Neuro Flashcards
How do you treat seizures in the community?
PR diazepam or buccal midazolam
How would you localise a lesion which causes facial paralysis with forehead sparring?
UMN lesion caused by the contralateral side
Sx of Ramsay Hunt Syndrome?
Ipsilateral LMN lesion
Facial paralysis (including the forehead), vertigo, hearing loss or hyperacusis, tinnitus and ear pain/rash
Which CNs can be affected by acoustic neuroma, what symptoms will this cause?
CN V, VII and VIII
V = absent corneal reflex
VII = facial nerve paralysis
VIII = vertigo, unilateral hearing loss and tinnitus
What is the commonest neurological presentation of sarcoidosis?
Facial nerve palsy
What should you always do in patients with a GCS of 3-8 and a known head injury?
ICP monitoring
What should you suspect in blurred (binocular) vision post-facial trauma?
Depressed fracture of the zygoma (cheek bone)
Which nerve injury will result in weakness of finger abduction and thumb adduction?
T1 injuries
Which features characterise Creutzfeldt-Jakob disease?
Rapid onset dementia and myoclonus
What causes a bitemporal hemianopia?
Optic chiasm compression
How can you localise homonymous quadrantopias?
Inferior quadrantopias are in the parietal lobe
Superior quadrantopias are in the temporal lobe
A patient has a left sided visual field defect, which side of the brain is affected?
Right
Sx and Mx of trigeminal neuralgia?
Unilateral electric-shock pains evoked by light touch e.g. brushing hair/teeth
Mx = carbamazepine, refer to neurology if they fail to respond
What is the 1st line management of focal seizures?
Lamotirgine
Which type of amnesia is an indication for non-contrast CT head in head injury?
Retrograde amnesia of >30 mins
Sx of syringomyelia?
Cape like loss of pain and temperature sensation due to spinothalamic compression
What do ring enhancing lesions of the brain imply? How do you treat?
Brain abscesses. Treat with IV cephalosporins (e.g. ceftriaxone) and IV metronidazole
What should you suspect as a cause of fluctuating consciousness in the elderly and alcoholics?
SDH
What is the most common cause of EDH?
Middle meningeal artery rupture due to a pterion fracture
In a non-contrast CT what will cause a hyperdense collection?
An acute bleed
Sx and Mx of Bell’s Palsy?
Ipsilateral LMN paralysis
Facial paralysis (including the forehead), post-auricular pain, altered taste, dry eyes and hyperacusis
Mx = oral prednisolone within 72 hours
When should you non-contrast CT head in <1 hour?
Head injury with:
GCS <13 initially or <15 after 2 hours of the incident
Suspected open or depressed skull #
Sx of base of skull #
Post-traumatic seizure
Focal neurological deficit
>1 episode of vomiting
Which condition is associated with bilateral vestibular schwannomas?
Neurofibromatosis Type 2
Where do acoustic neuromas most commonly occur?
At the cerebellopontine angle
What is the gold standard for diagnosis of venous sinus thrombosis?
MRI venogram
When should you CT head a patient within 8 hours?
If they have loss of consciousness or amnesia following a head injury and one of:
>= 65 years old, bleeding disorder or clotting abnormality including anticoagulants, dangerous mechanism of injury (e.g. fall from more than 5 stairs or >1m), >30 mins retrograde amnesia
If a patient is on warfarin and has a head injury but no other symptoms, should you CT head?
Yes within 8 hours
What is the most common tumour to metastasise to the brain? What are some other tumours which commonly metastasise?
Lung - most common
Also breast, bowel, kidney and skin (mainly melanoma)
What is the difference between a medical and surgical 3rd nerve palsy
Medical = spares the pupils and will be painless e.g. in diabetes
Surgical = painful and associated with fixed dilated pupil
Which nerves control eye movements?
All are controlled by CNIII except lateral rectus (controlled by CN VI) and superior oblique (controlled by CN IV)
How do you investigate GBS?
Nerve conduction studies
How do you investigate MG?
Anti-acetylcholine receptor antibodies
How do you localise focal seizures?
Temporal = aura (often epigastric) and automatisms
Frontal = head/leg movements and posturing, post-ictal weakness and dysphagia, Jacksonian march and Todd’s paresis
Parietal = paraesthesia
Occipital = floaters/flashes
What is seen on LP in GBS?
Isolated raised proteins
What should you consider in a painful 3rd nerve palsy?
Posterior communicating artery aneurysm
How does a posterior inferior cerebellar stoke present?
Ataxia, nystagmus, dysphagia, ipsilateral facial nerve palsy/Horner’s syndrome with contralateral limb sensory loss
Which type of seizures are worsened by carbamazepine?
Myoclonic and absence seizures
Name 1 important side effect of phenytoin?
Peripheral neuropathy
What is a common complication of intraventricular heaemorrhages?
Hydrocephalus
What causes subacute degeneration of the spinal cord? Which tracts does it affect?
Vitamin B12 deficiency
Affects the dorsal columns and lateral corticospinal tracts - impaired proprioception and vibration with UMN signs in the legs
Sx of subacute degeneration of the spinal cord?
Loss of proprioception and vibration then distal paraesthesia
UMN signs in the legs (Babinski positive, brisk knee but absent ankle jerk reflexes)
How should you immediately treat TIA? What should you give for secondary prevention?
Immediate = 300mg aspirin
Secondary prevention = 75mg clopidogrel
What is seen on scan in normal pressure hydrocephalus? What symptoms are seen?
Large ventricles but normal pressure
Sx = dementia, incontinence and disturbed gait
What is a sunsetting gaze?
Failure of upward gaze, it occurs in children presenting with severe hydrocephalus
What is the most common symptom of carbon monoxide poisoning? What other symptoms may occur?
Headache = most common
Also nausea and vomiting, vertigo, confusion and weakness
How do we investigate carbon monoxide poisoning?
Do ABG, pulse oximetry may be falsely elevated.
Measure carboxyhaemoglobin levels, they should be <10% in smokers and <3% in non-smokers. If raised treat!
How do we treat carbon monoxide poisoning?
100% high flow oxygen, target sats 100%. Continue treatment until all symptoms have resolved
Sx of lambert eaton syndrome? What antibodies are seen?
Limb girdle weakness mainly affecting the lower limbs, hyporeflexia, and autonomic symptoms. In the beginning muscle strength improves with use. Eye symptoms are not commonly seen
Voltage gated calcium channel antibodies may be seen
Which condition is associated with anti-Mi-2 antibodies? What are the symptoms?
Dermatomyositis
Proximal muscle weakness, systemic upset and rash will be seen
What is seen in Cushing’s triad?
Widening pulse pressure, irregular breathing and bradycardia.
There will also be hypertension
Mx of Tonic-Clonic seizures?
M = Sodium Valproate
F = Lamotrigine or Levetiracetam
Mx of Focal seizures?
1st line Lamotrigine or Levetiracetam for everyone
2nd line = Carbamezepine
Mx of Absence seizures?
1st line = Ethosuximide
2nd line = M = Sodium Valproate
F = Lamotrigine or Levetiracetam
Mx Myoclonic seizures?
M = Sodium Valproate
F = Levetiracetam
Mx of Atonic or Tonic seizures?
M = Sodium Valproate
F = Lamotrigine or Levetiracetam
Describe Broca’s Aphasia?
Occurs secondary to a frontal lobe stroke
Normal comprehension but impaired repetition and non-fluent speech
Describe Wernicke’s Aphasia?
Occurs secondary to a temporal lobe stroke
Impaired comprehension and repetition but fluent illogical/word salad speech
Describe Conduction Aphasia?
Occurs secondary to an arcuate fasciculus stroke
Normal comprehension, speech is fluent but repetition is impaired - patients are aware of their mistakes
How is sodium commonly affected in brain injury?
You often get hyponatraemia secondary to SIADH
How can we differentiate between drug induced and idiopathic PD?
Idiopathic is asymmetrical, drug induced is symmetrical
What is postural hypotension?
A drop in systolic BP of >= 20 and/or a fall in diastolic BP of >=10 within 3 mins of standing
Describe essential tremor?
An AD condition which causes a tremor of both upper limbs which is worse when arms are outstretched. It will be relieved by rest and alcohol.
Mx = propranolol or primidone
Describe Idiopathic Intracranial Hypertension?
Headache, blurred vision and papilloedema (bilaterally blurred optic disc) with an enlarged blind spot and CN VI palsy seen in overweight women
Mx = weight loss, acetazolamide and topiramate
Which cranial nerves control the light reflex?
CN II = afferent (sensory)
CN III = efferent (motor)
Which cranial nerves control the corneal reflex?
CN V = afferent (sensory)
CN VII = efferent (motor)
How can we differentiate clinically between brain abscesses and meningitis?
Brain Abscesses are more likely to cause focal neurology where as meningitis is more likely to cause reduced consciousness or confusion
What is seen in EEG in absence seizures?
3Hz spike and wave
What do nerve conduction studies show in MND?
Normal motor conduction
Why should you always correct B12 levels before you give folate replacement?
To avoid subacute combined degeneration of the spinal cord
What is the first line Mx of Raynaud’s?
Nifedipine
What should you give to prevent vasospasm in SAH?
Nimodipine
What are the commonest type of focal seizure?
Temporal lobe seizures
What are some red flag symptoms which may be seen in trigeminal neuralgia which would require refferal?
Sensory changes, Deafness/hearing changes, Hx of skin/oral lesions which may have spread, pain only in the ophthalmic division or bilaterally, optic neuritis, family Hx of MS and <40 at age of onset
What is the management of an intracranial aneurysm which has bled?
Coiling
Sx of Guillain-Barre Syndrome?
Symmetrical progressive weakness of all limbs which starts in the legs and is ascending), reduced or absent reflexes and distal paraesthesia may be present
Mx of cluster headaches?
100% oxygen and s/c triptan acutely, prophylaxis is with verapamil
Which nerve is commonly damaged in a Colles #?
Median nerve
How quickly should symptoms resolve/return to baseline after stopping using opioids in opioid overuse headaches?
2 months
How quickly should you refer patients presenting with a TIA to see a specialist?
If they have presented within the first week refer to see a specialist within 24 hours
If they have presented after the first week refer to see a specialist within 1 week
Give all patients 300mg aspirin
What happens in internuclear opthalmoplegia?
A lesion of the medial longitudinal fasciculus causes impaired eye adduction of the ipsilateral eye and nystagmus during abduction of the contralateral eye
Which nerve is affected in wrist drop? Which fracture is this commonly associated with?
Radial nerve. Commonly associated with a shaft of Humerus #
Mx of MG?
1st line = Long acting acetylcholinesterase inhibitors e.g. Pyridostigmine
Immunosuppression e.g. with prednisolone or azathioprine
Consider thymectomy
In CN V (trigeminal nerve) damage, what do you see?
Loss of the afferent aspect of the corneal reflex, loss of facial sensation, paralysis of muscles of mastication and the jaw deviates to the weak side
In CN VII (facial nerve) damage, what do you see?
Flaccid paralysis of upper and lower face, loss of the efferent aspect of the corneal reflex, loss of taste and hyperacusis
In CN IX (glossopharyngeal nerve) damage, what do you see?
Hypersensitive carotid sinus reflex and loss of the afferent aspect of the gag reflex
In CN X (vagus nerve) damage, what do you see?
Loss of the efferent aspect of the gag reflex and the uvula deviates away from the site of the lesion
In CN XI (accessory nerve) damage, what do you see?
Weakness in turning the head to the contralateral side
In CN XII (hypoglossal nerve) damage, what do you see?
The tongue deviates towards the side of the lesion
Describe Juvenile Myoclonic Epilepsy?
Classically begins in the teen years (more common in girls)
There are infrequent generalized seizures often worse in the morning/following sleep deprivation, daytime absences, sudden shock-like myoclonic seizures which may go on to generalised tonic-clonic seizures.
Responds well to sodium valproate
How may a craniopharyngioma present?
Bitemporal Hemianopia (worse in the lower aspect), growth retardation, diabetes insipidus (patients will produce large amounts of urine).
CT brain scan will show calcification
What is mononeuritis multiplex?
Simultaneous damage to multiple nerves which are not linked. There may be acute or subacute sensory loss or motor function loss of individual nerves
Which drugs increase the risk of IIH?
COCP, Steroids, Tetracycline Abx, Retinoids and Lithium
What organism classically triggers Guillain-Barre Syndrome?
Campylobacter Jejuni
What is the adult dose for rectal diazepam used to Mx seizures?
10mg
Describe Multiple System Atrophy?
Parkinsonism, autonomic disturbance (e.g. erectile dysfunction, postural hypotension and atonic bladder) and cerebellar signs
True or false, pregnancy is a risk factor for Bell’s Palsy?
True
When should you CT head a patient with a coagulation disorder and LOC/amnesia post-head injury?
Within 8 hours
What normally causes encephalitis? Ix and Mx?
Normal caused by HSV1
Ix = CSF PCR, there will be an increased WCC and increased protein on CSF
Mx = IV aciclovir
What type of tumour is MG associated with?
Thyomas
Which nerve is damaged if there is an inability to flex the 1st, 2nd and 3rd digits?
Median nerve
Which nerve is damaged if there is an inability to extend the 4th and 5th digits?
Ulnar nerve
Sx of a myoclonic seizure?
Clonus (upper and lower limb contraction and relaxation) without LOC, tongue biting, incontinence or a post-ictal period
What is Thoracic outlet obstruction?
Compression of the brachial plexus/subclavian artery/vein - often caused by a cervical rib
Sx: nerve compression = painless muscle wasting of the hands, weakness and tinging
vein compression = arm swelling
artery compression = pain and claudication
Sx may be worse when the arm is raised
What is the cause of SDH?
Damage to the bridging veins between the cortex and venous sinuses
How long do cluster headache clusters typically last for?
4-12 weeks
When should you suspect SJS?
Fever, photophobia and a rash after starting a new medication
Mx of Myasthenia Gravis Crisis?
IVIG and plasma electrophoresis
What are the common migraine triggers?
CHOCOLATE
Chocolate, Hangovers, Orgasms, Caffeine/Cheese, Oral contraceptives, Lie-ins, Alcohol, Travel and Exercise
Which type of dementia are those with MND more at risk of?
Frontotemporal dementia
Syringomyelia is associated with Chiari malformation. What may be seen? Ix?
Cape like loss of pain and temperature. Spastic weakness of the lower limbs and upgoing plantars may be seen
Ix = full spine and brain MRI
True or false essential tremors can affect the vocal cords? How do you manage essential tremor?
TRUE
Mx with propranolol
Sx of Progressive Supranuclear Palsy?
Parkinsonism + Dysarthria + Reduced vertical eye movements
What is the ROSIER score used for?
Used to differentiate stroke and stroke mimics
True or false if a person on warfarin has sustained a head injury you should CT head <8 hours even if there are no other symptoms
TRUE
What is conductive dysphasia?
Speech is fluent but repetition is poor. Comprehension is intact
Seen in parietal lobe strokes
Where are the inferior and superior optic radiations found?
Inferior optic radiation is found in the temporal lobe - temporal lobe stroke = superior quadrantopia
Superior optic radiation is found in the parietal lobe - parietal lobe stroke = inferior quadrantopia
What does the empty delta sign indicate when seen on MR venogram?
Sagittal sinus thrombosis
What should you start before giving phenytoin?
Cardiac monitoring
What is the cause of a wrist drop after a night of heavy drinking?
Saturday night palsy, due to compression of the radial nerve
True or false, abdominal symptoms are not commonly seen in children with migrains?
False! children often experience nausea, vomiting and abdo pain with migrains
What is the cause of a high stepping gait?
Compensating for a peripheral neuropathy leading to foot drop
Unilateral = common peroneal nerve damage
Bilateral = peripheral neuropathy
What type of anaemia can phenytoin cause?
A macrocytic anaemia as it alters folate metabolism
