NEURO Flashcards
1
Q
Features of psychogenic seizures? Which ones most sensitive?
A
Most sensitive: ictal eye closure, pelvic thrusting
Longer than 2 mins
Variable motor activity; waxing/waning
Vocalisation
Rapidly awake and reoriented
Twitching all 4 limbs
No prolactin rise
Surface EEG normal
UNCOMMON
- autonomic signs
- incontinence
2
Q
Limbic encephalitis? Causes: 3 categories?
A
Paraneoplastic
- NMDA: ovarian
- AMPA: breast lung thymoma
- GABA: SCLC
- LGI1: SCLC, thymoma
- CV2/CRMP5: SCLC, thymoma
- Hu: SCLC
- Anti-Ma2: testicular
- GAD: SCLC, thymoma
Infection
- HSV
- VZV
- HHV
AI
- check for oligoclonal bands
3
Q
Limbic encephalitis imaging findings?
A
Temporal lobe/ limbic/hippocampal changes
T2 FLAIR hyperintensities
4
Q
ACA stroke features
A
Dear motivation
Limb apraxia
LL > UL
Incontinence: faecal/urinary
5
Q
MCA superior stroke features
A
Broca
Temporal vision loss, opposite side
UL > LL
6
Q
MCA inferior stroke features
A
Wernicke
Parietal vision, opp side
7
Q
MCA dominant side stroke features
A
Gerstmann Syndrome
Agraphia: can’t write
Acalculia: can’t calculate
Finger agnosia
L-R disorientation
8
Q
MCA non-dominant side stroke features
A
Contralateral neglect
Hemianopia
Hemiparesis
Constructional aprexia
9
Q
Posterior communicating artery stroke features
A
CN III palsy
10
Q
PCA stroke features
A
CN III, IV
Vision: homonymous hemianopia with macular sparing
Alexia: can’t read but can write
Weber
- CNIII
- hemiplegia contralateral
Clause
- CNIIII
- contralateral ataxia and sensory loss
11
Q
Lenticular/subcortical stroke features
A
Pure motor MOST COMMON
Pure sensory
Sensorimotor
Hemiballismus
Dysarthria-clumsy hand syndrome
Ataxic hemiparesis
12
Q
Basilar stroke features
A
LOC
Locked in syndrome
Medial pontine syndrome
- CN VI, VII
- contralateral hemiparesis and sensation loss
13
Q
AICA stroke features
A
Lateral pontine syndrome
- V, VII, VIII ipsi
- Ipsi horners
- Ipsi cerebellar
- Contralateral pain/temp
14
Q
PICA stroke features
A
Lateral medullary syndrome
- IX, X, XI ipsi
- Ipsi horners
- Ipsi cerebellar
- Contralateral pain/temp
15
Q
Anterior spinal a stroke features
A
Medial medullary syndrome
- XII ipsi
- contralateral hemiparesis
16
Q
Carotid stroke features
- internal
- common
A
ICA
- amaurosis fugax
- ipsi dysphagia, tongue deviation
- CL vision/ sensory/ weakness
CCA
- Horner
- MCA
17
Q
Carpel tunnel vs proximal median n lesion?
A
Proximal
- hypothenar, proximal thenar, dorsal of hypothenar numbness
- flexor weakness
Carpel tunnel
- pain/paraesthesia
- numbness on palm under 2/3/4th funger
- proximal thenar sensation PRESERVED
18
Q
Ulnar nerve: elbow vs wrist lesion
A
WRIST
- sensation fibres don’t pass through guyon canal
- weakness ONLY
Elbow
- weakness and paraesthesiae
19
Q
Difference between common peroneal/ L5/S1 neuropathy?
A
Check notes
20
Q
Difference between radial n and C7 palsy
A
Check notes
21
Q
PRRF lesion on (R) –> manifestations?
A
Can’t abduct (R) eye and adduct (L) eye
22
Q
MLF lesion on (R)
A
Can’t adduct (R) eye
(L) eye nystagmus
INO
23
Q
FEF lesion on (L)
A
Can’t look to the (R)
- drift slowly to (L)
24
Q
How to differentiate MS/NMO/MOG
A
Check notes: non compressive myelopathy table
25
Nystagmus: peripheral vs central?
Peripheral
- torsional
- direction depends on canal (post = up, mid = horizontal, anterior=down)
- away from lesion
Central
- pure vertical
- toward lesion
26
Head impulse; how to differentiate central vs peripeheral?
Normal = Stroke
Abnormal = Peripheral
27
Migraine pathophysiology?
CNS dysfunction --> cortical depression spreads --> irritates trigeminal --> CGRP release --> meninges irritated -->
Chemicals
- 5HT
- GABA
- Glutamate
- DA
28
Features of migraine headache?
Unilateral
Photophobia
Phonophobia
Throbbing
Aggravated by movement
Lasts 4-72 hours
Moderate intensity
N+V
29
Migraine treatment
ACUTE
- 5HT (CI CVS NVS disease)
- NSAIDs/paracetamol/aspirin
- DA antagonists
- MAB against CRGP
PROPHYLAXIS
- SSRIs (pztoifen)
- CCB/BB
- TCA
- Anticonvulsants
30
Tardive dyskinesia/ drug induced Parkinsonism commonly assoc with? Treatment?
Antispychotics
Benztropine, Tetrabenazine
31
Hemiballismus assoc with:
Huntingtons
Basilar stroke
Lesions of Subthalamic nucleus, basal ganglia
32
Tourettes: associations and treatment
ADHD: Clonidine
OCD: SSRI
Habit reversal training
Risperdone
Tetrabenezine
33
Dystonia treatment?
Levodopa
Clonaz
Botox
34
RLS causes and treatment
Fe def
Low DA
TX
- opioids
- dopamine agonists
- Fe replacement
- gabapentin, pregabalin
35
How would latent and active TB be differentiated on testing?
Active: TST, IGRA, culture (+)
Latent: TST, IGRA (+)
36
Treatment for latent TB?
Monotherapy
- rifamp 4 months
- isoniazid 9 months
- rifapentine 3 months
37
When would you treat latent TB?
Immunocomp
Recent negative --> positive
Young
HCW
Recent exposure
38
How to treat TB meningitis?
Moxiflox: penetrates meninges
Dex: reduces mortality
39
How to treat TB in pregnancy?
Same: most safe
40
MDR TB options?
Moxiflox/ levoflox
Mero
Amikacin
Linezolid
Bedaquiline
Cycloserine
Clofazimine
Pyrazinimide
Delamanid
Ethionamide
p-aminosalicylic acid
41
Risk factors for TB infection?
Acquired immunodeficiency = MOST POTENT
HIV
Transplantation
Renal failure
Length of exposure
Infectiousness of contact
Smear positive
Transplant
42
How to diagnose TB?
Smear/culture/ microscopy/ PCR
Tissue, sputum, pleural fluid, CSF
43
What is IGRA used for? What is the significance?
Evidence of past exposure
Detects T cell producing IFN-gamma to TB antigens
- false negative in immunocompromised
- can be active/latent/past/reinfection
44
Which genetic diagnosis associated with aortic coarctation?
Turners
45
Which immunosuppressed states are at highest risk of PJP?
Steroids
Lymphopenia
TNF-alpha
Transplant
46
Tests for aspergillus?
Serum galactomann
PCG Aspergillus precipitans
47
Management of C diff?
- first episode
- second episode
- third episode
- severe
1st: vanc/metro
2nd: vanc/fidoxamicin
3rd: FMT (comp --> bowel perd)
Severe: IV metro or PO vanc
48
When do you repeat stool culture for C diff?
If symptomatic
If asymptomatic, remains (+) for > 1 month so means nothing
49
What drugs frequently cause C diff?
Clindamycin
2nd/3rd cephalosporins
Fluoroquinolones
Amoxicillin/ Ampicillin
50
ACA features?
Motor and/or sensory deficit (leg > face, arm)
Limb apraxia
- Inability to perform coordinated movements
Urinary/faecal incontinence
Decr motivation
51
MCA features? Dominant and non dominant? Superior and inferior?
Face/ arm > leg: motor and sensory deficit
Ipsilateral gaze deviation
Wernicke's - IF DOMINANT inferior
- Wernicke's (receptive) aphasia if in dominant hemisphere: impaired ability to comprehend speech
Broca's - IF DOMINANT superior
- Expressive aphasia
Optic radiations
- Contralateral homonymous hemianopia
Non dominant parietal lobe (R)
- Contralateral spatial Neglect, hemianopia, hemiparesis, constructional apraxia (difficulty with dressing)
Dominant parietal lobe (ANGULAR GYRUS) --> GERSTMANN SYNDROME (L)
- Agraphia: deficiency in ability to write
- Dyscalculia: def comprehending mathematics
- Finger agnosia: inability to distinguish fingers on hand
- L-R disorientation
52
Posterior community artery stroke?
CN III
53
PCA stroke?
CNII
Contralateral hemiparesis/ataxia
Homonomynous hemianopia with macular sparing
Alexia WITHOUT agraphia
Hallucinations
54
Penetrating vessel stroke?
Pure motor
Pure sensory
Hemiballismus
Ataxic hemiparesis
Dysarthria-clumsy hand
Sensorimotor
55
Basilar artery stroke?
Medial pontine
Decr consc
CN VI VII
56
AICA stroke?
Lateral pontine
CN V VII VII
Horners
Ipsi cerebella
Contra sensation
57
PICA stroke?
Lateral medullary
CN IX X XI
Horners
Ipsi cerebella
Contra sensation
58
Anterior spinal a stroke?
CN XII
Contralateral weakness + sensation loss
59
What causes the pupil to constrict?
CNIII
Parasympathetics
60
What causes the pupil to dilate?
Sympathetics --> long ciliary nerve
61
Pathway from CNII to CNIII?
CNII --> Edinger Westphal (part of OM nucleus) --> CNIII
62
Nerves in cavernous sinus?
II IV V VI
63
Physiology behind Horner's
Travels from:
Hypothalamus --> pons --> C8 --> T2
Crosses over to sympathetic trunk --> up towards lung apex + bifurcation of common carotid
Follows ICA --> cavernous sinus --> innervates iris and Mullers muscle
64
Causes of Horners at each synapse?
1st neuron: (hypothalamus/pons/brainstem/spinal cord)
lateral medullary syndrome, spinal cord lesion above T1, pontine haemorrhage
2nd neuron: (sympathetic trunk to neck)
Pancoast tumour, tumour involvement thoracic outlet/ spinal cord/ lung apex
3rd neuron: (bifurcation of CC --> cavernous sinus --> eye)
ICA dissection / cavernous carotid aneurysm, neck mass, otitis media
65
Essential tremor treatment?
Propanolol - 1st line
Primedone
Clonaz
Gaba/barbituates
66
Neutrotransmitters: receptors + action
SEROTONIN
* GI
○ Entochromoaffin cells -> regulate intestinal motility
* CNS (limbic system)
○ Mood
○ Appetite
○ Sleep
○ N+V
○ Arousal
* Vascular
○ Stored in platelets -> released when platelets bind to a clot -> regulate haemostasis + blood clotting
Inhibits release of noradrenaline
67
Neutrotransmitters: receptors + action
ACh
Nicotinic
Muscarinic
- Neuromuscular junction
* Removed by acetylcholinesterase
ANS - sympathetic and parasympathetic
68
Neutrotransmitters: receptors + action
Glutamate
NMDA
Kainate
AMPA
- Main neurotransmitter in brain/spinal cord
69
PE treatment?
* Provoked (surgery, hospitalisation with immobilisation, estrogen therapy, postpartum)
○ Distal + transient risk factor: 6 weeks
○ Proximal + Transient risk factor: 3 months
○ Permanent risk factor: indefinite
* Unprovoked 3-6 months
* Submassive 6-12 months
* Massive - indefinite
70
DVT treatment
- Distal DVT provoking factor no longer present - 6 weeks
- Proximal DVT, provoking factor no longer present - 3 months
- Unprovoked distal DVT - 3 months
Continue therapy after 3 months if
Multiple prior unprovoked episodes of DVT/PE
71
CN control of blinking:
CN V
CN VII
72
Bell's palsy: how to differentiate
Central
Spares eyelid and forehead muscles
CANT SOMETIMES be due to peripheral cause
Peripheral
RARELY CAN spare eyelid and forehead muscles if distal peripheral cause
Upper and low facial weakness
- Inability to close eye
- Drooping corner of mouth
- Disappearance basolabial fold
- Eyebrow sagging
Impairment in volitonal movements of facial muscles
Impaired in emotional expression
Ipsilateral impaired taste
Decreased tearing/salivation
Ear pain
73
Cavernous sinus syndrome features:
3rd,4th, sixth
Trigeminal neuropathy: V1 and sometimes V2
74
Cerebellopontine syndrome features:
Vestibular schwannoma,
- Junction between pons + cerebellum
- Lateral cranial nerves
○ V, VI, VIII
75
Superior orbital fissure lesion
III, IV, first division V, VI
Invasive tumors of sphenoid bone; aneurysms
76
Brain death definition
Complete + irreversible cessation of brain function (permanent absence of cerebral and brainstem function)
+
Preservation of cardiac activity + maintenance of respiratory/somatic function artificially
77
Brain death criteria
(1) Widespread cortical destruction reflected by
- Deep coma
- No brain- originating motor response to all forms of stimulation
- Pain
- Seizures
- Posturing
(2) Global brainstem damage
Absent pupillary light reaction
Midposition/dilated 4-9mm
Loss of corneal reflexes
Loss of oculocephalic reflex
Oculocephalic (Doll's eye): moving head + neck --> eyes turn with movement
Loss of vestibuloocular reflex
Vestibulo=ocular (caloric testing): put ice water in wear --> absence of eyes turning to irrigated side
Loss of jaw jerk
Loss of gag reflex
Absent cough with tracheal suctioning
Absent sucking/rooting reflexes
Complete + irreversible apnea
78
Brain death IX
Cerebral angiography: gold standard
EEG
Transcranial doppler
MRA with agolinium
CTA
79
Drug induced parkinsonism signs + tx
Tardive dyskinesia
Dystonia
Akathisia
Tx: Benztropine
80
Dystonia treatment
Levodopa
Clonaz
Botox
DBS
81
Changes of hormones during sleep: what increases and decreases?
Prolactin
GH
TSH
Cortisol
Urine
Body
- Prolactin secretion increases
- GH secretion enhanced
LOW
○ Cortisol + thyroprotin inhibited
○ Urine production
○ Body temp
82
Components of sleep wake cycle?
Circadian timing
○ Driven by suprachiasmatic nuclei of hypothalamus
○ Imposes 24 hour rhythms onto a wide range of behaviours, including sleep
Pineal gland
○ Synthesises + secretes melatonin into blood + CSF
SCN
○ Has 2 melatonin receptors
Promotes sleepiness; helps synchronise light-dark cycle (exposure to light = wakefulness)
Neurotransmitters
- GABA, histamine : inhibitory
- Orexin
- NE
- Serotonin
83
Cerebellar: midline vs hemispheric signs/symptoms
MIDLINE
Imbalance:
Truncal ataxia: swaying of head when patient is sitting
Titubation: involuntary rhythmic nodding of head/neck/trunk
LL dysmetria
Saccadic intrusions
Nystagmus
Vertigo
HEMISPHEREIC
Dysfidokinesia
Dysmetria UL
Limb ataxia
Intention tremor
Dysarthria
Broken pursuits
84
Genes assoc with ALS/FTD
○ SOD1 mutation
○ TDP43 inclusions
○ Chr 21
○ C9ORF72 --> linked with ALS/FTD
Increased CSF glutamate = excitotoxicity theory
85
ALS features?
Upper and motor neuron weakness
NO SENSORY
Cognitive: FTD
Flail Limb
Split hand syndrome
86
ALS treatment
Riluzole
Glutamate release blocker
Mutlidiscplinary care improves survival
NIV: improved survival, improved QOL
Symptomatic therapy
§ Spasticity: baclofen, botox
§ Sialorrhea: botox, amitrytilline
§ Dyspnea: NIV
§ Weight loss/dysphagia: PEG, high protein diet
87
JVP:
Describe waveform
a’ wave = atrial contraction ( a for atrial)
‘c’ wave (c for closure)
‘v’ wave (v for volume filling)
‘x’ descent = fall in atrial pressure during ventricular systole
‘y’ descent = opening of tricuspid valve
88
JVP: cases for
- absent a wave
- large a wave
- cannon a wave
- large v wave
- rise in JVP during inspiration (Kussmaul's)
- absent a wave: AF
- large a wave: pHTN/ pstenosis
- cannon a wave: beating against closed valve --> CHB, vent arrhythmias
- large v wave: TR
- rise in JVP during inspiration (Kussmaul's): constrictive pericarditis
89
Medications that can trigger MG crises?
○ Aminoglycosides
○ Quinolones
○ Mg
○ BB
Hydroxychloroquine
90
GBS treatment?
Ventilatory support
IVIG 0.4 g/kg intravenously, daily for 5 days = NOT STEROIDS
Plasma exchange
91
CIDP treatment?
IVIG
CIDP responds to steroids but GBS does not
Plasma exchange
○ Less preferred
92
MG medication triggers?
○ Aminoglycosides
○ Quinolones
○ Mg
○ BB
○ Hydroxychloroquine
93
MG signs? Which ones are earliest?
PRESERVED REFLEXES
NO CARDIAC INVOLVEMENT
Weakness
- fatiguable
Earliest signs
- ptosis
- diplopia
- bulbar
94
MG antibodies + associations?
- Acetylcholine receptor Abs
○ Assoc with thymoma
- Anti muscle specific kinase (MuSK) Abs
○ More likely to cause severe bulbar/ resp/ cervical weakness
○ Post synaptic
- LRP4 antibodies
- Stiational antibodies
○ In patients with onset < 50
○ 95% Incr likelihood thymoma
- Neuronal + titn
○ Assoc with thymoma, late onset
95
MG treatment
Mild + symptomatic:
- anti-acetylcholineterases (pyridostigmine, neostigmine)
Adv
- steroids (NOT HIGH DOSE = WILL WORSEN)
- immunosuppressants:
96
MG treatment
Mild + symptomatic:
- anti-acetylcholineterases (pyridostigmine, neostigmine)
Adv
- steroids (NOT HIGH DOSE = WILL WORSEN)
- immunosuppressants: AZA, mycoph, MTX
- refractory: rites, cyclo, efgartidimod (accelerates pathogenic removal)
Crises
- IVIG
- plasmapharesis
97
Thymemectomy indications in MG?
○ Even if hyperplasia only + < 65 years age
○ Allows you to wean
○ Can't tell if malignancy on imaging
Supported by 2016 RCT --> even if MG only mild
98
Anti MUSK treatment?
More aggressive
- Needs, PLEX, steroids, ritux
99
MG risk in pregnancy?
Transient neonatal MG for up to 3 months for 15%
100
Diference between LEMS and MG?
VGCC: pre synpatic
No opthalmoparesis, bulbar involvement
Incremental CMAP
101
Vestibular syndrome: midline vs hemispheric symptoms?
MIDLINE
- Vermis, vestibulocerebellum (flocculus, nodulus), paravermis
- Function
○ Motor execution
○ Rapid and slow eye movement
○ Balance/ LL coordination
○ Vestibular function
- Damage causes
○ Imbalance:
○ Truncal ataxia: swaying of head when patient is sitting
○ Titubation: involuntary rhythmic nodding of head/neck/trunk
○ LL dysmetria
○ Saccadic intrusions
○ Nystagmus
○ Vertigo
HEMISPHEREIC
- Function
○ Motor planning, coordination of complex tasks
- Damage causes
○ Ipsilateral
§ Dysfidokinesia
§ Dysmetria UL
§ Limb ataxia
§ Intention tremor
§ Dysarthria
§ Broken pursuits
