neuro Flashcards
ACA vs MCA vs PCA stroke?
ACA:
contralateral sensory and motor loss
Lower> upper
MCA: (most common)
Contralateral sensory and motor loss
Upper> lower
aphasia
contralateral homonymous hemianopia
PCA:
Contralateral homonymous hemianopia with macular sparing
Visual agnosia (can’t recognise objects seen)
Webers syndrome vs basilar artery stroke vs lacunar stroke?
Webers:
Affects branches of PCA which supply midbrain
Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity
Basilar artery: Locked in syndrome
Lacunar stroke: either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
common sites include the basal ganglia, thalamus and internal capsule
Management of ischaemic stroke? 1st line ix?
qst line ix - CT head WITHOUT contrast
A combination of thrombolysis AND thrombectomy is recommend for patients with an acute ischaemic stroke who present within 4.5 hours
Can have just thrombectomy within 6 hours of an acute anterior ischaemic stroke - can be extended beyond 6hrs to 24 hr time limit if there is the potential to salvage brain tissue as shown as CT perfusion of diffusion-weighted MRI
aspirin 300mg orally or rectally should be given as soon as possible if a haemorrhagic stroke has been excluded
Management of suspected temporal arteritis with visual loss and without visual loss?
- Steroids: give urgent high dose steroids as soon as suspected, before biopsy IF no visual loss.
If visual loss IV methylprednisolone is given prior to PO steroids as above.
there should be a dramatic response, if not the diagnosis should be reconsidered - urgent ophthalmology review
- bone protection with bisphosphonates due to high dose steroids
cubital tunnel syndrome presentation?
Compression of ulnar nerve
Motor to:
medial two lumbricals
aDductor pollicis
interossei
hypothenar muscles: abductor digiti minimi, flexor digiti minimi
flexor carpi ulnaris
‘claw hand’ - hyperextension of the metacarpophalangeal joints and flexion at the distal and proximal interphalangeal joints of the 4th and 5th digits
Sensory to:
medial 1 1/2 fingers (palmar and dorsal aspects) - little finger
What type of brain bleeding can present several weeks after head injury?
chronic subdural haematoma
Wernickes vs brocas area?
Spoken word is heard at the ear. This passes to Wernicke’s area in the temporal lobe (near the ear) to comprehend what was said. Once understood, the signal passes along the arcuate fasciculus, before reaching Broca’s area. The Broca’s area in the frontal lobe (near the mouth) then generates a signal to coordinate the mouth to speak what is thought (fluent speech).
What are the indications for an urgent vs less urgent CT head according to NICE guidelines? What timeframe should they be done in?
CT head within 1 hour
GCS < 13 on initial assessment
GCS < 15 at 2 hours post-injury
suspected open or depressed skull fracture
any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).
post-traumatic seizure.
focal neurological deficit.
more than 1 episode of vomiting
CT head scan within 8 hours of the head injury - for adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury:
age 65 years or older
any history of bleeding or clotting disorders including anticogulants
dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs)
more than 30 minutes’ retrograde amnesia of events immediately before the head injury
If a patient is on warfarin/a DOAC/ or has a bleeding disorder and they are suspected of having a TIA, what should you do?
they should be admitted immediately for imaging to exclude a haemorrhage
Wernicke’s encephalopathy triad
Confusion, gait ataxia, nystagmus + ophthalmoplegia are features
Korsakoffs?
non-reversible
Confabulation
Anterograde and
Retrograde amnesia
Temperament altered
SDH vs SAH vs extradural haemtoma on CT? What vascular involvement?
SDH: crescent (banana shape), crosses sutures , involved bridging veins
Epidural haemorrhage is associated with the middle meningeal artery
Subarachnoid haemorrhages are associated with vessels of the circle of Willis, such as basilar and anterior circulating arteries.
Frontal vs temporal vs occipital vs partial lobe epilpesy?
Jacksonian movements are a feature of frontal lobe epilepsy. clonic movements travelling proximally
Temporal lobe seizures are associated with aura, lip smacking and clothes plucking.
Occipital seizures are associated with visual abnormalities.
Parietal seizures are associated with sensory abnormalities.
What is the long term mx of an ishcaemic stroke? what if have allergies to normal long term anti-platelet?
Aspirin + clopi for two weeks
Clopidogrel 75mg once daily (alternatively aspirin plus dipyridamole) for life
What is internuclear opthalmoplegia?
Internuclear ophthalmoplegia (INO) occurs due to a lesion of the medial longitudinal fasciculus (MLF), a tract that allows conjugate eye movement. This results in impairment of adduction of the ipsilateral eye. The contralateral eye abducts, however with nystagmus.
Basically the pathway that normally works to allow the 3rd nerve and 6th nerve to move together is broken (usually on one eye) - so if you have a right internuclear opthalmoplegia you look to the right the left eye will abduct but the right eye wont and will get double vision and nystagmus
How does spinal stenosis present?
Usually gradual onset
Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as ‘aching’, ‘crawling’.
Relieved by sitting down, leaning forwards and crouching down
Clinical examination is often normal
Requires MRI to confirm diagnostic
In B12 and folate deficiency what should be replaced first?
vitamin B12 deficiency must be treated first to avoid subacute combined degeneration of spinal cord
What features are seen in tuberous sclerosis
Cutaneous features:
depigmented ‘ash-leaf’ spotswhich fluoresce under UV light
roughened patches of skin over lumbar spine (Shagreen patches)
adenoma sebaceum(angiofibromas): butterfly distribution over nose
fibromata beneath nails (subungual fibromata)
cafe-au-lait spots may be seen, more common in neurofibroma
Neurological features: developmental delay, LD, epilepsy
Mx of generalised seizures vs focal seizures?
Generalised tonic-clonic/ myoclonic/ tonic seizures
males: sodium valproate
females: lamotrigine or levetiracetam
Focal seizures
first line: lamotrigine or levetiracetam
second line: carbamazepine,
Mx of absence seizures?
Absence seizures (Petit mal)
first line: ethosuximide
second line:
male: sodium valproate
child beaeing female: lamotrigine or levetiracetam
carbamazepine/ phenytoin may exacerbate absence seizures
Mx of meningitis in non-immunocomp adults?
IV ceftriaxone
If raised ICP then LP CI
Dexamethasone (CI in sepsis)
How long after your first seizure can you not drive for? (if ix are normal vs abnormal)
first unprovoked/isolated seizure: 6 months off if there are no relevant structural abnormalities on brain imaging and no definite epileptiform activity on EEG.
If these conditions are not met then this is increased to 12 months
What drug is used to prevent vasospasm in aneurysmal subarachnoid haemorrhages
Nimodipine
Partial vs total anterior circulation stroke?
involves middle and anterior cerebral arteries
1.Unilateral weakness (and/or sensory deficit) of the face, arm and leg
2.Homonymous hemianopia
3.Higher cerebral dysfunction (dysphasia, visuospatial disorder)
2/3 = partial
3/3 = total
Posterior circulation stroke features?
involves vertebrobasilar arteries
presents with 1 of the following:
1. cerebellar or brainstem syndromes
2. loss of consciousness
3. isolated homonymous hemianopia
Posterior vs anterior inferior cerebellar stroke?
Lateral medullary syndrome (posterior inferior cerebellar artery)
aka Wallenberg’s syndrome
ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner’s
contralateral: limb sensory loss
Anterior inferior cerebllar AKA lateral pontine syndrome: Symptoms are similar to Wallenberg’s (see above), but:
Ipsilateral: facial paralysis and deafness
When is hoffmans sign post?
UMN lesion
Anti-emetic of choice for migraines?
metoclopramide
Mx of spasticity in MS?
baclofen
gabapentin
Which arteries are involved in a posterior circulation infarct?
vertebrobasilar arteries
What is an example of a dopamine receptor agonist? SE?
e.g. bromocriptine, ropinirole, cabergoline, apomorphine
SE: pulmonary + cardiac fibrosis
hallucinations
If levodopa is stopped suddenly what can happen to patients?
acute dystonia
(need dopamine patch)
Example of MAO-B (Monoamine Oxidase-B) inhibitors
REemember you mow the lawn in straight lines
e.g. selegiline
Example of COMT (Catechol-O-Methyl Transferase) inhibitors
e.g. entacapone, tolcapone
Mx of drug induced parkinsonisms?
Antimuscarinics
e.g. procyclidine, benzotropine, trihexyphenidyl (benzhexol)
Where is the lesion if someone is having a Homonymous hemianopia?
Occipital tract/ cortex
Where is the lesions in Homonymous quadrantanopias (superior vs inferior)?
superior: lesion of the inferior optic radiations in the temporal lobe(Meyer’s loop)
inferior: lesion of the superior optic radiations in the parietal lobe
PITS (Parietal-Inferior, Temporal-Superior)
where is the lesion in a bitemporal heminopia?
optic chiasm
upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour
lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma
At what timeframe does alcohol withdrawal seizures occur
Alcohol withdrawal
symptoms: 6-12 hours
seizures: 36 hours
delirium tremens: 72 hours
Presentation of 3rd, 4th and 6th nerve palsy?
3rd- ptosis; ‘down and out’ eye; dilated, fixed pupil
4th -Palsy results in defective downward gaze eg going down the stairs → vertical diplopia (images stacked on top of each other), eye deviated upwards towards nose
6th- Palsy results in defective abduction → horizontal diplopi, eye devaited medially
Which side does the pathology deviate towards in vagus vs accessory vs hypoglassal palsy?
Vagus - uvula deviates away from site of lesion
UvulA= Away
accessory - weakness turning head to contralateral side
hypoglassal - Tongue deviates towards side of lesion
Tongue = Towards
What examination findings would you expect in nerve root compression in the following nerves:
L3, L4, L5, S1?
L3 nerve root compression - Sensory loss over anterior thigh; Weak hip flexion, knee extension and hip adduction; Reduced knee reflex; Positive femoral stretch test
L4 nerve root compression - Sensory loss anterior aspect of knee and medial malleolus
Weak knee extension and hip adduction
Reduced knee reflex
Positive femoral stretch test
L5 nerve root compression - Sensory loss dorsum of foot; Weakness in foot and big toe dorsiflexion; Reflexes intact; Positive sciatic nerve stretch test
S1 nerve root compression - Sensory loss posterolateral aspect of leg and lateral aspect of foot; Weakness in plantar flexion of foot; Reduced ankle reflex; Positive sciatic nerve stretch test
What is the best way to assess motor function for the following nerves:
C5-C8
T1
L2-L5
S1?
C5 - elbow flexion
C6 - wrist extension
C7 - elbow extension
C8 - finger flexion
T1 - finger abduction of little finger
L2 - hip flexion
L3 - knee extension
L4 - ankle dorsiflexion
L5- long toe extension
S1 - ankle plantarflexion
Where are the dermatomes for:
C4-C8
T1
T4
T10
L2-L5
S1?
C4: over the acromioclavicular joint.
C5: the lateral aspect of the lower edge of the deltoid muscle (known as the “regimental badge”).
C6: the palmar side of the tip of thumb.
C7: the palmar side of the tip of the middle finger.
C8: the palmar side of the tip of the little finger.
T1: the medial aspect antecubital fossa
T4- nipples
T10 - belly button
L2: the middle aspect of the anterior thigh.
L3: medial to the knee
L4: the medial malleolus.
L5: the dorsum of the foot at the third metatarsophalangeal joint.
S1: the lateral aspect of the calcaneus.
What causes Homonymous heminopia vs bitemporal heminopia vs anopia (full eye loss of vision) visual field loss?
Homonymous heminopia = lesion in optic tract
Bitemporal heminopia - lesion in optic chiasm
Anopia - optic nerve lesion
Presentation of transverse myelitis?
Transverse myelitis usually presents more acutely than in this case, with a sensory level and upper motor neuron signs below the level affected. It can occur in patients with multiple sclerosis or Devics disease (neuromyelitis optica). These patients tend to also have features such as optic neuritis.
what drugs can exacerbte myasthenia gravis?
The following drugs may exacerbate myasthenia:
penicillamine
quinidine, procainamide
beta-blockers
lithium
phenytoin
antibiotics: gentamicin, macrolides, quinolones, tetracyclines
Presentaiom of subacute combined degen of cord
Subacute combined degeneration of the cord results from long-standing vitamin B12 deficiency, classically presenting as a posterior cord syndrome with impaired proprioception. It can feature both upper and lower motor neuron signs. B12 deficiency can be associated with several neurological features. These include a myelopathy (classically the subacute combined degeneration of the cord), neuropathy and paraesthesias without neurological signs [3]. Subacute combined degeneration is extremely rare in developed countries, though in tropical countries it is frequently the commonest cause of non-traumatic myelopathy [4].
DCM (degen cervical myelopathy) presentation?
by compressing the motor fibres to the lower limbs as they run down the cervical spinal cord. It classically causes lower motor neuron signs at the level and upper motor neuron signs below, as it impairs signalling beyond the area of compression.
Pain (affecting the neck, upper or lower limbs)
Loss of motor function (loss of digital dexterity, preventing simple tasks such as holding a fork or doing up their shirt buttons, arm or leg weakness/stiffness leading to impaired gait and imbalance
Loss of sensory function causing numbness
Loss of autonomic function (urinary or faecal incontinence and/or impotence) - these can occur and do not necessarily suggest cauda equina syndrome in the absence of other hallmarks of that condition
Hoffman’s sign: is a reflex test to assess for cervical myelopathy. It is performed by gently flicking one finger on a patient’s hand. A positive test results in reflex twitching of the other fingers on the same hand in response to the flick.
What is syringomyelia
collection of cerebrospinal fluid within the spinal cord.
A chiari malformation associated
spinothalamic damage → pain and temperature lost, cape like distribution
mx of narcolepsy?
modafinil (provigil)
How long does it take to reduce antiepileptic? How long do you need to be fit free to consider stopping? What is safest antiepileptic for pregnancy?
Reduce over 3m
Can try stopping meds at 2 yrs fit free
Lamotrigine at lowest dose poss is safest - if on this need high dose folic acid
Multiple system atrophy vs progressive supranuclear palsy?
MSA - orthostatic hypotension, dry mouth + skin, urinary inctoninence + parkinsonisms
PSP- Vertical gaze palsy, especially downward gaze, leading to a fixed stare + parkinsonisms
Cause of foot drop and therefore high steppage gait?
common peroneal nerve
Mx of myasthenia gravis?
thymectomy (may help even without thyoma)
acetylcholinesterase inhibitors eg
pyridostigmine
steroids
azathioprine
plasma exchange
What is an arnold chiari malformation?
herniation of cerebellum thru foramen magnum
Describe the MRC power scale
1 = flicker, 2= move without gravity, 3=moves against gravity only, 4= movement against resistance 5= full power
Normal pressure hydrocephalus sx and mx?
wet, wacky and wobbly. Normal pressure opening CSF. diagnose via response to removing CSF (should improve), may treat with a shunt
What is the most helpful diagnostic test for MS?
MRI head and spine with contrast
How to differentiate lambert eaton syndrome from MG?
LES sx unlike myasthenia gravis, are worst in the AM and are better with exercise
When do you start DOAC post stroke in newly identified AF
2 weeks to stop haemorrhagic transformation
When is carotid endartectomy recommended for stroke/ TIA?
carotid stenosis over 50%
How is brain death verified?
Brain death testing should be undertaken by two separate doctors who have training on this on separate occasions
WHat is a medical third nerve palsy?
A medical third nerve palsy = caused by diabetes/ ischaemia, pupil spared, ptosis, unable to adduct
