NEURO Flashcards
what scoring systems are used following a TIA
ABCD2
CHA2DS2VASc
HASBLED
what is the ABCD2 scoring system
risk of developing a stroke following a TIA
A- Age >60 =1
B- blood pressure >140/90=1
C- clinical unilateral leg weaknes =2, speech impairment =1
D- Duration >60=2, 10-59=1
D- DM=1
what is the CHADVASc score
risk of stroke in pts with AF
what is the HASBLED score
estimates the 1-year risk of a major bleeding event in patients with AF on anticoagulation
Management of TIA
300mg aspirin
inform DVLA and not to drive until specialist review
No aspirin if…
- >7 days since S/S
- Bleeding disorder / on an anticoagulant
- Takes regular low-dose aspirin
- Aspirin CI
long term Rx
1st line: clopidogrel + statin
2nd line: aspirin + dipyradimole + stain
which parts of the brain does the MCA supply
lateral frontal, lateral parietal and parts of temporal
frontal eye fields
motor cortex
sensory cortex
wernikes (inf division)
and brocas area (superior division)
main features of a MCA stroke
contralateral hemiparesis of face and upper limbs>lower limbs
contralateral sensory loss of face and upper limbs> lower limbs
ipsilateral gaze deviation
wernikes area- receptive aphasia - can talk but it makes no sense
brocas area- expressive dysphasia - cant talk
contralateral homonymous hemianopia (inferior div)
what parts of the brain does the ACA supply?
medial frontal lobe and medial parietal lobe
features of an ACA stroke
contralateral hepiaplegia lower extremities > upper extremities
contralateral sensory loss lower extre> upper extrem
paracentral lobule affected- urinary and faecal incontinence
features of ICA stroke
Amourosis fugax- vision loss
features of a PCA stroke
contralateral homonymous hemianopia
cant read, can write (alexia without agraphia)
anomia (cant name colours and objects)
midbrain: webers syndrome/ claude syndrome
Thalamus:
contralatoral sensory loss
contralateral pain
decreased arousal
where does the PCA
brainstem - esp midbrain
occipital lobe - primary visual cortex and association zone
thalamus
what is the watershed zone
what is webers synrome
What is claude syndrome
causes of a coma
metabolic:
- hypoglycaemia
- myxoedema coma
- drug OD, alcohol withdrawal
- hypercalcaemia
intracranial:
- SAH
- meningitis
- head injury
- encephalitis
- epilepsy, delerium tremens
things that can cause a lesion in the brain
- infarct
- haemorrhage
- abscess
- tumour
- TB
- WAW: cryptococcus, mucormycosis, toxo
causative organisms of meningitis
Neisseria meningitidis
Streptococcus pneumoniae
Listeria monocytogenes
Group B Streptococcus
Haemophilus influenzae
Mycobacterium tuberculosis
Viral
causes of headache
benign
tension headache
dehydration
medication overuse
febrile illness
severe
-migraine
- cluster
- meningitis
- tumour
- abscess
- intracranial bleed eg. SAH
- giant cell arteritis
differentials for dizziness
Is it Vertigo
Is it syncope
Is it hypotension
Is it hypoglycaemia
Is it epilepsy
Is it migraine
What is parkinsons
degeneration of the neurones in the substantra nigra
beta synuclein deposition
features of parkinsons
face:
- masked face
- monotonous speech
- reduction in spontaneous blinking
gait:
- difficulty initiating
walking,
- walking with small
slow shuffling steps
or rapid small steps
(festination)
- ‘Freezing’ occurs
on turning or
changing direction.
tremor:
- resting tremor
- pin rolling tremor
rigidity:
- cogwheel rigidity
side effects of L-DOPA
nausea or vomiting
postural hypotension
worsening of peptic ulcer symptoms
sweating
discoloration of urine/sweat
with long-term use:
–Motor fluctuations and dyskinesias.
–Neuropsychiatric problems. Confusion,
hallucinations, psychosis.
dorsal columns senses
(Visible panty line VPL)
vibration
proprioception
light touch
spinothalamic tract senses
pain
temperature
crude touch
where do nerves cross in the dorsal column ?
brainstem passing to the thalamus
where do nerves in the spinothalamic tract cross?
in the spinal chord as soon as it enters
where are the most common tumours to metastasise to the brain
lung, breast, kidney, melanoma and colorectal cancers metastases
features of multisystem atrophy
parkinsonism
autonomic disturbance
erectile dysfunction: often an early feature
postural hypotension
atonic bladder
cerebellar signs
features of normal pressure hydrocephalus
progressive dementia
falls and difficulty walking
urinary incontinence
parkinsonism differentials
parkinsons
drug induced
multisystem atrophy
progressive supranuclear palsy
lewy body dementia
gait disturbances causes:
foot drop
neuropathy
damage to the anterior tibialis
gait disturbances causes:
ataxia
cerebellar pathology
alcohol
Korsikoffs syndrome
gait disturbances causes:
parkinsonism
shuffling gait
loss of arm movement
gait disturbances causes:
gail apraxia
small vessel disease
hydrocephalus
gait disturbances causes:
spastic paraparesis (walking through mud)
chord lesion
parasaggital lesion
gait disturbances causes:
myopathic/ waddling
myopathic, dystrophic disorders
features of GBS
preceding GI or URT infection
ascending muscel weakness
back pain
gradual loss in tendon reflexes
causes of loss of conciousness
neurological causes:
- epilepsy
- rasied ICP
- SAH
- sleeping disorders eg. narcolepsy
neurally mediated
- vasovagal syncope
- carotid sinus syncope
- situational syncope
cardiac
- arrhythmias
- structural eg. AS, HOCM
orthostatic:
- postural hypotension
- drugs
metabolic/ endocrine
- Addisons
- hypoglycaemia
- metabolic acid base disturbances
sudden onset of vertigo, hearing loss, tinnitus, and sensation of fullness in the affected ear
menieres disease
acute vertigo DDx
Benign proxysmal positional vertigo (BPPV)- Hx after head injury or infections
acute vestibular neuritis- Hx develops over hrs, resolves in days, viral
Menieres disease- Hx- hasting minutes to hrs, recurrent, tinitus and hearing loss
surgical sieve
Vascular
Iatrogenic
Trauma
Autoimmune, inflammatory
Metabolic
Infection
Neoplastic
Congenital
Degenerative
Environment
Functional (medically unexplained)
causes of cerebellar disease
V- ischaemic/ haemorrhagic stroke
I- drugs: phenytoin, lithium
T- head trauma
A-autoimmune demyelination
M- alcohol excess, thyrotoxicosis
I- measles, HIV, prion
N- metastases, primary brain tumors, neuroblastoma
Nutritions- vit E def, vit B1 def (wernickes)
optic neuritis differentials
inflammatory/autoimmine:
- SLE
- autoimmune optic neuropathy
- Bechets disease
- post infectious
- multiple sclerosis
Compressive
- tumours
- Thyroid opthalmopathy
infectious
- syphilis
- TB
- lyme
- HIV
Toxic and nutritional:
- vit B12 def
- methanol intoxication
- ethambutol
- amiodarone
- diabetic retinopathy
causes of a tremor
Parkinsonism
Thyrotoxicosis
medications: salbutamol, immunosuppressive drugs, lithium, steroids
demyelination diseases
Toxins: alcohol, cocaine
chorea differentials
Hereditary:
- huntingtons
- benign hereditary chorea
- wilsons disease
- mitochondrial disease
Infection:
- sydenhams chorea, rheumatic fever
- HIV
- vCJD
vascular:
- polycythemia
- infarction
Metabolic:
- hypocalcaemia
- hyperthyroidism
- hyper and hypo gylcaemia
Immunological:
- SLE
- APLS
- chorea gravidarum
Drug induced:
- anti-parkinsons drugs
- amphetamines
features of posterior inferior cerebellar artery (lateral medullary syndrome, Wallenberg syndrome
Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus
absolute contraindications for thrombolysis in stroke
- Previous intracranial haemorrhage
- Seizure at onset of stroke
- Intracranial neoplasm
- Suspected subarachnoid haemorrhage
- Stroke or traumatic brain injury in preceding 3 months
- Lumbar puncture in preceding 7 days
- Gastrointestinal haemorrhage in preceding 3 weeks
- Active bleeding
- Pregnancy
- Oesophageal varices
- Uncontrolled hypertension >200/120mmHg
investigations for suspected stroke
non contrast CT head- determine if ischaemic or haemorrhagic
bloods:
U&Es- hyponatraemia can cause neurological signs
glucose: hypoglycaemia can mimic stroke
FBC- polycythemia
clotting- exclude coagulopathy
Management of acute stroke
CT- determine if ischaemic or haemorrhagic
ischaemic:
thrombolysis with alteplase within 4.5hrs
consider mechanical thrombectomy
start on aspirin and clopidogrel for 21 days after
or aspirin + ticagrelor for 30 days
management of haemorrhagic stroke
supportive
urgent neurosurgeon referral
control of BP
urgent reversal of any anticoagulation medication
reversal agent of warfarin
vitamin K
reversal agent of dabigatran
idarucizumab
management of myasthenia crisis
plasmaphoresis and IVIG
diplopia differentials
multiple sclerosis
myesthenia gravis
thyroid opthalmopathy
associations in myesthenia gravis
thymomas in 15%
autoimmune disorders: pernicious anaemia, autoimmune thyroid disorders, rheumatoid, SLE
thymic hyperplasia in 50-70%
causes of LMN facial nerve palsy
Bell’s palsy
Ramsay-Hunt syndrome (due to herpes zoster)
acoustic neuroma
parotid tumours
HIV
multiple sclerosis*
diabetes mellitus
difference between UMN and LMN facial nerve palsy
UMN is forehead sparing
causes of peripheral neuropathy
Acute:
GBS
porphyria
diptheria
chronic
Diabetes
B12 deficiency
drugs: isoniazid, HIV medications, alcohol
hypothyroidism
features of central chord syndrome
man in a barrel
legs are fine but arms have no power
features of a Total anterior circulation infarct (TACI)
Unilateral weakness (and/or sensory deficit) of the face, arm and leg
Homonymous hemianopia
Higher cerebral dysfunction (dysphasia, visuospatial disorder)
must have all 3 to be a TACI
features of a partial anterior circulation infarct
1-2/3 of the following
Unilateral weakness (and/or sensory deficit) of the face, arm and leg
Homonymous hemianopia
Higher cerebral dysfunction (dysphasia, visuospatial disorder)
Posterior circulation syndrome (POCS)
One of the following need to be present for a diagnosis of a POCS:
Cranial nerve palsy and a contralateral motor/sensory deficit
Bilateral motor/sensory deficit
Conjugate eye movement disorder (e.g. horizontal gaze palsy)
Cerebellar dysfunction (e.g. vertigo, nystagmus, ataxia)
Isolated homonymous hemianopia
features of a lacunar stroke (LACS)
One of the following needs to be present for a diagnosis of a LACS:
Pure sensory stroke
Pure motor stroke
Sensori-motor stroke
Ataxic hemiparesis
What are you at risk of with a bleed in the ventricles
hydrocephalus
causes of bilateral peripheral neuropathy
diabetic neuropathy
B12 deficiency
causes of cerebellar dysfunction
Parneoplastic
Atrophy, autoimmune
Stroke
Trauma (rare)
Raised ICP
Infection
Ethanol, drugs eg. phenytoin
Sclerosis (MS)
features of a brainstem stroke
ipsilateral facial signs with LMN features (ie. forehead sparing)- stroke at the CN nucleus will give LMN
conterlateral hemiparesis (UMN features)
causes of an UMN lesion
Stroke- haemorrhagic/infarct
Trauma
Infection- meningitis, TB
Inflammation- sarcoid, lupus, amyloidosis, MS
Causes of LMN lesion
Cranial nerve
Brainstem stroke
bells palsy
Anteriorhorn cells:
Amyotrophic lateral sclerosis
infection- polio, west nile
NMJ:
Myesthenia gravis, labert eaton
Clostridium botulinum + tetani
peripheral demyelination
GBS, MFS
myopathy
polymyositis
dermatomyositis
metabolic- DM, cushings, hypothyroid
features of cauda equina syndrome
saddle parasthesia
back pain
bowel and bladder incontinence
lower limb weakness
causes of causa equina synddrome
Mechanical:
vertebral collapse and compression
spondolytis
Infection
Potts disease (TB spine)
osteomyelitis
systemic
metastasis
Imaging findings in MS
Periventricular white matter lesions not necessarily matching the clinical pitcture
triggers for myasthenia gravis crisis
emotions
infection
hypokalaemia
exercise
drugs- opioids, antibiotics, beta-blockers
features of 4th nerve palsy
vertical diplopia
classically noticed when reading a book or going downstairs
subjective tilting of objects (torsional diplopia)
the patient may develop a head tilt, which they may or may not be aware of
when looking straight ahead, the affected eye appears to deviate upwards and is rotated outwards
causes of peripheral neuropathy with predominant motor loss
Guillain-Barre syndrome
porphyria
lead poisoning
hereditary sensorimotor neuropathies (HSMN) - Charcot-Marie-Tooth
chronic inflammatory demyelinating polyneuropathy (CIDP)
diphtheria
causes of peripheral neuropathy with predominant sensory loss
diabetes
alcohol
B12 deficiency
chemotherapy
amyloidosis
subtypes of peripheral neuropathy
axonal loss- sensory deficit
demyelination- motor deficit
red flag symptoms of trigeminal neuralgia propting urgent neurology referral
Sensory changes
Deafness or other ear problems
History of skin or oral lesions that could spread perineurally
Pain only in the ophthalmic division of the trigeminal nerve (eye socket, forehead, and nose), or bilaterally
Optic neuritis
A family history of multiple sclerosis
Age of onset before 40 years
managament of trigeminal neuralgia
carbamazepine
neuro referral if redflag signs
what are 2 characteristic signs of MS
Lhermitte’s sign- neck flexion causes tingling down spine
Uhthoff’s sign- symptoms worsening (espesially visual sx) when body temperature raised
differentials for symmetrical parkinsonism signs
progressive supranuclear palsy
multisystem atrophy
Drug induced
features that would suggest progressive supranuclear palsy
symmetrical parkinsonism
early presentation with falls
vertical gaze palsy
features that would suggest mutisystem atrophy
symmetrical parkonsonism
autonomic features early (eg. urinary incontenence)
cerebellar signs
poor response to levodopa
differentials for MS
neuromyelitis optics
neurosarcoidosis
MG crisis triggers
infection
drugs: b blockers, amninoglycosides (gentamycin, amikacin), tetracycline (doxy, lemy),statins
stress/surgery/trauma
management of acute MG crisis
FVC and early ITU involvement if low
IVIG +/- plasmaphoresis
chronic Rx of MG
pyridostigmine
steroids
immunosuppressives (azathioprine, MMF methotrexate)
examples of MND
amyotrophic lateral sclerosis
bulbar palsy
progressive muscular atrophy (purely LMN)
primary lateral sclerosis (purely UMN)
MND mimics
spondylotic myeloradiculopathy
multifocal motor neuropathy
syringomyelia
benign fasciculation syndrome
