Neuro 2 Flashcards
65-M presents with 12hr Hx sudden headache + difficulty walking (balance problem). He feels nauseous and has vomited. His speech is slurred.
Likely diagnosis? Cardinal symptoms?
Cerebellar stroke
Cardinal symptoms:
- ataxia
- headache
- vertigo
- vomiting
Pt presents with complete paralysis of facial muscles on one side.
Mouth droop, flattened nasolabial fold, cannot close eye, smoothened brow.
Likely diagnosis?
CNVII Palsy
- ipsilateral side
Pt presents with dizziness, and feel faint when they get up from standing. They are on medication for their recently diagnosed BPH.
Likely diagnosis and cause?
Postural Hypotension 2o to Tamsulosin
65-M presents complaining of a Hx sudden headache + difficulty walking (balance problem). He felt nauseous and has vomited. He noticed his speech was slurred. This resolved within 1 hour.
Likely diagnosis? Cardinal symptoms?
TIA
Presentations of Subarachnoid haemorrhage
Sudden thunderclap headache, 10/10 severity
Neck stiffness, meningism
Pt presents with stroke symptoms. Full acute management plan?
ABCDE
Within 4.5hr window:
- CT Head (within time-frame)
If confirmed Ischaemic stroke:
- IV Alteplase (within time-frame)
- Thrombectomy
- w/in 6hr anterior circulation
- w/in 12hrs posterior circulation
- a) 2wks Aspirin 300mg
b) Long-term Clopidogrel - Carotid US, CT Angiography, Echo.
CI to Alteplase: head trauma, GI/brain bleed, recent surgery, normal BP, plt count, INR
If confirmed Haemorrhagic stroke (ICH, SAH):
- SAH - Nimodipine, IV fluid
- Endovascular coiling, stent, Decompressive hemicraniectomy
- Serum toxicology screen (cocaine)
Chronic stroke management
HALTSS
Hypertension*, 2-wks after
Antiplatelet - Clopidogrel. If Ischaemic, 2o to AF then Warfarin/ Rivaroxaban
Lipid-lowering - Atorvastatin
Tobacco - stop smoking
Sugar - Diabetes screening
Surgery - if ipsilateral carotid stenosis >50% > carotid endarterectomy
*No benefit in lowering acutely :: reduces brain perfusion UNLESS malignant
Focal seizure of the frontal lobe presentations
MOTOR features
- posturing
- pedalling of legs
- Jacksonian march
- behavioural change
Myoclonic seizure
Sudden jerk of limb, face, trunk; violent, disobedient limb
Tonic seizure
Sudden limb stiffness
Jason is a 34yr old builder. He developed sudden intense back pain at work + weakness and sensory loss in both limbs
Likely diagnosis? Possible underlying causes?
Spinal Cord compression
- BILATERAL sensory loss
Possible causes:
- disc herniation
- congenital stenosis
Subarachnoid haemorrhage mx
IV Fluid + Nimodipine (Ca2B - reduces vasospasms - reduces cerebral ischaemia)
Endovascular coiling, intravascular stent
Subdural haemorrhage mx
ABCDE + IV Mannitol
Burr-twist irrigation/ craniotomy
Extradural haemorrhage mx
ABCDE + IV Mannitol
Clot evac/ ligation
Drug used to lower intracranial pressure
Mannitol
Which artery is commonly affected in an extradural (epidural) haemorrhage?
Middle meningeal artery
Main types of seizures, presentations and their proportions
Primary generalised (40%)
- LOC
- BILATERAL, SYMMETRICAL
Partial/focal (60%)
- depends on lobe location
Epilepsy causes
Epilepsy RF
Epilepsy causes:
2/3 IDIOPATHIC.
Tumour, stroke, cortical scarring.
Epilepsy RF:
FHx, abnormal cerebral perfusion, cocaine
Epilepsy management
- uncomplicated
- F child-bearing age
1L Valproate
If F child-bearing age - LAMOTRIGINE
Simple vs Complex partial seizure
Complex affects awareness
Temporal partial/focal seizure px
Lip smacking, chewing, fiddling
Frontal partial/focal seizure px
Motor: Jacksonian, peddling,
Parkinson’s RF
Parkinson’s associations
55 - 65 M, pesticide exposure
Associated with LEWY-BODY dementia
Parkinson’s diagnosis
Parkinson’s management
Clinical diagnosis - response to L-dopa
Mx: MDT care
- Levodopa + Co-Careldopa
- Cabergoline/Rantipole - DA agonist
- Selegline - MAO-B inhibitor
- Entacaopone - COMT i
Parkinson’s presentations
Parkinson’s pathophysiology
Resting tremor
Bradykinesia
Cogwheeling
Rigidity, foot drop, insidious onset
Pathophysiology: reduced DA in Substantia Nigra
Migraine management
What should you avoid?
Prophylaxis: Propranolol, Topiramate, TCAs, Bockulinum toxin A
Acute attack:
NSAIDs, Paracetamol > Triptan. Metoclopramide (antiemetic)
Avoid opiates and the pill
Cluster headache management
Prophylaxis:
Verapamil
Acute attack:
High flow O2 > Nasal Triptan
Trigeminal neuralgia mx
Carbamazepine
Tension headache triggers
Stress, sleep deprivation, hunger, anxiety, eye strain
NOT DEHYDRATION
Tension headache mx
Avoid triggers
Aspirin
Paracetamol, NSAIDs
Multiple Sclerosis pathophysiology
MS
CD4-mediated demyelinating condition affecting oligodendrocytes > gliosis + neuronal damage
Multiple Sclerosis presentations + demographic
F 20-40, NORTHERN latitude (SWEDEN), HLA-DRB1
1) Optic neuritis - one blurry eye
2) Pyramidal weakness - upper limb extensors + leg flexors
3) Sensory phenomena
Spastic paraparesis + numbness + declining cognition + UMN signs
Lhermitte’s sign
Sensory WORSE in SHOWER
MS Investigations
MCDONALD CRITERIA
CSF - oligoclonal bands/ IgG
GOLD: MRI Brain + Spinal Cord - Demyelinating lesions (ventricles)
Gadolinium-enhanced hyperintensity of ventricles
MS Management
Acute relapse: Methylprednisolone
Chronic relapse-remitting: Interferon-B, Fingolimod, Natalizumab
MND Investigations + Diagnosis
El Escorial Criteria
EMG nerve condition studies
Kerning’s sign indicates
Meningitis - severe hamstring stiffness
Encephalitis presentations
Encephalitis mx
What can you prescribe for seizures?
Looks like meningitis + Stroke
- meningism + fever + ALTERED MENTAL STATUS + seizure
Mx:
primary: IV Benzylpenicillin
Hospital: IV Ceftriaxone + ACICLOVIR (HSV1) (2wks)
Anticonvulsants: Phenytoin
Encephalitis common cause
Encephalitis ix
HERPES SIMPLEX VIRUS 1 (HSV1)
Bloods/ culture, CSF, Viral PCR, CT/MRI
SE Acyclovir
Fatigue, GI disturbance, photosensitivity, rash
Alzheimer’s px
Alzheimer’s Ix
Memory loss, speech/ motor deficit, personality change, disorientation
1L: MMME + Blessed Dementia Scale
GOLD: CT - cortical atrophy
Mx:
- Acetylcholinesterase inhibitor - Donezpil/ Rivastigmine
- CSF amyloid-beta monitoring
“see friends, play board-game”
Acetylcholinesterase inhibitor uses
Examples
Myasthenia Gravis + Alzheimer’s disease
Donepezil, Rivastigmine
Alzheimer’s complications
Aspiration pneumonia 2o to dysphasia, UTI
Alzheimer’s pathophysiology
Beta-amyloid peptide accumulation > AMYLOID PLAQUES + NEUROFIBRILLARY/TAU TANGLES, lost ACh, Tau
Frontotemporal dementia (aka Pick’s) px
Associations?
Younger, semantic dementia (teacher can’t spell)
Personality change, episodic memory loss, lowered inhibitions
Associated with MOTOR NEURONE DISEASE
Pick’s disease diagnosis
Port-mortem - TAU proteins stain with silver
Causes FRONTOTEMPORAL DEMENTIA
Vascular dementia px + aetiology
CVD/ stroke aetiology - HTN + Focal signs
Px: Stepwise:
- visual disturbance
- UMN
- Attention deficit
- Depression
- Emotional disturbance
Lewy Body Dementia px
Association
Fluctuating, cognitive impairment, visual hallucinations
+ Parkinsonism
PARKINSON’S DISEASE association
Lewy body dementia mx
Acetylcholinesterase inhibitors
Most common type of brain tumour
Glioma - #1 = Astrocytoma
Common sites which metastasis TO brain
Lung, breast, skin , kidney, GI
Brain tumour px
Brain tumour Ix
Raised ICP
- headache
- drowsy
- nausea
Local effects
Ix: Neuro exam
GOLD: Brain CT/MRI
Most affected vessel in GCA?
Carotid artery
GCA Investigations
American College of Rheum Classification
GOLD: Temporal Artery Biopsy, ^ESR/CRP
GCA Management
High dose steroid, low dose aspirin, tocilizumab
SC Compression px
Contralateral UMN signs + Back pain
Paresis + Sensory loss
+ Bladder/ bowel dysfunction if lumbar lesion
SC Compression Ix
SC Compression Mx + Mx for underlying malignancy
Acute SCC emergency = Immediate WHOLE SPINE MRI
Mx: Surgical decompression w/in 48hrs
If Malignancy - IV Dexamethasone
Types of SC Compressions
Cauda Equina Syndrome
Brown-Sequard Syndrome
Cauda Equina Syndrome Presentations
SADDLE PARASTHESIA, bladder/ bowel dysfunction
Lower back pain, absent ankle reflex
Brown-Sequard Syndrome presentations
Isilateral:
- hemiplegia
- loss of proprioception + vibration
Contralateral:
Loss of pain + temperature
Common peroneal nerve palsy px
L5 Radiculopathy px
Common peroneal nerve: Foot drop + affects ankle eversion
L5 Radiculopathy: Foot drop + affects ankle inversion
Myasthenia Gravis investigations
Mx
Clinical, TFT, crushed ice test (ptosis)
ACh_R Ab + MuSK
Tensilon Test
Mx:
- Acetylcholinesterase inhibitors - pyridostigmine
CT Chest - Thymoma??
Causes of peripheral neuropathy
Diabetes Mellitus
B12 deficiency
Lead poisoning
Trauma
Huntington’s disease Pathophysiology
Presentations
Ix
Ppx: CAG repeats > TOO MUCH DA
Px: Chorea, cognitive decline, hyperkinesia, incoordination, depression
Ix: CAG Repeat Testing +
MRI/CT - basal ganglia lesions
Differential:
- Wilson’s (Copper - Liver biopsy, rings in eyes)
Wilson’s presentations
Ix
Rings in eyes
Similar to Parkinsons/Huntingtons
Ix: Liver Biopsy (copper)
Huntington’s Disease Mx for:
- Chorea
- Psychosis
- Jerk
Chorea: Tetrabenazine
Psychosis: Haloperidol
Jerk: Risperidone
Guillain-Barre Syndrome presentations
Ix
Mx (+ DVT prophylaxis)
Viral > Neuro
- TOES to NOSE weakness
distal > proximal
Ix: Bloods, LP (protein), spirometry, ECH
EMG - slow conduction
Mx: Plasma exchange + IV Ig (AVOID corticosteroids).
DVT prophylaxis: LMW Heparin
Lambert-Eaton Syndrome
RF, Px, Ix, Mx
RF Malignancy, AI, smoking
Px: GRADUAL proximal limb weakness, dry mouth, dysarthria
Ix: Ab against Voltage-gated Ca Channel
Mx: Plasma exchange, IV Ig, Amifampridine
Define amaurosis Fugax
Painless temporary vision loss
Charcot-Marie-Tooth
Ix
Progressive peripheral neuropathy + PES CAVUS + FOOT DROP /slapping
Ix: EMG - symmetrical change
GOLD: CMT mut
Duchenne Muscular Dystrophy
Ix
<3, delayed motor milestone, lower limb weakness, GOWER’s sign
Ix: Muscle biopsy - absent dystrophin
Wernicke’s Encephalopathy
Define
Px
Thiamine (B1) deficiency due tp alcohol abuse/ GI surgery
Px: Confusion, ataxia, ophthalmoplegia, asterixis
Mx: Pabrinex - IV Thiamine + Mg Supplement
Depression screening tool
PHQ-9
ABCD2 score parameters
Age >60 BP >140/ >90 Clinical - speech, weak, sleep disturbance Duration <1hr (1), >2hr (2) DM
Signs of radial nerve damage
Can’t open fist
BEST muscles
Signs of Median nerve damage
Carpal Tunnel
Precision grip muscles - LOAF
Signs of Ulnar nerve damage
Vulnerable to elbow trauma
CLAW sign
Signs of axillary nerve damage
Weak shoulder abduction
Differentiate between Myasthenia Gravis and Lambert Eaton Syndrome
Myasthenia Gravis:
- Muscle fatigue worsens with exercise
- EMG - decremental (muscle response goes down)
Lambert Eaton:
- Muscle fatigue improves with exercise
- EMG - Incremental (muscle response goes up)
- Autonomic: incontinence, dry mouth, low libido
Antiphospholipid syndrome
Px, Ix, Mx
ANTIPHOSPHOLIPID SYNDROME
Px: thromboses, preg-related morbidity (miscarriage)
Ix: Antiphospholipid Ab + (2, 12 wks apart)
- Lupus anticoag
- Anticardiolipin Ab
- Anti-B2-Glycoprotein I Ab
Mx: Dalteparin (UF/LMW Heparin) AND Warfarin AND Vit K Antagonist
AND aspirin if prior thrombosis
