Neuro Flashcards
What are the side effects of phenytoin?
Gingival hyperplasia
Peripheral neuropathy
Megaloblastic anaemia
Teratogenic
Cerebellar syndrome
What are the EEG findings for absence seizures?
Symmetrical 3Hz spike and wave pattern
What are the signs of Charcot Marie Tooth Disease?
Pes cavus
Inverted champagne bottle appearance
Scoliosis
Hand muscle wasting
What anterior horn cell diseases can cause a flaccid paraparesis?
MND
Poliomyelitis
Name 6 causes of inflammatory motor neuropathies
Sarcoid, vasculitis, GBS, CIDP, multifocal motor neuropathy, amyloidosis
Name 5 other causes of motor neuropathy
HSMN (CMT)
HIV
Diabetic amytrophy
Ciclosporin
Lyme disease
Porphyria
Myasthenia gravis and Lambert-Eaton Myasthenic syndrome are examples of what disorder that can cause a flaccid paraparesis?
Neuromuscular junction
In a unilateral cerebellar lesion, to which side does the patient veer towards when walking?
Towards the side of the lesion
What are the most common causes of ataxia?
Demyelinating disease
Stroke/SOL
Paraneoplastic
For ataxia, what clues point towards a demyelinating cause?
Internuclear ophthalmoplegia
RAPD
UMN weakness
Sensory disturbance
Bowel/bladder history
What are some rarer causes of ataxia?
Alcohol
Phenytoin
Miller-Fisher syndrome
Friedrich’s ataxia
Wilson’s disease
Ataxic telangiectasia
Spinocerebellar ataxia
What is the cause of bulbar palsy?
Diseases affecting the lower cranial nerves (7-11)
What is the cause of pseudobulbar palsy?
Disease of corticobulbar tracts to medullary brainstem motor nuclei
What is the difference in signs between bulbar and pseudobulbar palsy?
Bulbar:
-Weak and wasted tongue with fasciculations
-Gag reflex absent
-Jaw jerk absent/normal
-Nasal speech
Pseudobulbar:
-Spastic paralysed tongue, no fasciculations
-Gag reflex increased or normal
-Jaw jerk increased
-Spastic speechW
What are the causes of pseudobulbar palsy?
MND
MS
Bilateral CVA
Brainstem tumours
What are the causes of bulbar palsy?
MND
GBS
MG (with ptosis and ophthalmoplegia)
Syringobulbia
What are the signs of sciatic nerve palsy?
Foot drop
Weak knee flexion
Absent ankle reflex
Widespread sensory loss
Loss of plantarflexion, dorsiflexion, eversion, inversion
Palsy of which nerve can cause foot drop?
Common peroneal
What are the signs of lumbosacral plexopathy?
Foot drop
Sensory loss on sole, anterolateral shin, dorsum of foot
Loss of inversion, eversion, and dorsiflexion
Cannot straight leg raise
Foot drop with no sensory deficit is likely to be caused by…
MND
What muscle is involved in foot drop?
Anterior tibialis
What is the cause of Friedrich’s ataxia?
Autosomal recessive trinucleotide repeat disorder (GAA) which codes for frataxin
What are the signs of FA?
Presents at 10-15 years
Gait ataxia
Optic atrophy
Dysarthria
Absent ankle jerks
Extensor plantars
Peripheral sensory neuropathy
Hammer toes and pes cavus
What are the complications of Friedrich’s ataxia?
Hypertrophic cardiomyopathy in 90%
Diabetes mellitus
How is FA diagnosed?
Nerve conduction studies - motor velocities >40ms in arms, absent sensory action potentials
Genetic analysis
What is the cause of myotonic dystrophy?
CTG trinucleotide repeat disorder at DMPK gene
What are the signs of myotonic dystrophy?
Myotonic facies
Frontal balding
Bilateral ptosis
Cataracts
Dysarthria
Weakness of arms and legs (DM1 - distal, DM2 - proximal)
PPM
What are the complications of myotonic dystrophy?
Cardiomyopathy, heart block
Testicular atrophy
Diabetes mellitus
What are the signs of spinal muscular atrophy type 3?
Proximal muscle weakness
Bulbar palsy
What is the cause of Huntington’s disease?
Mutation in huntingtin gene on chromosome 4 - CAG repeat expansion
What are the genetic characteristics of Huntington’s disease?
Compete penetrance
Anticipation
What is the pathophysiology of Huntington’s disease?
Loss of dopamine D2 receptors and neurodegeneration in cortex, striatum, and caudate nucleus
What are the signs of Huntington’s disease?
Slow saccadic eye movements
Chorea
Depression
Behavioural changes
What is the triad of normal pressure hydrocephalus?
Urinary incontinence
Dementia
Bradyphrenia
What are the risk factors for idiopathic intracranial hypertension?
Obesity
Female
Pregnancy
COCP, steroids, tetrocyclines, vitamin A, lithium, isotretinoin
What are the signs of IIH?
Papilloedema
6th nerve palsy
What is the management of IIH?
Rule out cerebral venous sinus thrombosis
LP for high opening pressures - therapeutic
Weight loss
Acetazolamide
Topiramate 2nd line
What is syringomyelia?
Dilatation of a CSF space within the spinal cord, usually within cervical or thoracic segments
Causes compression of spinothalamic tracts
What are the signs of syringomyelia?
Loss of sensation of pain and temperature in a cape-like distribution
Extension of syrinx with coughing or sneezing
Pyramidal signs in lower limbs
What are the features of pituitary apoplexy?
Mimics SAH + features of pituitary insufficiency (hypoadrenalism leading to hypotension and hyponatraemia
Extra ocular nerve palsies
What malignancies is LEMS associated with?
Small cell lung cancer
Breast cancer
Ovarian cancer
What antibody is seen in LEMS?
Antibody against pre-synaptic voltage gated calcium channels
What are the signs of LEMS?
Repeated muscle contractions lead to increased muscle strength
Proximal > distal
Hyporeflexia which recovers following brief muscle activation
Dry mouth
Impotence
What are the signs of PSP (progressive supranuclear palsy)?
Impairment of vertical gaze (difficulty reading/descending stairs)
Stiff broad based gait
Postural instability and falls
Parkinsonism with prominent bradykinesia
Cognitive impairment
Poor response to levodopa
What are the signs of multiple system atrophy?
Parkinsonism
Cerebellar signs
Autonomic disturbance - ED, postural hypotension, atonic bladder
What is affected in anterior spinal artery syndrome?
Lateral corticospinal and spinothalamic tracts at the level of and below the lesion.
What are the signs of anterior spinal artery syndrome?
Bilateral spastic paresis
Bilateral loss of temperature and pain sensation
Which inflammatory myopathy initially affects finger and wrist flexion and is non-tender?
Inclusion body myositis
What is seen on muscle biopsy in inclusion body myositis?
Cytoplasmic inclusions
Which drugs affect the ear?
Aspirin/NSAIDs
Aminoglycosides
Loop diuretics
Quinine
Which antibodies are seen in myasthenia gravis?
ACh receptors
Anti-muscle specific tyrosine kinase antibodies
What are the signs of myasthenia gravis?
Muscle fatiguability
Extra ocular muscle weakness - diplopia
Proximal muscle weakness
Ptosis
Dysphagia
Which drugs worsen myasthenia symptoms?
Aminoglycosides
What are the associations with myasthenia gravis?
Thymoma
Thymic hyperplasia
What is the management of myasthenia gravis?
EMG
CT thorax for thymoma
Autoantibody testing
Long acting AChE inhibitors e.g. pyridostigmine
Thymectomy
Immunosuppression
What is the management of myasthenic crisis?
Plasmaphresis
IVIG
What are the characteristics of multifocal motor neuropathy?
Demyelinating
Acute onset - over a week
Distal neuropathy
Anti-GM1 antibodies
Conduction block
What is the management of MND?
MRI head/neck to rule out intracranial SOL and cervical myelopathy
EMG - acute and chronic denervation
Riluzole
NIV
Physiotherapy
Management of spasticity
What are the signs of ataxic telangiectasia?
Cerebellar ataxia
Telangiectasia
IgA deficiency and hypogammaglobulinaemia
What are the signs of Miller-Fisher syndrome?
Ophthalmoplegia
Areflexia
Ataxia
Descending paralysis
What are the forms of multiple sclerosis?
Relapsing remitting
Primary progressive
Secondary progressive
How is MS diagnosed?
McDonald criteria
MRI - demyelinating lesions
CSF - high levels of immunoglobulin with oligoclonal bands, high protein
What are the signs of tuberus sclerosis?
Ash leaf spots - fluoresce under UV light
Shagreen patches over lumbar spine
Adenoma sebaceum over nose
Subungal fibromata
Cafe au lait spots
Developmental delay
What are the associations of tuberus sclerosis?
Retinal hamartomas
Rhabdomyomas of the heart
PKD
What is neuromyelitis optica?
Relapsing remitting demyelinating CNS disorder
What are the features of neuromyelitis optica?
Bilateral optic neuritis
Myelitis
Spinal cord lesions
Aquaporin 4 antibody
What are the features of basilar migraine?
Brainstem associated range of symptoms - LOC, vertigo, dysarthria
What are the signs of Ramsey-Hunt syndrome?
Unilateral facial nerve palsy with taste loss in anterior 2/3 of tongue
Vesicles on external auditory meatus/soft palate
Vertigo
Sensorineural hearing loss
What is the management of TIA?
MRI brain
Clopidogrel and aspirin 300mg followed by DAPT at 75mg for 21 days
Then monotherapy with clopidogrel 75mg
PPI
Carotid dopplers
What is an acceptable blood pressure prior to thrombolysis?
185/110
What is the time threshold for thrombolysis in acute stroke?
4.5 hours
After 4.5 hours, when is thrombolysis indicated in acute stroke?
Symptoms within 9 hours/9 hours from midpoint of sleep
Core-perfusion mismatch on CT or MR perfusion OR DWI-FLAIR mismatch on MRI
What is the criteria for mechanical thrombectomy in acute anterior circulation stroke?
Symptoms within 6 hours
Proximal large artery (ICA/M1)
mRS 0-2
NIHSS 6 or more
What are some differentials for multiple sclerosis?
Hereditary spastic paraplegia
Cerebral SLE
Sarcoidosis
AIDS
What are the symptoms of optic neuritis?
Unilateral reduction in vision
Painful eye movements
Loss of colour vision (particularly for red)
What autonomic symptoms are seen in MS?
Bladder: impaired emptying, urgency, frequency, incontinence
Bowels: incontinence
Sexual problems
Loss of thermoregulation
What features may point towards MS?
Lhermitte’s sign
Symptoms worse after a hot bath
What is the management of MS?
Oral methylprednisolone 5/7 for flares
DMARDS for relapsing remitting (e.g. interferon beta, natalizumab, glatiramer)
Baclofen and diazepam for spasticity
ISC
Exercise and smoking cessation
Exercise programmes
Optometry, SALT, PTOTW
What is the difference between MND and cervical myeloradiculopathy?
MND has no sensory disturbance
Which drugs cause seizures?
Isoniazid
TCAs
BDZ withdrawal
Alcohol withdrawal/binge
What is the diagnostic criteria for epilepsy?
At least two unprovoked seizures more than 24h apart
What are some differentials for a seizure?
Transient global amnesia
TIA
Migraine
Hypoglycaemia
Sleep disorder
NEAD
Syncope
Cardiac arrhythmia
Tic disorder
How is epilepsy diagnosed?
Video recording
MRI
EEG, if normal can consider sleep deprived EEG
What are is the management of epilepsy?
GTCS: lamotrigine/Keppra
Focal: lamotrigine/carbamazepine
Absence: ethosuximide
Epilepsy specialist nurse
Patient education and seizure diary
Pre-conception counselling
Occupation: unable to work at heights
Do not swim or bath alone
Trigger avoidance
What are the DVLA rules for seizures?
6 months seizure free
What is the non pharmacological management of PD?
Physiotherapy - gait re-training
Occupational therapy
Speech and language therapy (Lee Silverman Voice treatment)
Inform DVLA
Social care assessment
PD specialist nurse
What medications are used in PD?
Early: MAO-i, dopamine agonist, levodopa, amantadine
Later: add COMT inhibitor if on levodopa
What are the complications of drug treatment in PD?
Wearing-off effect
On-off fluctuations
Dyskinesias
Hallucinations and psychosis
Compulsive behaviours
What is a Holmes-Adie pupil?
Myotonic pupil with or without hyporeflexia which responds slowly to light and dilates slowly following normal accommodation
What is an Argyl-Robertson pupil?
Irregular pupil, does not constrict to light but accommodates normally on convergence
What are the signs of 4th nerve palsy?
Innervates superior oblique muscle
Diplopia
Contralateral head tilt
What are the signs of a 3rd nerve palsy?
Deviated down and out (diplopia looking nasally and upwards)
Ptosis
Dilated pupil
Fails to adduct/supraduct/infraduct (supplies IR, IO, MR, SR)
What are the signs of a 6th nerve palsy?
Eye deviated inwards
Unable to abduct
What is a cause of 3rd nerve palsy?
Posterior communicating artery aneurysm
