN lesion of tongue - flaccid, fasciculating, jaw jerk normal/absent, speech quiet, hoarse, nasal

PLS - UMN
Everything goes up
Spasticity
Brisk reflexes - tendon and jaw reflexes, positive Babinski
Upper limb extensors weaker than flexors, lower limb flexors weaker than extensors, finer movt impaired
Velocity dependent spasticity - clasp knife
Less prominent muscle wasting

FTD in 25%
Weakness and atrophy spreads from start to other parts of body

115
Q

MND DDx

A

MS and polyneuropathies - have sensory loss, sphincter disturbance

MG - eye movts affected

Diabetic amyotrophy, GBS, spinal cord tumours

116
Q

MND Ix

A

Clinical findings

Brain/cord MRI, LP - exclude structural causes

Nerve conduction studies (NCS), electromyography (EMG) - shows denervation of muscles

117
Q

MND Mx

A

Oral riluzole (inhibits glutamate release, thought to play role in cell death)

Drooling - oral propantheline (anti-muscarinic) or oral amitriptyline (dries mouth)

Dysphagia - blend food, NG tube

Spasm - oral baclofen (CNS depressant, skeletal muscle relaxant)

Analgesia - NSAIDs, opioids

Palliative MDT care (death from resp failure in 3yrs)

118
Q

Multiple sclerosis

A

Autoimmune inflammatory disorder of CNS - multiple plaques of demyelination in brain and spinal cord, occurring sporadically over years

119
Q

MS patho

A

T cell mediated, oligodendrocytes targeted, auto-ABs against myelin created

Multiple areas of scar tissue form along neurons - slow/block transmission

acute attacks, period of remission where there is remyelination, but is less efficient, temp dependent

Types - relapsing/remitting, 2 progressive, 1 progressive

RFs - race (caucasian), genetics (HLADR2), FHx, maybe low sunlight and vit D

120
Q

MS Px

A

Usually monosymptomatic
Unilateral optic neuritis - pain on eye movt, decreasing central vision
Symptoms may worsen with heat, eg bath, exercise

sensory
dysaesthesia - unpleasant sensation when touched
pins/needles
decreased vibration sense
trigeminal neuralgia
GI - dysphagia, constipation
Eye - diplopia, hemianopia, optic neuritis, visual phenomena, pupil defects

motor
spastic weakness
transverse myelitis - weakness/paralysis of both legs
Cerebellum - trunk/limb ataxia, intention tremor, scanning speech (monotonous), falls

sexual/GU
erectile dysfunction
anorgasmia, urine retention, incontinence

Malaise, N+V, positional vertigo, seizures, aphasia, meningism

121
Q

MS Ix

A

Clinical Dx with McDonald’s criteria - 2+ attacks affecting different parts of CNS

Exclude differentials - FBC, inflammatory markers, U+E, glucose, HIV serology, auto-ABs, Ca, vit B12

MRI brain, spinal cord

LP - oligoclonal IgG bands

Electrophysiology - visual evoked potential studies

122
Q

MS Mx

A

Exercise, stop smoking, reduce stress

Dimethyl fumarate (decreases worsening episodes), MABs

Methylprednisolone - for relapses

Spasticity - baclofen/gabapentin
Tremor - botox
Urgency/frequency - self-catheterisation/tolterodine
Fatigue - amantadine, CBT

Stem cell transplant

123
Q

Myasthenia gravis

A

autoimmune disease with ABs against nicotinic ACh receptors in NMJ

124
Q

MG patho

A

If <50yo, commoner in women, associated with other autoimmune disease - pernicious anaemia, SLE, RA, thymic hyperplasia

IF >50yo, commoner in men, associated with RA, SLE, thymic atrophy/tumour

Transient MG sometimes caused by penicillamine tx for Wilson’s

Destruction of AChR, immune complex deposition, blocks excitatory effect of ACh on nicotinic receptors - muscle weakenss

125
Q

MG Px

A

Increasing muscular fatigue
Muscle groups affected in order: extra-ocular, bulbar, face, neck, trunk
Proximal limb muscles, speech, facial expression commonly affected
Ptosis, diplopia, myasthenic snarl
Resp difficulties
Tendon reflexes normal, may be fatigable

Ask to count to 50, voice becomes less audible
Hold finger up high, ask patient to look up, after a while will not be able to keep eyes raised

Worsened by - pregnancy, hypokalaemia, infection, emotion, drugs

126
Q

MG DDx

A

Other causes of generalised muscle weakness - MS, hyperthyroidism, acute GBS
Lambert-Eaton myasthenic syndrome (defective ACh release, weakness tends to improve after exercise)

127
Q

MG Ix

A

Serum anti-AChR, if negative look for anti-MuSK (muscle specific tyrosine kinase)

EMG, NCS

CT thymus - hyperplasia, atrophy, tumour

128
Q

MG Mx

A

Anti-cholinesterase, so more ACh remains in NMJ - oral pyridostigmine

Immunosuppression - prednisolone, azathioprine, methotrexate

Thymectomy

129
Q

MG Cx

A

Myasthenic crisis - weakness of resp muscles during relapse, tx plasmapheresis (AB removal), IV Ig

aspiration pneumonia, acute resp failure, ADL restrictions

130
Q

Carpal tunnel syndrome

A

Compression of median nerve as it passes through carpal tunnel in wrist

131
Q

CTS patho

A

entrapment of median nerve - anything that causes swelling/compression of tunnel

DM, pregnancy, amyloidosis, obesity, RA, acromegaly, hypothyroidism

132
Q

CTS Px

A

Intermittent symptoms, gradual onset

Aching in hand and arm, esp at night, can wake patient up

Paraesthesia in thumb, index, middle, 1/2 ring finger and palm

Relieved by dangling hand over bed

May be sensory loss, weakness of abductor pollicis brevis +/- wasting of thenar eminence

Light touch, 2-point discrimination and sweating may be impaired

133
Q

CTS DDx

A

peripheral neuropathy, MND, MS

134
Q

CTS Ix

A

Electroneurography (ENG)

Electromyography (EMG)

Phalen’s test - patient can only maximally flex wrist for 1min and will produce symptoms of carpal tunnel

Tinel’s test - tapping on nerve at wrist induces tingling

135
Q

CTS Mx

A

Wrist splint at night

Local steroid injection

Decompression surgery

136
Q

Sciatica

A

L5/S1 root compression

137
Q

Sciatica causes

A

Spinal - disc prolapses, spinal stenosis, spondylolisthesis

Piriformis syndrome, pregnancy, trauma, back injury

OA

138
Q

Sciatica Px

A 
signs
unilateral
weak plantar flexion
absent right ankle jerk
decreased sensation over lateral edge and sole of right foot

symptoms
pain in buttock, back of thigh, lateral aspect of little toe (sciatic nerve distribution)

139
Q

Sciatica Ix

A

MRI/CT

Examination - straight leg raise test (gently raise leg, if pain then positive)

140
Q

Sciatica Mx

A

Analgesia

Surgical decompression

141
Q

Olfactory nerve palsy (CN1)

A

anosmia - can’t smell

142
Q

optic nerve palsy (CN2)

A

visual defects depend on location of lesion

143
Q

oculomotor nerve palsy (CN3)

A

ptosis
fixed dilated pupil (loss of psym outflow)
Eye looks down and out

causes - raised ICP, diabetes, HTN, GCA, berry aneurysm

144
Q

trochlear nerve palsy (CN4)

A

Innervates superior oblique

Palsy results in head tilt to correct extortion that results in diplopia on looking down

Causes - trauma to orbit (rare)

145
Q

abducens nerve palsy (CN6)

A

innervates LR, eye will be adducted, looking in

Causes - MS, Wenicke’s encephalopathy, pontine stroke (presents with small fixed pupils +/- quadriparesis)

146
Q

CN3,4,6 palsy

A

non-functioning eye

Causes - stroke, tumours, Wernicke’s encephalopathy

147
Q

Trigeminal nerve palsy (CN5)

A

jaw deviates to side of lesion
loss of corneal blink reflex

Causes - trigeminal neuralgia, herpes zoster, nasopharyngeal cancer

148
Q

Facial nerve palsy (CN7)

A

facial droop and weakness

Forehead sparing if lesion is central, before facial nerve nucleus

Causes - Bell’s palsy, fractures of petrous bones, middle ear infections, inflammation of parotid gland (facial nerve passes through)

Tx with steroids

149
Q

vestibulocochlear nerve palsy (CN8)

A

hearing impairment, vertigo, lack of balance

Causes - surrounding tumour, skull fracture, toxic drug effects, ear infections

150
Q

glossopharyngeal (CN9) and vagus (CN10) palsy

A

gag reflex issues, swallowing issues, vocal issues

causes - jugular foramen lesion

151
Q

accessory nerve lesion (CN11)

A

SCM and trapezius

can’t shrug shoulder or shake head

152
Q

hypoglossal nerve palsy (CN12)

A

tongue deviates towards side of lesion

153
Q

Spinal cord tract

A

Corticospinal
motor
descending UMN
decussates at medulla

DCML
ascending sensory tract
fine touch, proprioception, vibration, 2-point discrimination
decussates at medulla

Spinothalamic
ascending sensory
pain, temp, crude touch
decussates almost immediately in spinal cord

154
Q

Brown-Sequard Syndrome

A

Hemisection of spinal cord

Causes
Space-occupying lesions
Intervertebral disc prolapses
Vertebral bone fractures
Trauma - GSW, knife
Infectious - HIV
MS

Px
Level of lesion:
- ipsilateral spinothalamic dysfunction - loss of temp, pain, pressure sense

Below lesion:

  • ipsilateral corticospinal dysfunction - loss of motor function (weakness)
  • ipsilateral DCML dysfunction - loss of fine touch, proprioception, vibration, 2-point discrimination
  • contralateral spinothalamic dysfunction - loss of temp, pain, pressure

Overall - ipsilateral loss of fine touch, proprioception, motor, contralateral loss of pain, temp, crude touch

Ix
MRI spine

Mx
physical and occu therapy
Steroids - reduce swelling inflammation

155
Q

Paraplegia

A

paralysis of both legs - always spinal cord lesion

156
Q

Hemiplegia

A

paralysis of one side of body - brain lesion

157
Q

UMN signs

A

signs contralateral to lesion - indicates lesion is above anterior horn cell - in spinal cord, brainstem, motor cortex

Increased muscle tone - spastic paralysis, velocity dependent, non-uniform, clasp-knife

Weakness - flexors weaker than extensors in legs, extensors weaker than flexors in arms

Hyperreflexia - reflexes increased, are brisk

158
Q

LMN signs

A

Signs ipsilateral to lesion

decreased muscle tone, flaccid paralysis (nerve to muscle cut, will go floppy for life…)

wasting/atrophy, fasciculations

reflexes reduced/absent

159
Q

Parkinson’s disease

A

degenerative movt disorder caused by reduction in dopamine in substantia nigra

160
Q

PD patho

A

associated with dementia and depression

combination of environ, genetics, oxidative stress, mito dysfunction

progressive loss of dopaminergic neurons from pars compacta of SN in midbrain - less dopamine, thalamus inhibited - decrease of movt

neural inclusions present

RFs- FHx, environmental factors

161
Q

PD Px

A

gradual, asymmetrical onset of symptoms, commonly present with impaired dexterity

anosmia, depression, anxiety, aches and pains, REM sleep disorders, urinary urgency, hypotension and constipation

Tremor
worse at rest, asymmetrical
issue with repetitive hand movts, worsening in rhythm the longer attempted

Rigidity
increased tone in limbs and trunk
limb resists passive movt throughout (as opposed to UMN lesion spasticity - clasp knife)

Bradykinesia
slow to initiate movt
reduced blink rate, monotonous hypophonic speech, writing smaller, difficulty with fine movt, narrow gait, reduced asymmetrical arm swing, problems with balance, stooped posture, shuffling steps
expressionless face

162
Q

PD DDx

A

benign essential tremor, multiple cerebral infarcts, drug induced, Wilson’s disease, trauma, HD

163
Q

PD Ix

A

Clinical dx, can confirm by levodopa response

CT/MRI head

164
Q

PD Mx

A

Oral levodopa, with deoxycarbolase inhibitor (co-careldopa / co-beneldopa) which prevents peripheral conversion of l-dopa to dopamine (cannot cross BBB)

Dopamine agonists - oral ropinirole / oral pramipexole

Mono oxidase B (MAO-B) inhibitors - oral selegiline / oral rasagiline

Catechol-O-methyltransferase (COMT) inhibitors - oral entacapone / oral tolcapone

COMT and MAO-B break down dopamine

Surgical - ablation of overactive basal ganglia circuits, eg subthalamic nuclei

165
Q

PD Cx

A

Depression, dementia, psychosis
SSRI - oral citalopram
Anti-psychotic - oral quetiapine

166
Q

Radiculopathy

A

pinched nerve - compression of nerve root and LMN

167
Q

Mononeuropathy

A

disease affecting single nerve - peripheral/cranial nerve

causes usually local - eg trauma, entrapment, tumour

Common - CTS, ulnar neuropathy, peroneal neuropathy, cranial neuropathies

168
Q

Mononeuritis multiplex

A

2+ peripheral nerves affected (separate areas)

when causes tend to be systemic - WARDS PLC
Wegener's granulomatosis
AIDs/amyloid
RA
DM
Sarcoidosis
PAN
Leprosy
Carcinoma
169
Q

Polyneuropathy

A

disease of many nerves

diffuse, symmetrical, usually starts peripherally

Can be sensory/motor/autonomic/mixed

Mostly motor - GBS, lead poisoning, Charcot-Marie-Tooth syndrome

Mostly sensory - DM, renal failure, leprosy

Px
SENSORY
numbness, paraesthesia
glove+stocking
loss of dexterity maybe
signs of trauma (not noticed by patient)

MOTOR
progressive
weak/clumsy hands
difficulty in walking, breathing, weakness, wasting

170
Q

6 mechanisms that can cause nerve malfunction

A

Demyelination

Axonal degeneration - causes nerve to die back from periphery

Compression

Infarction

Infiltration - by inflammatory cells

Wallerian degeneration - nerve fibre cut, distal part of axon separated from cell body dies

171
Q

Peripheral neuropathies Px

A

symptoms
sensory - loss of pain, warmth/cold, proprioception, balance, pressure, vibration (depends on fibre affected)

motor - muscle cramps, weakness, fasciculations, atrophy, ataxia, high arched feet from excessive atrophy

signs

  • symmetrical sensorimotor - commonest neuropathy, starts distally, initially sensory, then sensorimotor
  • asymmetrical sensory - patchy, dorsal root ganglia affected, uncommon - paraneoplastic, Sjogrens, coeliac disease
  • asymmetrical sensorimotor - mononeuritis multiplex, very uncommon - vasculitis
172
Q

Peripheral neuropathy Ix

A

H+E

Neurophysiological examination - nerve conduction studies/quantitative sensory test

173
Q

Peripheral neuropathy Mx

A

Anti-neuralgic for pain - gabapentin, amitriptyline, pregabalin

Cramps - quinine

174
Q

Spinal cord compression

A

compression can occur in any part of spinal cord

Causes
spondylosis (degeneration of spine), disc prolapse, spondylolisthesis, tumour, stenosis, abscess, TB, trauma, infection

RFs
osteoporosis, trauma, tumour, RA, ankylosing spondylitis

Px
At level of lesion - back pain, nerve root pain, numbness, paraesthesia, LMN signs
Below lesion - UMN signs
Sphincter disturbance, loss of bladder and bowel control

Ix
MRI

Mx
Surgical - decompressive laminectomy
Dexamethasone/chemo/radio if malignancy

175
Q

Stroke

A

disruption of blood supply to the brain, leading to neurological deficit from focal infarction

176
Q

Stroke patho

A 
Ischaemic/infarction (80%)
loss of blood flow, lack of oxygen
- thrombosis in situ
- emboli from atheroma (carotid bifurcation commonly)
- heart emboli - AF, valve disease, IE, fat emboli after long bone fracture
- large artery stenosis
- watershed stroke - drop in BP
- venous sinus thrombosis (1%)

Haemorrhage (17%)
Bleeding in CNS - trauma, aneurysm rupture, thrombolysis, anticoagulation, carotid artery dissection, SAH, HTN -> microaneurysm rupture

RFs
HTN, smoking, DM, heart disease, PAD, post-TIA, polycythaemia, combined OCP, hyperlipidaemia, exess alcohol

177
Q

Stroke Px

A

Worse at onset
Distinguish between the two (not reliable)
Haemorrhagic - meningism, severe headache, coma
Ischaemic - carotid bruit, AF, past TIA, IHD

FAST

ACA
Leg weakness > arm weakness
leg sensory disturbances
gait apraxia
truncal ataxia
incontinence
drowsiness
akinetic mutism - stuporous state

MCA
contralateral arm and leg weakness, sensory loss
hemianopia
aphasia (cannot understand/produce speech)
dysphasia (deficiency in speech generation)
facial droop

PCA
contralateral homonymous hemianopia
cortical blindness (brain tissue causes blindness, eye is healthy)
visual agnosia (cannot interpret visual info)
prosopagnosia - cannot see faces

Posterior circulation
brainstem, cerebellum
locked in syndrome - aware, cannot respond
motor deficits - hemiparesis, tetraparesis, facial paralysis
dysarthria, speech impairment
vertigo, N+V
visual disturbance
altered consciousness
Lacunar stroke
25%
basal ganglia, internal capsule, thalamus, pons
unilateral weakness +/- sensory deficit
ataxic hemiparesis
cerebellar and motor symptoms
178
Q

Stroke DDx

A

head injury, hypo/hyperglycaemia, SDH, hepatic encephalopathy

179
Q

Stroke Ix

A

Head CT

BP, ECG - look for AF
Bloods - FBC (polycythaemia), glucose, ESR

180
Q

Stroke Mx

A

ABCDE

Aspirin (once haemorrhagic excluded)

Thrombolytic drugs - alteplase

Thrombectomy - surgical removal

Haemorrhagic
Surgery
Mannitol for raised ICP
Control HTN

Prevention
Aspirin, clopidogrel
Simvastatin
AF tx
HTN tx
181
Q

Transient ischaemic attack

A

temporary inadequacy of circulation to part of brain

<24hrs, most <30 mins

182
Q

TIA causes

A

atherothromboembolism

cardioembolism - post-MI, valve disease, AF

hyperviscosity - polycythaemia, sickle cell, myeloma

Vasculitis

Hypoperfusion - cardiac dysrhythmia, postural hypotension

183
Q

TIA RFs

A

HTN, smoking, DM, heart disease, PAD, polycythaemia, hyperlipidaemia

184
Q

TIA Px

A

sudden loss of function, lasts minutes

FAST

Anterior circulation
weak, numb contralateral leg, maybe similar arm symptoms
hemiparesis
hemisensory disturbance
dysphagia
amaurosis fugax - temporary loss of vision, eg emboli in retinal, ophthalmic, ciliary blood flow

Posterior circulation
diplopia
vertigo
vomiting
choking, dysarthria
ataxia
hemisensory loss
hemianopia
LOC
transient global amnesia
tetraparesis (muscle weakness at all 4 extremities)
185
Q

TIA Ix

A

Bloods - FBC (polycythaemia), ESR (vasculitis), glucose, creatinine, electrolytes, cholesterol

Carotid artery doppler USS - look for atheroma/stenosis

MRI/CT angiography

ECG - AF or MI ischaemia

Calculate ABCD2 score - risk of stroke after TIA

186
Q

TIA Mx

A

Control CV risk factors - ACEi/ARB, simvastatin, DM, stop smoking

Aspirin, clopidogrel

If CV source of emboli - heparin, warfarin

Carotid endarterectomy - correct stenosis

Phase 2a Concise (9 decks)

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