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Neuro Flashcards

1
Q

types of stroke

A

ischaemic
haemorrhagic

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2
Q

blood supply can be disrupted to the brain by?

A
  • A thrombus or embolus
  • Atherosclerosis
  • Shock
  • Vasculitis
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3
Q

what is a TIA

A
  • temporary neurological dysfunction (lasting < 24hrs)
  • caused by ischaemia but without infarction
  • Sx have a rapid onset and often resolve before the patient is seen
  • may precede a stroke
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4
Q

What is a crescendo TIA

A

two or more TIAs within a week and indicate a high risk of stroke

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5
Q

Presentation of stroke

A
  • asymmetrical
  • Limb weakness
  • Facial weakness
  • Dysphasia
  • Visual field defects
  • Sensory loss
  • Ataxia and vertigo (posterior circulation infarction)
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6
Q

RFs for stroke

A
  • Previous stroke or TIA
  • Atrial fibrillation
  • Carotid artery stenosis
  • Hypertension
  • Diabetes
  • Raised cholesterol
  • Family history
  • Smoking and obesity
  • Vasculitis
  • Thrombophilia
  • COCP
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7
Q

what is the ROSIER tool

A

score of stroke likelihood in ED

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8
Q

Mx of TIA

A
  • sx resolved within 24hrs
  • aspirin 300mg
  • referral within 24hrs (within 7 days if more than 7 days since episode)
  • diffusion weighted MRI
  • aspirin and clopidogrel to prevent future stroke for 3 weeks then just clopidogrel
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9
Q

Mx of stroke

A
  • exclude hypoglycaemia
  • CT brain to exclude haemorrhage
  • aspirin 300mg 2weeks
  • admission
  • thrombolysis when haemorrhage excluded
  • thrombectomy if confirmed blockage in proximal anterior circulation or proximal posterior circulation
  • only give antihypertensives if an emergency in ischaemic, be aggressive in haemorrhagic
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10
Q

how does alteplase work

A

tissue plasminogen activator

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11
Q

when can you give alteplase

A

within 4.5hrs
or within 4.5-9hrs of onset if known to be well prior

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12
Q

when can you do thrombectomy

A
  • within 6hrs
  • 6-24hrs if confirmed occlusion of the proximal posterior circulation, potential to salvage brain tissue shown by CT/MRI, or last known to be well up to 24 hours previously
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13
Q

Underlying ix for stroke

A
  • carotid imaging for stenosis (carotid endarterectomy or angioplasty)
  • ECG for AF (give anticoag post 2 weeks of asiprin)
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14
Q

Secondary prevention of stroke (post 14 days)

A
  • clopidogrel 75mg OD
  • atorvastatin 20-80mg
  • BP and diabetes control
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15
Q

MDT for stroke

A
  • stroke physicians, nurses
  • SALT
  • dieticians
  • phyio, OT
  • optometry, orthotics
  • psychology
  • social services
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16
Q

Types of intracranial bleeds

A
  1. Extradural (skull and dura)
  2. Subdural (dura and arachnoid)
  3. Intracerebral (brain)
  4. Subarachnoid (subarachnoid)
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17
Q

RFs for intracranial bleed

A
  • anticoagulants
  • trauma
  • aneurysm
  • bleeding disorder
  • thrombocytopenia
  • stroke
  • tumour
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18
Q

Presentation of intracranial bleed

A
  • Sudden-onset headache is a key feature
  • Seizures
  • Vomiting
  • Reduced consciousness
  • Focal neurological symptoms (e.g., weakness
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19
Q

GCS

A

EVM- 4, 5, 6
E: Spon, Voice, Pain, None
V: Orientated, Confused, Odd words, Odd sounds, None
M: Obeys commands, Localise to pain, Normal flexion, Abnormal flexion, Extends, None

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20
Q

Extradural haemorrhage cause

A

rupture of middle meningeal artery in tempoparietal region

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21
Q

Features of extradural haemorrhage

A
  • can fracture temporal bone
  • lens/lemon shape
  • limited by cranial sutures
  • improve neuro sx then rapid decline
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22
Q

Subdural haemorrhage cause

A

rupture of bridging veins in outermost meningeal layer

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23
Q

Subdural haemorrhage features

A
  • crescent shape
  • not limited by cranial sutures so. can diffuse out hens shape
  • elderly, alcoholic pts with more atrophy making vessels more prone to rupture
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24
Q

Intracerebral haemorrhage cause

A

Spontaneous or secondary to stroke, tumour/aneurysm
can occur anywhere:
- Lobar intracerebral haemorrhage
- Deep intracerebral haemorrhage
- Intraventricular haemorrhage
- Basal ganglia haemorrhage
- Cerebellar haemorrhage

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25
Q

Features of intracerebral haemorrhage

A

presents similarly to an ischaemic stroke with sudden-onset focal neurological symptoms e.g.
- limb or facial weakness
- dysphasia
- vision loss

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26
Q

Subarachnoid haemorrhage cause

A

ruptured cerebral aneurysm between pia mater and arachnoid mater

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27
Q

Features of subarachnoid haemorrhage

A
  • thunderclap occipital headache doing strenuous activity
  • neck stiffness
  • photophobia
  • visual changes
  • vomiting
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28
Q

Mx of intracranial bleeds

A
  • CT
  • FBC and coagulation
  • Subdural and extradural: Craniotomy or Burr hole
  • Subarachnoid: coiling
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29
Q

RF for subarachnoid haemorrhage

A
  • 45-70
  • female
  • black
  • Hypertension
  • Smoking
  • Excessive alcohol intake
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30
Q

Conditions associated with subarachnoid haemorrhages

A
  • Family history
  • Cocaine use
  • Sickle cell anaemia
  • Connective tissue disorders (e.g., Marfan syndrome or Ehlers-Danlos syndrome)
  • Neurofibromatosis
  • AD polycystic kidney disease
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31
Q

Ix for subarachnoid haemorrhage

A
  • CT
  • LP if normal CT (wait >12hrs from sx onset) (raiased RCC and xanthochromia)
  • CT angio to confirm source
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32
Q

Mx of subarachnoid haemorrhage

A
  • endovascular coiling
  • neurosurgical clipping
  • nimodipine (CCB) prevents vasospasm
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33
Q

Complication and mx of subarachnoid haemorrhage

A

Hydrocephalus
- LP
- external ventricular drain
- ventriculoperitoneal shunt

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34
Q

What is multiple sclerosis

A
  • progressive autoimmune condition
  • demyelination of CNS
  • myelin provided by oligodendrocytes and Schwann cells
  • UMN disease
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35
Q

characteristic feature of MS

A

lesions that are disseminated in time and space
- lesions occur at various sites at different points
- can get remyelination in early stages

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36
Q

Causes of multiple sclerosis

A
  • genes
  • EBV
  • low vitamin D
  • smoking
  • obesity
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37
Q

Most common presentation of multiple sclerosis

A

Optic neuritis
- demyelination of ON = unilateral reduced vision over hours to days
- central scotoma
- pain with eye movement
- impaired colour vision
- RAPD

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38
Q

Other causes of optic neuritis

A
  • sarcoidosis
  • SLE
  • syphilis
  • measles/mumps
  • Neuromyelitis optica
  • Lyme disease
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39
Q

Mx of optic neuritis

A

high dose steroids

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40
Q

Eye movement abnormality in MS

A

lesions in:
- CN 3, 4, 6 = diplopia and nystagmus
- medial longitudinal fasciculus = internuclear ophthalmoplegia, ipsilateral impaired adduction and contralateral nystagmus
- CN6 = conjugate lateral gaze disorder

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41
Q

Focal neurological sx in multiple sclerosis

A

Focal weakness:
- Incontinence
- Horner syndrome
- Facial nerve palsy
- Limb paralysis

Focal sensory symptoms:
- Trigeminal neuralgia
- Numbness
- Paraesthesia
- Lhermitte’s sign

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42
Q

What is Lhermitte’s sign

A
  • In multiple sclerosis
  • electric shock sensation that travels down the spine and into the limbs when flexing the neck.
  • Indicates disease in the cervical spinal cord in the dorsal column
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43
Q

what is transverse myelitis

A

inflammation of spinal cord resulting sneosry and motor sx depending on lesion site

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44
Q

Disease pattern of multiple sclerosis

A
  • relapsing remitting (active, not active, worsening, not worsening)
  • clinically isolated syndrome
  • secondary progressive (RR + progression and incomplete remission)
  • primary progressive (no remission)
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45
Q

How to diagnose multiple sclerosis

A
  • clinical
  • MRI with contrast for lesions
  • LP for oligoclonal bands in CSF
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46
Q

Mx of multiple sclerosis

A
  • Relapses: steroids oral or IV
  • disease modifying therapies to induce remission
  • spasticity: baclofen or gabapentin
  • Monoclonal antibodies such as natalizumab have the strongest evidence base for reducing relapse in multiple sclerosis
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47
Q

what is motor neurone disease

A
  • progressive eventually fatal condition
  • motor neurones stop working
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48
Q

types of motor neurone disease

A
  • Amyotrophic lateral sclerosis (ALS) = most common (stephen hawking)
  • Progressive bulbar palsy = second most common. affects muscles of talking and swallowing
  • progressive muscular atrophy
  • primary lateral sclerosis
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49
Q

cause of MND

A
  • degeneration of upper and lower motor neurones
  • unknown cause
  • FH important
  • smoking
    heavy metal and pesticide exposure
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50
Q

presentation of MND

A
  • 60-90 male
  • insidious progressive weakness of muscles everywhere
  • weakness first in UL
  • dysarthria
  • fasciculations
  • clumsiness
  • mixed UMN and LMN sx
  • wasting of the small hand muscles/tibialis anterior is common
  • eye movements typically spared
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51
Q

UMND and LMND signs

A

lower
- Muscle wasting
- Reduced tone
- Fasciculations
- Reduced reflexes

upper
- Increased tone or spasticity
- Brisk reflexes
- Upgoing plantar reflex

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52
Q

How to diagnose MND

A

clinical
diagnosis of exclusion

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53
Q

Mx of MND

A
  • riluzole can slow progression in ALS
  • NIV
  • baclofen for spasm
  • benzos
  • percutaneous gastrostomy tube (PEG) is the preferred way to support nutrition and prolongs survival
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54
Q

What is Parkinson’s disease

A
  • reduction in dopamine in substantia nigra in basal ganglia
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55
Q

triad of parkinson’s

A
  • resting tremor (pill rolling): improves with movement
  • rigidity (resisting passive): cogwheel
  • bradykinesia e.g. handwriting getting smaller, shuffling gait, hypomimia

(one side of body normally affected more)

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56
Q

other features of parkinson’s

A
  • Depression
  • Sleep disturbance and insomnia
  • Anosmia
  • Postural instability
  • Cognitive impairment and memory problems
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57
Q

Differences between Parkinson’s tremor and benign essential tremor

A

Parkinson’s Tremor
- Asymmetrical
- 4-6 hertz
- Worse at rest
- Improves with intentional movement
- Other Parkinson’s features
- No change with alcohol

Benign Essential Tremor
- Symmetrical
- 6-12 hertz
- Improves at rest
- Worse with intentional movement
- No other Parkinson’s features
- Improves with alcohol

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58
Q

Parkinson’s Plus Syndromes

A
  • Dementia with Lewy bodies
  • Progressive supranuclear palsy: dysarthria and reduced vertical eye movement
  • Corticobasal degeneration
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59
Q

What is multiple system atrophy

A

key differentiator from parkinson’s is unilateral sx and severe autonomic dysfunction
1) MSA-P - Predominant Parkinsonian features
2) MSA-C - Predominant Cerebellar features
Shy-Drager syndrome is a type of multiple system atrophy.

Features
parkinsonism
autonomic disturbance
erectile dysfunction: often an early feature
postural hypotension
atonic bladder
cerebellar signs

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60
Q

Mx of Parkinson’s

A
  • Levodopa (combined with peripheral decarboxylase inhibitors)
  • COMT inhibitors: entacapone
  • Dopamine agonists: cabergoline, bromocriptine (can cause pulm fibrosis)
  • MAOIs: selegiline
  • antimuscarinics: procyclidine for tremor
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61
Q

Side effect of levodopa

A

dyskinesia: can be managed by amantadine
nausea: can give domperidone as an anti-emetic

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62
Q

benign essential tremor features

A
  • fine tremor affecting all voluntary muscle
  • MC in hands
  • symmetrical
  • worse when tired
  • absent during sleep
  • improved by alcohol
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63
Q

Mx of benign essential tremor

A
  • propanolol
  • primidone
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64
Q

types of seizures

A
  • Generalised tonic-clonic seizures
  • Partial seizures (or focal seizures)
  • Myoclonic seizures
  • Tonic seizures
  • Atonic seizures
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65
Q

Common seizures in children

A
  • Absence seizures
  • Infantile spasms
  • Febrile convulsions
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66
Q

Tonic clonic seizure features

A
  • muscle tensing and jerking
  • loss of conciousness
  • post ictal phase
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67
Q

Partial (focal) seizure feature

A
  • isolated brain area, often temporal
  • affect hearing, speech, memory and emotions
  • awake
  • simple= aware, complex = LOC
  • strange smell
  • automatisms (lip smacking etc.)
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68
Q

myoclonic seizure features

A

sudden, brief muscle contractions
juvenile myoclonic epilepsy

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69
Q

tonic seizure features

A

sudden increase in tone, whole body stiffens
few seconds-minutes

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70
Q

atonic seizure features

A
  • sudden loss of muscle tone–> fall
  • brief and aware
  • sign of Lennox-Gastaut syndrome
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71
Q

Absence seizure features

A
  • stare blankly
  • unaware
  • seconds
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72
Q

infantile spasm features

A
  • West Syndrome
  • hypsarrhythmia on EEG
  • full body spasm
  • MX: ACTH and vigabatrin
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73
Q

febrile convulsion features

A
  • tonic clonic
  • high fever
  • 6month to 5y/os
  • 1in3 will have another
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74
Q

Driving with seizures

A

Only if seizure free for 1 year

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75
Q

Mx of seizures

A

Generalised tonic-clonic
Sodium valproate*
Lamotrigine/Levetiracetam (P)

Partial (or focal)
Lamotrigine or Levetiracetam (B)

Myoclonic
Sodium valproate*
Levetiracetam (P)

Tonic and atonic
Sodium valproate*
Lamotrigine (P)

Absence
Ethosuximide (B)

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76
Q

Status epilepticus

A

Seizure >5 mins or multiple seizures without regaining consciousness

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77
Q

Mx of status epilepticus

A
  • O2
  • check BM
  • Rectal diaz, buccal midaz or IV loraz
  • IV keppra, phenytoin or valproate if 2 doses of benzos doens’t work
  • 3rd line- phenobarbital or intubation
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78
Q

where does the facial nerve exit

A

cerebellopontine angle then travels through temporal bone and parotid gland

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79
Q

divisions of facial nerve

A
  • tempora;
  • zygomatic
  • buccal
  • marginal mandibular
  • cervical
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80
Q

function of facial nerve

A
  • motor: facial expressions, strapedius in inner ear
  • sensory: anterior 2/3 taste
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81
Q

Innervation of forehead

A

UMN by both sides of the brain
LMN by only one side of the brain

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82
Q

UMN vs LMN facial palsy

A

UMN- forehead is spared (can move on affected side)
LMN- not spared (cannot move forehead on affected side)

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83
Q

Causes of UMN lesions

A
  • Unilateral: stroke and tumour
    Bilateral: pseudobulbar palsies and MND
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84
Q

What is Bell’s palsy

A
  • idiopathic
  • unilateral LMN facial nerve palsy
  • can have hyperacusis due to FN palsy, affects stapedius muscle in ear which normally dampens loud sound
  • recover over weeks can take 1yr
  • 1/3 left with weakness
  • within 72hrs of sx
  • Mx: prednisolone and lubricating eye drops, eye tape
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85
Q

What is Ramsay Hunt syndrome

A
  • VZV
  • unilateral LMN facial palsy
  • painful vesicular rash in ear canal, pinna, around ear 2/3 tongue
  • Mx aciclovir, prednisolone, eye drops
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86
Q

Other causes of LMN facial nerve palsy

A
  • Infection: otitis media and externa, HIV, lyme disease
  • Systemic: diabetes, sarcoid, leukaemia, MS, GBS
  • Tumour: acoustic neuroma, parotid tumour, cholesteatoma
  • Trauma: nerve trauma, surgery, base of skull fracture
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87
Q

Presentation of brain tumours

A
  • asymptomatic
  • progressive focal neurological sx
  • raised ICP
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88
Q

Causes of raised ICP in intracranial space

A
  • tumour
  • haemorrhage
  • idiopathic intracranial HTN
  • abscess or infection
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89
Q

Signs of intracranial hypertension

A
  • Constant headache
  • Nocturnal
  • Worse on waking
  • Worse on coughing, straining or bending forward
  • Vomiting
  • Papilloedema
  • seizures
  • visual field defects
  • CN3 and 6 palsies
90
Q

idiopathic intracranial hypertension

A
  • RF: female, obese, pregnant, COCP, tetracyclines, steroids, retinoids
  • headache, blurred vision
  • papilloedema (usually present)
  • enlarged blind spot
  • sixth nerve palsy may be present
  • LP can cause low pressure headache
  • Mx: weight loss, acetazolamide (carbonic anhydrase inhibitor), topiramate, LP, VP shunt
91
Q

what is papilloedema

A
  • swelling of optic disc due to raised ICP
  • blurred optic disc
  • haemorrhages
  • Paton’s line
92
Q

What is a glioma

A
  • tumour in brain or spinal cord
  • glial cells include astrocytes, oligodendrocytes and ependymal cells
  • graded 1 (benign) to 4
  • astrocytoma (gliobastoma most aggressive form)
  • Oligodendroglioma
  • Ependymoma
93
Q

What are meningiomas

A
  • tumour from meninges
  • benign
  • large
  • incidence increases with age
  • psamomma bodies
94
Q

Most common cancers that metastasise to the brain

A
  • lung
  • brest
  • RCC
  • melanoma
95
Q

what are pituitary tumours

A
  • benign
  • press on optic chiasm –> bitemporal hemianopia
  • can cause hormone deficiencies or excess
  • Mx: transphenoidal surgery, radiotherapy, bromocriptine, octreotide
96
Q

what is an acoustic neuroma

A
  • benign tumour of Schwann cells surrounding audtory nerve
  • at cerebellopontine angle
  • usually unilateral
  • bilateral assoc with neurofibromatosis type 2
97
Q

Features of acoustic neuroma

A
  • 40-60 year old
  • Unilateral sensorineural hearing loss (often the first symptom)
  • Unilateral tinnitus
  • Dizziness or imbalance
  • Sensation of fullness in the ear
  • Facial nerve palsy (if the tumour grows large enough to compress the facial nerve)
  • KEY: lack of corneal reflex
98
Q

Ix of acoustic neuroma

A

audiogram
gadolinium-enhanced MRI head scan

99
Q

Mx of acoustic neuroma

A
  • conservative
  • surgery
  • radiotherapy
100
Q

most common form of brain tumour

A

metastasis

101
Q

Features of a Pilocytic
astrocytoma

A
  • grade 1
  • 0-20y/o
  • BRAF mutation
102
Q

what is a diffuse glioma

A
  • grade 2 to 3
  • 20-40 y/o
103
Q

what is gliobastoma multiforme

A
  • BAD grade 4
  • 50+
  • most common aggressive primary tumour
104
Q

feature of medulloblastoma

A

2nd MC brain tumour in children after astrocytoma

105
Q

What is Huntington’s disease

A
  • AD
  • progressive neurological dysfunction
  • HTT gene Chr4 mutation
  • sx begin 30-50 y/o
  • earlier onset each generation and increased severity
106
Q

presentation of huntington’s

A
  • begins with cognitive/psych/mood problems
  • chorea
  • dystonia
  • rigidity
  • eye movement disorders
  • dysarthria and dysphagia
107
Q

Mx of Huntington’s

A
  • genetic testing
  • nothing to slow or halt progression
  • supportive care
  • LE 10-20 yrs after sx onset
  • death often due to aspiration pneumonia
108
Q

what is myasthenia gravis

A
  • autoimmune condition affecting NMJ
  • causes muscle weakness with activity
  • Women <40 and men >60
  • strong like with thymoma
109
Q

Antibodies that can cause myasthenia gravis

A
  • Acetylcholine receptor (AChR) antibodies
  • Muscle-specific kinase (MuSK) antibodies
  • Low-density lipoprotein receptor-related protein 4 (LRP4) antibodies
110
Q

Presentation of myasthenia gravis

A
  • sx range from mild to life threatening
  • weakness that worsens with muscle use and improves with rest
  • sx best in morning
  • proximal muscles and small muscles of head and neck effected
  • diplopia, ptosis
    difficult climbing stairs
  • dysphagia, fatigue in jaw
  • slurred speech
111
Q

how to elicit muscle fatigablity in myasthenia gravis

A
  • Repeated blinking will exacerbate ptosis
  • Prolonged upward gazing will exacerbate diplopia
  • Repeated abduction of one arm 20 times will result in unilateral weakness when comparing both sides
112
Q

Ix for myasthenia gravis

A
  • AChR antibodies (85%)
  • MuSK antibodies (<10%)
  • LRP4 antibodies (<5%)
  • A CT or MRI of the thymus gland to look for a thymoma
  • edrophonium test can be helpful if there is doubt on the diagnosis.
113
Q

What is the Edrophonium test

A
  • IV edrophonium chloride (or neostigmine).
  • Blocks cholinesterase enzymes in the NMJ that break down acetylcholine
  • level of acetylcholine at the neuromuscular junction rises, relieving the weakness
  • +ve result = myasthenia gravis
114
Q

Mx of myasthenia gravis

A
  • Pyridostigmine: long acting cholinesterase inhibitor
  • Immunosuppression (e.g., prednisolone or azathioprine) suppresses the production of antibodies
  • Thymectomy can improve symptoms, even in patients without a thymoma
  • Rituximab if other mx fails
115
Q

what is a myasthenic crisis

A
  • potentially life threatening complication
  • acute worsening of symptoms
  • triggered by another illness, such as RTI, BBs, penicillamine, lithium
  • Respiratory muscle weakness can lead to respiratory failure.
  • May need NIV/mechanical ventilation.
  • Mx: IV immunoglobulins and plasmapheresis.
116
Q

what is Lambert-Eaton myasthenic syndrome

A
  • similar to myasthenia gravis
  • sx more insidious and less pronounced
  • paraneoplastic syndrome alongisde SCLC, can occur without SCLC
117
Q

Presentation of Lambert eaton syndrome

A
  • Proximal muscle weakness
  • Autonomic dysfunction (dry mouth, blurred vision, impotence and dizziness)
  • Reduced or absent tendon reflexes
  • Ix: Voltage-gated calcium-channel antibodies
118
Q

difference between Lambert eaton and myasthenia gravis

A
  • LE improves after periods of muscle contraction, which is the reverse MG
  • muscle strength improves after use
119
Q

Mx of Lambert Eaton syndrome

A
  • exclude underlying malignancy (SCLC)
  • amifampridine 1st line
  • Pyridostigmine
  • Immunosuppressants (e.g., prednisolone or azathioprine)
  • IV immunoglobulins
  • Plasmapheresis
120
Q

what is charcot marie tooth disease

A
  • inherited, most AD
  • affects peripheral motor and sensory neurones
  • usually before 10/yo
121
Q

Presentation of Charcot Marie tooth disease

A
  • High foot arches (pes cavus)
  • Distal muscle wasting causing “inverted champagne bottle legs”
  • Lower leg weakness, particularly loss of ankle dorsiflexion (with a high stepping gait due to foot drop)
  • Weakness in the hands
  • Reduced tendon reflexes
  • Reduced muscle tone
  • Peripheral sensory loss “glove and stocking”
122
Q

Causes of peripheral neuropathy

A

A-E
A- alcohol
B- B12
C- Charcot marie tooth, cancer, CKD
D- diabetes and drugs (amiodarone, isoniazid, cisplatin)
E- every vasculitis

123
Q

Mx of Charcot Marie tooth disease

A

No cure or halting mx, supportive
- physio, OT, analgesia, orthopaedic surgeons

124
Q

What is Guillain-Barre syndrome

A
  • acute paralytic polyneuropathy that affects the peripheral nervous system
  • triggered by infection esp. Campylobacter jejuni, CMV and EBV
125
Q

Presentation of Guillain Barre syndrome

A
  • acute symmetrical ascending weakness
  • reduced reflexes
  • can also cause peripheral loss or sensation or neuropathic pain
  • within 4 weeks of infection
  • start in feet
  • sx peak within 2-4 weeks
  • recovery can last months to years
  • can progress to CNs and cause facial weakness
  • can have urinary retention, ileus, arrhythmias
126
Q

How to diagnose Guillain Barre syndrome

A
  • clinically using Brighton criteria
  • nerve conduction studies
  • LP (raised protein with normal WCC and glucose)
127
Q

Mx of Guillain Barre syndrome

A
  • supportive
  • VTE prophylaxis
  • IVIG
  • Plasmapheresis
  • Ventilation if resp failure
128
Q

Prognosis of Guillain Barre syndrome

A

most make full recovery or minor sx

129
Q

what is neurofibromatosis

A
  • genetic condition that causes benign nerve tumours (neuromas) to develop throughout the nervous system
    NF1 MC than NF2
130
Q

what is neurofibromatosis type 1

A
  • on chr17, AD
    CRABBING
    C- cafe au lait spots
    R- relative with NF1
    A- axillary/inguinal freckling
    BB- Bony dysplasia, e.g. Bowing of a long bone or sphenoid wing dysplasia
    I- Iris hamartomas (lisch nodules): yellow/brown spots on iris
    N- neurofibromas
    G- glioma of the optic pathway
131
Q

what is a neurofibroma

A
  • skin-coloured, raised nodules or papules with a smooth, regular surface
  • need 2 or more to be significant
  • a plexiform neurofibroma is a larger, irregular, complex neurofibroma –>significant
132
Q

Mx of Neurofibromatosis

A

monitor and mx sx and treat complications

133
Q

Complications from neurofibromatosis 1

A
  • Migraines and Epilepsy
    -Renal artery stenosis, causing hypertension
  • Learning disability
  • Behavioural problems (e.g., ADHD)
  • Scoliosis
  • Vision loss (secondary to optic nerve gliomas)
  • Malignant peripheral nerve sheath tumours KEY
  • GI stromal tumour (sarcoma) KEY
  • Brain tumours
  • Spinal cord tumours with associated neurology (e.g., paraplegia)
  • Increased risk of cancer (e.g., breast and leukaemia)
134
Q

what is neurofibromatosis 2

A
  • on chr22, AD
  • associated with bilateral acoustic neuromas
  • can resect tumour
135
Q

What is tuberous sclerosis

A
  • AD
  • development of hamartomas, benign tissue growths. Commonly affect the skin, brain, heart, lungs, kidneys and eye
  • mutations in: TSC1 gene on chr 9, codes for hamartin,
    TSC2 gene on ch 16, codes for tuberin
136
Q

Features of tuberous sclerosis

A
  • Ash leaf spots (depigmented areas of skin shaped like an ash leaf)
  • Shagreen patches (thickened, dimpled, pigmented patches of skin)
  • Angiofibromas (small skin-coloured or pigmented papules that occur over the nose and cheeks)
  • Ungual fibromas (circular painless lumps that slowly grow from the nail bed and displace the nail)
  • Cafe-au-lait spots
  • Poliosis (isolated patch of white hair on the head, eyebrows, eyelashes or beard)
137
Q

Neurological features of tuberous sclerosis

A
  • epilepsy
  • learning disability
  • brain tumour
138
Q

other features of tuberous sclerosis

A
  • Rhabdomyomas in the heart
  • Angiomyolipoma in the kidneys
  • Lymphangioleiomyomatosis in the lungs
  • Subependymal giant cell astrocytoma in the brain
  • Retinal hamartomas
139
Q

Mx of tuberous sclerosis

A
  • supportive
  • mTOR inhibitors ( everolimus or sirolimus) may be used to suppress the growth of brain, lung or kidney tumours
140
Q

Red flags of headaches

A
  • Fever, photophobia or neck stiffness
  • New neurological sx
  • Visual disturbance (GCA, glaucoma or tumours)
  • Sudden-onset occipital headache
  • Worse on coughing or straining (raised ICP)
  • Postural, worse on standing, lying or bending over (raised ICP)
  • Vomiting (raised ICP or carbon monoxide poisoning)
  • History of trauma
  • History of cancer
  • Pregnancy (pre-eclampsia)
141
Q

What are tension headaches

A
  • mild band like pattern
  • stress, alcohol, dehydration
  • Mx: reassure, paracetamol
  • Amitriptylline for recurrent headaches
142
Q

what is sinusitits

A

inflammation of paranasal sinuses
- pain and pressure post viral URTI
- tenderness and swelling on palpation
- resolve within 2-3 weeks
- >10 days give steroid nasal spray or phenoxymethylpenicillin

143
Q

what is a hormonal headache

A
  • related to low oestrogen
  • similar to migraine: unilateral pulsatile, nausea
  • Mx: NSAIDs
144
Q

what is cervical spondylosis

A
  • degenerative changes in cervical spine made worse on movement
  • presents with headaches
145
Q

what is trigeminal neuralgia

A
  • intense facial pain in distribution
  • opthalmic, maxillary, mandibular branches
  • 90% cases unilateral branch
  • MC in multiple sclerosis
  • sudden onset, seconds to hours
  • electricity like pain, attacks can worsen over time
  • Mx: carbamazepine
146
Q

types of migraines

A
  • with aura
  • without aura
  • silent (aura no headache)
  • hemiplegic
147
Q

presentation of migraine

A
  1. Premonitory or prodromal stage (can begin several days before the headache)
  2. Aura (up to 60 minutes)
  3. Headache stage (4-72 hrs)
  4. Resolution stage (headache may fade or be relieved abruptly by vomiting or sleeping)
  5. Postdromal or recovery phase
148
Q

Presentation of the headache in migraines

A
  • unilateral usually
  • mod to severe intensity
  • pounding/throbbing
  • photophobia
  • phonophobia
  • osmophobia
  • aura
  • N+V
149
Q

what is an aura

A
  • affect vision, sensation or language. Visual is most common
  • Sparks
  • Blurred vision
  • Lines across the vision
  • Loss of visual fields (e.g., scotoma)
  • tingling/numbness
  • dysphasia
150
Q

what is hemiplegic migraine

A
  • unilateral limb weakness
  • ataxia
  • impaired consciousness
  • can mimic stroke/TIA
151
Q

triggers for migraine

A
  • stress
  • alcohol
  • caffeine
  • lack of sleep
  • bright lights
  • strong smells
  • food
  • menstruation
  • trauma
152
Q

Mx of acute migraines

A
  • dark quiet room, sleep
  • NSAID
  • paracetamol
  • triptans
  • antiemetics
153
Q

contraindications to taking a triptan

A

risks associated with vasoconstriction:
- hypertension
- coronary artery disease
- previous stroke, MI, TIA

154
Q

Usual migraine prophylaxis

A
  • propanolol
  • amitriptylline
  • topiramate (teratogenic- cleft lip)
155
Q

Specialist migraine propyhlaxis

A
  • Pizotifen
  • Candesartan
  • Sodium valproate
  • Monoclonal antibodies (e.g., erenumab and fremanezumab)
  • CBT, acupuncture
156
Q

why can you not have COCP with migraine + aura

A

both increase VTE risk

157
Q

what are cluster headaches

A
  • severe unilateral headache around the eye
  • come in cluster of attacks then disappear
  • attacks last 15min-3hrs. for 4-12 wks
  • triggers: alcohol, smells, exercise
158
Q

Sx of cluster headache (suicide headache)

A
  • unilateral
  • Red, swollen and watering eye
  • Pupil constriction (miosis)
  • Eyelid drooping (ptosis)
  • Nasal discharge
  • Facial sweating
159
Q

Acute mx of cluster headaches

A
  • triptans (subcut or intranasal)
  • high flow oxygen
160
Q

Prophylaxis for cluster headaches

A
  • verapamil 1st line
  • occipital nerve block
  • prednisolone
  • lithium
161
Q

what are superior homonymous quadrantanopias are caused by

A

lesions of the inferior optic radiations in the temporal lobe

162
Q

Nerve palsy associated with seeing double going down the stairs

A

CN4 trochlear (supplies superior oblique muscle)

163
Q

what is locked in syndrome

A
  • conscious but unable to move or speak, can move eyes
  • basilar artery stroke
  • acute decreased GCS and advanced motor symptoms
164
Q

what is a lacunar stroke

A
  • present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
  • strong association with hypertension
  • common sites include the basal ganglia, thalamus and internal capsule
165
Q

what is broca’s dysphasia

A
  • lesion of the inferior frontal gyrus. It is typically supplied by the superior division of the left MCA
  • speech is non-fluent, halting and laboured. comprehension normal, repetition impaired
166
Q

What is Wernicke’s aphasia

A
  • lesion of the superior temporal gyrus. It is typically supplied by the inferior division of the left MCA
  • This area ‘forms’ the speech before ‘sending it’ to Broca’s area. Result in sentences that make no sense, word substitution and neologisms but speech remains fluent - ‘word salad’
  • Comprehension and repetition is impaired
167
Q

Features of Wernicke’e encephalopathy

A

CAN OPEN
- Confusion
- Ataxia
- Nystagmus

  • Ophthalmoplegia
  • Peripheral
  • Neuropathy
168
Q

What is conduction aphasia

A
  • stroke affecting the arcuate fasiculus - the connection between Wernicke’s and Broca’s area
  • Speech is fluent but repetition is poor. Aware of the errors they are making
  • Comprehension is normal
169
Q

what is global aphasia

A
  • Large lesion affecting all 3 of the above areas resulting in severe expressive and receptive aphasia
  • May still be able to communicate using gestures
170
Q

Types of aphasia

A
  • Broca’s
  • Wernicke’s
  • Conduction
  • Global
171
Q

which vessels supply Broca’s and Wernicke’s

A

MCA

172
Q

Pt with aphasia, which side of brain most commonly affected

A

left because most are right dominant

173
Q

dorsal column conveys what

A

fine touch, proprioception and vibration

174
Q

Degenerative cervical myopathy

A
  • RF smoking
  • pain in neck, UL, LL
  • loss of motor and sensory function
  • hoffman’s sign (flick the middle fingernail to see if the thumb or index finger flexes involuntarily)
  • Ix- MRI cervical spine
  • Mx- early decompressive surgery
175
Q

Hoffman’s sign interpretation

A

sign of upper motor neuron dysfunction –> CNS issue

176
Q

diabetes insipidus visual field defect

A

lower bitemporal hemianopia

177
Q

third nerve palsy

A
  • ipsilateral eye to lesion is deviated ‘down and out’
  • ptosis
  • pupil may be dilated
  • cause: false localizing sign* due to uncal herniation through tentorium if raised ICP
  • absent light reflex with intact consensual constriction
178
Q

HSV encephalitis

A
  • affects temporal lobes
  • fever, headache, psychiatric symptoms, seizures, vomiting
  • focal features e.g. aphasia
  • Mx IV aciclovir
179
Q

normal pressure hydrocephalus

A

classical triad of:
1. urinary incontinence
2. dementia and bradyphrenia
3. gait abnormality (may be similar to Parkinson’s disease)

Imaging: ventriculomegaly out of proportion to sulcal enlargement.
Mx- ventriculoperitoneal shunt

180
Q

homonymous quadrantonopias

A

PITS
Parietal- inferior
Temporal- superior

181
Q

Homonymous hemianopia

A
  • incongruous defects: lesion of optic tract
  • congruous defects: lesion of optic radiation or occipital cortex
  • macula sparing: lesion of occipital cortex
182
Q

Neuroleptic malignant syndrome

A
  • when on antipsychotics
  • pyrexia, muscle rigidity
  • autonomic lability: typical features include hypertension, tachycardia and tachypnoea
  • agitated delirium with confusion
  • CK high and AKI
  • Mx: stop antipsychotic and IV fluids, can give bromocriptine
183
Q

Features of wernicke’s encephalopathy

A
  • oculomotor dysfunction
    nystagmus (the most common ocular sign)
    ophthalmoplegia: lateral rectus palsy, conjugate gaze palsy
  • gait ataxia
  • encephalopathy: confusion, disorientation, indifference, and inattentiveness
  • peripheral sensory neuropathy

Mx- replace thiamine (pabrinex)

184
Q

common peroneal nerve injury

A

unable to dorsiflex and evert foot

185
Q

Syringomyelia

A
  • collection of cerebrospinal fluid within the spinal cord
  • cause: tumour, trauma, idiopathic
  • cape-like’ (neck, shoulders and arms) loss of sensation to temperature but the preservation of light touch, proprioception and vibration
  • due to the crossing spinothalamic tracts in the anterior commissure of the spinal cord being the first tracts to be affected
  • Ix- MRI spine
186
Q

Thoracic outlet syndrome

A
  • compression of brachial plexus, subclavian artery or vein at the site of the thoracic outlet
  • neurogenic (90%) or vascular
  • painless muscle wasting of hand muscles, with patients complaining of hand weakness e.g. grasping
  • physio, surgical decompression
187
Q

Oxford stroke classification criteria

A
  1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
  2. homonymous hemianopia
  3. higher cognitive dysfunction e.g. dysphasia
188
Q

Types of stroke

A
  • Total anterior circulation infarcts (TACI, c. 15%)
  • Partial anterior circulation infarcts (25%)
  • Lacunar infarcts (LACI, c. 25%)
  • Posterior circulation infarcts (25%)
  • Lateral medullary syndrome (posterior inferior cerebellar artery)
  • Weber’s syndrome
189
Q

Total anterior circulation infarcts

A
  • involves middle and anterior cerebral arteries
  • all 3 of the oxford classification criteria are present
190
Q

Partial anterior circulation infarcts

A
  • involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
  • 2 of the criteria are present
191
Q

Lacunar infarcts

A

involves perforating arteries around the internal capsule, thalamus and basal ganglia
presents with 1 of the following:
1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
2. pure sensory stroke.
3. ataxic hemiparesis

192
Q

Posterior circulation infarcts

A
  • involves vertebrobasilar arteries
    presents with 1 of the following:
    1. cerebellar or brainstem syndromes
    2. loss of consciousness
    3. isolated homonymous hemianopia
193
Q

lateral medullary syndrome

A

aka Wallenberg’s syndrome
ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner’s
contralateral: limb sensory loss

194
Q

Weber’s syndrome

A

ipsilateral III palsy
contralateral weakness

195
Q

ulnar nerve

A
  • Arises from medial cord of brachial plexus (C8, T1)
  • Motor to: medial two lumbricals, aDductor pollicis, interossei
    hypothenar muscles: abductor digiti minimi, flexor digiti minimi
    flexor carpi ulnaris
  • Sensory to: medial 1 1/2 fingers (palmar and dorsal aspects)
196
Q

radial nerve

A
  • wrist drop
  • supplies extensors of the wrist and fingers
  • assoc with mid shaft humeral fracture
  • Loss of sensation on the dorsum of the hand over the thumb and index finger
  • Sensory: supplying the proximal phalanges on the dorsal aspect of the hand exc little finger and part of ring
  • Motor: triceps, bracioradialis, extensors, supinator
197
Q

ulnar nerve

A
  • formed by the union of a lateral and medial root respectively from the lateral (C5,6,7) and medial (C8 and T1)
  • Damage at wrist e.g. carpal tunnel syndrome, Colle’s
198
Q

Raised ICP mx

A
  • head elevation to 30º
  • IV mannitol may be used as an osmotic diuretic
  • controlled hyperventilation
  • repeated LP, VP shunt
199
Q

L5 nerve lesion

A

weakened dorsiflexion, inversion and eversion of the ankle

200
Q

pituitary apoplexy

A
  • Sudden onset headache, visual field defects + evidence of pituitary insufficiency (e.g. hypotension)
  • Sudden enlargement of a pituitary tumour (usually non-functioning macroadenoma) secondary to haemorrhage or infarction.
  • Mx: urgent steroid replacement due to loss of ACTH, careful fluid balance, surgery
201
Q

causes of cerebellar injury

A

PASTRIES
- Posterior fossa tumour
- Alcohol
- Stroke
- Trauma
- Rare causes
- Inherited (e.g. Friedreich’s ataxia)
- Epilepsy treatment
- S Multiple sclerosis

202
Q

main clinical signs of cerebellar disease

A

DANISH
- Dysdiadochokinesia
- Ataxia
- Nystagmus multidirectional
- Intention tremor
- Speech
- Hypotonia

203
Q

cerebellar stroke signs

A
  • vertical nystagmus
  • unable to stand without support
  • l§esion of the superior cerebellar artery, anterior inferior cerebellar artery or the posterior inferior cerebellar artery (also known as lateral medullary syndrome)
204
Q

Subacute degeneration of the spinal cord

A
  • due to vitamin B12 deficiency or NO, resulting in impairment of the dorsal columns, lateral corticospinal tracts and spinocerebellar tracts.
  • DC: distal tingling/burning/sensory loss is symmetrical, LL>UL
  • LC: muscle weakness, hyperreflexia, and spasticity, babinski +ve
  • ST: sensory ataxia → gait abnormalities, +ve Romberg’s sign
205
Q

posterior communicating artery aneurysm

A

headache and painful third nerve palsy

206
Q

common reflexes and nerve roots

A

Ankle S1-S2
Knee L3-L4
Biceps C5-C6
Triceps C7-C8

207
Q

Autonomic dysreflexia

A
  • occurs in patients who have had a spinal cord injury at, or above T6 spinal level
  • triggered by urine infection/faecal impaction
  • extreme hypertension
  • flushing and sweating above the level of the cord lesion
  • associated with haemorrhagic stroke due to hypertension
  • agitation
  • Mx: remove stimulus
208
Q

Intracranial venous thrombosis

A
  • headache (may be sudden onset)
  • nausea & vomiting
  • reduced consciousness
  • Ix: MR venogram
  • Mx: anticoagulation
209
Q

pontine haemorrhage

A
  • commonly presents with reduced GCS, paralysis and bilateral pin point pupils
  • haemorrhagic stroke
210
Q

Carpal tunnel syndrome

A
  • PNS disease, compression of median nerve
  • Motor: LOAF muscles (lateral lumbricals, opponens pollicis, abductor pollicis brevis and flexor policis brevis)
  • tinnel’s, phalen’s, thenar wasting, lack of grip
211
Q

Cavernous sinus syndrome

A
  • most commonly caused by cavernous sinus tumours
  • Diagnosis is based on signs of pain, opthalmoplegia, proptosis, trigeminal nerve lesion (opthalmic branch) and Horner’s syndrome
212
Q

what condition are triptans contraindicated

A

coronary artery disease, can cause coronary vasospasm

213
Q

Brachial plexus injuries

A

Erb-Duchenne paralysis
- damage to C5,6 roots
- winged scapula
- may be caused by a breech presentation

Klumpke’s paralysis
- damage to T1
- loss of intrinsic hand muscles
- due to traction

214
Q

Creutzfeldt-Jakob disease

A

Rapidly progressive neurological condition caused by prion proteins
- sporadic, acquired, inherited types
- Features: dementia (rapid onset), myoclonus

215
Q

bitemporal hemianopia visual field defects

A
  • lesion of 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
216
Q

C8 fact

A

C8 is the ONLY cervical nerve root that comes out BELOW the vertebra

217
Q

side effect of lamotrigene

A

Steven-Johnsons syndrome (seek help if get a rash)

218
Q

ataxic gait

A

A wide-based gait with loss of heel to toe walking

219
Q

restless leg syndrome

A
  • uncontrollable urge to move legs (akathisia)
  • movements during sleep may be noted
  • causes: FH, diabetes, pregnancy, IDA
  • Mx: walking, stretching, dopamine agonist (ropinirole)
220
Q

combination of lower back pain, pain in the left leg, and tingling in the left big toe, which are consistent with the dermatomal distribution of…

A

the L5 nerve root

221
Q

left foot drop nerve effected

A

L5 nerve root

222
Q

hypoglossal nerve function

A
  • responsible for motor function of the tongue, including protrusion and side-to-side movements.
  • damage = tongue deviate towards affected side

Finals (25 decks)

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