Neuro Flashcards
Headache, particularly painful when touching right temple, pain spreads to jaw. Very high ESR.
Diagnosis and potential complication?
Giant cell arteritis!
Blindness. GCA is a medical emergency!!
What lobe is most commonly effected in complex seizure?
Temporal lobe
Which vitamin is deficient in Wernicke encephalopathy?
B1 (thiamine)
What is a common initial symptom of MS?
Optic neuritis
What is the most common complaint with MG?
Weakness worse after exertion
What is Horner’s syndrome? What kind of tumour can cause it?
Damage to sympathetic nerves
- anhydrosis (reduced sweating)
- miosis (pupil constriction)
- ptosis
Pancoast tumour can cause it.
Describe the consequences of Brown-Sequard syndrome
Ipsilateral loss of position, vibration sensation, and motor control at the level of the lesion
What are the lower MN sings?
Everything goes down!!
-hyporeflexia
-hypotonia
- negative babinski sign
- flaccid paralysis
Artery likely to be affected: stoke affecting the right lower limb
left anterior cerebral artery
First line pharmacological management of subarachnoid haemorrhage
Nimodipine (CCB)
Most appropriate first line investigation for suspected MS
MRI head (shows demyelination where CT cannot)
What is the first line acute treatment for migraines?
Sumatriptan
Serotonin 5-HTI receptor agonist
Early personality change is a key feature of which type of dementia?
Frontorotemporal dementia
What are the non motor symptoms of Parkinson’s?
- REM sleep disorder
- postural hypotension
- constipation
- depression
What is the name of the only life prolonging drug available to those with MND?
Riluzole
What tests should be done to diagnose MS? Give reasons for each
MRI and lumbar puncture
MRI: look for plaques
LP: look for oligoclonal bands in the CSF
Describe the mechanism of disease behind Alzheimer’s
Accumulation of beta-amyloid plaques and neurofibrilary tangles, resulting in memory loss
Pain in hand at night, progressively worse, tingling in index and middle fingers.
Most likely diagnosis?
Carpal tunnel syndrome
What clinical test is used to help diagnose Carpal tunnel’s?
Would result would indicate?
Phalen’s test
Inability to maintain wrist flex for longer than 1 min
What symtoms would a C7 compression cause?
Pain in the hand
Weakness with elbow extension
What symptoms would a L2-3 compression cause?
Pain in the inner leg
What would a L5 compression cause?
Pain in the outer leg
Weakness with dorsiflexion of the ankle
What would a S4 compression cause?
Pain and weakness with the perianal area, resulting in bladder and bowel dysfunction
How can you clinically distinguish between a common perineal nerve palsy and an L5 reticulopathy ?
If ankle eversion is affected = common perineal nerve palsy
If ankle inversion is weak = L5 reticulopathy
Give 4 clinical features of cauda equina syndrome
- saddle anaesthesia
- lower back pain radiating down both legs (bilateral sciatica)
- urinary incontinence
- loss of anal tone
How is cauda equina managed?
Surgical decompression
What does claw hand and elbow pain indicate?
Ulnar nerve damage
What is the first line management of trigeminal neuralgia?
Carbemazepine
Describe the pathology of granulomatosis with polyangiitis
Autoimmune condition associated with necrotising granulomatous vasculitis, effecting the respiratory tract and kidneys
List 3 respiratory symptoms of granulomatosis with polyangiitis
- epistaxis
- sinusitis
- nasal crusting
- haemoptosis
- dyspnoea
What effect does granulomatosis with polyangiitis have in the kidneys?
Rapidly progressive glomerulonephritis
What facial deformity is seen in granulomatosis with polyangiitis?
Saddle shape nose
List 4 medications used in migraine prophylaxis
Βeta blocker e.g. propranolol
Amitrytyline
Anti convulsant e.g. Topiramate
Botulinum toxin type A
List 4 investigations done in suspected dementia
- Mini mental state assessment
- MRI
- CSF analysis
- confusion screen
Dementia presentation: stepwise deterioration. Which type?
Vascular dementia
Describe the pathology of myasthenia gravis
Autoimmune disease caused by AChR antibodies that attack the post synaptic side of the neuromuscular junction, causing reduced muscle contraction
Mainly effects the muscles of the eyes and face
Give 4 features of MG
- fatiguability
- ptosis
- diplopia
- dysphasia
How is MG diagnosed?
Single fibre electromyography
What are the three management steps of MG?
- Pyridostigmine (long acting Ach inhibitor)
- Prednisolone
- Thymectomy
Describe the pathology of MS
Autoimmune demyelination of the CNS - affecting oligodendrocytes
What symptoms would a temporal lobe seizure cause?
Automatisms e.g. lip smacking, fiddling, chewing
What symptoms would a frontal lobe seizure cause?
Motor features e.g. peddling movements of the legs, ‘Jacksonian march’
What is the clinical difference between complex partial and simple partial seizures ?
Complex partial seizures cause a loss of awareness during the seizure, and post ictal symptoms such as confusion.
Simple partial seizures do not cause this
Dysarthria, dysphasia, regurgitation, choking.
Nasal/hoarse speech, flaccid tongue, absent jaw jerk.
Most likely diagnosis?
Progressive bulbar palsy
What cranial nerves can be affected in PBP?
9, 10, 11, 12
What symptoms can a cerebellar tumour cause?
- headache, drowsiness, vomiting - due to raised ICP
DAHSING: - dysdiadochokinesia
- ataxia
- slurred speech
- hypotonia
- intention tremor
- nystagmus
- gait abnormality
What investigation is contraindicated in suspected cerebellar tumour and why?
Lumbar puncture!
Due to raised ICP, risk of immediate coning
Most common causative bacteria of meningitis in adults?
Streptococcus pneumoniae
Most common causative bacteria of meningitis in Immunocompromised adults and the elderly ?
Listeria monocytogenes
What is the first line investigation for meningitis?
Blood cultures
From CSF analysis, name 4 factors that would indicate that the causative organism of meningitis is bacterial instead of viral?
- increased neutrophils
- increased protein levels
- decreased glucose levels
- cloudy CSF appearance
Name 3 contraindication to performing a lumbar puncture
- signs of raised ICP e.g. headache, vomiting
- coagulopathy
- focal neurology
- cardio vascular compromise e.g. bradycardia and hypertension
- infection at the site of LP
- decreased GCS
What prophylactic antibiotic treatment would be offered to the partner of a pt with meningitis?
Oral ciproloxacin
What is the medical terms for a feeling of curtains coming down over a pts eyes?
Amaurosis fugax
Suspected GCA biopsy. What artery is it taken from and describe the appearance of the cells?
Temporal artery
Multinucleated giant cells
What medicated is urgently prescribed in GCA?
Prednisolone
Is someone were to abruptly stop taking Prednisolone, what is the potential complication?
Adrenal crisis
If GCA isn’t treated urgently, what is a potential complication?
Blindness
Severe unilateral headache, around the orbital region. Right eye is blood shot, slight ptosis.
Diagnosis and 2 other features that would be seen on examination?
Cluster headache
- rhinorrhoea
- lid swelling
- lacrimation
- miosis
- sweating
What is the acute treatment for cluster headache?
100% O2 and SC sumatriptan
What drug is used as cluster headache prophylaxis?
CCB e.g. verapamil
What is encephalitis?
Inflammation of the brain parenchyma usually caused by virus
What is the most common infective cause of encephalitis in Immunocompromised pts?
Herpes simplex virus - type 1
What would be the diagnostic investigation in a patient with encephalitis?
Lumbar puncture with CSF viral PCR testing
What would be the first line treatment of viral encephalitis?
IV Acyclovir (antiviral)
Name 3 migraine triggers
- cheese
- chocolate
- oral contraceptive pill
- caffeine
- alcohol
- anxiety/stress
- menstruation
- bright lights
What is the immediate medical management for migraines?
simple analgesia e.g. paracetamol
triptans e.g. sumatriptan
Alzheimer’s disease: risk factors (3)
- increasing age
- family history of alzheimers
- Down syndrome
- caucasian ethnicity
- reduced physical/cognitive activity
What are some hallmark features of Alzheimer’s on CSF/bloods/MRI
- extracellular deposition of of beta amyloid plaques
- tau neurofibrillary tangles
- damaged synapses
- cortical atrophy
What is the first line medication used in management of Alzheimer’s?
Acetylcholinesterase e.g., donepezil, galantine, rivastigmine, memantine
List 5 symptoms of Parkinson’s
- bradykinesia
- resting tremor
- rigidity
- dementia
- REM sleep disturbance
- constipation
What is the pharmacological management for Parkinson’s?
Levodopa, dopamine agonists, COMT/MAO-B inhibitor
List 3 causes of Guillain-Barre syndrome
- Campylobacter jejuni infection
- Cytomegalovirus
- Epstein Barr Virus
List 4 clinical features expected in Guillain-Barre syndrome
Motor weakness – often distal and ascending
Paraesthesia
Respiratory involvement
Autonomic involvement – HR changes, BP changes, urinary control symptoms
How is GBS diagnosed?
Lumbar puncture, showing increased CSF proteins
What is the treatment for GBS?
- IV immunoglobulins
- plasma exchange
- supportive care in ITU
Acute onset facial drooping.
Give 3 DD
- Bell’s palsy
- Stoke
- TIA
Pt with unilateral facial drooping whose forehead wrinkles when asked to raise eyebrows. What DD is excluded and why?
Bell’s palsy is excluded.
Bell’s palsy is a LMN lesion of the facial nerve, so is not forehead sparing. Stroke and TIA are forehead sparing due to the bilateral innervation of the temporalis muscle (as stroke/TIA have UMN signs)
Facial drooping that self resolves within 24hrs. Diagnosis?
TIA
What type of medication should be added for TIA pt?
Aspirin and clopidogrel
How do you work out pack years?
Number of packs smoked per day X number of years smoking
Pt that appears to understand what you are saying, but is struggling to speak and is slurring his words. What type of aphasia is this?
Expressive aphasia / Brocca’s aphasia
What is an ABCD2 score? What are each of the points?
Score for the risk of a pt that had a TIA will experience a stroke in the following days
Age >60 = 1
Blood pressure = 1
Clinical features (unilateral weakness = 2, speech disturbance = 1)
Diabetes = 1
Duration (>60mins = 2, 10-59mins = 1)
GS diagnostic test for generalised tonic clonic seizure
EEG
List 2 medications that are used to manage generalised tonic clonic seizures in a young female
lamotrigine or levetiracetam
What medication is used first line for males with generalised tonic clonic seizures?
Sodium valporate
A 23-year-old man comes into A&E from a car accident, with a brief loss of consciousness but improved temporarily, but is deteriorating again. He has a headache, his pupil is dilated, his breathing has become deep and irregular and he is confused.
What type of haemorrhage is this likely to be and what is the most likely affected artery?
Extradural haemorrhage
Middle meningeal artery
Describe what is seen on CT of extradural haemorrhage
Hyperdense mass that is biconvex shaped and adjacent to the skull
How is raised ICP treated?
IV mannitol
A 20-year-old female comes in after a night out and fell asleep on her stomach. She woke up with numbness
and tingling in her hand and it was relieved by dangling it over the edge of the bed and shaking it out.
What is this syndrome called and what nerve is affected?
Carpal tunnel syndrome
Median nerve
Name two clinical tests used to examine suspected carpal tunnel
Phalen’s test
Tinel’s test
What are the nerve roots of the median nerve?
C6, C7, C8, T1
Define epilepsy
The recurrent tendency of spontaneous intermittent abnormal electrical activity in part of the brain manifesting in seizures
Define epileptic seizure
Paraoxysamal event that causes change of behaviour / cognitive processes due to hyper synchronous neuronal discharges in the brain
Define syncope
Paraoxysamal event that causes change of behaviour / cognitive processes due to a lack of oxygen or blood flow
Define non-epileptic seizure
Paraoxysamal event that causes change of behaviour / cognitive processes due to mental processes associated with psycho social distress
Give 2 RFs for epilepsy
- family history
- premature birth
- dementia
- use of drugs e.g. cocaine
- stroke
What 2 categories can epileptic seizures be classified into?
Primary generalised,
Partial / focal
What is the 1st line treatment for migraine
NSAIDs + sumatriptan
What is the diagnostic criteria for MS?
2+ lesions disseminated by space and time AND exclusion of differential diagnoses
They have primary progressive multiple sclerosis. Explain the course of this disease in regards to disability
disability over time
/
MS spinal cord lesion symptoms?
- numb/tingling limbs
- leg weakness
- bladder/sexual dysfunction
- Lhermitte’s sign (electric shock sensation on neck flexion)
What affect does heat have on patients with MS and why is this the case?
Worsens symptoms – new myelin ineffective
What is the Glasgow coma scale used for?
Measure of a patients state of consciousness
Subdural haematomas can also present as personality changes or unsteadiness. Give a differential diagnosis that should be considered
Stoke, dementia, CNS masses
In a subdural haematoma where does the bleeding come from?
Between the cortex and venous sinuses
Between which two meningeal layers do subdural haematomas form?
Internal dural layer and arachnoid layer
Alcoholics are at a higher risk of subdural haematomas, why is this?
Alcohol causes the veins to become thin walled making them more likely to bleed
How does ACUTE subdural haematoma appear on CT?
Crescent shaped, hyper dense mass
What is the preferred management for subdural haematoma?
Decompression surgery e.g. craniotomy
First line imaging investigation for suspected stroke
Head CT
What is the pattern of inheritance of huntingtons disease?
Autosommal dominant
Acute treatment of subarachnoid haemorrhage?
Nimodipine
Raised ICP treatment?
IV mannitol
Curative surgery for epilepsy
Respective surgery of affected area
Hemispherectomy
Parkinson’s Pathophysiology
- loss of dopamine in the substantia nigra of the pars compacta.
- Normally dopamine stimulates movement from the basal ganglia by inhibiting the inhibitory pathway of the striatum therefore allowing movement.
- In Parkinson’s the amount of dopamine is reduced, therefore there is less inhibition of the inhibitory pathway, therefore less movement.
By what mechanism does pyridostigmine help treat Myasthenia Gravis?
An anticholinesterase, increasing the availability of Acetylcholine in the synapse.
What is the triad presentation in bacterial meningitis?
- headache
- neck stiffness
- fever
List 2 of the common bacterial causes of meningitis in children.
Neisseria meningitis
Streptococcus pneumonia/pneumococcus
Haemophilus influenza
How would you manage someone with suspected meningococcal septicaemia?
Immediate IV cefotaxime
Do not perform lumbar puncture due to risk of coning cerebellar tonsils/raised intracranial pressure
Confirm diagnosis with blood cultures instead
Give 3 differences between an epileptic seizure and a non-epileptic seizure
- eyes closed in non-epileptic, open in epileptic
- epileptic involves incontinence
- epileptic involves tongue biting
- non epileptic involves hip thrusting
- non epileptic tends to last longer
Give 3 different types of generalised seizure
- Tonic clinic
- clonic
- absence
Give the diagnostic criteria for GCA
- age >50
- temporal artery tenderness
- new headache
- giant cells / neutrophils on temporal artery biopsy
Describe the management of GCA
High dose corticosteroids e.g. Prednisolone
Methotrexate
Drug classes given for acute management of migraine?
NSAIDs and Triptans
Secondary headaches examples
- meningitis
- encephalitis
- GCA
- medication overuse e.g. paracetamol
- venous thrombosis
- tumour
- subarachnoid haemorrhage
How long does an attack of trigeminal neuralgia last for?
1-180 seconds
Subarachnoid haemorrhage risk factors
- smoking
- alcohol
- hypertension
- bleeding disorder
- Ehlers Danilo’s syndrome
- polycystic kidney disease
Subarachnoid haemorrhage first line management
Head CT
Subarachnoid haemorrhage lumbar puncture.
Describe initially and after a few hours
Initial = uniformly bloody CSF
After a few hours = xanthochromic (yellow) CSF
List the layers of the scalp and the meninges starting from most superficial
SCALP
- Skin
- dense Connective tissue
- epicranial Aponeurosis
- Loose connective tissue
- Periosteum
DAP
- Dura mater
- Arachnoid mater
- Pia mater
