Neuro Flashcards
What is a stroke and TIA?
Stoke = permanent, neurological deficit lasting >24 hours
TIA = transient neurological dysfunction secondary to ischaemic without infarction
Px of TACS?
3/3 of:
1. Unilateral weakness (+/- sensory loss) of the face, arms and leg
2. Homonymous hemianopia
3. Higher cerebral dysfunction (dysphasia, visuospatial disorder)
Px of lacunar syndrome?
- Pure motor or pure sensory stroke
- Ataxic hemiparesis
- Dysarthia
Px of POCS?
- Isolate homonymous hemianopia
- Cerebellar dysfunction
MCA embolism affects?
Face & upper limb > lower limb
ACA embolism affects?
Lower limb > upper limb
Scoring tools to identify stroke?
In community -> FAST (Face, arm, speech, time)
+ Exclude hypoglycaemia
In hospital -> Rosier scoring tool
TIA Mx?
- Aspirin
- <24hr see stroke specialist
- Consider MRI, carotid imaging
- secondary prevention:
- Clopidogrel
- Atorvastatin
- If carotid stenosis >50%
-> endarterectomy
- Modify risk factor
- secondary prevention:
Acute ischaemic stroke mx?
- Aspirin
+ PPI if dyspepsia hx - Thrombolysis (alteplase)
- Within 4.5 hours - Thrombectomy
- Within 6 hours
- Salvageable brain tissue seen
- Thrombectomy
- Consider decompressive hemicraniectomy in previously fit cases
Haemorrhagic stroke mx?
Return clotting levels to normal
- Reverse warfarin with Prothrombin + IV vit K
Consider lowering BP if:
- Px within 6h
- Systolic Bp between 150-220
What does a dominant hemisphere stroke affect?
Often affects language
What does a non-dominant hemisphere stroke affect?
Affects spatial awareness
Points for eyes in GCS?
4 = Spontaneous
3 = Speech
2 = Pain
1 = None
Points for verbal response in GCS?
5 = Orientated
4 = Confused conversation
3 = Inappropriate words
2 = Incomprehensible words
1 = None
Points for motor response in GCS?
6 = Obeys commands
5 = Localises pain
4 = Normal flexion
3 = Abnormal flexion
2 = Extends
1 = None
At what score, consider securing airway?
8 or less
What is the origin of a extradural haemorrhage?
Middle meningeal artery
What is the origin of an subdural haemorrhage?
Bridging cerebral veins
What is the origin of a subarachnoid haemorrhage?
Circle of wilis, sacular
‘Berry’ aneurysms
Where does an extradural haemorrhage occur?
Between skull bone and dura
Where does a subdural haemorrhage occur?
Between dura and arachnoid
Who and Px of extradural haemorrhage?
Who:
Young
Head trauma
Rapid GCS decline
Temporal bone fracture
Px:
Lucid intervals
Unilateral fixed pupil ->
bilateral
Who and Px of subdural haemorrhage?
Who:
Older patients
Low impact trauma
Alcoholics
Px:
Progressive headache and confusion
Who and Px of subarachnoid haemorrhage?
Who:
Sickle cell anaemics
CTD
Cocaine use
Strenuous activity (weightlifting, sex)
Px:
Worst headache ever (occipital)
N&V
Neck stiffness Photophobia
CT of extradural & subdural
Extradural - Hyperdense biconvex lens (LEMON)
Subdural - Hypodense crescent shaped (BANANA)
Px of raised ICP?
Constant headache worse on waking / coughing / bending forward
Vomiting
Visual field defects
Unilateral ptosis
Initial Ix of raised ICP
Fundoscopy -> papilloedema
Complications of raised ICP
Cushing’s reflex
Herniation
What is the triad of cushing’s reflex?
Bradycardia, increased BP, irregular breathing
What herniates in a sub-falcine herniation and what is compressed?
Cingulate gyrus
Contralateral hemisphere -> hydrocephalus
Pericallosal arteries -> lower limb hemiparesis
What herniates in an uncal herniation and what is compressed?
Medial temporal lobe
CN III palsy -> unreactive, fixed & dilated pupil
Ipsi posterior c artery -> contralateral homo hemianopia
Px of brain tumours?
- Raised intra-cranial pressure
- Focal neurological symptoms
- Seizures
Px of brain tumours in children?
Tiptoeinig, ataxia, vomiting with headache
What could a ring-enhancing lesion be on MRI of brain?
(MAGIC DR)
M – metastasis
A – abscess
G – glioblastoma
I – infarct
C – contusion
D – demyelinating disease
R – radiation necrosis
Px of migraine?
Unilateral pounding
N&V
Worse moving
Photophobia
Aura
Px of tension headache?
Bilateral pressing ache
Non-pulsatile
Px of cluster headache?
Sharp, throbbing
around eye
30-50y
Smoker
Frequency and length of cluster headache?
8 / day lasting 45-90 mins
Frequency and length of paroxysmal hemicrania headache?
40/day, 10-30 mins
Frequency and length of SUNCT headache?
200/day, <2mins
Frequency and length of migraine headache?
> 5 month
Lasting 4-72 hours
Acute mx of migraine?
Paracetamol, NSAIDs, Triptans
Acute mx of cluster headache?
- High flow O2
- Subcut
sumatriptan
Acute mx of paroxysmal hemicrania headache?
Indomethacin
Acute mx of SUNCT headache?
Lamotrigine
Gabapentin
Migraine prophylaxis?
- Mindfulness or CBT
+ Vit B2 (riboflavin) - Consider 6-12mo:
- Amitriptyline
- Propranolol
- Topiramate - Acupuncture if drugs ineffective
Tension headache prophylaxis?
- Relaxation techniques
- Basic analgesia
- Amitriptyline
Mx of sinus headache?
<10 days -> self-limiting (majority viral) + basic analgesia
> 10 days with no improvement
- High-dose nasal corticosteroid (mometasone)
- Consider antibiotics
Px of hormonal headache?
Generic, non-specfic, tension-like headache
o Two days before and first three days of menstrual period
o Around the menopause
o Pregnancy (first few weeks)
Mx of hormonal headache?
Basic analgesia, COCP can improve symptoms
Menstrual migraine – Frovatriptan or zolmitriptan on days of migraine or from 2 days before period
Px of trigeminal neuralgia?
Sharp stabbing intense pain lasting up to 2 minutes of CN V distribution
- ‘Electric shock in jaw’
- 90% unilateral
Mx of trigeminal neuralgia?
Carbamazepine
Surgery to decompress trigeminal nerve
Facial nerve functions?
Motor:
- Muscles of facial expression
- Stapedius in the inner ear
- Neck muscles – posterior digastric, stylohyoid and platysma
Sensory:
- Taste from anterior 2/3rd tongue
Parasympathetic:
- Submandibular & sublingual salivary glands
- Lacrimal glands (tear production)
How to tell if lesion of facial palsy is UMN or LMN?
UMN lesion -> forehead spared as other side of brain saves day
Lower motor neuron lesion -> forehead affected
UMN lesion causes of facial palsy?
Strokes
Tumours
LMN lesion causes of facial palsy?
Bell’s palsy
Ramsay hunt syndrome
Acoustic neuroma
M.S
Px of Bell’s palsy?
Rapid onset (<72h) unilateral LMN facial nerve palsy
Facial muscle weakness – reduced movement, dropping of eyebrow & mouth corner
Difficulty chewing, change in taste
Incomplete eye closure -> dry eye
Ear and postauricular region pain
Mx of Bell’s palsy?
Full recovery in 3-4 months
- Oral prednisolone, lubricating eye drops, tape eye at bedtime
Mx of ramsay-hunt syndrome?
Prednisolone + aciclovir + lubricating eye drops
Px of ramsay-hunt syndrome?
LMN facial nerve palsy
Painful tender vesicular rash in ear canal, pinna and around affected ear
What nerve is affected and where is the numbness in carpal tunnel syndrome?
Median nerve
Numb thumb + radial 2 and a half fingers
What nerve is affected and where is the numbness in cubitaltunnel syndrome?
Ulnar nerve
Numb pinky + half of ring finger
Weakness of small muscles of hand but not the thumb
- Weak hand grip
What is the px of radial nerve injury?
Wrist drop – weak thumb, finger and wrist extension
Tenderness over distal radial head, pain worse at night
Mx of carpal tunnel syndrome?
A 6-week trial of:
- Wrist splint
- Steroid injection
- Hand exercises
Carpal tunnel nerve decompression
Mx of cubital tunnel syndrome?
Severe -> surgical decompression
Mx of radial nerve injury?
Severe -> Wrist splint to maintain extension
C6 sensation?
Sensation:
Neck
Lateral forearm
Thumb and index finger
C6 motor weakness?
Elbow flexion
Forearm supination
Wrist extension
C7 sensation?
Lower neck
Interscapular
Posterior forearm
Middle finger
C7 motor weakness?
Elbow extension
Forearm pronation
Wrist flexion
Finger extension
C8 sensation?
Inter- & infra-scapular
Medial forearm
4rth & 5th finger
C8 motor weakness?
Thumb extension
Finger flexion
L4 sensation?
Anterior thigh
Medial lower leg / foot
L4 motor weakness?
Knee extension
Ankle dorsiflexion
L5 sensation?
Posterolateral thigh
Lateral leg
Medial foot
L5 motor weakness?
Dorsiflexion foot/toes
Knee flexion & hip extension
S1 sensation?
Posterior thigh and leg
Lateral side of foot
S1 motor weakness?
Plantar flexion foot/toes
Knee flexion & hip extension
Causes of radiculopathy?
Degenerative changes – spondylosis (bony spurs impinging nerves), herniation
Lesions – tumours, osteomyelitis
Spinal stenosis
Cervical level and reflex?
C6 - Biceps, brachioradialis
C7 - Triceps
L4 - Patellar reflex
L5, S1 - Achilles reflex
Frontal lobe seizure px?
Unusual movements
Screaming, swearing or laughing
Urinary incontinence
Twitching / jerking of muscles
Occipital lobe seizure px?
Unusual visions (seeing things)
Uncontrollable eye movements
Repeated blinking
Parietal lobe seizures px?
Unusual sensations (numbness, tingling, burning, crawling)
Difficulty understanding language, reading, writing or doing maths
Seeing things as the wrong size
Temporal lobe seizures px?
Unusual feelings (deja vu, frightened)
Unpleasant taste, smell or sound
Lip smacking, repeated swallowing or chewing
Ix for epilepsy?
EEG
MRI
Mx of tonic-clonic seizures?
- Sodium valproate
- Lamotrigine or carbamazepine
Mx of focal seizures?
- Carbamazepine or lamotrigine
- Sodium valproate or levetiracetam
Mx of infantile spasms?
Prednisolone
Vigabatrin
S/e of sodium valproate?
Teratogenic
Liver damage
Hair loss
Tremor
Carbamazepine s/e?
Agranulocytosis
Aplastic anaemia
Phenytoin s/e?
Folate and VitD deficiency
Megaloblastic anaemia
Osteomalacia
Lamotrigine s/e?
Stevens-Johnson syndrome or DRESS syndrome
Leukopenia
Definition of status epilepticus?
Seizures lasting more than 5 minutes or more than 3 seizures in one hour
Does M.S affect peripheral or central nervous system?
Affects CNS (oligodendrocytes)
Common Px of M.S?
Optic neuritis
Eye movement abnormality
Focal weakness
Focal sensory symptom
Ataxia
Sixth nerve palsy description?
Internuclear ophthalmoplegia
Conjugate lateral gaze disorder
Types of M.S?
Relapsing-remitting (most common) - disease followed by recovery
Secondary progressive - initial relapsing-remitting which progressively worsens
Primary progressive - no relapses or remissions over 1 year
M.S Ix?
MRI
Lumbar puncture -> oligoclonal bands in CSF
Px of optic neuritis/
Unilateral reduced vision over hours - days
Central scotoma
Pain on eye movement
Impaired colour vision
RAPD
Mx of M.S relapse?
Methylprednisolone:
1. 500mg OD for 5 days
2. 1g IV for 3-5 days
Px of MND?
Progressive muscle weakness
No sensory loss
Fatigue when exercising
Clumsiness, dropping things
Mx of MND?
Riluzole - extends life by three months
Parkinson’s px?
Resting tremor - “pill rolling”
Rigidity - “cogwheel rigidity”
Bradykinesia:
- Hand writing gets smaller
- “shuffling gait”
- Reduced facial movements
Other px:
- Anosmia
- Depression, insomnia
- Postural instability
- Cognitive impairment
Parkinson’s tremor vs Benign essential tremor?
Parkinson’s tremor:
- Worse at rest
- Improves with movement
- No change with alcohol
Essential tremor:
- Improves at rest
- Worse with movement
- Improves with alcohol
Mx of Parkinson’s?
Motor symptoms affecting quality of life -> levodopa
Motor symptoms not affecting quality of life:
- Dopamine agonist
- Monoamine oxidase inhibitor
- Levodopa
Dopamine agonists:
- Bromocryptine
- Pergolide
- Cabergoline
MO-B inhibitor:
- Selegiline
- Rasagiline
Levodopa s/e?
Dyskinesias:
Dystonia - abnormal postures or exaggerated movements
Chorea - jerking, random abnormal involuntary movement
Athetosis - involuntary twisting or writhing movements
Neuroleptic malignant syndrome px?
Occurs within hours to days of starting an anti-psychotic
Pyrexia
Muscle rigidity
Autonomic lability
Agitated delirium
Raised creatine kinase
Neuroleptic malignant syndrome mx?
Stop antipsychotic
IV fluids to prevent renal failure
Consider - dantrolene, bromocriptine
Mx of benign essential tremor?
Propranolol
Primidone
First line Mx of neuropathic pain?
Amitriptyline
Duloxetine
Gabapentin
Pregabalin
First line Mx of trigeminal neuralgia?
Carbamazepine
Is forehead sparing in UMN lesion or LMN lesion?
Upper motor neuron lesion has forehead sparing
UMN has bilateral supply to forehead
LMN has unilateral supply to forehead
So if forehead affected, must be LMN
Px of bell’s palsy?
LMN facial nerve palsy
- Forehead affected
- Drooping of eyelid
- Loss of nasolabial fold
Mx of bell’s palsy?
If within 72h -> prednisolone + eye drops
Mx of Ramsay-hunt syndrome?
Acyclovir + prednisolone + eye drops
Px of Ramsay-Hunt syndrome?
LMN facial nerve palsy:
- Forehead affected
- Drooping of eyelid
- Loss of nasolabial fold
Painful and tender vesicular rash in ear canal
Signs of raised ICP?
Constant head
Worse on waking
Worse on coughing, straining or bending forward
Vomiting
Other:
- Visual field defects
- Focal seizures
- Papilledema
What cancers commonly metastasise to the brain? (5)
Lung
Breast
Bowel
Renal cell carcinoma
Melanoma
What is the inheritance of Huntington’s disease?
Autosomal dominant
Features of Huntington’s disease?
Chorea - sudden, uncontrollable jerky movements
Personality changes
Dystonia
Saccadic eye movements
Px of myasthenia gravis?
Proximal muscles and small muscles of head and neck affected more
- Diplopia
- Ptosis
- Weak facial movements
- Difficulty swallowing
- Jaw fatigue when chewing
- Slurred speech
Ix of myasthenia gravis?
Antibody testing:
- Acetylcholine receptor (ACh-R) antibodies
- Muscle-specific kinase (MuSK) antibodies
- LRP4 antibodies
CT or MRI of thymus to look for thymoma
Endrophonium test
Mx of myasthenia gravis?
Acetylcholinesterase inhibitors - Pyridostigmine
Immunosuppression - Prednisolone or Azathioprine
Monoclonal antibodies - Rituximab, Eculizumab
Mx of lambert-eaton syndrome?
Ix & Mx small cell lung cancer
Amifampridine
Causes of peripheral neuropathy mnemonic?
ABCDE
A - Alcohol
B – B12 deficiency
C – Cancer and Chronic Kidney Disease
D – Diabetes and Drugs (e.g. isoniazid, amiodarone and cisplatin)
E – Every vasculitis
Px of Charcot-Marie-Tooth?
High foot arches (pes cavus)
Distal muscle wasting -> “inverted champagne bottle legs”
Weakness in lower legs & hands
Peripheral sensory loss
Mx of Gullian Barre?
IV immunoglobulins
Plasma exchange
VTE prophylaxis
Supportive care
What is neurofibromatosis type 2 most associated with?
Acoustic neuromas
- Hearing loss
- Tinnitus
- Balance problems
Px of tuberous sclerosis?
Epilepsy + skin signs:
- Ash leaf spots
- Shagreen patches
- Angiofibromas
- Cafe-au-lait spots
- Poliosis - isolated patch of white hair on head
Px of neurofibromatosis type 1 mnemonic?
CRABBING
