Neuro Flashcards
Stroke definition
Syndrome rapid onset cerebral deficint lasting >24 hours or leading to death
RF ischaemic stroke
- HTN
- Smoking and alcohol
- Cholesterol
- Obesity
S+S ischaemic stroke
- FAST
- Limb weakness on opposite side infarct
- Contralateral hemiplegia/hemiparesis
- Vision loss/deficit
- HH
- Aphasia
Ix ischaemic stroke
- NCCT
- MRI
- Brachial BP
- Bloods, XR, ECG
- If CT shows hyper density = haemorrhagic
Ischaemic stroke acute Mx
- Thrombolysis within 4.5 hours onset
- IV alteplase
Ischaemic stroke long term Mx
- Antihypertensives
- Antiplatelet = long term aspirin, clopidogrel
Thrombolysis contraindications
- Recent surgery 3 months
- Recent arterial puncture
- Hx active malignancy
- Brain aneurysm
- Anticoagulation
- Liver disease or pancreatitis
Haemorrhagic stroke Mx
- Stop anticoagulants immediately =
- IV mannitol
TIA definition
- Brief episode neuro dysfunction due to temporary focal cerebral or retinal ischaemia
Carotid TIA S+S
- Amourosis fugax
- Aphasia
- Hemiparesis
- Hemisensory loss
- HH
Vertebrobasilar TIA S+S
- Diplopia, vertigo, vomiting
- Choking
- Ataxia
- Hemisensory loss
- HH
- Tetraparesis
TIA Ix
- FBC, ESR, U+E
- Carrotid doppler +/- angiography
- CT or diffuse weighted MRI
- Echo
TIA Mx
- Immediate = Aspirin 300mg then 75 after 2 weeks (or clopi)
- Statin
- If AF = anticoagulation
- Carotid endarterectomy if >70% carotid stenosis
Epilepsy definition
- Recurrent tendency to spontaneous, intermittent, abnormal electrical activity in brain
Clinical definition epilepsy
- At least 2 unprovoked seizures >24h apart
- 1 unprovoked seizure and probability of further
- Diagnosis of an epilepsy syndrome
Partial/focal seizure
- Focal onset that can be referrable to single lobe
- Simple = no affect on consciousness or memory, no post ictal
- Complex = memory/awareness affected, post ictal confision
Primary generalised seizure
- Tonic
- Tonic clonic
- Clonic
- Myoclonic
- Atonic
- Absence
Temporal lobe seizure
- Aura
- Anxiety
- Automatisms = lip smacking
Frontal lobe seizure
- Motor features
0 Jacksonian march - Post ictal todds palsy
Focal seizure mx
- Lamotrigine
- Levi
Mx tonic seizure
SV or lamot
Mx myoclonic seizure
SV or levi
Mx TC seizure
SV or lamot
Mx absence seizure
SV or ethos
Mx atonic seizure
SV or lamot
Status epilepticus
- TC seizure lasting 5+ minutes
- Buccal midazolam 1st line community
- Rectal diazepam or IV lorazepam
Extradural haemorrhage characteristic
Head injury followed by brief duration unconsciousness, followed by improvement
- Young males
Extradrual haemorrhage patho
- Often due ti fractured temporal or parietal bone causing laceration of MMA
S+S extradural
- Deteriorating consciousness after head injury
- Increasingly severe headache, vomiting and fits
- Ipsilateral pupil dilates, bilateral limb weakness
Ix and mx extradural
- CT = lemon
- Clot evacuation and ligation
- anticoag/antiplatelet cessation
- IV mannitol
Subdural haemmorhage RF
- Elderly = falls, atrophy
- Shaking baby
S+S subdural
- Fluctating consciousness
- Sleepiness
- Headache
- Personality change and confusion
- Unsteadiness
- Increased ICP
- Seizures
Subdural Ix
- CT/MRI = clot +/- midline shift
- Banana on CT
Mx subdural
- Irrigation/evacuation = Burr twist
- AC/AP cessation
- IV mannitol
- IV prothrombin and Vit K
SAH aetiology
- Berry aneurysms (PCKD< ED)
- Injury
SAH S+S
- Thunderclap
- Vomiting
- Seizures
- Coma/drowsiness
- Photophobia/vision changes
- Neck stiffness
- Kernig and Brudzinski
SAH Ix
- CT = star shaped
- LP if doubt CT = yellow within 12 hrs and detectable for 2 weeks
- CT angiography
SAH Mx
- Cerebral perfusion
- Nimodipine = ca agonist
- Dexamethasone
- Endovascular coiling
Migraine no aura
At least 2 of
- Unilateral pain
- Throbbing
- Moderate > severe
- Motion sensitive
and 1 of
- N/V
- Photophobia/phonophobia
Migraine with aura
- 1 or more typically fully reversible aura sx
at least 3 of - 1 aura sx spreasd gradually over 5 mins
- 2 or more aura sx in succession
- 5-60 minute aura duration
Aura Mx
- NSAID or analgesics for acute
- Triptans (avoid if IHD, HTN uncontrolled)
- Propranolol for prevention
S+S tension headache
- Bilateral non pulsing headache
- Scalp muscle tenderness
- Tight band sensations
- Pressure behind eyes
- Bursting sensations
Cluster headache S+S
- Retro orbital pain
- Tearing/lacrimation
- Swollen eyelid
- Facial flushing
- Rhinorrhoea
- Miosis and ptosis
RF cluster
- Male
FHx - Smoking
- Alcohol
Mx cluster
- Smoking cessation
- Analgesics unhelpful
- Subcut sumatriptan
- High flow oxygen (acute)
- Prevention = CCB = verapamil
RF drug overuse headache
- Analgesic medication (codeine, opiates)
- Triptans
ALS S+S (MND)
- UMN signs and LMN wasting
- Asymmetric onset
- Bab +ve
- progressive focal muscle weakness and wasting
- Fasciculations
- Increased plantar
PBL S+S (MND)
- Lower CN nuclei
- Elderly women
- Dysarthria, dysphagia, nasal regurgitation
- Fasciculation
- Emotional incontinence
- 1st affected = talking, chewing, swallowing
PMA S+S
- Pure LMN presentation = weakness, wasting, fasc
El Escorial criteria ALS
Definite = lwoer and upper in 3 regions
Probable = lowe and upper in 2
- Possible = in 1 region
- Suspected = U or LMN signs onlu in 1 or mroe
Mx MND
- Antiglutamatergic = riluzole
- NG tube
- Analgesic ladder
Triad in Parkinsons
- Tremor = at rest, may be unilateral
- Rigidity = pain, cogwheel,
- Bradykineia/hypokinesia = buttons, writing, walking, blank face
- Postural instability
- typically asymmetrical tremor
Patho parkinsons
- Decreased dopamine levels
- Mitochondrial dysfunction and oxidative stress on substantia nigra
- Progressive degeneration of dopaminergic neurones of substantia nigra
- Decreased DA synthesis in the striatum
- Decreased thalamus activity
- Decreased movement
Parkinsons Ix
- DaTSCAN
- MRI
Parkinsons Mx
- Levodopa (synthetic dopamine) with PDI like carbidopa and benserazide
- COMT inhibitors = entacapone to slow breakdown of levodopa
- dopamine agonists
- MAOB inhibitors = break down NT = rasagiline, selegiline
Levodopa complications
- Invol movements or dyskinesia
- Response fluctuations
- Psychiatric
MS S+S
- Optic neuritis = painful reduction vision
- Transverse myelitis
- Spasticity
- Lhermitte = electric shock
- Fatigue
- Bladder involvement
- UMN signs
- Worse with heat
MS Ix
- Disseminated in time and sspace
- MRI = gold
- CSF = oligoclonal bands IgG
MS Mx
- RR mild = dimethyl fumarate
- RR = monoclonal abs = alemtuzumab
- Methylprednisolone for acute relapses
- Baclofen and gabapentin for spasticity
Pathogens bacterial meningitis in age groups
- Neonates = GBS
- Children <2 = SP
- Up to 50 = NM and SP
- > 50 = SP
S+S meningitis
- Headache
- Fever
- Neck stiffness
- N+V, photophobia, irritability
- Confusion, delirium, sleepy
- Maculopapular rash
Meningitis Ix
- Bloods
- Cultures
- CT
- LP after CT
Bacterial LP - Cloudy and purulent
- Increased granulocytes
- High lactate and protein
- Decreased glucose
Viral LP - Clear fluid
- Cell count variable with increased lymph
- Normal or low lactate
- Normal protein and glucose
- No organisms
Meningitis Mx
- Primary care if NB rash = IM benzylpen 1.2mg
- Broad spec Abx, steroids (IV dex), LP
- 1st line abx empirical therapy before LP or after CT = cefs
- amox >60
Encephalitis S+S
- Fever, headache, N+V
- Seizures
- Altered mental state
- Rash
Enceph Ix
- Bloods
- CSF
- CT/MRI
- Cultures
Enceph Mx
- Aciclovir
- IV benzylpen
S+S carpal tunnel
- Aching in hand and arm esp. night
- Paraesthesia in thumb, index and middle finger
- Relived by dangling
- Sensory loss and weakness abductor pollis brevis
Causes carpal tunnel
- Swelling/compression
- Prolonged flexion
- Acromegaly
- Myeloma
- RA
- Pregnancy
Mx carpal tunnel
- Splinting
- Local steriod injection
- Decompression surgery
Myasthenia gravis definition
- Autoimmune disease medaited by antibodies to Ach receptors
MG pathophysiology
- Autoantibodies to ach receptors form
- AChR lost on postsynaptic membrane of NMJ
- Failure to trigger muscle action potential
MG S+S
- Increasing muscle fatigue = top down
- Proximal and asymetrical
- Ptosis
- Diplopia
- Snarl
- Voice deterioration
- Tendon reflexes
Myasthenic crisis
- Resp muscle weakness
- Monitor forced vital capacity
- Plasmanephrines or IVIG
MG Ix
- Tensilon test
- Anti AChR
- Decremental muscle response to repetitive nerve stimulation
- CT thymus
- Ice improves ptosis by >2mm
- Nerve conduction
MG Mx
- Anticholinesterase = pyridostigmine
- Relapses with prednisolone
- Thymectomy
Drugs that execerbate MG
- Ciprofloxacin
- Azithromycin
- Propranolol
- Atenolol
- Verapamil
- Lithium
- Statins
Cauda equina S+S
- Saddle paraesthesia
- Sudden onset
- Motor problems
- Lower back pain
- Bilateral LMN weakness
- Absent ankle reflex
- Decreased sphincter tone
- Perianal, perineal or sensory disturbance
- Incontinence
- Sexual dysfunction
- Bilateral motor and reflex deficits
CE Ix
- Spine MRI
- Femoral stretch test = L4
- Knee flexion test = L5/S1
- Straight leg raining test = L5/S1
- Plantar flexion test = S1/S2
CE Mx
- Epidural steroid
- Surical decompression
- Immobilise spine
- Anti inflams
HZV
- Shingles
- Reactivation of chickenpox = infects dermatomes
S+S HZV
- Localised dermatome pain and paraesthesia
- Localised dermatome erythematous maculopapular rash –> clear vesicles –> crust
- headache, fever, malaise
HZV Ix
- PCR
- CSF analysis
- Clinical
HZV Mx
- Vaccine
- Aciclovir <72 hours of rash onset
- Analgesia
- Topical abx
- TCA
Alzheimers pathology
- Atrophy of cerebral cortex
- formation of amyloid plaques and neurofibrillary tangles (contain tau proteins)
- Accumulation of B amyloid peptide
S+S Alzheimer’s
- Loss of recent memory
- Difficulty word finding
- Aphasia, apraxia, agnosia
- Frontal executive function
- Anosognosia = lack insight, stubbornness, denial
Alzheimers management
- Acetylcholinesterase inhibitors = donepezil, rivastigmine
- Memantine in late stage (antiglutaminergic)
Vascular dementia
- Multi infarct dementia
- Reduced blood supply to brain
- Onset can be within 3 months CVA
- Stepwise progression
Vascular dementia S+S
- Stepwise in severity of symptoms
- Gaint and attention problems
- Incontinence
- Personality change
- Focal neuro signs
- MRI = widespread small vessel disease
Lewy body dementia
- Parkinsonism
- LBD when cognitive Sx predate motor by >1 yr
- PDD when motor prior to or within 1yr cognitive issues
LBD S+S
- Fluctuating cognition
- Recurrent visual hallucinations
- REM
- 1 or more PD Sx
- Can treat with rivastigmine or donepezil
Fronto temporal dementia
- Common in younger
- Progressive degeneration
- Personality change and behaviour disturbance
- Progressive impairment of language
Vascular dementia Mx
- AChE inhibitors
- Memantine
Parkinsonian plus syndromes
- Progressive supranuclear palsy = PD and vertical gaze
- Multiple system atrophy = PD and PHypo, incontinence and impotence
- Cortico basal degeneration = PD and spontaneous activity limb
- LBD
Brown sequard findigns
- Ipsilateral hemiplegia
- Ipsilateral loss of vibration and proprioception
- Contralateral loss of pain and temperature
Wernicke’s aphasia
- superior temporal gyrus
- Speech fluent but word salad, neologisms, no sense
- Impaired comprehension
Broca’s aphasia
- Expressive
- Inferior frontal gyrus
- no fluent speech, laboured and halting but comprehension in tact and content words may be preserved
anterior cerebral artery
- contralateral hemiparesis and sensory loss
- lowe extremity > upper
MCA
- contralateral hemiparesis and sensory loss
- upper > lower
- Contralateral HH
- Aphasia
PCA
- Contralateral HH with macular sparing
- Visual agnosia
Weber’s syndrome
- Ipsilateral CN3 palsy
- Contralateral wekaness lower and upper extremity
PICA
- Ipsilateral facial pain and temp loss
- contralateral limb/torso pain and temperature loss
- ataxia, nystagmus
Basilar
locked in syndrome
Lacunar strokes
- isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
- HTN assocaited
- basal ganglia, thalamus and internal capsule
GCS motor response
6 = obey commands
5 = localises to pain
4 = flexes to pain
3 = Mr carrol says no
2 = extends to pain
1 = none
GCS verbal response
5 = orientated time place person
4 = confused
3 = innapropriate words
2 = sounds
1 = none
GCS eye response
4 = eye open spont
3 = open to speech
2 = open to pain
1 = none
Bell’s Palsy
- Acute unilateral facial nerve weakness or paralysis of rapid onset
- Herpes simplex, varicella zoster and autoimmunity
- unilateral LMN palsy (non forehead sparing)
- Droop eyebrow, corner of mouth and loss of nasolabial fold
Bell’s palsy symptoms
- Rapid onset
- Facial muscle weakness
- Drooping off eyebrow and corner of the mouth and loss of nasolabial fold
- Difficulty chewing, dry mouth and changes in taste
- Incomplete eye closure, dry eye or excessive tearing
- Numbness of tingling of cheek +/- mouth
Bell’s palsy management
- Keep eye lubricated with drops and ointment and tape
- Prednisolone
Ramsay hunt
- VZV
- Unilateral lower motor neurone facial nerve palsy
- Vesicular rash in ear canal
- within 72hrs prednisolone and aciclovir
Meniere’s
- Hearing loss
- Vertigo
- Tinnitus
- Excessive buildup of endolymph in inner ear
- Acute = prochlorperazine and antihistamine
- Prophylaxis = betahistine
total anterior circulation stroke
- Middle and anterior cerebral arteries
- Unilateral weakness (+/- sensory) of face, arm and leg
- Homonymous hemianopia
- Higher cerebral dysfunction = dysphasia, visuospatial
Partial anterior circulation stroke
2 of the following
- Unilateral weakness of face, arm, leg
- Homonymous hemianopia
- Higher cerebral dysfunction (and this alone can be PACS)
Posterior circulation syndrome
- Cerebellum and brainstem
1 of following - cranial nerve palsy and a contralateral motor/sensory deficit
- bilateral motor/sensory deficit
- conjugate eye movement disorder
- cerebellar dysfunction
- Isolated homonymous hemianopia
Lacunar stroke
- No loss of higher cererbal function
1 of - Pure sensory stroke
- Pure motor stroke
- Sensori-motor stroke
- Ataxic hemiparesis
Common peroneal nerve palsy
The sciatic nerve divides into the tibial and common peroneal nerves. Injury often occurs at the neck of the fibula
Common = foot drop.
Other features include:
weakness of foot dorsiflexion
weakness of foot eversion
weakness of extensor hallucis longus
sensory loss over the dorsum of the foot and the lower lateral part of the leg
wasting of the anterior tibial and peroneal muscles
subacute combined degeneration of the cord
due to vitamin B12 deficiency
dorsal columns + lateral corticospinal tracts are affected
joint position and vibration sense lost first then distal paraesthesia
upper motor neuron signs typically develop in the legs, classically extensor plantars, brisk knee reflexes, absent ankle jerks
if untreated stiffness and weakness persist
Red flag for trigeminal neuralgia
- <40
- Sensory changes
- Deafness or ear problems
- Skin or oral lesions
- Pain in Opthalmic division
- Optic neuritis
- ## FHx MS
Cushings triad in ICP
- Bradycardia
- Wide pulse pressure
- Irregular breathing
Effect of IIH on the eyes
down and out = 3rd nerve palsy
Pontine haemorrhage
- Secondary to chronic HTN
- Quadraplegia
- Miosis
- Absent horizontal eye movements
Bell’s palsy vs Ramsey Hunt
BP
- Lack of rash
- Normal otosopy
RH
- Vesicular rash around ear
- Abnormal otoscopy
4th CN palsy
- Defective downward gaze = vertical diplopia
5th CN palsy
- Trigeminal neuralgia
- Loss corneal reflex
- Loss of face sensation
- Deviation of jaw to weak side
6th nerve palsy
- Horizontal diplopia
9th nerve palsy
- loss of gag reflex
10th nerve palsy
- uvula away from lesion site
- loss gag reflex
12th nerve palsy
- tongue deviates to side of lesion
trigeminal neuralgia
- 5th CN
- paroxysmal attacks of pain = eating
- carbamezapine
Mx IIH
- weight loss
- Diuretics = acetazolamide
- topiramate
- repeat LPs
- Surgery
