Neuro Flashcards
Infarction of which artery can lead to locked in syndrome?
Basilar artery
Most important risk factor of a haemorrhagic stroke?
HTN
Presentation of Wallenberg syndrome (lateral medullary syndrome)?
DANVAH
D - Dysphagia (ipsi)
A - Ataxia (ipsi)
N - Nystagmus (ipsi)
V - Vertigo (ipsi)
A - Anaesthesia i.e. sensory loss (ipsi face, contra body)
H - Horner’s syndrome (ipsi)
What is thrombolysis done with in ischaemic stroke?
Alteplase
What is involved in 2ary prevention of ischaemic stroke (not due to AF)?
Following 2 weeks aspirin 300mg:
1) Clopidogrel 75mg lifelong (or aspirin + dipyridamole)
2) Atorvastatin 20-80mg
When must patients have presented within to have thrombolysis in ischaemic stroke?
4.5 hours of onset of stroke symptoms
A stroke affecting which artery presents with oculomotor nerve palsy (‘down and out’)?
Weber’s syndrome –> branches of posterior cerebral artery that supply the midbrain.
Referral for specialist assessment in TIA:
a) <7 days since TIA
b) >7 days since TIA
a) within 24 hours
b) within 1 week
Mechanism of alteplase?
Tissue plasminogen activator
What is a posterior inferior cerebral artery infarct also known as?
Lateral medullary syndrome / Wallenberg’s
When is a carotid endarterectomy considered in TIA or stroke?
Should only be considered if carotid artery stenosis is >70%
Mx of TIA?
Aspirin 300mg 2 weeks
Followed by lifelong clopidogrel 75mg
What scoring system measures disability or dependence in ADLs in stroke patients?
Barthel index
What blood tests are involved in ‘young’ people with stroke?
i.e. <55 y/o with no obvious cause of stroke
Thrombophilia & autoimmune screening
When is thrombectomy considered in ischaemic stroke (alongside thrombolysis)?
If <4.5h from onset AND confirmed occlusion of the proximal anterior circulation
Most likely mx of symptomatic chronic subdural bleeds?
Burr hole evacuation
When is an S3 heart sound normal?
<30 y/o
What medications can be used in the prophylaxis of migraines? (3)
1) propanolol
2) amitriptyline
3) topiramate
What condition is trigeminal neuralgia associated with?
MS
Which antiepileptic can cause SIADH?
Carbamazepine
1st line antiepileptic for focal seizure?
Lamotrigine or levetiracetam
When are antieplileptics started in the majority of cases?
After the 2nd epileptic seizure
What is involved in the mx of infantile spasms? (2)
1) ACTH
2) Vigabatrin
What condition may atonic seizures be indicative of?
Lennox-Gastaut syndrome
What is the characteristic EEG feature in infantile spasms?
Hypsarrhythmia
Mechanism of carbamazepine?
Binds to sodium channels, increasing their refractory period.
What are key contraindications to triptans?
Related to vasoconstriction caused by triptans:
- HTN
- Coronary artery disease
- Previous TIA/stroke/MI
1st line drug for prophylaxis of cluster headaches?
Verapamil
Features of hemiplegic migraines?
1) Hemiplegia
2) Ataxia (loss of coordination)
3) Impaired consciousness
What is familial hemiplegic migraine?
An autosomal dominant genetic condition that is characterised by hemiplegic migraines that run in families.
Management of an acute attack of a cluster headache?
1) High flow O2
2) Triptans
What vitamin can be used in the non-pharmacological prophylaxis of migraines?
Vitamin B2 (riboflavin)
Investigation of choice in cluster headaches?
MRI with gadolinium contrast
Management of acute migraine?
Often retreating to a dark, quiet room and sleeping.
Medical:
1) NSAIDs (e.g., ibuprofen or naproxen)
2) Paracetamol
3) Triptans (e.g., sumatriptan)
4) Antiemetics if vomiting occurs (e.g., metoclopramide or prochlorperazine)
what are hormonal headaches related to?
Low oestrogen
How does sodium valproate interact with the P450 system?
Inhibitor
What is 1st line for chronic or frequent tension headaches?
Amitriptyline
What are the 4 groups of treatment options in PD?
1) levodopa (+ peripheral decarboxylase inhibitors)
2) Dopamine agonists
3) COMT inhibitors
4) MAO-B inhibitors
Role of COMT inhibitors in PD?
COMT enzyme normally breaks down levodopa.
Which class of drug in PD provides the most improvement in motor symptoms?
Levodopa
Role of monoamine oxidase B inhibitors in PD?
MAO-B enzyme normally breaks down dopamine.
Give 3 examples of dopamine agonists used in PD
1) Bromocriptine
2) Cabergoline
3) Pergolide
Triad of features seen in multiple system atrophy?
1) Parkinsonism
2) Autonomic dysfunction e.g. postural hypotension, ED
3) Cerebellear dyfunction: ataxia
Give 2 examples of Monoamine oxidase-B inhibitors used in PD?
Selegiline
Rasagiline
In what type of dementia can delusions be seen (e.g. Capgras syndrome)?
LBD
What can be a key side effect of levodopa at peak dose?
Dyskinesia e.g. dystonia, chorea and athetosis (involuntary writhing movements)
What is a notable side effect of prolonged use of dopamine agonists e.g. bromocriptine?
Pulmonary fibrosis
Hz of tremor in PD vs BET?
PD - 3-5 hertz
BET - 6-12 hertz
Why is levodopa a time sensitive medication?
Due to risk of acute dystonia if stopped abruptly (e.g. if admitted to hospital).
PD medication can be associated with impulse control disorders.
These can occur with any dopaminergic therapy but are more common which which class of drug?
Dopamine agonists
Give an example of a COMT inhibitor used in PD
Entacapone
What may be given to manage dyskinesia associated with levodopa?
Amantadine (a glutamate antagonist)
What enzyme breaks down levodopa?
COMT
What type of headache commonly develops after a LP?
Low pressure headache (due to removal of some CSF which reduces the pressure around the brain).
Mx of low pressure headache?
1) supportive initially (analgesia, rest)
2) IV fluids, caffeine
3) Blood patch
How can ‘wearing off’ phenomenon in levodopa be managed?
By increasing the frequency of levodopa administration.
Which type of dementia typically presents with fluctuating cognition in contrast to other forms of dementia?
LBD
What should be considered in patients who remain conscious during whole-body convulsions, exhibit no post-ictal state and can remember what happened?
psychogenic non-epileptic seizure
Compensatory tachycardia in postural hypotension caused by:
a) Parkinson’s disease
b) levodopa
a) no compensatory tachycardia due to autonomic dysfunction
b) compensatory tachycardia
Is the mirena coil affected by enzyme inducers?
No
What class of medication is ropinerole?
Dopamine agonist
What class of drug is pizotifen?
Serotnin (5-HT3) antagonist
Indication of pizotifen?
primarily as a preventive to reduce the frequency of recurrent migraine headaches.
Which smoking cessation medication reduces the seizure threshold?
Bupropion
Which smoking cessation medication is asscoiated with an increased risk of suicide?
Varenicline
What steroid is indicated in acute MS flare?
Methylprednisolone
What class of medciation is solifenacin?
Antimuscarinic
What are 2 important investigations in MS?
1) MRI scan
2) LP - look for oligoclonal bands
Mx of spasticity in MS? (2)
1) Baclofen
2) Gabapentin
What is Romberg’s test?
Positive test is an inability to maintain an erect posture for >60s with eyes closed.
What can be used to support breathing when the respiratory muscles weaken in MND?
NIV (usually BiPAP)
Lhermitte’s sign can be seen in MS.
What is this?
paraesthesia in limbs on neck flexion
Uhthoff’s phenomenon can be seen in MS.
What is this?
Worsening of vision following rise in body temp (e.g. after hot bath)
Which MND carries the best prognosis?
Progressive muscular atrophy (affects LMNs only)
What is the most common type of MND?
Amyotrophic lateral sclerosis (ALS)
What is preferred way to support nutrition and has been associated with prolonged survival in MND?
PEG feeding
Management of oscillopsia in MS?
Gabapentin (or memantine)
What does Lhermitte’s sign indicate in MS?
Disease in the cervical spinal cord in the dorsal column.
How does optic neuritis typically present? Features?
Unilateral reduced vision:
1) Central scotoma
2) Pain on eye movement
3) Impaired colour vision
4) RAPD
What may an electromyography show in MND?
a reduced number of action potentials with increased amplitude
1st line mx in slowing disease progression in MND?
Riluzole
What type of incontinence can be seen in MS?
Urge incontinence
Can use antimuscarinics e.g. solifenacin (get bladder scan first)
What is often used 1st line for preventing MS relapse?
Natalizumab
What are fasciculations?
Spontaneous involuntary muscle contractions and relaxations - due to LMN lesion.
Think MND.
MRI with or without contrast in MS?
With contrast - to view demyelinating lesions.
What is myasthenia gravis?
An autoimmune disorder caused by Abs directed against the ACh receptor at the NMJ.
This causes muscle weakness & fatigability.
Muscle weakness in myasthenia gravis vs Lambert Eaton syndrome?
Lambert Eaton - proximal muscle weakness that improves with activity
Myasthenia gravis - weakness improves with rest
What tumour may be associated with myasthenia gravis?
Thymoma
What is the most important examination finding to check before starting triptans for migraines?
Why?
BP
Contraindicated in HTN
Which medication is used to treat the symptoms of Lambert-Eaton myasthenic syndrome?
Amifampridine
This increases ACh in the synaptic clefts of peripheral nerve endings.
Give 3 drugs that can cause peripheral neuropathy
1) amiodarone
2) isoniazid
3) cisplatin
What medications may be used to treat the symptoms of benign essential tremor? (2)
1) Propanolol
2) Primidone
What groups of muscles tend to be most affected in myasthenia gravis? (2)
1) Proximal muscles of limbs (ascending i.e. affects legs first)
2) Small muscles of head and neck
What tool gives a score based on the clinical features and duration to identify a stroke in A&E?
ROSIER
What is the imaging investigation of choice in a suspected TIA?
Diffuse weighted MRI
What medication may be used to slow the progression of the disease and extend survival by several months in amyotrophic lateral sclerosis (ALS)?
Riluzole
What cholinesterase inhibitor prolongs the action of acetylcholine and improves symptoms in myasthenia gravis?
Pyridostigmine
When should statins be started after stroke?
48h after stroke onset
What questionnaire can be used to assess whether pain is neuropathic?
DN4
What is the first-line medical treatment for Guillain-Barré syndrome?
IV immunoglobulins
What type of dementia is motor neurone disease most associated with?
Frontotemporal
What 3 complications can subclinical hyperthyroidism lead to?
1) AF
2) Osteoporosis
3) Dementia
Mechansim of bupropion?
Atypical antidepressant used for smoking cessation
Norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist.
How are triptans given in cluster headache?
SC
What drug has the strongest evidence base for reducing relapse in multiple sclerosis?
Monoclonal antibodies e.g. natalizumab
What is preferred drug for treatment of hyperthyroidism in pregnancy?
Propylthiouracil
What score categorises patients into levels of frailty according to their function?
Rockwood frailty scale
What can acute withdrawal of levodopa precipitate?
Neuroleptic malignant syndrome
Which 2 dopamine agonists are most associated with pulmonary fibrosis?
Ergot derived:
1) Bromocriptine
2) Cabergoline
What is cataplexy?
The sudden and transient loss of muscular tone caused by strong emotion (e.g. laughter, being frightened).
Features range from buckling knees to collapse.
What condition is cataplexy strongly associated with?
Nacrolepsy
What is the gold standard test for diagnosing venous sinus thrombosis?
MRI venography
Following an SAH, how are most intracranial aneurysms now treated?
Coiling by an interventional neuroradiologist
How can a head injury appear on an ECG?
‘Cerebral T waves’ –> global T wave inversion
CT head scan is required within 8 hours for patients with a dangerous mechanism of injury.
What does this incliude?
- Falling more than 1 metre
- Falling from a height of 5 stairs or more
Opening pressure on LP in SAH?
Normal or raised
Next step in patients >65 y/o who experienced some loss of consciousness or amnesia following a head injury
CT scan within 8 hours
