Neuro Flashcards
Give 5 medications that increase the risk of idiopathic intracranial HTN
- Corticosteriods
- Abx (tetracyclines e.g. lymecycline)
- COCP
- Lithium
- Vit A
What antibodies are seen in Lambert-Eaton myasthenic syndrome?
Voltage-gated calcium-channel antibodies
What drugs can worsen exacerbate myasthenia?
- Beta blockers
- Lithium
- Phenytoin
- Penicillamine
- Certain abx
What is the management of cerebral oedema?
- Slowing IV fluids
- IV mannitol
- IV hypertonic saline
What is always required to diagnose epilepsy?
An EEG
How can you differentiate Bells palsy and Ramsay Hunt?
- In Ramsay Hunt they would have ongoing ear pain + a vesicular rash in and around their ear
- In Bells ear pain comes on suddenly and then goes before weakness develops
- Ramsay Hunt is also associated with VZV
What is the stepwise Rx of idiopathic inter-cranial HTN?
- Lifestyle
- Acetazolamide
- Topiramate
- Repeated lumbar puncture
What condition do 50% of people with temporal arteritis have?
Polymyalgia rheumatica
What is the order and connections of ventricles in the brain?
Lateral ventricles -> foramina of Monro -> 3rd ventricle -> cerebral aqueduct -> 4th ventricle -> foramina of Luschken + Magendie -> subarachnoid space
Give 6 risk factors for SAH
- Smoking
- Alcohol
- Cocaine
- Ehlers Danlos
- Polycystic kidney disease
- Coarctation of the aorta
What is a simple febrile seizure?
- Tonic clonic
- <15 mins
- Occurs once during febrile illness
What is a complex febrile seizure?
- Partial/focal seizure
- > 15 mins
- Occurs multiple times during febrile illness
Do Parkinson’s tremors change with alcohol?
NO!
What CSF results are seen in bacterial meningitis?
- Cloudy CSF
- Low glucose
- Raised protein
- Raised neutrophils
What is the primary inhibitory neurotransmitter of the CNS? What is its effect?
- GABA
- It reduces neuronal excitability by inhibiting nerve transmission
What the primary excitatory neurotransmitter of the CNS?
Glutamate
Give some factors for differentiating between trigeminal neuralgia and temporal arteritis
- Pain in TA doesn’t radiate
- Pain in TA is present for days
- Pain in TN is present for months
- Pain in TN starts over CN V1/2 territories and later affects CN V3 territory
How long does it take the symptoms of optic neuritis to resolve?
Days/weeks
What is the first line medication for benign essential tremor?
Propanolol
What would patients with myelopathy complain of?
- Clumsy hands
- Difficulty walking:
- ‘Legs feel not my own’
- Legs feel heavy
- Can’t feel the ground under feet
What would patients with Radiculopathy complain of?
- Radiating limb pain
- Sharp shooting pain
- Pain often in pattern of a dermatome
What 1) myotome, 2) dermatome and 3) reflex are affected in a C6 radiculopathy?
1) Elbow flexion
2) Thumb
3) Biceps
What 1) myotome, 2) dermatome and 3) reflex are affected in a C7 radiculopathy?
1) Elbow extension
2) Middle finger
3) Triceps
What 1) myotome and 2) dermatome are affected in a L5 radiculopathy?
1) Dorsiflexion
2) Big toe, dorsum
What 1) myotome, 2) dermatome and 3) reflex are affected in a S1 radiculopathy?
1)Plantar flexion
2) Little toes, lat side of the foot, sole
3) Ankle jerk
What is bulbar palsy?
Impaired functioning of the lower CN (9-12)
What can cause bulbar palsy
- Brainstem tumours/strokes (main)
- ALS
- GBS
- Genetic diseases
How can bulbar palsy present?
- Difficulty chewing
- Dysphagia
- Slurred speech
- Drooling
How to test ulnar nerve function?
- Cross fingers or paper between thumb and first digit
- Ulnar function = finger ab/adduction and thumb adduction
How to test median nerve function?
- Keep thumb pointing to ceiling against resistance
- Median function = thumb abduction
How to test radial nerve function?
- Wrist and finger extension against resistance
What happens in radial nerve palsy?
Wrist drop
What bladder and bowel symptoms do you get with spinal cord lesions? Why?
- Constipation and urinary retention
- UMN involvement
- Increased sphincter tone preventing passage of urine and faeces
What bladder and bowel symptoms do you get in caudal equina? Why?
- Urinary and faecal incontinence
- Mainly LMN involvement
- Decreased sphincter tone resulting in incontinence
What spinal cord lesion can cause autonomic dysfunction? What are the symptoms?
- Lesion above T6
- HTN
- Bradycardia
- Urinary retention
- Constipation
- Flushing
- Sweating
What aspects of sensation are typically lost first with sensory loss?
- Fine touch, proprioception, vibration
- Pain and temp remain
What is the pattern of motor and sensory loss in Brown Squared Syndrome?
- Contralateral loss of pain and temp (fibres desucate in spinal cord)
- Ipsilateral loss of fine touch, vibration, proprioception (fibres desucate in brain
- Ipsilateral loss of motor
What is an important cause of reversible dementia?
Normal pressure hydrocephalus
What triad of features are typical of normal pressure hydrocephalus
- Urinary incontinence
- Dementia
- Gait abnormality
What is the management of normal pressure hydrocephalus?
Ventriculoperitoneal shunting
How does trigeminal neuralgia present?
- Sudden electric shock like pain
- Pain lasts seconds - mins
- Can be triggered by shaving, brushing teeth, wind
What causes trigeminal neuralgia?
- Compression of the trigeminal nerve by art/veins, tumours
- Can be caused by MS
What is the management of trigeminal neuralgia?
- Carbamazepine - gradual withdraw once pain free for one month
- Gabapentin and ropivacain injections
- Surgery - decompression
How does GCA present?
- Severe headache around the temple
- Unilateral
- Scalp tenderness
- Jaw claudication
- Visual changes (blurred/double vision)
- Systemic symptoms e.g. fever, wt loss, muscle aches
Gold standard investigation for GCA? What does it show.
- Temporal artery biopsy
- Multinucleated giant cells
What is the management of GCA?
- Steroids - 40/60mg pred
- Aspirin
- Consider bisphosphates for bone protection (steroids) and PPI for gastric protection
What is Bells Palsy?
A LMN facial palsy
Do you get forehead sparing in Bells Palsy?
- No
- Forehead sparing in UMN lesions
What is the management of bells palsy?
- Steroids within 72 hrs
- Eye care
What is the order of structures from the skull to the brain?
- Skull
- Dura mater
- Arachnoid mater
- Subarachnoid space
- Pia mater
- Brain
What are the 3 aspects of the GCS? What score are they out of?
- Eyes (/4)
- Verbal (/5)
- Motor (/6)
What are the criteria of the eye component of the GCS?
1 = none
2 = open to pain
3 = open to voice
What are the criteria of the verbal component of the GCS?
1 = none
2 = incomprehensible sounds
3 = inappropriate words
4 = confused conversation
5 = orientated
What are the criteria of the motor component of the GCS?
1 = none
2 = extends
3 = flexes
4 = withdraw from pain
5 = localises pain
6 = obeys commands
Subdural haemorrhage:
1) Cause
2) RFs
3) Appearance on CT
1) Rupture of the bridging veins in the outermost meningeal layer
2) Patients with increased brain atrophy e.g. older, alcoholics
3) Crescent shaped, not limited by cranial sutures
Extradural haemorrhage:
1) Cause
2) RF
3) Appearance on CT
4) Time course of deterioration
1) Rupture of the middle meningeal artery
2) Temporal bone fracture
3) Biconvex shape, limited by cranial sutures
4) Period of improved symptoms followed by rapid decline over hours
Where is CSF located?
In the subarachnoid space
Subarachnoid haemorrhage
1) Common cause
2) RF
3) Precipitating factors
1) Rupture of cerebral aneurysm
2) Cocaine use, sickle cell anaemia
3) Weight lifting, sex
What is the updated definition of TIA?
Transient neurological dysfunction secondary to ischaemia without infarction
What is a crescendo TIA?
Two or more TIAs within a week. High risk for stroke
What is the management of TIA?
- Start 300mg aspirin daily
- Start secondary prevention measures for CVD
- Refer to be seen within 24hrs by stroke specialist
What are seizures?
Transient episodes of abnormal electrical activity in the brain
First and second line management of tonic-clonic seizures
- First line: Sodium valproate
- Second line: Lamotrigine/carbamazepine
First and second line management of focal seizures
- First line: Carbamazepine/lamotrigine
- Second line: Sodium valproate/levetiracetam
First line management of absence seizures
- First line: Sodium valproate/ethosuximide
First and second line management of atonic seizures
- First line: Sodium valproate
- Second line: Lamotrigine
First and second line management of myoclonic seizures
- First line: Sodium valproate
- Second line: Lamotrigine/levetiracetam/topirimate
Define status epilepticus
Seizures lasting >5 mins OR more seizures without regaining consciousness
What is the stepwise management of status epileptics in hospital?
- Airway
- High concentration O2
- Check BM
- IV access
- IV lorazepam 4mg
- Repeat IV lorazepam after 10 minutes if still seizing
- IV phenobarbital/phenytoin
What triad of features is seen in Parkinson’s disease
- Resting unilateral tremor
- Cogwheel rigidity
- Bradykinesia
Pathophysiology of Parkinson’s disease
Loss of dopamine in the substantia nigra
What is the most effective treatment for symptoms of Parkinson’s disease? What is it combined with?
- Levodopa
- Levodopa is given with decarboxylase inhibitors that prevent it being broken down by the body
- Combination drugs include:
- Co-benyldopa
- Co-careldopa
Pathophysiology of multiple sclerosis?
Inflammation around myelin and infiltration of immune cells results in demyelination of neurones in the CNS
What are signs/symptoms of MS?
- Optic neuritis
- Eye movement disorders (6th nerve palsy)
- Focal weakness (bells palsy, Horner’s syndrome, limb paralysis, incontinence)
- Focal sensory symptoms (trigeminal neuralgia, numbness, paraesthesia, Lhermitte’s sign)
- Ataxia
Diagnosis of MS is largely clinical. What investigations can support a diagnosis?
- MRI to show lesions
- LP showing oligoclonal bands
What are features of optic neuritis?
- Central scotoma
- Pain on eye movement
- Colour blindness
- RAPD
What is the management of MS relapses?
- 500mg methylprednisolone for 5 days
- If oral treatment fails or if severe relapses - 1g IV daily for 3-5 days
Pathophysiology of MND?
Progressive degeneration of upper and lower motor neurones
Describe a typical MND patient
Late middle aged man (e.g. 60), possibly with an affected relative
How does MND present?
- Progressive weakness of muscles
- Affects the limbs, trunk, face and speech
- Weakness is often first in the upper limbs
What drug is used to slow the progression of ALS? How long can it extend survival?
- Riluzole
- Can extend survival by a few months
What are the common causes of death in MND?
Respiratory failure or pneumonia
How does a tension headache present? What headaches present in a similar pattern?
- Tight band around forehead
- Secondary headaches
What are the 4 sinuses?
- Frontal
- Ethmoid
- Maxillary
- Sphenoid
How does a sinusitis headache present? What can support a diagnosis?
- Facial pain behind the eyes, forehead and nose
- Palate the sinuses assessing for tenderness
What drugs can cause medication over use headache?
- Triptans
- Opioids
- Simple analgesics
Hormonal headaches:
1) What is the cause?
2) When are they common?
3) Management?
1) Low oestrogen
2) 2 days before period and for first 3 days of, around menopause, first few weeks of pregnancy
3) OCP
Cervical spondylosis:
1) Cause?
2) How can it present?
1) Degenerative changes in the cervical spine
2) Neck pain (worse with movement), headache
What are hemiplegic migraines?
Migraines that mimic a stroke
What medications are used for acute management of migraine?
- Paracetamol
- Triptans (sumatriptan 50mg as migraine starts)
- NSAIDs
- Antiemetics
What medications are used for migraine prophylaxis? Which is teratogenic?
- Propanolol
- Topiramate (teratogenic)
- Amitriptyline
What are features of cluster headaches?
- Unilateral
- Red, swollen, watery eye
- Ptosis
- Miosis
- Nasal discharge
- Facial sweating
What is the acute management of cluster headaches?
- Triptans (sumatriptan 6mg SC)
- High flow 100% O2 for 15-20 mins
What medications are used for cluster headache prophylaxis?
- Verapamil
- Lithium
- Prednisolone (2-3 week course to break a cycle of cluster headaches)
What is meningococcal meningitis vs meningococcal septicaemia?
- Meningococcal meningitis is when the meningococcus bacteria infects the meninges and CSF
- Meningococcal septicaemia is when the meningococcus bacteria infects the bloodstream
What does a ‘non-blanching rash’ in meningococcal septicaemia indicate?
That the infection has caused disseminated intravascular coagulopathy and subcutaneous haemorrhages
What are the 2 most common causes of bacterial meningitis in adults and children?
- N. meningitidis
- Strep pneumoniae
What is the most common cause of bacterial meningitis in neonates?
GBS
What 2 tests assess for meningeal irritation
- Kernigs
- Brudzinski’s
What is the treatment of bacterial meningitis 1) <3 months and 2) >3 months
1) Cefotaxime + amoxicillin
2) Ceftriaxone
When is dexamethasone given for bacterial meningitis? What is the function?
- In children >3 months with a positive LP
- Given 4 times daily for 4 days
- Reduces the severity of hearing loss and neurological damage
What meningitis contacts are at highest risk of infection?
People that had close contact within the 7 days prior to onset of illness
Where is a lumbar puncture needle inserted?
L3-L4 intervertebral space
