Neuro Flashcards
What is Wallenberg syndrome also known as?
Lateral Medullary syndrome
Symptoms of lateral medullary syndrome? (LMS)
Horner’s Syndrome
Cerebellar signs - ataxic gait
Contralateral sensory loss of limbs
Ipsilateral sensory loss of face
What is the likely arterial lesion in LMS
Posterior inferior cerebellar artery
Nerve roots for biceps reflex?
C5-C6
Baseline investigation for MS?
MRI brain with contrast - view demyelinating lesions
What is Guillain-Barre syndrome (GBS)
Immune-mediated demyelination of peripheral nervous system
Most common cause of GBS?
Campylobacter jejuni
Characteristic features of GBS?
ASCENDING weakness
Progressive, symmetrical weakness of all limbs
Reflexes reduced/absent
Few sensory signs
Hx gastroenteritis
Investigations for GBS?
Lumbar puncture - raised protein, normal WCC
Nerve conduction studies - reduced signals
Management of GBS?
Supportive
VTE prophylaxis
IVIG
Plasmapheresis
Pattern of signs in GBS?
Flaccid weakness and hyporeflexia
When should thrombolysis be given for stroke?
Within 4.5 hours
Contraindications for thrombolysis
Prev. haemorrhage
Seizure at onset of stroke
Neoplasm
LP in prev 7 days
Stroke/traumatic brain injury in last 3 months
Oesophageal varices
Uncontrolled HTN
Pregnancy
How soon should thrombectomy be given?
Within 6 hours, ideally give with IV thrombolysis
Secondary prevention after ischaemic stroke?
1st line - Clopidogrel
2nd line - Aspirin + dipyridamole
Most likely cause of encephalitis
Herpes simplex
Features of Wernicke’s encephalopathy?
Confusion, ataxia, nystagmus. ophthalmoplegia, peripheral neuropathy
Extradural haemorrhage caused by damage to which vessels?
Middle meningeal artery
Subdural haemorrhage caused by damage to which vessels?
Bridging veins between cortex and venous sinuses
Subarachnoid haemorrhage caused by damage to which vessels?
Berry aneurysm rupture
Presentation of extradural haemorrhage?
Sudden onset following a brief lucid interval
Presentation of subdural haemorrhage?
Chronic - 4-7 weeks following injury, gradual onset confusion
Presentation of subarachnoid haemorrhage?
thunderclap headache, acute onset
What is myasthenia gravis?
Autoimmune condition causing destruction of ACh receptors at neuromuscular junction
Symptoms of MG?
Muscle fatigability
Extraocular - diplopia
Muscle weakness
Ptosis
Dysphagia
Which cancer is associated with MG?
Thymoma
Investigations for MG?
Antibodies for ACh receptors
Tensilon test
Single fibre electromyography
What is the tensilon test?
IV edrophonium reduces muscle weakness temporarily
Management of MG?
Acetylcholinesterase inhibitors - pyridostigmine
Immunosuppressoin
Thymectomy
Myasthenia gravis exacerbating factors?
Penacillamine, BBs, lithium, phenytoin, Abx (gentamicin, macrolides, quinolones, tetracyclines)
What is Miller Fisher syndrome?
Variant of Gullain-Barre
Symptoms of Miller Fisher syndrome
Ophthalmoplegia, areflexia, ataxia
Descending rather than ascending symptoms
Which part of the brain most affected by HSV encephalitis?
Temporal lobes
Temporal lobe seizure symptoms?
Lip smacking, dysphasia
First line treatment for absence seizure in children
Ethosuximide
Describe parkinsons tremor
Unilateral tremor which improves with voluntary movements
Parkinsons triad
Bradykinesia, rigidity, termor
What is Weber’s syndrome + symptoms?
Midbrain stroke
Ipsilateral III palsy (down and out)
Contralateral weakness
Which vessel affected in Weber’s syndrome?
Branches of the posterior cerebral artery
Migraine prohylaxis treatments?
Propranolol
Topiramate (CI in childbearing women)
Treatment for idiopathic intracranial hypertension?
Carbonic anyhdrase inhibitor - Acetazolamide
Presentation of idiopathic intracranial hypertension?
Chronic headache, worsen in morning
Worsens on coughing/straining
Papilloedema
Clear CT
Presentation of cluster headache?
Unilateral
Pain around eye and tearing
Runny nose
40-60 mins
Multiple episodes
Acute management of cluster headaches?
High flow oxygen and triptans
Preventative management of cluster headaches?
Verapamil
Normal pressure hydrocephalus symptoms
Wet, wacky and wobbly
Urinary incontinence
Dementia
Gait abnormality
Imaging findings for NPH?
CT - ventriculomegaly out of proportion to sulcal enlargement
Management of NPH?
Ventriculoperitoneal shunting
What is autonomic dysreflexia?
Clinical syndrome in pts with spinal cord injury T6 or above
Physiology of autonomic dysreflexia?
Faecal impaction/urinary retention»triggers afferent signals»sympathetic spinal reflex»normal parasympathetic response prevented by cord lesion
Features of autonomic dysreflexia?
Extreme hypertension
Flushing and sweating above the level of the cord
Management of autonomic dysreflexia?
Removal/control of stimulus
Treatment of hypertension/bradycardia
21y/o male w/ unilateral facial palsy following trauma. R sided facial nerve paralysis and watery discharge from nose
Petrous temporal fracture (basal skull fracture)
Which nerve palsy causes impaired downward gaze?
CN IV - Trochelar
What is syringomyelia?
Collection of CSF in the spinal cord
Syringomyelia symptoms?
‘Cape-like’ (neck, shoulders arms):
loss temperature sensation
spastic weakness
neuropathic pain
Migraine triggers?
C - chocolate
H - hangovers
O - orgasms
C - cheese/caffeine
O - oral contraceptive
L - lie-ins
A - alcohol
T - travel
E - exercise
Facial nerve palsy symptoms?
Face, ear, taste, tear
- Hyperacusis
- Reduced tearing
- Reduced salivation
Driving rules following first seizure?
Inform DVLA, no driving until 6 months seizure free
Presentations of lacunar strokes?
Complete one sided sensory loss OR
unilateral motor disturbance affective face/arm/leg/all 3
Ataxia hemiparesis
What is total anterior circulation infarct?
Middle and anterior cerebral arteries.
Unilateral hemiparesis +/- hemisesnory loss of face, arm and leg
Homonymous hemianopia
Higher cognitive dysfunction
What is a partial anterior circulation infarct?
Smaller arteries of ant. circulation
2 of bamford classifications
What are the Bamford classification criteria?
- unilateral hemiparesis +/- hemisensory loss of the face, arm and leg
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphasia
What is a posterior circulation infarct?
Verterobasilar arteries
1 of following:
Cerebellar or brainstem syndromes
Loss of consciousness
Isolated homonymous hemianopia
Anterior cerebral artery stroke
Contralateral hemiparesis and sensory loss
Lower > upper extremity
Middle cerebral artery stroke
Contralateral hemiparesis and sensory loss
Upper > lower extremity
Posterior cerebral artery stroke
Contralateral homonymous hemianopia with macular sparing
Visual agnosia
Anterior inferior cerebellar artery stroke
Lateral pontine syndrome
Similar to Wallenbergs but:
Ipsilateral facial paralysis and deafness
What is amaurosis fugax
Loss of vision due to stroke in retinal/ophthalmic artery (ipsilateral)
Locked in syndrome
Caused by stroke to basilar artery. Paralysis of voluntary muscles except eyes
What must be monitored during phenytoin infusion (during status epilepticus)
Cardiac monitoring - arrhythmias
First line management for TIA?
Aspirin 300mg and specialist review in 24 hours
Which tool measures disability/dependence in ADLs in stroke patients?
Barthel index
Treatment for suspected encephalitis
Aciclovir
What is Broca’s dysphasia (expressive)?
Non-fluent speech, repetition impaired, comprehension normal
What is Wernicke’s (receptive) dysphasia?
Impaired language comprehension, repetition of words and phrases also impaired.
Fluent speech but lacking meaning - word salad
Which vessel supplies Broca’s area?
Superior division of left MCA - inferior frontal gyrus
Which vessel supplies Wernicke’s area?
Inferior division of left MCA - superior temporal gyrus
What is conduction aphasia?
Fluent speech, repetition poor. Aware of errors they are making. Comprehension normal
Antiplatelet of choice for TIA?
Clopidogrel
Reflexes in GBS
Reduced/absent
What is Brown-Sequard syndrome?
Spinal cord hemisection (injury to one side of the spinal cord)
Symptoms of brown-sequard?
Unilateral spastic paresis and loss of proprioception/vibration.
Loss of pain and temperature sensation on contralateral side
Which tracts are damaged in Brown-Sequard?
Corticospinal tract
Spinothalamic tract
Dorsal columns
Which nerve affected in trouble going downstairs/double vision?
CN IV - Trochlear
Symptoms of pituitary apoplexy?
Sudden onset headache
Visual field defects
Hypotension
Which area of the brain for homonymous quandrantanopia?
PITS
Parietal - inferior
Temporal - superior
Cause of visual homonymous hemianopia?
Contralateral optic tract
First line treatment for spasticity in MS?
Baclofen and Gabapentin
How should MND patients have nutrition delivered?
PEG tube (percutaneous gastrostomy)
What are the EMV scores for GCS?
Eyes - 4 Verbal - 5 Motor - 6
What is the eye scale for GCS?
1 - None
2 - To pain
3 - To speech
4 - Spontaneous
What is the verbal scale for GCS?
1 - None
2 - Sounds
3 - Words
4 - Confused
5 - Orientated
What is the motor scale for GCS?
1 - None
2 - Extending to pain
3 - Abnormal flexion to pain
4 - Withdraws from pain
5 - Localises to pain
6 - Follows command
When to refer a Bell’s Palsy patient to ENT?
If no improvement after 2 weeks with steroids - urgent referral
Which nerve for ankle dorsiflexion?
Common peroneal nerve
Acoustic neuroma symptoms?
Vertigo, hearing loss, tinnitus and absent corneal reflex.
What is acoustic neuroma?
Vestibular schwannoma
In which condition is acoustic neuroma commonly seen?
Neurofibromatosis type 2
What is menieres disease?
Disorder of the inner ear of unknown cause
Symptoms of Meniere’s disease?
Vertigo, tinnitus and hearing loss (sensorineural)
Differences between acoustic neuroma and menieres?
Onset -
Menieres lasts minutes to hours
AN progressive onset and constant hearing loss
What is the first line treatment for trigeminal neuralgia?
Carbamazepine
Which anti-epileptic is first line in women of childbearing age?
Levetiracetam
Which blood test can differentiate between pseudoseizures and true epileptic seizures?
Prolactin
How to manage an acute relapse of MS?
Course of steroids
Which lobe is most common in a seizure preceded by aura?
Temporal
Which antiepileptics are common causes of stevens-johnson syndrome?
Lamotrigine, carbamazepine, phenytoin
Which anti-epileptics are safest in women of childbearing age?
Levetiracetam and lamotrigine
What is cataplexy?
Sudden and transient episode of muscle weakness
What are common triggers of cataplexy?
Strong emotions - laughter, anger, surprise
What are the investigations for syringomyelia?
MRI spine with contrast + brain MRI
When is mannitol used?
Raised ICP - causes an osmotic shift of water out of the brain parenchyma
Palsy of which nerve causes wrist drop?
Radial nerve
Drug treatment for brain abscess?
Ceftriaxone and Metronidazole
Signs of brain abscess on CT?
Ring enhancing lesion
Which antiepileptic can cause megaloblastic anaemia?
Phenytoin
Why give B12 before replacing folate in macrocytic anaemia?
Can precipitate subacute degeneration of the spinal cord
Symptoms of subacute degeneration of the spinal cord?
Distal tingling/burning - symmetrical and legs/arms
Loss of proprioception and vibration
Sensory ataxia
What is degenerative cervical myelopathy?
Degenerative spinal cord compression
Risk factors for idiopathic intracranial hypertension?
High BMI
Female sex
Pregnancy
Certain drugs
Which drugs increase risk of idiopathic intracranial hypertension?
COCP
Steroids
Tetracyclines
Retinoids
Lithium
Which type of dementia is associated with MND?
Frontotemporal dementia
Causes of GBS?
Campylobacter jejune
CMV
Zika virus
Influenza virus
EBV
Hepatitis A, B, C, E
Why should repeat ABGs not be carried out in patients with diaphragmatic paralysis?
Changes in ABG occur after the onset of resp compromise - late in identifying problem
Histopathological findings in Parkinson’s?
Loss of dopaminergic neurons in substantia nigra
Presence of levy bodies
Presence of eosinophilia cytoplasmic inclusions
CT findings for Parkinson’s?
Normal CT/no findings
Different types of MND?
ALS - amyotrophic lateral sclerosis
PLS - primary lateral sclerosis
PMA - progressive muscular atrophy
PBA - progressive bulbar palsy
Symptoms of ALS?
Both LMN and UMN
Typically LMN in arms, UMN in legs
Symptoms of primary lateral sclerosis?
UMN signs only
Progressive muscular atrophy symptoms?
LMN signs only
Affects distal muscle before proximal
Carries best prognosis
Progressive bulbar palsy symptoms?
Palsy of the tongue
Muscles of chewing/swallowing
Facial muscles
Due to loss of function of brainstem motor nuclei
Carries worst prognosis
What is global aphasia?
Severe expressive and receptive aphasia
May still be able to communicate using gestures
What is Charcot-Marie-Tooth disease?
Hereditary peripheral neuropathy resulting in predominantly motor loss
Symptoms of Charcot-Marie-Tooth?
History of frequently sprained ankles
Foot drop
High-arched feet
Hammer toes
Distal muscle weakness/atrophy
Hyporeflexia
Stork leg deformity
What is the Cushing reflex?
Nervous system response to increased intracranial pressure
Obs in Cushing reflex?
Bradycardia, bradypnoea, hypertension, wide pulse pressure
Which Parkinson’s drug has the highest chance of inhibiton of behaviours?
Dopamine receptor agonists e.g. ropinirole
Red flags for headache needing CT?
Vomiting without obvious cause
Impaired level consciousness
Worsening headache w/ fever
Sudden onset
Headache triggered by cough/sneeze
Recent head trauma
Most common causes of brain metastases?
Lung cancer
Key features of tubular sclerosis?
Childhood seizures
Shagreen patch - roughened skin over lumbar spine
What is lambert-eaton syndrome?
Autoimmune disease affecting the presynaptic voltage-gated calcium channel in the PNS
Symptoms of Lambert-Eaton?
Repeated muscle contractions = increased muscle strength
Hyporeflexia
Limb-girdle weakness
Which cranial nerves are affected in vestibular schwannomas?
III - Oculomotor
VII - Facial
VIII - Vestibulocochlear
Intubate when GCS is below what score?
8
Criteria for carotid endartectomy?
Stenosis >50%
First two causes which should be ruled out in status epilepticus?
Hypoxia
Hypoglycaemia
Reflex findings in subacute degenerations of the spinal cord?
Hyperreflexia
Symptoms of multiple system atrophy?
Parkinsonism
Cerebellar signs
Autonomic disturbance:
Erectile dysfunction, postural hypotension, atonic bladder
CNIII palsy vs Horner’s syndrome?
CN III = ptosis and dilated
Horner’s = ptosis and constricted
Which alternative should be used if a Parkinson’s patient cannot orally take their levodopa?
Transdermal patch - dopamine agonist e.g. rotigotine
Symptoms of Lateral pontine syndrome?
Ipsilateral facial weakness and DEAFNESS
Loss of temperature and pain ipsilateral face and contralateral body
Ataxic gait
Lean towards the side of the lesion
Dizziness
Vessel affected in Lateral pontine syndrome?
Anterior inferior cerebellar artery
Contraindication for triptan use?
Ischaemic heart disease
Most common causes of upper/lower quadrantanopia?
Upper = pituitary tumour
Lower = craniopharyngioma
Most common trigger for cluster migraines?
Alcohol
Most common genetic mutation associated with Charcot-Marie-Tooth?
PMP22 duplication
Symptoms of optic neuritis?
Pain
Vision loss
Decreased visual acuity
Impaired colour vision
Central scotoma
Drugs for MS shown to reduce flare ups?
Natalizumab
Beta-interferon
Which gene marker is associated with narcolepsy?
HLA-DR2
First line treatment for myoclonic seizures in women?
Levetiracetam
First line treatment for tonic or atonic seizures in women?
Lamotrigine
DVLA rules for those with established epilepsy/recurrent seizures?
12 months
Signs of non-epileptic seizures?
Pelvic thrusting
Much more common in females
Crying after seizure
Con’t occur when alone
Gradual onset
Eyes closed during episode
Normal prolactin levels
Drug used for raised ICP?
Mannitol
Symptoms of cauda equina syndrome?
Saddle anaesthesia
Loss of anal tone
Urinary retention/incontinence
Hypotonia of lower limbs
Lower limb weakness
Absent reflexes
Why does orthostatic hypotension result in syncope?
Cerebral hypoperfusion
MRC grading for muscle strength?
0 - no muscle movement
1 - trace of contraction
2 - movement at the joint with gravity eliminated
3 - movement against gravity, but not against added resistance
4 - movement against an external resistance with reduced strength
5 - normal strength
Charcot-Marie-Tooth inheritance pattern (type 1)?
Autosomal dominant
DVLA rules after TIA?
Can drive if symptom free after 1 month - don’t need to inform DVLA
Vestibular schwannoma investigations?
Audiogram and gadolinium-enhanced MRI head
Symptoms of craniopharyngioma?
Inferior bitemporal hemianopia
Diabetes insipidus
When and how should anti-epileptics be stopped/reduced?
If seizure free for >2 years
AEDs stopped over 2-3 months
First line treatment for focal seizures? (Regardless of gender)
Lamotrigine or levetiracetam
Common cause of painful third nerve palsy?
Posterior communicating artery aneurysm
Characteristic symptoms of pontine haemorrhage?
Reduced GCS
Paralysis
Bilateral pin point pupils
Primary areas of the brain affected in Alzheimer’s?
Cortex and hippocampus
Management of myasthenic crisis?
IVIG and plasmapheresis
Drugs to be avoided in myasthenia gravis?
Beta blockers
Adverse effects of triptans?
‘Triptan sensations’ - tingling, heat, tightness (e.g. throat and chest), heaviness, pressure
GCS threshold for CT head within 1 hour?
<12
Which vessel affected in homonymous hemianopia with macular sparing?
CONTRALATERAL posterior cerebral artery
Where is affected in bi-temporal homonymous hemianopia?
Optic CHIASM
What is affected in total blindness of one eye?
IPSILATERAL optic nerve
What is affected in one sided homonymous hemianopia (e.g. left)?
CONTRALATERAL optic tract
What is Kernig’s sign?
Hips and knees at 90 degrees -> Extend knees = spinal pain/resistance
What is Brudzinski’s test?
Lie flat and passive flexion of neck = hips and knees flex involuntarily
How long after symptoms should an LP be performed if SAH suspected?
12 hours
Signs of SAH on lumbar puncture?
Xanthochromia (RBC breakdown)
Adverse effects of levodopa?
Dyskinesia
Postural hypotension
Arrhythmias
N+V
Psychosis
On-off effect
Investigations in a young person with a stroke?
Thrombophilia and autoimmune screening
What is Todd’s palsy?
Temporary weakness following a seizure
Which airway should be used in a seizing patient?
Nasopharyngeal
What steps can be taken during a seizure for a patient (non-pharmacological)?
Recovery position
Pillow under head
Move items which may cause harm
Call senior
Progressive supranuclear palsy symptoms?
Postural instability/falls
Impaired vertical gaze
Parkinsonism
Cognitive impairment
Which Parkinson’s drugs associated with pulmonary fibrosis?
Cabergoline, bromocriptine, ropinirole
LP findings in Guillain-Barre syndrome?
Raised opening pressure
Raised protein
Normal WCC
Normal RBC
Normal glucose