Neuro Flashcards
extrapyramidal vs pyramidal symptoms and cause
Extrapyramidal symptoms include dystonic reactions, akathisia, parkinsonism, tremor, and tardive dyskinesia.
Pyramidal symptoms include spasticity, weakness, slowing of rapid alternating movements, and hyperreflexia.
Extrapyramidal symptoms are caused by dopamine blockade or depletion in the basal ganglia.
Pyramidal symptoms are caused by partial or complete damage of the pyramidal tract
A 71-year-old man presents to the neurology clinic after being referred by his GP for suspected Parkinson’s disease. On examination, he has bradykinesia, a shuffling gait and cogwheel rigidity. He appears to have no cognitive impairment. The neurologist decides to treat him with levodopa but explains that this will need to be combined with another medication to increase the bioavailability of levodopa.
Which other medication should be given with levodopa?
Carbidopa is given along with levodopa (Co-careldopa) as it reduces the breakdown of levodopa peripherally, leading to a better therapeutic effect.
trigeminal neuralgia first line
carbamazepine
A 31-year-old female presents to Accident and Emergency with progressive difficulty walking and reduced sensation in her feet and hands.
She has no past medical history.
On examination, she has reduced fine-touch sensation and proprioception bilaterally in her feet and hands, with preserved pain and temperature sensation. She has symmetrical mild power loss in both lower limbs. She has brisk knee reflexes, absent ankle reflexes and upgoing plantar reflexes. She has trouble balancing when walking.
Which of the following is the best investigation?
Magnetic resonance imaging (MRI) of the spine
This woman has subacute combined degeneration of the cord demonstrated by functional deficits in the dorsal columns (fine touch, vibration and proprioceptive sense) and lateral corticospinal tracts (motor). Pain and temperature sensation (spinothalamic) is typically preserved. Symmetrical distal weakness is observed. Reflexes classically reflect upper motor neurone impairment (hyperreflexia and upgoing plantar reflexes), except ankle reflexes are lost (likely due to distal sensory loss). It is caused by actual or functional vitamin B12 deficiency. The best investigation is MRI which would show a symmetrical bilateral high signal in the dorsal columns.
A 78-year-old man presents with recurrent cramping pain in his thighs and lower legs whilst standing at the bus stop. It usually improves after he sits down on the bus.
He has a background of type 2 diabetes and takes Metformin. His HbA1c is 44 mmol/mol.
On examination, he has altered sensation on his upper thighs bilaterally with normal knee and ankle reflexes. The pulses in his lower limbs are present.
What is the most underlying diagnosis?
Not peripheral neuropathy as Hba1c normal (48 or 6.5% or below is normal)
Lumbar stenosis
Neurogenic claudication, as described in the stem, is caused by spinal stenosis. Lumbar stenosis presents with pain in the buttocks, thighs and lower legs. The pain is classically worsened by extension of the back e.g. standing and relieved by flexion e.g. sitting down.
Topiramate CI
Topiramate is relatively contraindicated in a woman of child bearing age
A 22 year old female presents to headache clinic complaining of headaches for the last few months. She describes these as occurring on one side only, throbbing and are preceded by tingling in her fingers. She usually has to hide under the covers in a quiet room whilst these attacks occur.
Her past medical history includes asthma, type 2 diabetes and Raynaud’s.
She is keen to be given something to stop these from happening preventively.
What would be the treatment of choice?
Amitriptyline
This is the prophylactic management of migraine. Management includes the following:
1st line = Beta-blocker or Amitriptyline
2nd line = Topiromate/valproate
3rd line = Pizotifen
Beta interferon is a
Beta interferon is a disease-modifying treatment for multiple sclerosis (MS), where it works by modulating the immune response to reduce the frequency and severity of relapses.
A 55 year old man presents to his GP with a two week history of increasing difficulty with walking, superimposed on a 6-10 week history of fatigue and generalised weakness.
On examination, there is generalised muscular wasting, with fasciculations in the thigh and tongue. There is reduced power universally in the limbs, with apparent spasticity and hyperreflexia in both the upper and lower limbs bilaterally. There is no evidence of sensory disturbance. Basic blood tests for B12-folate status and thyroid dysfunction are normal.
Given the likely underlying diagnosis, what is the most appropriate disease-modifying treatment?
Riluzole
Correct. The clinical presentation suggests motor neurone disease (MND), which is characterised by a combination of upper and lower motor neuron signs. Riluzole is the most appropriate disease-modifying treatment for MND and has been shown to extend survival by aproximately 3 months.
A 58-year-old teacher is brought to her GP by her daughter, who is concerned that she has been more forgetful than usual. For the past 6 weeks, she has been forgetting important appointments, and, most recently, forgetting the names of close family members. She is currently off work after breaking her ankle due to a fall, and has experienced several episodes of urinary incontinence. Prior to this, she had been fit and well. She takes no medication other than hormone-replacement therapy (HRT), and paracetamol due to ankle pain.
What is the most appropriate treatment for this patient’s condition?
Ventriculo-peritoneal shunting
This patient likely has normal-pressure hydrocephalus. She demonstrates the core triad of urinary incontinence, dementia and gait abnormality, developing over several months. In patients fit for surgery, the first-line treatment for this is ventriculo-peritoneal shunting.
HIV positive man presents post seizure, with preceding prodrome. India ink stain positive, raised protein, low glucose. Dx?
This is caused by Cryptococcus neoformans. Risk factors include immunocompromise, and given this patient’s HIV and lack of compliance with anti-retroviral therapy, he is at high risk. Cryptococcal meningitis has a subacute course, progressing slowly over days with gradual symptoms such as headache, vomiting, and fatigue, with eventual severe neurological dysfunction such as seizures and drowsiness. India ink stain is a special stain that looks for Cryptococcus neoformans. Classical CSF findings are a raised protein and low glucose.
A 55-year-old is referred to neurology by his GP due to difficulty walking. Specifically, he’s noticed that he trips or stumbles more often with his right leg. On examination, a right foot drop is noted, with prominent weakness of ankle dorsiflexion, inversion and eversion.
Where does the lesion localise to?
L5 radiculopathy
The combination of weakness of foot dorsiflexors, inverters and evertors indicates L5 radiculopathy. This is commonly associated with neuropathic pain radiating down the lumbar region and posterior thigh, down the anterolateral leg to the foot and big toe. Sensory loss over the first web space is also possible.
L5 radiculopathy is the most common lumbar radiculopathy, resulting most often from a herniated disc or spondylosis.
Though palsy of the common fibular (peroneal) nerve is the most common cause of foot drop, it manifests as sensory loss or paresthesias across the lateral leg below the knee level and anterolateral foot, with weakness of ankle dorsiflexors, toe extension, and ankle evertors.
If only the deep fibular portion is affected, there will be minimal sensory deficits (the web space between the first two digits), and isolated weakness of toe and ankle extensors.
1st line for spasticity in MS
Baclofen and gabapentin
Bells palsy risk factor
pregnancy
MS Ix
MRI with contrast
Herpes simplex encephalitis Ix and finding
CT head showing temporal changes
temporal lesions cause a
contralateral superior quandranopia
Diabetes insipidus due to craniopharyngioma causes a
lower bitemporal hemianopia
parietal lesions cause a
contralateral inferior quadranopia
Left homonymous hemianopia means visual defect to the xxx and pathology to the xxx
defect to left, pathology is lesion of right optic tract
how to remember homonymous quandrantinopias
PITS - parietal inferior temporal superior
pituitary tumour causes
upper quadrant bitemporal hemianopia
tonic or atonic seizures 1st line male and female
Female - lamotrigine, Male - sodium valproate
large artery acute ischeamic stroke consider
mechanical clot retrieval
diplopia in Parkinsons
not common- suggests alternate cause of Parkinsonism such as progressive supra nuclear palsy
Describe subacute combined degeneration of the spinal cord
distal sensory loss, tingling, absent ankle jerks/extensor planters, gait abnormalities, Romberg’s positive
can be caused by functional B12 deficiency (e.g. nos, or problem with absorption)
which medication is linked with impulse control disorders
dopamine receptor agonists - overstimulation of reward pathways, leading to hyper sexuality, gambling, shopping and binge eating e.g. bromocriptine
Pt with spinal cord injury develops severe HTN, full bladder Diagnosis
autonomic dysreflexia
Mx of a pt on warfarin/DOAC or with bleeding disorder in suspected TIA
admitted immediately for imaging to exclude haemorrhage - immediate CT head without contrast
reduced GCS, paralysis and bilateral pinpoint pupils cause
pontine haemorrhage - can be caused by long standing HTN, penetrating arteries from basilar artery extending to pons rupture. V poor prognosis
30y old man with FH of blindness, tunnel vision, diagnosis?
retinitis pigmentosa
Left hom hemi with macular sparing lesion
occipital cortex - due to macular sparing
suspected TIA requiring brain imaging modality
MRI brain with diffusion weighted imaging
SAH CT sensitivity
100% in first 6 hours
reversible cause of dementia
Urinary incontinence + gait abnormality + dementia = normal pressure hydrocephalus
ventriculoperitoneal shunting
A 28-year-old female presents with a two-day history of a gradual onset severe headache associated with nausea and three episodes of vomiting. She comes across as blunted and states she is having difficulty in finding the right words. She has no significant past medical history and her only medication is the combined oral contraceptive pill. The only thing of note in her family history is that her mother had an unprovoked DVT in her 30s. Given the likely diagnosis, what is the gold standard test to diagnose her condition?
This woman has a number of risk factors for a cerebral venous sinus thrombosis - combined oral contraceptive pill use and a family history of VTE. The gold standard test for diagnosing this is an MR venogram. The headache of a cerebral venous sinus thrombosis is commonly severe but usually presents slightly more insidiously than a ‘thunderclap headache’, with potentially subtle and non-specific neurology. Sometimes patients presentation includes nausea, vomiting and seizures.
preferred antiplatelet for secondary prevention following stroke
Clopidogrel is the preferred antiplatelet for secondary prevention following stroke
MG key features
symptomatic MG management
Pyridostigmine is a long-acting acetylcholinesterase inhibitor that reduces the breakdown of acetylcholine in the neuromuscular junction, temporarily improving symptoms of myasthenia gravis
then steroids
Defective eye abduction and horizontal diplopia - CN ?
6
Confusion, ataxia, nystagmus/ophthalmoplegia→
give Pabrinex (IV B/C vitamins)
IV vitamin B substances with ascorbic acid is correct. The patient exhibits a classic triad of symptoms: confusion, nystagmus, and ophthalmoplegia, which are suggestive of Wernicke’s encephalopathy. Wernicke’s encephalopathy is typically secondary to thiamine deficiency, most frequently associated with malnutrition due to chronic alcohol misuse. However, it can also arise from other causes of malnutrition such as post-bariatric surgery or hyperemesis gravidarum. It is imperative to administer thiamine promptly (alongside other B and C vitamins) to prevent progression to Wernicke-Korsakoff syndrome, which may result in irreversible damage.
The interossei are supplied by the
ulnar nerve. cannot adduct
concerning feature re raised ICP
and HTN
A 78-year-old man visits his GP with his wife.
She tells you he has been very forgetful over the past 2 months and is concerned about some inappropriate comments he has made, which is out of character.
He has also had multiple falls and two admissions to hospital recently with falls.
On examination, you note he has bradykinesia of movement, a pill-rolling left-sided tremor and cogwheel rigidity of his left arm. His pupils are equal and reactive to light but he can’t look upwards.
Progressive supranuclear palsy: postural instability, impairment of vertical gaze, parkinsonism, frontal lobe dysfunction
HTN in ischaemic stroke treatments
labetalol prior to alteplas`e
Management of autonomic dysreflexia involves
removal/control of the stimulus and treatment of any life-threatening hypertension and/or bradycardia
MND nutritional method
PEG
ataxia, nystagmus, dysphagia, ipsilateral facial sensory loss and contralateral upper and lower limb sensory loss.
diagnosis?
Right posterior inferior cerebellar artery is correct. This patient is presenting with features of lateral medullary syndrome, a neurological disorder causing a range of symptoms due to ischemia in the lateral part of the medulla oblongata in the brainstem. The features are usually ataxia, nystagmus, dysphagia, ipsilateral facial sensory loss and contralateral upper and lower limb sensory loss. Most commonly, this is caused by occlusion of the posterior inferior cerebellar artery.
features of lateral medullary syndrome
ataxia, nystagmus, dysphagia, ipsilateral facial sensory loss and contralateral upper and lower limb sensory loss.
opioid for neuropathic pain if really needed
tramadol
dopamine receptor agonists
UMN vs LMN signs
