Neuro Flashcards
Treatment of CVA
If CT shows ischaemia
Thrombolysis within 4.5 hours
Thrombectomy if within 6 hours with thrombolysis for proximal anterior circulation demonstrated by CTA
If unable to- aspirin 300mg for 2 weeks
If thrombolysis given- aspirin 24 hours after repeat CT
Ix for SAH
CT head- non contrast
>12 hrs later- LP for xanthochromia
CI to thrombylysis
ABC SHIP
Bleeding- GI bleed in 3 weeks, LP in 7 days
Coagulation problems
Stroke <3 months
Uncontrolled Hypertension- >200
Intracranial neoplasm
Pregnancy
Scoring systems of stroke
NIHSS- quantifies severity
ROSIER- differentiate between strokes and mimics
Mx of TIA
Aspirin 300mg
Unless taking warfarin, DOAC, bleeding disorder- CT head
Or >7d since sx
When to give carotid endarterectomy
When occlusion is >70%
What is total anterior circulation infarct and its symptoms
Middle and anterior cerebral
Unilateral hemiparesis +/- hemisensory
Homonymous hemianopia
Cognitive dysfunction
Posterior inferior cerebellar infarct symptoms
Lateral medullary syndrome Loss of pain and temp ipsilateral face, loss on contralateral limbs
Ataxia, nystagmus
Can get difficulty swallowing
Anterior inferior cerebellar infarcts
Loss of pain and temp ipsilateral face, loss on contralateral limbs
Ipsilateral paralysis and deafness - hearing is AICA over PICA
Ataxia, nystagmus
Can get difficulty swallowing
Vestibular schwannoma symptoms
Vertigo, hearing loss, tinnitus
Absent corneal reflex
Associated with NFM 2
Canvernous sinus thrombosis affects
Cranial nerves V1+2
3+4+6
What Ix for MG
Tenilson test
AchR AB
CXR- thymic hyperplasia
What can cause normal pressure hydrocephalus
SAH
Meningitis
Trauma
Types of focal seizures and symptoms
Aware and unaware or evolving into generalised typically tonic clonic
Temporal-hallucinations, lip smacking
Frontal- head movements
Occipital- floaters
Parietal- parasthesia
Symptoms of GBS
Ascending weakness LMN
After GE or STI
Secondary prevention of CVA
Clopidogrel 75mg
Tx of SAH
Coiling
Parkinsonism vs parkinsons
Parkinsonism- symmetrical, rapid, poor response to levadopa
Parkinsons- asymmetrical, progressive, good response
Parksonism
A group of neurological disorders that cause movement problems similar to those seen in Parkinson’s disease such as tremors, slow movement and stiffnes
Parkinson plus syndromes
MSA- autonomic dysfunction- postural hypotension, cerebellar ataxia- falls, ED
Vertical gaze palsy- postural instability falls, speech, dementia
CBD- unilateral parks, aphasia, alien limb
Dementia with LB- hallucinations
Tx of Parkinson’s
Levadopa with dopa decarboxylase
Co-careldopa
Tx of epilepsy
Tonic clonic- valproate, females- lamotrigine or leve
Absence-Ethosuximide
Myoclonic- valproate, female- leve
Tonic/atonic- valproate, female- lamo
Focal- lamo/leve
SE management
ABC
Pre-hospital- PR diazepam/buccal midazolam, hospital IV lorazepam
Second dose after 10-20 mins then phenytoin then ICU after 45 mins
CT head immediately guidelines
FFS
GCS <13
Vomit >1
Fracture of skull
Focal neurological deficit
Seizure
CT head within 8 hours
LOC/amnesis AND
Age >65
Bleeding disorder
Cant remember- Retrograde amnesia >30 mins
Dangerous MOI
Sx of raised ICP
Headache- worse leaning forward
Altered GCS- focal neuro
Cushing response- high BP, low HR, irregular breathing
Papiloedema
Horners syndrome
Miosis
Ptsosis
Anhydrosis
Mx of cauda equina
PO dexa
Decompressive laminectomy
Mx of spinal compression
Dex or surgery
Differentials for headache
Tension- tight band, bilateral
Cluster- around eye
Migraine- aura, throbbing, unilateral
Temporal arteritis- jaw claudication
Med overuse- worse with meds
Types of MND
Amyotrophic Lateral Sclerosis- LMN in arms, UMN in legs
Primary Lateral Sclerosis- UMN
Progressive Muscular Atrophy- LMN distal before- best prognosis
Progressive Bulbar Palsy- palsy of tongue, facial- worst prognosis
Causes of tremor
Parkinsons- stiff, resting
Essential – worse if outstretched, improved by rest and alcohol, FH
CO2 retention- COPD
Cerebellar- intention- with nystagmus, past pointing
Types of MS
Replase-remitting- acute attacks last 1-2m
Primary progressive
Secondary progresive- RR to this, gait and bladder too
Progressive remitting
Sx of MS
TEAM
Tingling
Eye- optic neuritis
Ataxis- other cerebellar- DANISH- dysdiadokinesia, ataxia, nystagmus, intention tremor, slurred speech, hypotonia
Motor- spastic
Warm temps- make worse
Ix of MS
Lp- IgG oligoclonal bands
AB- Anti MBP
Prognostic signs for MS
Good- female, sensory lesions, <25, long intervals in relapse
Mysthenic crisis sx and tx
Reduced RR with MG
Ix- ABG
Mx- plasmapheresis, IVIG, intubation
Ix of MG
Single fibre EMG
Anti-AchR
Mx of MG
Symptomatic- pyridostigmine after diagnosis
Immunosuppress- prednisilone eventually
Thymectomy
UMN signs
Increased tone
Reduced reflexes
Reduced power
Babinski +ve- upgoing plantars
Causes of peripheral neuropathy
Infection
Metabolic- DM, sensory predominant , ETOH sensory then motor
Autoimmune
Vit B12 def
Cerebellar vs vestibular nystagmus
Cerebellar- fast phase towards lesion
Maximal towards
Vestibular- away
Causes of Quadranopia
PITS- parietal inferior, temporal superior
Parietal superior radiation
Temporal- inferior
Causes of bitemporall hemianopia
Pituitary- superior
Craniopharyngioma- inferior
3rd nerve palsy sx
Down and out
Ptosis
Dilated pupil
Wernickes vs Brocas aphasia
Werncikes- receptive
Broca- expressive
Left posterior inferior cerebral artery Sx
Webers syndrome
Contralateral UMN of limbs
Ipsilateral CN3
Cluster headaches Tx
Oxygen
Triptan
Prophylaxis- verapamil
When do you need a CT for pupil sx
If pupil is unreactive to light and dilated
No para- meaning being compressed
Mx of acute MS flare up
IM methyprednisilone
Medical vs surgical 3rd nerve palsy
Medical- ptsosis and abducted
Surgical- dilated due to compression
Idiopathic intracranial hypertension sx
Secondary to impaired drainage
Causes raised ICP
Tinnitus
Affects young obese women
6th nerve palsy
Papiloedema
Change in acuity when changing posture- visual obscuration
Blood supply of Wernickes and Broca area
Wernickes- Inferior left MCA- superior temporal gyrus
Broca- superior left MCA- inferior frontal gyrus
Stroke mx after 4.5 hrs
Aspirin 300mg
Amurosis Fugax
Affects retinal/opthalmic artery
A temporary loss of vision in one or both eyes due to a lack of blood flow to the retin
Degenerative cervical myelopathy sx, dx and mx
Compression of spinal cord in neck
Poor coordination
Pain in neck
loss of sensory and motor
Hoffman sign- flick finger, another fingers twitches
MRI and surgery urgent
Nacolepsy ix
Multiple sleep latency EEG
Bells palsy Mx
10 day course of Pred
If no improvement after 3weeks- urgent referral to ENT
Main Ix of status epilepticus
Rule of hypoxia and hypoglycaemia
BM and ABG
Neuroleptic malignant syndrome sx
pyrexia
muscle rigidity
autonomic lability: typical features include hypertension, tachycardia and tachypnoea
agitated delirium with confusion
Elevated CK
Starts soon after starting new AP
Where touch and proprioception nerves travel
Dorsal columns
Where pain and temp nerves run
Spinothalamic columns
Scale that measures how stroke patients cope with ADLS
Barthel index
Tx of bells palsy
Prednisilone- 3w follow up- no improvement- ENT
Imaging of TIA
Diffuse weighted MR
SAH meds
Nimodipine for vasospasm
Epidural haemorrhage sx
Injury, lucid, LOC
Levadopa SEs
On off effect
Postural hypotension
Arrythmias
Psycosis
Red urine
When shouldn’t you do an LP in meningitis
Sepsis or rash
Bleeding risk
Raised ICp
Tx of brain mets
Dexamethasone
Syringomyelia sx
Fluid cavity- Chiari malformation
Cape like- neck shoulders, arms - loss of temperature and pain- spinothalamic tract - compression of anterior white commissure
Ventral horns- flaccid paralysis
Ix of syringomyelia
MRI spine
Tx of Parkinsons when NBM
Dopamine agonist patch
Pernicious anaemia neuro sc
Peripheral neuropathy- pins and needles
Subacute combined degeneration of spinal cord- progressive weakness
Psychiatric disorder
Sx of Guillain Barre
Ascending
Progressive
Symmetrical
Reflex absent
Sensory- mild
Normal pressure HC sx
Wide gait- ataxia
Urinary symptoms
Cognitive impairment
Wernickes sx
Altered mental state
Ataxic gait
Opthalmoplegia
Korsakoff sx
Wernickes
Plus confabulation and amnesia
Causes of vertigo
Viral labrythitis
Vestibular neuronitis
BPPV
Menieres
Acoustic neruoma
Labrynthitis vs vest neuronitis vs menieres vs BPPV
Recent infection- labry, neuronitis
Lab- hearing loss sometimes, not in neuro
Menieres- fullness- hearing loss, tinnitus
BPPV- short, triggered by head position
Parkinson tx that causes personality changes
Dopamine agonist
Ropinirole
Types of speech disorder
Wernickes- speech fluent, comprehension impaired, repetition imapired
Broca- speech broken
Conduction- link between 2- speech fluent but repetition is poor
Global- affecting all
When are you allowed to stop AED
If seizure free for 2 years
With AEDs stopped 2-3 months
Cerebellar stroke Sx
Ataxia
Nystagmus
Features of cluster headaches
Last 15 min-2 hours
Clusters- 4-12 weeks
Lacrimation, redness
Nasal stuffiness
Factors favouring true seizure over pseudo seizure
Raised prolactin
Tongue biting
Sudden onset
Sx of sinus thrombosis
Headache
N+V
Reduced consciousness
RF of venous thrombosis
Gradual onset
Ix of sinus thrombosis
MRI venography
Usually CT head first
Sign for differentiating between organic and nonorganic lower leg weakness
Hoover sign
Tell them to press down with weak side- will show no affect
Then next flex hip of contralateral (normal) side
If weak side extends (you fell it push down) - non organic
Medication for spasticity in MS
Baclofen or gabapentin
Dx to decrease relapses of MS
Natalizumab
Which drugs should be avoided in MG
AB- gentamicin, macrocodes
Beta blockers
Lithium
Phenytoin
Dx of young obese female with headache/blurred vision?
Idiopathic intracranial HTN
Can cause papiloedema
Ix for suspected demyelination
MRI with contrast
What should be measured for an alternative diagnosis to TIA
Glucose- hypo can mimic TIA
Types of cerebellar lesions
Hemisphere- peripheral ataxia- finger nose
Vermis- gait ataxia
If someone in public having a stroke, appropriate action?
999- -medical emergency
Only give aspirin once haemorrhage ruled out
Efferent vs afferent defect in the eye
Efferent- ipsilateral doesn’t , opposite eye will react
Afferent- consensual reflex will not work
Ix for vestibular schwannoma
Audiogram and gadolinium enhanced MRI head- cerebellopontine angle
ECG if unresponsive patient with SAH
Torsades pe pointes
Tx of stroke vs TIA with AF as the cause
Stroke- Aspirin 300mg 2 weeks then AC
TIA- AC immediately
Mononeuropathy multiplex vs polyneuropathy
Both peripheral neuropathy
Poly-symmetrical
Mono- not
Causes of injury of median, radial and ulnar nerve
Radial- humeral shaft
Supracondyl- ulnar and median less
Proximal humerus- axillary
Sx of migraine more common in children
GI disturbance
Sensory innervation of hand
Ulnar- median side of palm and dorsal
Median- lateral side of palm
Radial- dorsal side but not finger tops
Neuropathic pain tx
Amitriptyline, duloxetine, gaba or pregabalin
Switch to another if not working
Tramadol used as rescue therapy
How long do chronic subdural take to present
4-7 weeks
Tx of hydrocephalus
VP shunt
Saggital sinus thrombosis sx
Headache, diploma, bilateral papiloedema
Empty delta sign on CT venography
Cavernous sinus syndrome
Opthalmoplegia
Proptosis
Periorbital oedema
MRC power grade
0- no movement
1- flicker
2- between
3- against gravity
4-between
5- normal
Raised ICP symptoms
Cushing triad- irregular breathing, hypertension, bradycardia
Damage to lower brachial plexus
Klumpke palsy
Lower brachial palsy - forceful abduction or radiotherapy
C8-T1
Sensory loss
Hand muscle weakness
Damage to upper brachial plexus
Erbs palsy
Waiter tip sign
C5-6 dermatome loss- upper arm
Tx of trigeminal neuralgia
Carbmazepine
Subacute combined degeneration of the spinal cord
B12 deficiency
Presents With sensory and UMN due to dorsal and cortical column degeneration
Peripheral neuropathy may be seen as a confounder with it
Imaging of brain mets
MRI
Inheritance of Charcot Marie tooth
AD
Features of Charcot Marie tooth
Starts at puberty
Motor
Distal wasting
Pes cavus- high arch
Foot drop, leg weakness
Can get some sensory loss too
Increase urination with lower homonymous hemianopia
Cranipharyngioma
Paroxysmal hemicrania sx and tx
Unilateral severe headache- autonomic features
Tx with indomethacin
Tx of stroke and TIA with and without AF
Aspirin 300mg daily for 2 week Then AC with AF
If TIA start immediately
Without- clopidogrel 75mg after 2 weeks
Neurofibromatosis vs tuberous sclerosis
Ash leaf spots- hypo pigmented , epilepsy, retinal hamartomas, subungal fibromata - TS
Cafe au lait, phaeo, acoustic neuromas- NFM
Neuroliptic malignant syndrome fx and tx
Pyrexia
Muscle rigidity
Raised CK- lead to rhabdo
High WCC
Bromocriptine
Tx of spasticity in MS
Baclofen
Tx of pain, urgency and tremor in MS
Pain- amitriptyline
Urgency- oxybutynin
Tremor- clonazepam
Tx of subdural haemorrhage
Acute- decompressive craniectomy
Chronic- Burr hole
HIV patient with brain lesion- ring enhancing vs homogenous
Homogenous- lymphoma
Ring- abscess- toxoplasmosis
Tx of idiopathic intracranial HTN
Acetazolamdie
Pontine haemorrhage sx
Pin point pupils
Quadraplegia
If young and had a stroke what ix to do to try identify cause
AI and thrombophilia screen
Mx of restless leg syndrome
Dopamine agonist
Ropinirole
When to start anti epileptic treatment after first seizure
Neuro Deficit
Structure abnormality on imagine
Epileptic activity EEG
If spinal MRI shows several lesions and too frail for surgery
Radiotherapy
When can you drive after TIA
1 month free of sx no need to inform DVLA
Most important causes of SE to rule out
Hypoxia and hypoglycaemia
Jacksonian movememtns
Frontal lobe epilepsy
Clonic movements travelling proximally
Drug for atonic/tonic seizures female
Lamotrigine
Drug for myoclonic seizures females
Levetiracetam
Tx of brain abscess
ceftriaxone and metronidazole
If high suspicion of spinal cord compression due to bone mets what should you do
MRI and prescribed dexamethasone whilst waiting
If ct done <6 hours of sx of SAH show nothing what to do next
Consider alternate diagnosis
When does diffuse axonal injury happen
Head rapidly accelerated or decelerated
Often no signs
If GP and Parkinson’s symptoms what do you do
Refer urgently to neuro
What medication increases risk of II HTN
Tetracycline
Fludrocortisone
AMiodaron
INO on examination
Affected side abducts
Contralateral fails to adduct
Eye signs in MS
Red desaturation
INO
Painful eye with reduced acuity
Which medication are ototoxic
Gentamicin
Vancomycin
Furosemide
If CT shows nothing for acute stroke what imaging next
Diffuse weighted MRI- appears bright
First seizure driving rules
Inform DVLA do not drive for 6 months
Essential tremor Tx
Worse with intention
BB
Charles bonnet syndrome
Visual loss causing hallucinations
Atonic vs tonic falls when having a seizure
Atonic- loss of tension- forwards
Tonic- back spasm- backwards
Todds paralysis
Paralysed after seizure for 10hrs - 1d
SE of phenytoin
Gingival hypertrophy
Aplastic anaemai
Hypocalaemia
SE of lamotrigine
SJS
SE of ethosuximide
Night tremors
What can intraventricular bleeds cause
Hydrocephalus- reducing GCS
Raised ICP ventilation tx
Controlled hyperventilation
Reduces CO2 causing vasoconstriction- reducing pressure
Nerve affected in herniation
CN 3- down and out
4th CN palsy
Weak adduction and depression
Eye goes out and up
6th nerve palsy
Weak abduction
Acute intermittent porphyria px
Abdominal pain
Neuro and psych sx
MND motor/nerve conduction studies
Normal
Tx of bac meningitis >50
Cef and amox
Phenytoin SE
Peripheral neuropathy
Gum hypertrophy
Aplastic anaemia
When are triptans CI
In patents with CAD
Should avoid SSRI with them- serotonin syndrome
Tracts affected in subacute degeneration of spinal cord and sx
Lateral corticospinal tracts - motor - bilateral spastic paresis
Dorsal columns - sensory- loss of proprioception, sensory and vibration- start in legs
Spinocerebellar - cerebellar - ataxia
Tracts affected in Fredriech’s ataxia and sx
Lateral corticospinal tracts - motor - bilateral spastic paresis
Dorsal columns - sensory- loss of proprioception, sensory and vibration- start in legs
High arched palate, per caves, kyphoscoliosis
Spinocerebellar - cerebellar - ataxia, intention tremor
Anterior spinal artery occlusion
Lateral corticospinal- spastic paresis
Lateral spinothalamic- loss of pain and temp bilaterally
Loss of corneal reflex nerve damage
V1
Mx of MND with lack of eating
PEG
Pyridostigmine moa
Long acting ACHe Inhibitor
Median nerve motor function
LOAF
Lateral lumbicals
Opponens, abductor and flexor polices
Thoracic outlet syndrome sx
Tingling, muscle wasting
Cervical rib
Types of MS
Relapse remitting - sx then no sx
Primary progressive - gets worse
Secondary progressive- RR and progress
Miller Fischer variant of GBS
Ophthalmoplegia, areflexia and ataxia
Descending paralysis
Transverse myelitis sx
Acute
Sensory and UMN below
MS or infection
Coming off opioids and triptans
Wean opioids and stop Tristan abruptly
Autonomic dyreflexia sx
Extreme HTN
Flushing
Sweating above cord lesion
Can cause haemorrhage stroke
Ulnar nerve muscle innervation
Hypothenar- abductor, flexor digits minimi
Adductor pollicis
Interossei
Medial lumbricals
Ix of TIA
BP, ECG, carotid USS< bloods- lipid profile, glucose, clotting
Signs on CT of infarct over time
Hyperacute- hyper dense artery, loss of white grey interface
Acute- hypodense
Painful 3rd nerve palsy cause
Posterior communicating artery rupture
What muscles are spared in MND
Ocular
Where bleed occurs in subdural haemorrhage
Bridging veins between cortex and venous sinus
Headache red flags
Systemic- fever, cancer
Neuro signs
Onset sudden
Onset- thunder
Papilloedema
Mx of drug induced Parkinson’s tremor
Procyclidine
What can happen if you stop levodopa abruptly
Can cause acute dystonia
What PD medication can cause impulse disorder
Dopamine agonist
If clopidogrel not tolerate for stroke
Give aspirin 75mg and modified release dipyridamole
Which medications increase mortality in dementia patients
AP
How to tx on off effect of levodopa
Increase frequency of it
Which sided lesions to cranial nerves cause
Same side as do not cross over
Apart from 4th CN
Anti emetic for PD
Domperidone
Triptan SE
Tight chest
Tingling
Heat
Cause of waddling gait
Weak hips- myopathy
Move trunk to move hips
LEMS- affects legs first
Saturday night palsy
Radial nerve compression
Unable to extend wrists
Main way to distinguish between levy body and idiopathic PD
Lewy- dementia before motor
IPD- motor before
Essential tremor sx
Increased with more muscle tone
Can affect vocal cords
Tx of GBS
IVIG
CDIP- chronic- steroids
Intercerebral haemorrhage after Ischameic infarct tx
Stop aspirin and BP control
CN for corneal reflex and mastication muscle
Trigeminal
CN causing vertical diplopia
Trochlear
Valproate SE
Vomiting
Anorexia
Liver toxicity
Pancreatitis
Retention of weight
Oedema
Alopecia
Teratogenicity, tremor
Enzyme inhibitor
Which epilepsy is carbmazepine CI in
Myoclonic and absence
Most common form of MND
ALS
Stroke and allergic to clopidogrel Mx
Aspirin and dipyridamole lifelong
Posterior circulation infarcts classification
presents with 1 of the following:
1. cerebellar or brainstem syndromes
2. loss of consciousness
3. isolated homonymous hemianopia- can be macula sparing
Isolated high protein in LP
GBS
Only cervical nerve root to exit under vertebra
C8 under C7- all others on top
All other nerve roots under after
Locked in syndrome infarct
Basillar artery
AchE side effects
GI- N+V, diarrhoea
Fatigue, dizziness
Most common cause of amaurosis fugax
Atherosclerosis of internal carotid
Brain abcess vs tumour on MRI
Diffuse restricting- abscess
Multiple ring enhancing lesions HIV patient with focal neuro signs
Toxoplasmosis
Charcot marie tooth vs Fredrichs vs MND presentation
CMT- wasting small hands first, pet vacus, hyperkyphosis
Fredrichs- cerebellar
MND- fasciculations, no ocular, sensory or cerebellar signs, cramps and spasms
Causes of 3rd nerve palsy
Vascular- stroke, CS thrombosis
Lesion- malignancy, abscess
DM
Diplopia when looking down stairs
4th CN palsy
Rigidity vs spasticity
Rigidity- not velocity dependent
PD
Spasticity- velocity- stroke
Cause of cerebellar syndrome
MS- days, SOL- years, infection- days, stroke- minutes
Types of ataxia
Cerebellar- broad gait, overshoot
Sensory- broad, stamping, Romberg +
Level spinal cord finishes at
L1-2
Driving rules with epilepsy
Must be seizure free for 1 year before getting licence back
If withdrawing medication- must not drive for 6 months
When to do CT neck immediately
GCS <13
Intubated
Clinical suspicion and >65, neuro deficit, high impact or parasthesia
What should you avoid with cluster headaches
Alcohol
Kernig and Brudsinski sign
Kernig- knee extension causes pain
Brudsinski- neck flexion causes knee flexion
If had a CT and shows intercerebrayl bleed and patient deteriorates what should you do
Second CT to check for hydrocephalus
When to measure phenytoin conc
Before next dose
Signs og atonic seizure in face
Eyelid droop or head nodding
