Neuro Flashcards
Parkinsonism DDx
IPD
Drug-induced parkinsonism
Vascular dementia
Parkinson’s plus: LBD, CBD, PSA, MSA
Toxins
Wilson’s
Post - Encephalitis
Demyelination in basal ganglia
Repetetive trauma
Clinical features to diagnose PD
BRADYKINESIA + >1
Tremor
Rigidity
Postural instability/ gait disturbance
Clinical features on examination of PD
Hypomimic face, quiet speech, shuffling gait, stooped posture, reduced arm swing, unilateral pill rolling tremor, postural instability, turning en bloc
Features of Parkinson’s plus
Phantom limb: CBD
Restricted upgaze: PSP
Cerebellar signs and autonomic dysfunction: MSA
Dementia and hallucinations: LBD
Non-motor features of PD
Anosmia
Pain
Mood disturbance
Sleep disorders
Constipation
Memory impairment
Drugs which can cause parkinsonism
Antipsychotics (dopamine antagonists), prochlorperazine, metoclopramide
Mx for drug-induced parkinsonism
Antimuscarinics e.g. trihexyphenidyl
Clinical features to assess in neuro exam for suspected PD
Gait
Tremor (Distraction i.e. count backwards or tap thigh with other hand)
Cog wheel rigidity
Upgaze restriction
Cerebellary signs (past pointing, nystagmus)
LSBP
Medical mx of PD
Levodopa + dopa decarboxylase inhibitor ie co-careldopa or co-beneldopa
Oral dopamine agonist: ropinirole, bromocriptine
Adjuncts: MAO-B inhibitors (selegeline), COMT inhibitors (entacapone)
Amantadine
SE of oral dopamine agonists
Impulse control disorders and hallucinations, less motor SE
Levodopa SE
Motor SE but also best for motor sx of PD
ropinirole drug class
Oral dopamine agonists
PD diagnosis and investigations
Mostly clinical diagnosis by neurologist
SWALLOW assessment
Micrographia
Anosmia
MMSE
DAT scan if ?drug-induced vs IPD/Parkinson’s plus
Mx principles in PD
Urgent neurology referral to make diagnosis
MDT: Neurologist, specialist nurses, pT/OT, SLT, Dietitian, Parkinson’s uK/support groups, GP, psychologist
Non-medical: safety, driving and DVLA, patient education
Medical: Levodopa etc
Surgical: DBS
Ix to differentiate between essential tremor and PD
DAT scan
Screening tools for pD
Distraction + tremor
Arms out for postural tremor
Finger nose testing for cerebellar signs
Speech for cerebellar speech
Nystagmus
UPgaze
LSBP
Things to consider in a younger patient with Parkinsonism
?Wilson’s - Kayser fLeischer rings (Serum ceruloplasmin and urinary copper)
What constitutes bradykinesia?
Decrement in amplitude and frequency of repetitive movement
Essential tremor features
AD
Comes on at a younger age
Diminished by mental activity
involves hands head “yes yes no no” , voice
Enhanced by maintaining posture
Improved with alcohol and beta blockers
How would you complete your pD exam?
Cognitive assessment
LSBP
Handwriting
Drug chart
L-DOPA SE
Dyskinesia
On/off symptoms
Hallucinations
Psychosis
N&V
Excessive day time sleepiness
Vascular parkinsonism features
Legs >arms
sudden onset
pyramidal signs
DDx postural tremor
BET
ANxiety
Hyperthyroidism
Salbutamol
Alcohol withdrawal
What does SPECT stand for and when is it used?
Single photon emmission computed tomography (DaT scan)
Used to assess dopamine uptake in basal ganglia - helpful to differentiate between essential tremor and PD or drug-induced causes vs idiopathic/parkinson’s plus
Motor SE of levodopa
tardive dyskinesia
dystonia
What is tardive dyskinesia?
Repetitive, involuntary movements of face and jaw i.e. lip smacking and tongue protrusion
What is dystonia?
Involuntary abnormal sustained or repetitive muscle contraction
What gait do you suspect in unilateral spasticity?
Circumduction
What gait in bilateral UMN spasticity?
Scissoring
4 features of pyramidal UMN pathology
Increased tone (spastic, velocity dependent)
Power reduced in pyramidal pattern of weakness
Hyperreflexia
Upgoing plantars
FUELS
Flexors Upper Extensors Lower Stronger
At what level does the spinal cord end?
L1
What is the cauda equina?
After cord ends at L1, the lumbosacral nerve roots form the cauda equina
What is Brown-sequard
Hemisection of the spinal cord resulting in ipsilateral loss of JPS and vibration sense and weakness
contralateral loss of pain and temperature sensation
DDx for unilateral spasticity
SOL
Stroke
MS
CP
Causes of upgoing plantars and absent ankle jerk
Friedrich’s ataxia
MND
SCDC
Tabes dorsalis
Dual pathology i.e. cervical myelopathy and peripheral neuropathy in an older patient
Features to look for on inspection of spastic paraperesis patient
Foot orthoses
Spinal surgery scars
Gait for scissoring
Presence of a catheter
Neuropathic joints
disuse atrophy
By definition, in a myelopathy, where must the lesion be above?
Must be above the level of L1 as this is where the cord ends
If spastic paraperesis and absence of sensory signs, which diagnoses?
MND (PLS)
HSP
Anterior spinal artery occlusion features
Spastic paraperesis
Involvement of corticospinal tracts -> pyramidal pattern of weakness
Involvement of spinothalamic -> loss of pain and temperature sensation
Dorsal columns spared (jPS and vibration)
Posterior spinal artery occlusion features
Sensory ataxia, impaired proprioception
Loss of JPS and vibration sense
birth injury or illness around the neonatal period, intellectual impairment, spastic paraparesis, brisk reflexes, upgoing plantars.
Cerebral palsy
spastic paraperesis, cerebellar signs, pes cavus, upgoing plantars, absent ankle jerk, peripheral sensory neuropathy including dorsal columns
Friedrich’s ataxia
Spastic paraparesis, brisk reflexes, upgoing plantars, cerebellar signs, and a history of visual or sphincter disturbance. There may be sensory signs, dorsal column more commonly than spinothalamic.
MS
Spastic paraparesis, brisk reflexes, upgoing plantars, wasting, faciculations. Absence of sensory signs.
MND
What are fasciculations almost pathognomic of?
ANterior horn cell disease i.e. MND
spastic paraparesis, cerebellar signs and dorsal column signs
friedrich’s ataxia/ demyelination as differential
spastic paraperesis + small hand muscle wasting + fasciculations
MND
Cervical myelopathy
Spastic paraperesis + UMN signs in upper limb
Cervical myelopathy
Bilateral strokes
Spastic paraperesis + INO/RAPD
Demyelination
After examining spastic paraparesis, how would you complete your exam?
PR - Check for anal tone and saddle anaesthesia
UMN examination - any LMN signs suggestive of MND, any UMN signs suggestive of cortical pathology, any wasitng/fasciculations
Cerebellar examination: eyes, speech
Bulbar symptoms (syringomyelia)
Fundoscopy: optic neuritis
History: FH, spinal trauma, history of bowel/bladder disturbance, visual impairment
Which subtype of MND results in purely UMN features?
Primary lateral sclerosis PLS
Possible sites of lesion in spastic paraperesis
Spinal cord
Anterior horn cell
Parasagittal (meningioma)
Common causes of spastic paraperesis
MS
Cord compression/myelopathy/trauma
MND
Rarer causes
Anterior spinal cord syndrome (Stroke)
Inflammatory: NMO, SLE, sjogrens
Syringomyelia
HSP
HTLV-1
SCDC
Friedrich’s ataxia
Parasagittal falx meningioma
Why can a parasagittal falx meningioma cause a SP?
Compresses at the midline i.e. the leg motor cortex areas
Causes of cord compression
Disc
Bone
Tumour
Abscess
Treatment of cord compression
Emergency requiring urgent spinal MRI and neurosurgery referral/discussion
Urgent surgical decompression +/- steroids and radiotherapy
Cauda equina symptoms
Back pain
B/L LMN signs in legs and sensory loss in lumbosacral dermatomes with sphincteric function impairment
Intrinsic abnormality of spinal cord causing SP
Demyelination
Spinal cord infarction
Transverse myelitis due to infection
CTDs - SLE, Sjogrens
Extrinsic compression of spinal cord causes
Spondylosis
Vertebral disc disease like tumour or haematoma
Cord compression from bone fracture
Congenital abnormality like CP or spina bifida
Degenerative conditions causing SP
HSP
PLS
Anterior cord syndrome causes
Infarct
Compression by vertebral disc disease
Anterior tumour
Which tracts affected in anterior cord syndrome
Corticospinal and spinothalamic
Causes of posterior cord syndrome
Demyelination
Posterior spinal artery infarct
Compression (disc, bone, tumour, abscess)
Taboparesis
SCDC
Demyelinating causes of SP
MS, NMO, SCDC, Transverse myelitis (HSV VZV HIV paraneoplastic), HTLV-1/ tropical spastic paraperesis
what is taboparesis
combination of tabes dorsalis (due to tertiary syphilis) and spastic paraperesis
Spastic paraperesis, syphilis, dorsal column involvement
Causes of transverse myelitis
Demyelinating: MS, NMO
Post-infective (HSV VZV HIV)
Autoimmune: SLE, Sjogrens, sarcoid
Paraneoplastic
spastic paraperesis + dorsal column loss
Demyelination
Friedrichs
SACDC
Taboparesis (syphilis)
SP and cerebellar signs
MS (Demyelination)
FA
SCA
Ix for MS
MRI spine and brain (lesions disseminated in time and space)
VEPs
LP - CSF for protein, lymphocytes, unpaired oligoclonal bands
Bloods to request in SP
FBC, UE, LFT, Bone profile, anti-AQP4, anti-MOG, BBV screen, HTLV1, syphilis, anti neuronal antibodies, ACE, ANA, ESR, Complement, anti dsDNA, B12, serum electrophoresis
Why may you request an EMG in sP?
To look for fasciculations and fibrillations seen in MND
Cancers which commonly metastasise to bone
Solid: lung, prostate, kidney, breast, thyroid
Haem: MM
Flaccid paraperesis DDx
AHC disease i.e. MND, poliovirus, west nile virus
Acute spinal infarct
Myopathy
NMJ disorder ie MG, botulism
Neuropathy: lead poisoning, porphyria, HMSN
Causes of SCDC
B12 deficiency:
- Nitrous oxide
- Dietary i.e. vegans
- Malabsorption: pernicious anaemia, crohn’s, gastric or ileal resection, bacterial overgrowth
HMSN types
HMSN 1 - Demyelinating (AD)
HMSN 2 - Axonal (AD)
However there are many more types and inheritance pattern variable (AD, AR, X linked etc)
Ix for HMSN/CMT
NCS: Demyelinating - reduced velocity, axonal - reduced amplitude
Above will guide genetic testing
HMSN features on examination
Pes cavus
Hammer toes
Foot drop
High stepping gait
Loss/reduced ankle reflex
Symmetrical distal wasting “inverted champagne bottle”
claw hands
Charcot joints
Ankle foot orthoses
Variable loss of sensation in stocking distribution
Palpation: thickened nerves
HMSN DDx
Diabetic neuropathy
Alcohol related neuropathy
Lead toxicity
GBS
CIDP
vasculitis and mononeuritis multiplex in a younger patient
What does pes cavus indicate
Motor neuropathy during development
Palpable lateral popliteal nerve
CMT
