Neuro Flashcards
Stroke Patterns by Anatomy
Anterior Cerebral
= contralateral hemiparesis + sensory loss (lower limb worse than upper)
Middle Cerebral
= contralateral hemiparesis + sensory loss (upper limb worse than lower), contra HH, aphasia
Posterior Cerebral
= contralateral HH with macular sparing, visual agnosia
Weber’s (branches of PCA to midbrain)
= ipsilateral CN3 palsy, contra limb weakness
Posterior Inferior Cerebellar (lat medullary, Wallenberg)
= ipsilateral face pain + temp loss, contralateral limb/ torso pain + temp loss, also ataxia, nystagmus
Anterior Inferior Cerebellar (lat pontine)
= wallenbergs + ipsilateral facial paralysis and deafness
Retinal/ Ophthalmic
= amaurosis fugax
Basilar
= locked-in
Third Nerve Palsy
Causes - PCA aneurysm (dilated, pain), cavernous sinus thrombosis, Weber’s, DM, vasculitis (TA, SLE), ^ICP
= down and out eye, ptosis, mydriasis if surgical
Encephalitis
Cause - HSV-1 (95%, ^temporal and inferior frontal lobes)
= fever, headache, psych symptoms (mood, behaviour, cognition), seizures (^temporal, HEAD), vomiting, focal (aphasia)
Inv - LP (CSF lymphocytosis, ^protein), PCR (HSV, VZV, enteroviruses), MRI, EEG
-> IV acyclovir to all suspected
Bell’s Palsy
Acute, unilateral, idiopathic facial paralysis, LMN so forehead is affected
RF - 20-40yrs, pregnant
= unilateral facial paralysis, pain behind ear may precede, altered taste, dry eyes, hyperacusis
-> PO pred <72hrs of onset, may add antiviral, artificial tears and lubricants to prevent exposure keratopathy
Prog - if no better at 3wks then refer urgently to ENT, most better in 3-4m, 15% have weakness if not treated
Meningitis: Causes
0-3m: Group B strep, E.coli, listeria
3m-6yrs - Neisseria meningitidis, strep pnuem, Hib
6-60yrs - Neisseria meningitidis, strep pnuem
> 60yrs - Strep pneum, Nm, listeria
IS - Listeria
Viral: more common, less severe
- enterovirus (coxsackie, echo), mumps, HSV, CMV, HIV, measles
Meningitis
= headache, fever, n+v, photophobia, seizures, drowsy, neck stiffness, purpuric rash if meningococcal sepsis
Inv - FBC, CRP, blood cultures, glucose, ABG, LP (not if sepsis/ signs of ^ICP)
-> notifiable, pre-hospital give IM benpen, in hospital 3m-50yrs give IV cefotaxime, + IV amoxicillin to infants/ older, IV dex may v neuro comp (contra if sepsis, IC, <3m)
Contacts <7d -> ciprofloxacin or rifampicin, vacc
Meningitis: Complications
Comp - SN hearing loss, seizures, focal deficit, sepsis, IC abscess, hydrocephalus, brain herniation
Meningococcal septicaemia: risk of Waterhouse Friedrichsen syndrome (adrenal haemorrhage causing insufficiency)
Meningitis: CSF
Bacterial - cloudy, vv glucose, ^protein, 10-5000 polymorphs
Viral - clear/ cloudy, v glucose, norm/^protein, 15-1000 lymphocytes
TB - cloudy/ fibrin web, vv glucose, ^protein, 30-300 lymphocytes
Fungal - cloudy, vv glucose, ^protein, 20-200 lymphocytes
Aphasia
Wernicke’s: superior temporal gyrus lesion (inf left MCA)
= receptive, fluent but makes no sense, word salad, impaired comprehension
Broca’s: inferior frontal gyrus lesion (superior left MCA)
= expressive, non-fluent speech and impaired repetition, normal comprehension
Conduction: arcuate fasciculus lesion (connects B+W)
= fluent but poor repetition, normal comprehension
Global: all 3 areas affected
= expressive and receptive aphasia, may communicate using gestures
Multiple Sclerosis
Chronic cell-mediated AI demyelination of the CNS
RF - 3F:M, 20-40yrs, tropics, smoking, low vit D, EBV
Types
Relapsing-remitting: ^common, 1-2m attack then remit
Secondary progressive - deteriorated, symptoms between attacks (gait, bladder)
Primary progressive - 10%, progressive from onset.
Symptoms are disseminated in time and space
= fatigue, optic neuritis, optic atrophy, Uhthoff’s (^body temp, v vision), internuclear ophthalmoplegia, oscillopsia
= Lhermitte’s (neck flexion, limb paresthesia), pins and needles, trigeminal neuralgia
= spastic weakness (^legs), ataxia, tremor, incontinence, sex issues, intellect
MS: Management
Inv - MRI (high signal T2 lesions, periventricular plaques, Dawson fingers), CSF (oligoclonal bands, ^IgG synthesis), visual evoked potentials (delayed, well preserved)
Aim to reduce the frequency and duration of relapses
Acute relapse -> high dose PO/ IV methylpred 5d to shorten
Reducing relapse -> DMARDs if 2 relapses in 2yrs + walk (natalizumab, ocrelizumab, fingolimod, beta-interferon)
Symptoms -> amantadine (fatigue), baclofen and gabapentin (spasticity), US + catheters/ anti-Ach (bladder dysfunction), gabapentin (oscillating visual field)
Migraine
RF - 3F:M, stress, tired, alcohol, COCP, cheese, periods
= severe, unilateral, throbbing, nausea, photo/ phonophobia, last 4-72hrs, 5-60min aura precedes (scintillating scotoma)
-> PO triptan + NSAID/ paracetamol, nasal if 12-17yrs, prophylaxis with propranolol or topiramate, acupuncture
Hemiplegic migraine: aura is motor weakness, FHx
Visual Field Defects
Homonymous hemianopia: optic tract if incongruous, optic radiation/ cortex if congruous
Homonymous quadrantanopia: PiTs (parietal inferior, temporal superior)
Bitemporal hemianopia: lesion of optic chiasm, upper quadrant lost if inferior chiasm compressed (pit tumour), lower quadrant if craniopharyngioma
Raised ICP
Normally 7-15mmHg (supine), CPP = mean arterial pressure - ICP
Causes - idiopathic IC HTN, trauma, meningitis, hydrocephalus, tumour
= headache, vom, v consciousness, papilledema, Cushing’s triad (widening pulse pressure, bradycardia, irregular breathing)
Inv - CT/ MRI, invasive ICP (catheter in lateral ventricles)
-> head elevation to 30°, IV mannitol, controlled hyperventilation (v pCO2 to constrict cerebral arteries), drain/ repeated LP/ VP shunt
Oxford Stroke Classification - Anterior
Criteria
1. Unilateral hemiparesis +/- hemisensory loss
2. HH
3. Higher cognition loss
Total Anterior Circulation Infarcts (TACI): middle and ant cerebral arteries
= all 3
Partial ACI: small arteries of anterior circulation
= 2 out of 3
Oxford Stroke Classification - Lacunar and Posterior
Lacunar Infarcts: perforating arteries of internal capsule/ thalamus/ BG
= 1 of; unilateral weakness/ sensory loss (arm +/- face or leg), pure sensory stroke, ataxic hemiparesis
Posterior Circulation Infarct (POCI): vertebrobasilar
= 1 of; cerebellar/ brainstem syndrome, LOC, isolated HH
Stroke Management
-> PO aspirin 300mg (once bleed excl) for 2wks then swap to clopidogrel (or A+DP), statin at 48hrs
Thrombolysis (alteplase) if <4.5hrs and bleed excl
+/- Thrombectomy if;
<6hrs and proximal anterior occlusion on CTA (or 6-24hrs with potential to save)
<24hrs and proximal posterior occlusion on CTA
Carotid artery endarterectomy - stroke in carotid territory and >50/70% stenosis
Stroke Anticoagulation in AF
2wk asp
Stroke -> start anticoag at 2wks (warfarin or Xa inh)
TIA -> start anticoag asap after bleed excluded
TIA
Transient episode of neuro dysfunction caused by focal brain, spinal cord, or retinal ischaemia without infarction
Inv - MRI best, all get urgent carotid doppler
-> aspirin 300mg asap (unless bleeding disorder/ AC - image, on aspirin already), clopidogrel long term
-> specialist review (<24hrs if in last week, <7d if more than), no driving until assessed (1m), consider admitting if >1 (crescendo)
Syringomyelia
Collection of CSF in the spinal cord
Cause - Arnold-Chiari (herniation of cerebellar tonsils through foramen magnum), trauma, tumour
= loss of temp sensation in cape distribution, spastic weakness (^lower limb), nerve pain, upgoing plantar
Inv - full MRI of spine and brain
Comp - scoliosis over years
Ataxia Telangiectasia
AR disorder, one of the inherited combined immunodeficiency disorders
Cause - defect in ATM gene encoding DNA repair enzymes
= 1-5yrs, abnormal movements (cerebellar ataxia), telangiectasia, IgA deficiency, lymphoma/ leukaemia
Autonomic Dysreflexia
Occurs in patients with spinal cord injury at or above T6
Cause - fecal impaction/ urinary retention causes sympathetic spinal reflex (no normal parasymp)
= extreme HTN, flushing, sweating above lesion level
-> remove/ control the stimulus, treat HTN and brady
Comp - haemorrhagic stoke
Brachial Plexus Injuries
Erb-Duchenne - C5/6 damage, breech, winged scapula
Klumpke’s - T1 damage, traction injury, lose intrinsic hand muscles
Brain Abscess
Causes - middle ear, sinus, trauma, surgery, endocarditis
= dull persistent headache, fever, focal neuro (nerve palsy 2nd to ^ICP), nausea, seizures, papilledema
Inv - CT (ring enhancing lesions)
-> craniotomy, debridement, IV 3rd gen cephalosporin + metronidazole, dex
Brain Lesions
Parietal Lobe
= sensory inattention, apraxia, astereognosis/ tactile agnosia, inferior homonymous quadrantanopia, Gestmann’s syndrome (maths, fingers, R-L)
Occipital Lobe
= HH, cortical blindness, visual agnosia
Temporal Lobe
= Wernicke’s, superior HQ, auditory agnosia, facial recognition
Frontal Lobe
= Broca’s, disinhibition, preservation, anosmia, can’t list
Subthalamic nucleus of BG
= hemiballism (suddenly fling arm)
Types of Brain Tumour
Mostly supratentorial in adults, infratentorial in kids
Mets - from lung, breast, bowel, melanoma, kidney
Glioblastoma Multiforme - ^common adult primary, 1yr survival, central necrosis and enhanced rim
Meningioma - benign, from arachnoid cap cells of meninges, next to dura = compression symptoms, spindle cells and psammoma bodies on histology
Oligodendroma - benign, frontal lobe, fried egg calcification
Kids
Pilocytic Astrocytoma - ^common in kids, Rosenthal fibres
Medulloblastoma - aggressive, small blue cells in rosette
Ependymoma - 4th ventricle tumour, cause hydrocephalus
Craniopharyngioma - most common paeds supratentorial, remnants of rathke’s pouch, causes hormone issues, hydrocephalus, bitemp hemianopia
Brown-Sequard Syndrome
Lateral hemisection of the spinal cord
= below the lesion only, ipsilateral weakness, ipsilateral loss of proprioception/ vibration, contra loss of pain and temp
Cerebellar signs
V - Vertigo
A - Ataxia
N - Nystagmus (downbeat)
I - Intention tremor
S - Slurred staccato speech, Scanning dysarthria
H - Hypotonia
E - Exaggerated broad based gait
D - Dysdiadochokinesia, dysmetria
Charcot Marie Tooth Disease
Most common hereditary peripheral neuropathy, mostly motor loss
= footdrop, pes cavus, hammer toes, distal muscle weakness and atrophy (stork legs), hyporeflexia
Cluster Headache
RF: 3M:F, smokers, alcohol may trigger an attack
= 15m-2hrs of intense, sharp, stabbing pain around one eye, clusters last 4-12wks, restless, lacrimation, red, lid swelling, nasal stuffiness, miosis, ptosis
Inv - MRI with gadolinium contrast
-> 100% oxygen and SC triptan, verapamil to prevent
Common Peroneal Nerve
Branch of the sciatic nerve, risk at neck of fibula
= foot drop (+ weakness of hip abduction is L5 radiculopathy), weak dorsiflexion and eversion, weak EHL, sensory loss over dorsum of foot and lateral leg
Creutzfeldt-Jakob Disease
Prion proteins cause rapidly progressing dementia and myoclonus
Causes - 85% sporadic (65yrs), new variant (25yrs)
Inv - LP (normal CSF), EEG (biphasic, high amplitude), MRI (hyperintense in BG and thalamus)
Degenerative Cervical Myelopathy
= variable, neck/ limb pain, loss of motor function (v dexterity, gait, imbalance), numbness, incontinence, impotence, Hoffman’s sign (flick finger, others on same hand twitch)
Inv - MRI cervical spine (disc degeneration, ligament hypertrophy)
-> urgent referral to neurosurgery/ ortho, decompressive surgery <6m
Causes of PN
D - Diabetes
A - Alcohol
V - Vitamin B12 issues
I - Infective / inherited
D - Drugs (amiodarone, isoniazid, vincristine, nitrofurantoin, metronidazole)
Muscular Dystrophies
X-linked recessive, dystrophin gene on chr21
Duchenne
= progressive prox msucle weakness from 5yrs, calf pseudohypertrophy, gower’s sign, 30% v intellect
Becker
= milder form, after age 10
Childhood Epilepsy Syndromes
Infantile Spasms (West syndrome)
Usually 2nd to neuro abnormality e.g., TS
= flexion of head/ trunk/ limbs (salaam attack), progressive v intellect
-> poor prognosis, vigabatrin and steroids
Lennox-Gastaut
May be extension of West
= 1-5yrs at onset, atypical absence, falls, jerks, 90% mod mental handicap
Benign Rolandic
= boys, unilateral facial paresthesia on waking
Juvenile Myoclonic (Janz syndrome)
= teenage girls, generalised seizures after sleep deprivation, daytime absence, sudden myoclonus
Absence Seizures
Causes - hyperventilation, stress
= 4-8yr at onset, last a few seconds, no awareness
Inv - EEG (3Hz spike and wave)
-> ethosuximide, 90% seizure-free by teen
Classification of Seizures
Focal: start in specific area on one side of the brain
= aware or impaired awareness, split by location;
Temporal - (HEAD) hallucinations, epigastric rising, automatisms/ aura, deja vu/ dysphasia
Frontal - post-ictal weakness (Todd’s), Jacksonian march, posturing, head/ leg movements
Parietal - paraesthesia
Occipital - flashes, floaters
Generalised: involve networks on both sides of the brain
= all lose consciousness, split into tonic-clonic, tonic, clonic, absence or atonic
Epilepsy: Management
Tonic-Clonic
M - sodium valproate
F - lamotrigine or levetiracetam
Focal
1) Lamotrigine or levetiracetam
2) carbamazepine
Myoclonic
M - sodium valproate
F - levetiracetam
Tonic/ Atonic
M - sodium valproate
F - Lamotrigine
Absence
1) ethosuximide
2) sodium valproate for M, L/L for F
Status Epilepticus
Single seizure >5mins or 2+ without returning to baseline in between
-> A-E, PR diazepam/ buccal midazolam in community or IV lorazepam in hopsital, repeat once after 5-10mins, if ongoing use levetiracetam/ phenytoin/ SV, refractory (45mins) use GA or phenobarbital
Psychogenic Seizures
= ^females, pelvic thrusting, crying after, never occur alone, gradual onset
More likely to be true seizure if ^prolactin and tongue biting
Essential Tremor
AD, affects both upper limbs
= postural (worse when arms outstretched and on voluntary movement, better with alcohol and rest, titubation (head tremor)
-> propranolol
Subdural Haemorrhage
= fluctuating consciousness, confusion, unilateral headache
Acute (<48hrs)
Cause - high-impact trauma
Inv - CT (hyperdense crescent, not limited by sutures)
-> observe small, craniotomy for large,
Chronic (weeks-months)
Cause - rupture of small bridging veins in elderly/ alcoholic
Inv - CT (hypodense)
-> leave if no symptoms, surgical decompression with burr holes
Comp - ^ICP and herniation (low GCS, abnormal posturing, CN3 palsy, seizures)
Extradural Haematoma
Collection of blood between the skull and dura, ^middle meningeal artery due to thin skull in temporal region
Causes - low impact trauma
= lose consciousness, lucid interval (brief regain), lose again, CN palsy (fixed dilated pupil)
Inv - CT (convex, limited by suture lines)
Subarachnoid Haemorrhage
Bleed in the subarachnoid space
Causes - head injury, spontaneous (berry aneurysm, AV malformation, pit apoplexy)
= sudden onset severe occipital headache, n+v, meningism, seizures, coma
Inv - ECG (ST elevation), non-contrast CT head, if done >6hrs and neg then do an LP at 12hrs (xanthochromia), CT angiogram for cause
-> refer to neurosurgery, coil, PO nimodipine to prevent vasospasm
Comp - rebleed, hydrocephalus, vasospasm (7-14d), SIADH and v Na
Facial Nerve Palsy
Exits brainstem at cerebellopontine angle, role in face (expression), ear (stapedius), taste (ant 2/3), tear
Causes
Bilateral; sarcoid, GBS, lyme, NF2, Bell’s palsy
Unilateral; Bell’s, ramsay-hunt, acoustic neuroma, HIV, MS, DM, stroke
4th Nerve Palsy
Supplies superior oblique (moves eye down and in)
= eye is up and out, vertical diplopia (reading, downstairs), subjective tilting of objects/ head tilt
Freidreich’s Ataxia
AR, trinucleotide repeat disorder, no genetic anticipation
= 10-15yrs, gait ataxia, kyphoscoliosis, absent ankle jerk, optic atrophy, high-arched palate
Comp - 90% HOCM (^mort), DM
GCS
M (6-1) - obeys, localises to pain, withdraws, abnormal flexion, extension, none
Verbal (5-1) - orientated, confused, words, sounds, none
Eyes (4-1) - spontaneous, to speech, pain, none
Guillain-Barre Syndrome
Immune-mediated demyelination of PNS, molecular mimicry, 80% recover, 5% mort
Causes - triggered by infection (^campylobacter)
= 4wks after infection, symmetrical ascending paralysis, v reflexes, v sensation
Inv - normal WCC, LP (^protein), v motor nerve conduction, anti-GM1 Ab (25%)
-> support, VTE prophylaxis, IV Ig, plasma exchange
Miller Fisher: sub-type, eyes and descending paralysis, anti-GQ1B Ab
Huntington’s
AD, TNR disorder causing degeneration of cholinergic and GABA neurons in BG, death <20yrs of onset
Causes - Huntingtin (chr 4, anticipation)
= <35yrs, chorea (involuntary abnormal movements), personality change, v intellect, dystonia, saccadic eye movement
Idiopathic Intracranial HTN
RF - young fat F, tetracyclines, COCP, steroids, lithium
= headache, blurred vision, papilledema, enlarged blind spot, CN6 palsy
-> weight loss, acetazolamide (CA inh), LP, surgery
Internuclear Opthalmoplegia
Horizontal disconjugate eye movement
RF - MS, vascular disease
Cause - unilateral lesions in medial longitudinal fasciculus (CN6 to CN3)
= impaired ipsi adduction, contralateral horizontal abducting nystgamus/ saccade
Intracranial Venous Thrombosis
Less common cause of cerebral infarct
Subtypes
Sagittal sinus - seizures, hemiplegia
Cavernous sinus - periorbital oedema, CN6 palsy before 3/4, trigeminal issues, central retinal vein thrombosis
Lateral sinus - CN 6/7 palsy
= headache, n+v, v consciousness
Inv - MRI venography (empty delta sign in SST), non-contrast CT head (70% normal)
-> LMWH, warfarin long-term
Lambert-Eaton Syndrome
Antibody directed against VG-Ca2+ channels in PNS, inhibits release of acetylcholine
Causes - small cell lung ca, breast/ ovarian, independent AI disorder
= ^strength with repeated contraction, limb girdle weakness (legs first), v reflexes, dry mouth, impotence, LUTS, post-tetanic potentiation (reflexes temp normal after strong muscle contraction)
Inv - EMG (incremental response to repeated stim)
-> treat cause, IS, 34-diaminopyridine
Motor Neuron Disease
Progressive degeneration of U/LMN, spares sensory neurons, 50% die in 3 years
RF - >40yrs, genetics, heavy metals, smoking
= UMN + LMN signs, asymmetric limb weakness, small hand/ tibialis anterior wasting, fasciculation, no sensory/ extra-ocular/ cerebrellar
Inv - clinical, nerve conduction (normal motor), EMG (v number of APs, ^amplitude)
-> riluzole (v glutamate, ^LE by 3m), BIPAP (^LE by 7m), PEG tube
MND: Types
Amyotrophic lateral sclerosis: ^common, LMN in arms, UMN in legs
Primary lateral sclerosis: UMN signs only
Progressive muscular atrophy: LMN signs only, distal muscles first, best prog
Progressive bulbar palsy: palsy of tongue, chewing and swallowing, worst prog
Multiple System Atrophy
Degeneration of neurons in multiple systems of brain
Types - Shy-Drager syndrome
= parkinsonism, cerebellar, autonomic (impotence, postural hypotension, atonic bladder)
Progressive supranuclear palsy
A Parkinson-plus syndrome
= postural instability, falls, impaired vertical gaze (down is worse, reading/ downstairs), prominent bradykinesia, cog impairment
-> poor response to L dopa
Myasthenia Gravis
AI disorder, Ab to acetylcholine receptors in 90%
RF - 2F:M, worse with b-blockers, lithium, phenytoin, Abx
Link - thymoma, AI (pernicious, thyroid, RA, SLE)
= F<40 (M>60), fatigability (worse with activity), diplopia, prox muscles weakness, ptosis, distended neck veins with thymoma
Inv - single fibre EMG, CT thorax (excl. thymoma), ACh receptor Ab, Tensilon test (Edrophonium blocks AchE, not used anymore)
-> pyridostigmine (long acting AChE inhibitor), thymectomy, in crisis use plasmapheresis and IV Ig, monitor FVC for resp function
Pathophysiology of Myasthenia
Acetylcholine released at NMJ, antibodies block these receptors
Receptors are used more during activity so more get blocked leading to worsening weakness
In 15% there are other Ab - Muscle specific kinase and Lipoprotein receptor related protein (create and organise the receptor)
Special tests incl. repeated arm abduction, ptosis with repeated blinking, held upward gaze worsens diplopia
Myotonic Dystrophy
AD, TNR inherited myopathy, DM1 (^distal weakness), DM2 (^proximal)
= onset in 20s, long haggard face, frontal balding, bilateral ptosis, dysarthria, cataracts
Comp - DM, testicular atrophy, heart block, CM
Neuroleptic Malignant Syndrome
Dopamine blockage with antipsychotics triggers a massive glutamate release
Causes - antipsych, Parkinson’s drugs stopped/ reduced
= onset hrs-days, fever, lead-pipe rigidity, ^BP, ^HR, v reflexes, agitated delirium, confusion, AKI (2nd to rhabdomyolysis)
Inv - ^CK, leukocytosis
-> stop the antipsych, IV fluids, dantrolene, dopamine agonists (bromocriptine)
Normal Pressure Hydrocephalus
Reversible cause of dementia in elderly
RF - head injury, SAH, meningitis
Cause - 2nd to v CSF absorption in arachnoid villi
= wet (incontinent), wobbly (gait abnormality), wacky (dementia)
Inv - CT (hydrocephalus with ventriculomegaly ≠ sulcal enlargement)
-> VP shunt
Parkinsons Disease
Degeneration of dopaminergic neurons in SN
Bradykinesia = poverty of movement, short shuffling steps, v arm swinging, hard to initiate
Tremor = worse at rest/ stress/ distracted, better with voluntary movement, 3-5hz, pill-rolling, asymmetrical
Rigidity = cogwheel, lead pipe
= mask face, flexed posture, micrographia, depression, dementia, REM issues, fatigue, postural hypotension
Inv - clinical, SPECT if doubt
Parkinson’s Disease: Management
Diagnosed and started by specialist
-> levodopa if motor affecting QoL, if not use dopamine agonists/ levodopa/ MAOB inhibitor, if continues then add 2nd or COMT inhibitor
Impulse control disorders: ^risk with dopamine agonists, Hx of impulsive behaviour, Hx of alcohol/ smoking
Drug-Induced Parkinsonism
= rapid onset motor symptoms, bilateral
Rigidity and resting tremor uncommon
Paroxysmal Hemicrania
A type of trigeminal autonomic cephalgia (also contains cluster)
= attack of severe unilateral headache, usually orbital/ temporal, autonomic features, last <30mins, multiple times a day
-> completely responsive to indomethacin
Pituitary Apoplexy
Sudden enlargement of a pituitary tumour 2nd to bleed or infarct
RF - HTN, pregnancy, trauma, anticoagulation
= headache, vomiting, neck stiffness, visual field (^bitemporal superior quadrantic defect), pituitary insufficiency
Inv - MRI
->urgent steroid replacement (v ACTH), fluid balance
Post-LP headache
RF - ^needle size, direction of bevel, not replacing stylet, ^number of attempts, young skinny F
= 1-2days after, worse when upright
-> supportive, treat if >72hrs with blood patch, epidural saline or IV caffeine
Restless Legs Syndrome
Spontaneous continuous lower limb movements, may be paraesthesia
RF - FHx, iron def anaemia, uraemia, DM, pregnancy
= uncontrollable urge to move legs (akathisia), initially at night but worsens, crawling/ throbbing sensations
Inv - clinical, ferritin
-> treat anaemia, dopamine agonists (ropinirole, pramipexole)
Reye’s Syndrome
Severe progressive encephalopathy, associated fatty infiltration of the liver kidneys and pancreas
RF - aspirin use in children
= 2yrs, Hx preceding virus, confusion, seizures, cerebral oedema, v glucose
-> supportive, 20% mort
Spontaneous Intracranial Hypotension
Rare cause of headaches caused by CSF leak from the thoracic nerve root sleeves
RF - CTD e.g., Marfan’s
= headache worse when upright
Inv - MRI with gadolinium
-> conservative, epidural blood patch
Subacute Combined Degeneration of the Cord
Due to vit B12 deficiency, affects DC/ lateral CS/ SC tracts
= distal sensory loss (^legs), loss of proprioception and vibration, spastic muscle weakness, ^ knee jerk, absent ankle jerk, Rhomberg +ve, abnormal gait
Thoracic Outlet Syndrome
Compression of brachial plexus, subclavian artery/ vein
RF - 40yrs, thin F, long neck, drooping shoulders, cervical rib
Neurogenic (90%)
= painless wasting of hand, hand weakness, numbness
Vascular
= diffuse arm swelling vs painful claudication
Inv - CXR, cervical spine XR, CT/ MRI, venography/ angio
-> conservative for neuro, surgery if fails or vascular
Trigeminal Neuralgia
Cause - idiopathic, compression of trigeminal root
= unilateral electric shock like pains, abrupt onset and termination, brought on by light touch/ spont
-> carbamazepine, refer to neuro if no response
Red flags incl;
Sensory changes
Deafness
Pain only in ophthalmic division
Optic neuritis
FHx of MS
Age <40yrs
Neurofibromatosis
AD, neurocutaneous disorders
NF1: Chr17
= cafe au lait spots, axillary/ groin freckles, peripheral neurofibromas, iris hamartoma (Lisch nodules), scoliosis, phaeochromocytoma
NF2: Chr22
= bilateral AN, other neuro tumours
Tuberous Sclerosis
AD, neurocutaneous disorder
= depigmented ash-leaf spots (fluoresce under UV), Shagreen patches (rough lumbar), angiofibroma (butterfly over nose), subungual fibromata, cafe au lait spots, developmental delay, v intellect, epilepsy
Organ involvement - retinal hamartomas (white), heart rhabdomyoma, glioma, PCKD, lung cysts
Von Hippel-Lindau
AD, predisposition to neoplasia, Chr3
= Cerebellar and retinal hemangiomas, renal/ pancreatic/ liver cysts, phaeochromocytoma, clear cell RCC
Wernicke’s Encephalopathy
Neuropsychiatric disorder caused by thiamine deficiency
RF - alcoholism, persistent vomiting, stomach ca, diet
= nystagmus, ophthalmoplegia, gait ataxia, encephalopathy
Inv - v red cell transketolase
-> urgent replacement of thiamine
Comp - if not treated can lead to Korsakoffs syndrome (ant/retrograde amnesia and confabulation)
NICE CT head guidelines
Within 1 hour:
GCS <13 initially or <15 at 2hrs
Suspect open/ depressed/ basal skull fracture
Seizure
Focal neuro issue
>1 vomit
Within 8 hours: warfarin, or LOC/ amnesia +
65+
Bleeding / clotting issues / on AC
>30min retrograde amnesia
Dangerous mechanism - height of 1m or 5 stairs
Upper Limb Dermatomes
C4 - AMC joint
C5 - regiments patch
C6 - thumb
C7 - middle finger
C8 - palmar little finger
T1 - medial ACF
Upper Limb Myotomes
C4 - shoulder shrugs
C5 - shoulder abduction and external rotation
C6 - wrist extension
C7 - wrist flexion and elbow extension
C8 - thumb extension and finger flexion
T1 - finger abduction
Pneumonic for Leva dopa side effects
D - dyskinesia
O - on and off effect
P - psychosis
A - arterial Bp low
M - mouth dry
I - insomnia
N - n+v
E - excessive daytime somnolence
Pontine Haemorrhage
Complication of chronic HTN
= reduced GCS, quadriplegia, bilateral miosis
UMN signs vs LMN signs
UMN - ^tone, ^reflexes, upgoing planar, pyramidal weakness (extensors weaker than flexors in arms, opposite in legs)
LMN - v tone, v reflexes, downgoing plantar, wasting, fasciculations
Common side effect of spinal anaesthesia
Low pressure headache
Mononeuritis Multiplex vs Polyneuropathy
Mononeuritis - non-contiguous nerves (different nerves all over body)
Polyneuroapthy - all from similar sites of body
Anterior Spinal Artery Occlusion
Affects lateral corticospinal/ ST tracts
= bilateral spastic paresis, bilateral loss of pain and temperature sensation
Neurosyphilis (Tabes Dorsalis)
Affects dorsal column
= loss of proprioception and vibration, normal motor
