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Neuro Flashcards

1
Q

Stroke Patterns by Anatomy

A

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

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2
Q

Third Nerve Palsy

A

Causes - PCA aneurysm (dilated, pain), cavernous sinus thrombosis, Weber’s, DM, vasculitis (TA, SLE), ^ICP

= down and out eye, ptosis, mydriasis if surgical

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3
Q

Encephalitis

A

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

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4
Q

Bell’s Palsy

A

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

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5
Q

Meningitis: Causes

A

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

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6
Q

Meningitis

A

= 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

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7
Q

Meningitis: Complications

A

Comp - SN hearing loss, seizures, focal deficit, sepsis, IC abscess, hydrocephalus, brain herniation

Meningococcal septicaemia: risk of Waterhouse Friedrichsen syndrome (adrenal haemorrhage causing insufficiency)

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8
Q

Meningitis: CSF

A

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

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9
Q

Aphasia

A

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

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10
Q

Multiple Sclerosis

A

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

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11
Q

MS: Management

A

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)

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12
Q

Migraine

A

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

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13
Q

Visual Field Defects

A

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

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14
Q

Raised ICP

A

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

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15
Q

Oxford Stroke Classification - Anterior

A

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

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16
Q

Oxford Stroke Classification - Lacunar and Posterior

A

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

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17
Q

Stroke Management

A

-> 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

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18
Q

Stroke Anticoagulation in AF

A

2wk asp

Stroke -> start anticoag at 2wks (warfarin or Xa inh)

TIA -> start anticoag asap after bleed excluded

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19
Q

TIA

A

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)

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20
Q

Syringomyelia

A

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

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21
Q

Ataxia Telangiectasia

A

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

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22
Q

Autonomic Dysreflexia

A

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

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23
Q

Brachial Plexus Injuries

A

Erb-Duchenne - C5/6 damage, breech, winged scapula

Klumpke’s - T1 damage, traction injury, lose intrinsic hand muscles

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24
Q

Brain Abscess

A

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

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25
Q

Brain Lesions

A

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)

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26
Q

Types of Brain Tumour

A

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

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27
Q

Brown-Sequard Syndrome

A

Lateral hemisection of the spinal cord

= below the lesion only, ipsilateral weakness, ipsilateral loss of proprioception/ vibration, contra loss of pain and temp

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28
Q

Cerebellar signs

A

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

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29
Q

Charcot Marie Tooth Disease

A

Most common hereditary peripheral neuropathy, mostly motor loss

= footdrop, pes cavus, hammer toes, distal muscle weakness and atrophy (stork legs), hyporeflexia

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30
Q

Cluster Headache

A

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

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31
Q

Common Peroneal Nerve

A

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

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32
Q

Creutzfeldt-Jakob Disease

A

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)

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33
Q

Degenerative Cervical Myelopathy

A

= 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

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34
Q

Causes of PN

A

D - Diabetes
A - Alcohol
V - Vitamin B12 issues
I - Infective / inherited
D - Drugs (amiodarone, isoniazid, vincristine, nitrofurantoin, metronidazole)

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35
Q

Muscular Dystrophies

A

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

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36
Q

Childhood Epilepsy Syndromes

A

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

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37
Q

Absence Seizures

A

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

38
Q

Classification of Seizures

A

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

39
Q

Epilepsy: Management

A

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

40
Q

Status Epilepticus

A

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

41
Q

Psychogenic Seizures

A

= ^females, pelvic thrusting, crying after, never occur alone, gradual onset

More likely to be true seizure if ^prolactin and tongue biting

42
Q

Essential Tremor

A

AD, affects both upper limbs

= postural (worse when arms outstretched and on voluntary movement, better with alcohol and rest, titubation (head tremor)

-> propranolol

43
Q

Subdural Haemorrhage

A

= 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)

44
Q

Extradural Haematoma

A

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)

45
Q

Subarachnoid Haemorrhage

A

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

46
Q

Facial Nerve Palsy

A

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

47
Q

4th Nerve Palsy

A

Supplies superior oblique (moves eye down and in)

= eye is up and out, vertical diplopia (reading, downstairs), subjective tilting of objects/ head tilt

48
Q

Freidreich’s Ataxia

A

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

49
Q

GCS

A

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

50
Q

Guillain-Barre Syndrome

A

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

51
Q

Huntington’s

A

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

52
Q

Idiopathic Intracranial HTN

A

RF - young fat F, tetracyclines, COCP, steroids, lithium

= headache, blurred vision, papilledema, enlarged blind spot, CN6 palsy

-> weight loss, acetazolamide (CA inh), LP, surgery

53
Q

Internuclear Opthalmoplegia

A

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

54
Q

Intracranial Venous Thrombosis

A

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

55
Q

Lambert-Eaton Syndrome

A

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

56
Q

Motor Neuron Disease

A

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

57
Q

MND: Types

A

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

58
Q

Multiple System Atrophy

A

Degeneration of neurons in multiple systems of brain

Types - Shy-Drager syndrome

= parkinsonism, cerebellar, autonomic (impotence, postural hypotension, atonic bladder)

59
Q

Progressive supranuclear palsy

A

A Parkinson-plus syndrome

= postural instability, falls, impaired vertical gaze (down is worse, reading/ downstairs), prominent bradykinesia, cog impairment

-> poor response to L dopa

60
Q

Myasthenia Gravis

A

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

61
Q

Pathophysiology of Myasthenia

A

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

62
Q

Myotonic Dystrophy

A

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

63
Q

Neuroleptic Malignant Syndrome

A

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)

64
Q

Normal Pressure Hydrocephalus

A

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

65
Q

Parkinsons Disease

A

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

66
Q

Parkinson’s Disease: Management

A

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

67
Q

Drug-Induced Parkinsonism

A

= rapid onset motor symptoms, bilateral

Rigidity and resting tremor uncommon

68
Q

Paroxysmal Hemicrania

A

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

69
Q

Pituitary Apoplexy

A

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

70
Q

Post-LP headache

A

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

71
Q

Restless Legs Syndrome

A

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)

72
Q

Reye’s Syndrome

A

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

73
Q

Spontaneous Intracranial Hypotension

A

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

74
Q

Subacute Combined Degeneration of the Cord

A

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

75
Q

Thoracic Outlet Syndrome

A

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

76
Q

Trigeminal Neuralgia

A

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

77
Q

Neurofibromatosis

A

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

78
Q

Tuberous Sclerosis

A

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

79
Q

Von Hippel-Lindau

A

AD, predisposition to neoplasia, Chr3

= Cerebellar and retinal hemangiomas, renal/ pancreatic/ liver cysts, phaeochromocytoma, clear cell RCC

80
Q

Wernicke’s Encephalopathy

A

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)

81
Q

NICE CT head guidelines

A

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

82
Q

Upper Limb Dermatomes

A

C4 - AMC joint
C5 - regiments patch
C6 - thumb
C7 - middle finger
C8 - palmar little finger
T1 - medial ACF

83
Q

Upper Limb Myotomes

A

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

84
Q

Pneumonic for Leva dopa side effects

A

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

85
Q

Pontine Haemorrhage

A

Complication of chronic HTN

= reduced GCS, quadriplegia, bilateral miosis

86
Q

UMN signs vs LMN signs

A

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

87
Q

Common side effect of spinal anaesthesia

A

Low pressure headache

88
Q

Mononeuritis Multiplex vs Polyneuropathy

A

Mononeuritis - non-contiguous nerves (different nerves all over body)

Polyneuroapthy - all from similar sites of body

89
Q

Anterior Spinal Artery Occlusion

A

Affects lateral corticospinal/ ST tracts

= bilateral spastic paresis, bilateral loss of pain and temperature sensation

90
Q

Neurosyphilis (Tabes Dorsalis)

A

Affects dorsal column

= loss of proprioception and vibration, normal motor

ALS (22 decks)

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