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3rd year medicine > neuro (264) > Flashcards

neuro (264) Flashcards

1
Q

Ax Duchenne muscular dystrophy?

S/s

A

X-linked recessive - mutation in dystrophin gene results in dystrophin deficiency

s/s

* delay in motor development

* onset of weakness in 3-4 years

(Gower’s sign, toe walking, exaggerated lumbar lardosis, calf hypertrophy)

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2
Q

Dx DMD?

A

raised CK

genetic testing (dystrophin gene)

EMG

muscle biopsy

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3
Q

is DMD inherited?

A

2/3rds inherited from asymptomatic mother 1/3rd sporadic

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4
Q

huntington’s disease onset?

S/s?

Ax?

A

30-50 years

S/s

* dementia

* chorea

Ax = autosomal dominant CAG42

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5
Q

appearance of Huntington brain

A

flattening of normal convex curve of lateral ventricles - due to loss of ganglia from caudate nucleus

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6
Q

Spinal muscular atrophy Ax?

S/s?

Tx?

A

autosomal recessive - loss of anterior horn cells

* floppy/weak arms and legs

* breathing difficulties

Tx = synthetic oligonucleotide

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7
Q

Alzheimers brain appearance genes?

A

neurofibrillary tangles + amyloid plaques

AD (presenilin) in 5% of cases - usually multifactorial

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8
Q

ApoE4?

A

carriers more likely to get Alzhiemer’s in old age

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9
Q

classification meningitis

A

acute pyogenic (bacterial)

acute aseptic e.g. viral

chronic bacterial - TB

acute encephalitis

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10
Q

pyogenic meningitis dx?

A

suppurative exudate

neutrophils in subarachnoid space

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11
Q

Ax bacterial meningitis?

A

strep pneumo (gram +ve cocci)

neisseria meningitidis (gram -ve diplococci)

listeria (gram +ve bacilli) - seen in alcoholics, immunosuppressed, elderly or neonates

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12
Q

Tx bacterial meningitis

A

ceftriaxone! + dexamethasone

*if penicillin allergic = chloramphenicol

if at risk for listeria (alcohol, old, immunosuppressed) add amoxicillin

(ceftrizone does not cover listeria)

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13
Q

viral meningitis Ax?

Dx?

Tx?

A

enteroviruses e.g. ECHO virus

Dx = viral stool culture, throat swab, CSF PCR

Tx = supportive, self-limiting

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14
Q

encephalitis vs meningitis

s/s?

A

encephalitis = brain parenchyma

meningitis = meninges

encephalitis = confusion, behaviour disturbances, psychosis, altered consciousness, seizures

meningitis = fever, photophobia, headache, neck stiffness, ?rash

meningo-encephalitis = combo

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15
Q

Ax encephalitis

Ix

Tx?

A

Ax = herpes simplex

Ix = LP, EEG (abnormalities), MRI (temporal lobe)

Tx = IV aciclovir

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16
Q

Ax brain asbcess?

Tx?

A

strep + bacteroides

Tx = ceftriaxone

* if penicillin allergic = vancomycin

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17
Q

most likely cause of meningitis in

1 - neonates

2 - children

3 - ages 10-64

4 - over 65

5 - decreased immunity

6 - fracture of cribiform plate

7 - head trauma

A

neonates = listeria

children = haemophilus

10-64 = strep penumo

>65 = strep pneumo + listeria

decreased immunity = listeria

fracture of cribiform plate = strep pneumo

head trauma = staph

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18
Q

complications meningitis?

A

exudate around CN III + VI

brain abscess

cerebral oedema

communicting hydrocephalus

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19
Q

sources of infection meningitis

A

nasopharyngeal colonisation (sinusitis, otitis media)

remote foci of infection - endocarditis, pneumonia, UTI

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20
Q

when should lumbar puncture be avoided?

A

increased ICP

GCS <12

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21
Q

bacterial vs viral CSF

A
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22
Q

PCR meningitis?

A

used for viruses

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23
Q

are you more likely to see neisseria or haemophilus as cause of meningitis in children?

A

neisseria meningitidis because Hib vaccine?

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24
Q

most common cause of meningitis?

A

strep pneumo

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25
Q

tuberculous meningitis Tx?

A

isoniazid + rifampacin key

(pyrazinamide + ethamutol too)

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26
Q

Ax aseptic meningitis

A

Viral

malignancy

sarcoidosis

vasculitis

dural venous sinus thrombosis

drugs - co-trimox, NSAIDs

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27
Q

Tx listeria?

if penicillin allergic?

A

amoxicillin

if penicillin allergic = co-trimoxazole

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28
Q

contact prophylaxis meningitis?

A

500mg ciprofloxacin

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29
Q

vaccines meningitis?

A

neisseria - ACYW

Haemophilus - Hib

strep pneumo

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30
Q

glial cells CNS?

A

astrocytes - BBB

oligodendrocytes - myelin

epdenymal cells - ventricles

microglia - macrophages

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31
Q

red neuron?

A

hallmark of acute neuronal injury due to hypoxia e.g. stroke

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32
Q

example of inclusions?

A

neurofibrillary tangles in Alzheimer’s

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33
Q

oligodendrocite damage is a feature of?

A

demyelinating disorders

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34
Q

Gliosis?

A

astrocytes - scarring

most important indicator of CNS injury

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35
Q

types of microglia

A

M1 = acute

M2 = chronic

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36
Q

why does hypxoxia afect brain so much?

A

needs 20% total body oxygen

can only increse bloodflow 2-fold in response to hypoxia

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37
Q

excitotoxcity?

A

makes ischaemia worse

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38
Q

when can autoregulary brain mechanisms not compensate for BP?

A

when MAP falls below 50 mmHg

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39
Q

where in the brain are thromboembolic events most common?

A

middle cerebral artery

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40
Q

which areas of the brain are particularly sensitive to ischaemia?

A

watershed areas - zone between 2 arterial territories i.e. parieto-occipital

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41
Q

stroke?

A

sudden disturbance of cerebral function of vascular origin that causes death or lasts over 24 hours

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42
Q

cerebral infarction Ax

A

thrombotic

* atherosclerosis - most common MCA!!

embolic

* from atherom ain internal carotid artery/aortic arch

rarer

* osteophytes compressing vertebral arteries

* vasculitis

* septal defects - right to left shunts

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43
Q

risk factors stroke

A

atheroma

hypertension

cholesterol

obesity

diabetes

drugs

smoking

septal defects

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44
Q

stroke after 12 hours

48 hours

a week

few weeks

A

12 hours = red neuron

48 hours = lots of micoglia

a week = gliosis begins

few weeks = gliotic scar

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45
Q

symptoms carotid artery infarct?

A

contra-lateral weakness or sensory loss

sometimes aphasia/apraxia

sudden severe headache

sudden vision loss

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46
Q

symptoms middle cerebral artery infarct?

A

weakness of contralateral face and arm

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47
Q

anterior cerebral artery infarct?

A

weakness and sensory loss in contralateral leg

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48
Q

vertebro-basilar artery infarct?

A

vertigo

ataxia

dysarthria

dysphasia

complex brain stem syndromes

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49
Q

lacunar infarcts Ax?

Affect?

multiple lacunar infarcts?

A

atherosclerosis/thrombus or distal embolism

affect basal ganglia

multiple = multi-infarct dementia

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50
Q

hypertensive encephalopathy symptoms?

signs?

A

symptoms

* severely hypertensive

* symptoms of raised ICP - headache, vomiting, altered balance, fits

signs

* global cerebral oedema

* tentorial and tonsillar herniation

* petechiae

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51
Q

types of intracrnaial haemorrhage

A

extradural haematoma = does not cross suture line

subdural haematoma = crosses suture line

subarachnoid hemorrhage

intracerebral haemorrhage

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52
Q

Ax intracerebral haemorrhage

A

causes of vascular injury - hypertension, amyloid angiopathy, diabetes, drugs (cocaine, alcohol), vasculitis

aneurysms

vascular malformations

coagulation disorders/iatrogenic anticoagulation

neoplasms

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53
Q

amyloid angiopathy Ax?

complication?

A

most commobly due to Alzheimers

complication = intracereberal haemorrhage (amyloid deposited in vessels causes rupture)

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54
Q

examples of vascular malformations in the brain

complications?

which are most likely to cause these complications?

A

arteriovenous malformations

cavernous angiomas

venous angiomas

capillary telangectases

can cause intracerebral haemorrhage, headaches, seizures + focal neurological deficits

arteriovenous and cavernous angiomas are most likely to cause intracrnaial haemorrhage

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55
Q

most common vascular abnormality?

where are they found?

A

arteriovenous malformation

MCA

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56
Q

subarachnoid haemorrhage Ax?

areas effected?

associated with?

A

most common cause is rupture of berry aneurysm

90% in territory of carotid artery

associated with ADPKD

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57
Q

subarachnoid haemorrhage risk factors

S/s?

common complication?

A

smoking, hypertension, drugs

s/s

* severe thunderclap headache

* vomiting

* loss of consciousness

complication = hydrocephalus

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58
Q

what seperates the 2 hemispheres?

what covers cerebellum

A

falx cerebri seperates 2 hemispheres

tentorium cerebelli covers cerebellum

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59
Q

normal CSF cytology

A

clear fluid

tiny amounts of lymphocytes

no neutrophils

no RBCs

no protein

glucose >2.2

will see neutrophils in bacterial meningitis

lymphocytes in viral meningitis

RBCs in SAH

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60
Q

hydrocephalus Ax

A

obstruction to CSF - inflammation, pus, tumours

decreased reabsorption of CSF - SAH, meningitis

overproduction of CSF - tumours of choroid plexus (very rare)

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61
Q

hydrocephalus classification

A

non-communicating = obstruction to flow of CSF within ventricular system

communicating = obstruction to flow of CSF outside ventricular system e.g. subarachnoid space or arachnoid granulations

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62
Q

timing of hydrocephalus

A
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63
Q

hydrocephalus ex vacuo

A

dilation of ventricular system + increase in CSF volume secondary to loss of brain parenchyma - Alzheimer’s disease

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64
Q

Ax raised ICP

A

increased CSF (hydrocephalus)

SOL

oedema

increased venous volume

physiological (hypoxia, hypercapnia, pain)

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65
Q

consequences raised ICP

A

intracranial shifts + herniations (e.g coning)

midline shift

pressure on cranial nerves

impaired cerebral blood flow

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66
Q

examples of herniations

A

tonsillar through foramen magnum

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67
Q

signs of raised ICP

A

papilloedema

headache

nausea + vomiting

neck stiffness

reduced consciousness

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68
Q

examples of SOLs

A

tumours

abscesses

haematomas

localised brain swelling i.e. oedema around infarct

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69
Q

symptoms + signs brain tumour

A

symptoms = heaahce (worse in morning), vomiting, seizures, visual disturbances

signs = focal deficit, papilloedema

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70
Q

brain tumours children?

adults?

A

children = below tentorium cerebelli

adults = above tenorium cerebelli

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71
Q

brain metastases

from?

A

far more common than primary brain tumours

* breast

* bronchus

* kidney

* thyroid

* colon

* melanoma

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72
Q

commonest primary brain tumour in adults?

children?

A

adults = astrocytoma

children = medulloblastoma

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73
Q

astrocytoma grading

A

grade 1 = pilocytic

* childhood, benign

grade 2 = well differntiated, some nuclear atypia but overall low grade appearance

grade 3 = more atypia

grade 4 = glioblastoma

* extreme atypia, necrosis

* 10-12 month survival

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74
Q

medulloblastoma?

found?

complication

Tx

A

most common tumour in children followed by pilocytic astrocytoma

occur in midline of cerebellum i.e. below tentorium cerebelli

complication = hydrocephalus

Tx = surgery + radiotherapy

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75
Q

brain abscess Ax

A

single abscesses = mastoiditis, chronic otitis media, sinusitis, dental infections, skull fracture (tend to occur adjacent to source)

multiple abscesses = haematogenous spread from bronchopneumonia, bacterial endocarditis, bronchiectasis, lung abscesses, congenital heart disease, IV drug use (tend to coccur at grey and white matter boundary)

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76
Q

appearance brain abscesses

S/s?

Dx?

Tx?

A

central necrosis, oedema, fibrous capsule

S/s = fever, raised ICP

Dx = CT, MRI (ring enhancing)

Tx = aspiration + antibiotics

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77
Q

brain abscess organisms?

A

strep, bacteriodes, staph

immunocompromised patients = fungi, toxoplasma in AIDS

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78
Q

why do contra-coup injuries tend to be worse despite being non-impact side?

A

denser CSF moves to coup side first

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79
Q

most common intracranial haematoma?

A

epidural

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80
Q

“burst lobe”

A

subdural + intracerebral haematoma

occurs mostly in frontal + temporal lobe

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81
Q

Ax epidural haematoma?

A

fracture of tempero-parietal region = midle meningeal artery

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82
Q

subdural haemorrhage Ax

A

disruption of bridging veins

(blood accumulates between dura and arachnoid mater)

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83
Q

acute vs chronic subdural haemorrhage

A

acute = elderly, cleat history of trauma

chronic = commin in injury but often no clear history of trauma

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84
Q
A

B - juvenile myoclonic epilepsy is generalised epilepsy so not associated with hippocampal sclerosis (focal)

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85
Q

important features in epilepsy history

A

onset - what were they doing? what did they look like? aura?

type of movements - rigor? clonus? tonic phase?

speed of recovery

ask about birth + development, family history, previous seizures (e.g. febrile fits), drugs, alcohol

social history - driving, occupation

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86
Q

what drug can make epilepsy worse

A

tramadol

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87
Q

Ix for epilepsy?

A

MUST DO ECG - prolonged Qt syndrome (most common presentation is episode of collapse)

CT to screen for injury

EEG

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88
Q

differential diagnoses epilepsy?

A

syncope

pseudoseizures, psychogenic

panic attacks

TIA

migraine

hypoglycaemia

parasomnia

paroxysmal movement disorders

cataplexy

tonic spasms of MS

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89
Q

driving rules epilepsy

A

1st seizure = 6 months (car), 5 years (HGV)

epilepsy = 1 year or 3 years during sleep (car), 10 years off medication (HGV)

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90
Q

types of epilepsy?

further classification?

A

focal + generalised (cortical network)

focal

* simple = without impaired consciousness

* complex = with impaired consciousness

generalised

* absence - petit mal

* myoclonic

* atonic

* tonic

* tonic clonic - grand mal

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91
Q

focal seizure locations + symptoms

A

Motor (frontal lobe) = rhythmic jerking, posturing, head and eye deviation, other movements (e.g. cycling), automatisms (e.g. plucking), vocalisation

(most common = movements of hands and face)

Sensory (parietal lobe) = omatosensory, olfactory, gustatory, visual, auditory

Psychic = memories, deja vu, jamais vu, depersonalisation, aphasia, complex visual hallucinations

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92
Q

generalised epilepsy onset?

tx?

e.g.?

A

onset = childhood + teens

Tx = sodium valproate

e.g. juvenile myoclonic epilepsy

* early monring jerks

* generalised seizures

* risk factors - sleep deprivation, flashing lights

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93
Q

focal epilepsy onset?

Ax?

Tx?

A

any age

Ax = underlying structural cause e.g. hippocampal sclerosis

Tx = carbamazepine

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94
Q

how to AEDs work?

A

activate GABA system

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95
Q

side effects sodium valproate?

A

weight gain, hair loss, fatigue

teratogenic!!

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96
Q

what drug is avoided in primary generalised epilepsy?

A

carbamazepine - can make way worse!

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97
Q

which AEDs induce hepatic enzymes?

A

carbamazepine, phenobarbital + phenytoin

(so avoid in POP and COCP)

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98
Q

status epilepticus?

Ax?

A

medical emergency - seizure activity >30 mins

Ax = hyponatraemia, pyridoxine (B6) deficiency, infection, head trauma, SAH, abrupt withdrawal of anticonvulsants, treating absence seizures with carbamazepine

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99
Q

convulsive status?

Complications?

Tx?

A

most dangerous form of status epilepticus - generalised tonic clonic fits without cessation

comps = hypoxia, hypotension, hyperthermia, rhabdomyolysis

Tx = ABCDE

* identify cause - infection, SAH, etc - so FBC, CT

* phenytoin + benzodiazepines!!

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100
Q

Tx epileptic seziure

A

IV lorazepam (1st line)

once stabilised = restablish normal AED Tx

if seizures don’t stop = IV phenytoin/phenobarbital

if still don’t stop = transfer to ICU for general anaesthesia

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101
Q

patient presenting with acute confusional state?

A

always suspect partial status epilepticus in addition to septic encephalitis (as they are difficult to distinguish)

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102
Q

functional attacks?

Ax?

Dx?

A

not epilepsy but patient has no control of attacks

related to trauamatic events, physical/sexual abuse, other stress, anxiety/depression

Dx = EEG + history

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103
Q

types of aura

A

Somatosensory auras = numbness, tingling, electric shocks, thermal sensations, pain

Visual auras = simple shapes, static, flashing, moving lights, colours

Auditory auras

Vertiginous auras = temporal-parietal lobe

Autonomic auras = temporal lobe (insula, amygdala, etc)

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104
Q

Tx functional attacks?

A

removal of epiletpic drugs

CBT

Tx of anxiety or depression

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105
Q

motor neurone disease?

s/s?

A

Untreatable and rapidly progressive neurodegenerative condition

s/s = muscle weakness, problems with speech, swallow problems, breathing problems

upper/lower motor neuron signs WITHOUT sensory problems

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106
Q

most common subtype MND?

A

ALS

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107
Q

prognosis MND?

A

average survival time = 3 years

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108
Q

Ax MND?

Types?

features of these types?

A

90% sporadic, 10% familial

types = ALS, PLS, progressive musclar atrophy, progressive bulbar palsy

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109
Q

ALS with fronto-temporal dementia associated with?

A

c9orf72 gene

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110
Q

upper vs lower motor signs in MND?

A
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111
Q

ALS symptoms?

PLS symptoms?

PBP symptoms?

A

ALS = mixed UMN and LMN signs

PLS = pure UMN

PBP (LMN) = wasting of the tongue, dysphagia, difficulty speaking (slurring)

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112
Q

progressive bulbar palsy will eventually become?

A

ALS

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113
Q

split hand syndrome?

A

ALS

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114
Q

C9orf72 mutation?

A

ALS with FTD

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115
Q

which subtype of MND has best prognosis?

A

primary lateral sclerosis

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116
Q

Ix MND?

A

EMG

neurological exam

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117
Q

Tx MND?

A

riluzole - gives an extra 3 months

communication needs

nutritional needs (dietician, gastrostomy) - metabolic rate in MND is doubled so weight loss expected

respiratory needs

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118
Q

sialorrhoea tx MND?

muscle cramps?

muscle spasms?

A

sialorrhoea = hyoscine/buscopan, glycopyronium (esp in cognitive impairment), botox

muscle cramps = quinine, baclofen

muscle spasms = baclofen, gabapentin

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119
Q

SOB MND?

A

lorezepam

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120
Q

S/s MND?

A

UMN/LMN signs without sensory issues

emotional lability i.e. inappropriate crying/laughing (early UMN sign)

cognitive impairment (50%) - ALS associated with FTD

* apathy, disinhibition, poor planning/decision making

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121
Q

hypokinetic vs hyperkinetic movement disorder

A

hypokinetic (too little movement) = parkinsons

hyperkinetic (too much movement) = tremor, tics, chorea, myoclonus, dystonia, athetosis

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122
Q

important points in history for movement disorders?

A

birth history - anoxia, perinatal problems, milestones

family history

drug and toxin history - neuroleptics, antiepileptics, illicit substances, toxins

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123
Q

s/s parkinsonism/akinetic rigid syndrome?

A

TRAP

tremor

rigidity

akinesia/bradykineasia

postural disturbances (flexed posture, postural instability)

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124
Q

how to distinguish rigidity from spasticity?

A

rigidity = no increase with higher mobilising speed

spacticity = yes!

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125
Q

positive froment’s maneuver?

A

parkinson’s (rigidity increases in examine dbody segment by movement of other body parts)

not to be confused with froment’s test for ulnar nerve palsy (adductor pollicis)

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126
Q

camptocornia?

A

extreme anterior truncal flexion sometimes seen in Parkinson’s

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127
Q

parkinsonian gait?

A

slow shuffling steps

decreased arm swing

slow turning with multiple small steps

festination

postural instability (pull test)

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128
Q

types of tremor?

A

resting - occurs when body part at rest

postural - occurs when arms outstretched

kinetic - occurs during movement of body part

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129
Q

dystonia?

Ax?

A

sustained intermittent muscle contractions

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130
Q

chorea?

Ax?

A

irregular purposeless movement

can be difficult to distinguish chorea from myoclonus (chorea shifts from one body part to another)

Ax = drugs (COCP), basal ganglia lesions, Sydenham’s chorea (rheumatic fever), APS, Huntington’s, neuroacanthyocytosis

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131
Q

Myoclonus

A

electric shock like jerks

caused by brief activation of a group of muscles leading to jerk of affected body part

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132
Q

ballism?

suggestive of?

A

severe type of chorea

involves proximal joints resulting in large movements

strongly suggestive of contralateral lesion involving striatum of subthalamic nucleus

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133
Q

essential tremor?

seen when?

what makes better?

A

most common type of postural tremor (not associated with Parkinson’s = resting tremor)

seen in hands (5Hz) while holding outstretched

often made better with alcohol intake

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134
Q

pathological hallmarks of parkinson’s?

A

lewy bodies

loss of dopaminergic neurons from substantia nigra

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135
Q

non-motor symptoms Parkinson’s?

A

hypomimia

sleep disorders

hallucinations

GI dysfunction (constipation)

bladder problems

depression

congitive imapirment/dementia

anosmia

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136
Q

3 subtypes parkinsons

A

tremor-dominant (slower rate of progression)

non-tremor dominant (akinetic-rigid syndrome + postural instability gait disorder)

mixed

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137
Q

leadpipe vs cogwheel

A

Lead pipe = constant resistance throughout passive movement

Cogwheel = jerky resistance throughout movement as muscles contract and relax

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138
Q

Dx Parkinsons

A

DAT scan (SPECT)

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139
Q

does parkinsons reduce life expectancy?

A

barely - by 1 or 2 years

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140
Q

greatest risk factor parkinsons?

what decreases risk?

A

advancing age

smoking and alcohol decreases risk

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141
Q

Tx parkinsons?

A

levodopa

dopamine agonists

monamine oxidase B inhibitors

amantadine

anticholinergics for tremor

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142
Q

side effects parkinsons Tx?

A

dopamine agonists

* nausea

* daytime sleepiness

* oedema

* impulse control - gambling, hypersexuality, binge eating, compulsive spending

* hallucinations

levodopa

* greatest symptoamtic benefit but associated with dyskinesia (involuntary movments) and fluctuations in motor symptoms

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143
Q

red flag symptoms PD?

i.e. suggests not Parkinson’s

A

absence of asymmetry

severe axial or lower limb involvement

frequent falls

eye movement disorder

other unexpected movement disordrs (tics, myoclonus, chorea)

bulbar features

apraxia

severe cognitive deterioration or psychosis

marked autonomic dysfunction

negative levodop challenge

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144
Q

differential diagnoses Parkinson’s?

A

vascular Parkinsons

drug induced Parkinsons

tremor disorders

multi system atrophy

progressive supranuclear palsy

fragile X tremor ataxia syndrome

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145
Q

vascular parkinsonism features?

Dx?

A

affects predominantly lower limbs

rest tremor uncommon

poor levodopa response

Dx = brain imaging

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146
Q

drug induced parkinsonism?

A

symmetrical

coarse postural tremor

presence of other drug-induced disorders - orolingual dyskinesias, tardive dystonia, akathasia

usually narcoleptic/antipsychotic drugs

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147
Q

essential tremor vs parkinsons?

A

symmetrical, higher frequency (12Hz)

infrequently observed at rest

alcohol responsiveness

head tremor (mild)

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148
Q

multi system atrophy vs parkinsons?

Dx?

A

core triad = dysautonomia, cerebellar features, parkinsonism

60-70 y/o

jerky postural tremor, pyramidal signs (hyperreflexia and extensor plantar responses)

suboptimal levodopa response

other suggestive features = severe dysarthria/dysphonia, marked antecollis, inspiratory sighing, orofacial dystonia

Dx = MRI “hot cross bun” sign

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149
Q

progressive supraneuclear palsy vs parkinsons

A

symmetric akinetic-rigid syndrome

predominantly axial involvement

falls

tremor not usually seen

vertical gaze supranuclaer palsy

pseudobulbar symptoms

retrocollis

eyes wide open (staring)

no response to levodopa

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150
Q

fragile X tremor ataxia syndrome (FXTAS) vs Parkinsonism?

A

late onset (>50 years) neurodegenerative disorder

cerebellar gait ataxia

postural tremor

parkinsonism

dysautonomia

cognitive decline

periperal neuropathy

151
Q

“where” history brain injury

152
Q

“where” examination brain injury

153
Q
A

CNS

diagnosis = MS

154
Q
A

neuromuscular junction problem so either lambert-eaton or myesthenia gravis

lambert eaton = absent deep tendon reflexes

myestheia gravis = hyperreflexia

so Dx = MG

155
Q
A

PNS problem

acute = GBS

chronic = diabetes/alcohol

so Dx = GBS

156
Q

peripheral neuropathy

157
Q

pseudoathetosis?

A

Abnormal writhing (usually of fingers) - due to failure of proprioception

Indicates disruption of proprioceptive pathway

158
Q

bilateral foot drop + high stepping gait

A

deep fibular nerve

161
Q

Guillain barre syndrome

Tx?

A

progressive paraplegia over days (up to 4 weeks)

sensory symptoms (unlike MND)

pain very common

peak symptoms 10-14 days after onset

post-infectious e.g. campylobacter!

Tx = immunoglobulin infusion, plasma exchange

162
Q

charcot marie tooth disease?

A

hereditory sensory motor neuropathy

163
Q

vasculitis often associated with which neuropathy?

A

mononeuritis complex

164
Q

causes of peripheral neuropathy

A

vasculitis - mononeuritis multiplex

myeloma

hepatitis B/C, HIV, syphillis, Lyme

alcohol

amiodarone, phenytoin, chemo

diabetes

B12/folate deficiency

acute = GBS, porphyria

165
Q

complication guillain barre syndrome?

A

autonomic failure (autonomic neuropathy) - cardiac

also respiratory failure

166
Q

Tx peripheral neuropathy?

A

treat cause i.e hep C, diabetes

vasculitis = prednisolone + cyclophosphamide

guillain barre = IV immunoglobulin

neuropathic pain relief - gabapentin etc

170
Q

multiple sclerosis?

most common type?

A

inflammatory demyelinating disorder in CNS

90% of people will have relapsing remitting MS

171
Q

clinical features MS?

A

pyramidal dysfunction (increased tone, hyperreflexia, babinski)

  • (extensors = upper limb week, lower limb strong)
  • (flexors = upper limb strong, lower limb weak)

optic neuritis

sensory symptoms

urinary tract dysfunction

cerebellar and brainstem features

cognitive impairment

172
Q

pyramidal dysfunction?

A

can be symptom of MS

increased tone, spasticity, hyperreflexia, babinski

extensors = weak upper limb, strong lower limb

flexors = strong upper limb, weak lower limb

173
Q

optic neuritis?

A

painful vision loss

1-2 weeks

RAPD!!!

174
Q

cerebellar dysfunction?

A

(DANISH + PP)

Dysarthria

Ataxia

Nystagmus

Intention tremor

Past pointing

Pendular reflexes

Dysdiadokinesis

175
Q

internuclear opthalmoplegia?

A

associated with MS in young people

medial longitudinal fasciculus

lid lag, nystagmus, failure of adduction (diplopia)

176
Q

urinary tract dysfunction MS?

A

Frequency

Nocturia

Urgency

Urge incontinence

Retention

177
Q

Dx MS?

DDx?

A

at least 2 episodes suggestive of demyelination

MRI (plaques)

CSF (oligoclonal bands)

blood tests to rule out infection, B12/folate deficiency

DDx = mononeuritis complex (vasculitis), structural lesion, infection (syphillis, HIV, borrelia), B12/folate def

178
Q

Tx MS?

A

acute exacerbation = steroids (i.e. optic neuritis)

disease modifying therapy = 1st line tecfidera, interferon beta (2nd line monoclonal antibodies, 3rd line stem cell transplant)

symptomatic Tx:

pyramidal dysfunction = baclofen 1st line

sensory = gabapentin/amitriptyline

urge incontinence = oxybutynin

fatigue = amantadine/modafinil

179
Q

1st line Tx relapsing remitting MS?

A

tecfidera

40% reduction in relapse rate

180
Q

lambert eaton myesthenic syndrome (LEMS) associated with?

pathophys?

A

small cell lung cancer

antibodies to presynaptic calcium channels

181
Q

myesthenia gravis?

associated with?

A

autoimmune anitbodies to AChR

association with thymoma

182
Q

clinical features MG?

Tx?

A

fatiguable weakness

extraocular, facial + bulbar weakness

limb weakness typically proximal

Tx = pyridostigmine (anticholinesterase), IV immunoglobulin, thymectomy

183
Q

drug to avoid MG?

A

gentamicin - makes MG worse

also avoid macrolide antibiotics

184
Q

muscle power grading?

185
Q

polymyositis?

Ix?

Tx?

dermatomyositis?

A

symmetrical, progressive proximal muscle weakness

Ix = raised CK

Tx = steroids

Dermatomyositis

* clinically similar but associated with skin lesions

* Heliotrope rash on face

* 50% have underlying malignancy

186
Q

commonest muscular dystrophy?

S/s

A

myotonic dystrophy - autosomal dominant

s/s = myotonia, weakness, cataracts, ptosis, frontal balding, cardiac defects

187
Q

drugs that can cause myopathies?

A

statins + corticosteroids

188
Q

rhabdomyolysis triad?

complications

A

traid = myalgia, muscle weakness + myoglobinuria

comps = acute renal failure + DIC

189
Q

traumatic brain injury Tx?

A

ABCDE

GCS, pupils

check c-spine

190
Q

head injury severity scale?

A

Mild = 14 or 15, brief LOC

Moderate = 9-13

Severe = 3-8

191
Q

NICE guidelines CT scan head injury?

A

>65 y/o

coagulopathy

RTA or fallen from large height

192
Q

Dx?

A

Battle sign = base of skull fracture

193
Q

Dx?

classical presentation

A

Epidural haematoma

classic presentation:

Injury with LOC

“Lucid interval”

Deteriorating GCS

hemiparesis

Unilateral fixed and dilated pupil

Apnoea and death

194
Q

Dx?

A

acute subdural haematoma

195
Q
A

chronic subdural haematoma

196
Q

Dx?

A

intracerebral haematoma

197
Q

Dx?

A

diffuse axonal injury

198
Q

Tx raised ICP?

A

sedation - benzos, propofol

head of bed tilt

mannitol

if all of this fails = decompressive craniectomy

199
Q

brainstem death?

200
Q

what MRI sequence do you use for water?

A

T2 hyperintense

201
Q

supect haemorrhage?

202
Q

Dx?

A

subarachnoid haemorrhage

203
Q

Dx?

A

diffuse haemorrhage - VERY BAD

204
Q

Dx?

A

subdural haematoma with midline shift

205
Q

extra-axial (outside brain parenchyma) tumours?

A

meningioma

pituitary adenoma

dermoid/epidermoid tumour

acoustic schwannoma

206
Q

intra-axial brain tumours?

A

glioma

glioblastoma

metastases

207
Q
A

either metastases or abscesses

208
Q

chiari malformation?

complication?

s/s?

A

cerebellum herniates through foramen magnum

complication = can cause obstructive hydrocephalus

S/s = headaches, neck stiffness, seizures etc

209
Q
A

cortical dysplasia - presents with seizures

210
Q
A

schizencephaly (slit from ventricles)

211
Q
A

arachnoid cyst

212
Q
A

demyelination - MS

usually see lesions in spinal cord as well

213
Q
A

encephalitis

Tx = aciclovir

214
Q

classification brain tumours?

A

Supratentorial (usually adults) = above tentorium cerebelli

Infratentorial (usually in children)

Extrinsic (bone, meninges)

Intrinsic (glioblastoma)

215
Q

presentation brain tumour?

A

neurological deficit

motor weakness

headache (wakes up from sleep and associated with nausea + vomiting)

seizures

216
Q

raised ICP triad?

S/s?

A

cushing’s triad = hypertension, irregular breathing, bradycardia

s/s

  • headaches
  • vomiting
  • mental changes
  • seizures
217
Q

which nerve is most likely to be dysfunctional with tumour?

with uncal herniation?

A

6th cranial nerve (abducens) most likely to be dysfunctional with tumour

uncal herniation = occulomotor nerve (CN III)

218
Q

cerebellar examination?

A

DANISH

Dysdiadokinesia

Ataxia (gait and posture)

Nystagmus

Intention tremor

Slurred, staccato speech

Hypotonia/heel-shin test

219
Q

investigation of choice for brain tumour?

220
Q

commonest brain tumour?

A

metastasis

221
Q

commonest primary brain tumour?

A

glioma (glioblastoma)

222
Q

neuroepithlial tissue?

A

astrocytes

oligodendroglial cells

epednymal cells/choroid plexus

neuronal cells

pineal cells

223
Q

astrocytic tumours grading

A

grade 1 = pilocytic

grade 2 = low grade astrocytoma

grade 3 = anaplastic astrocytoma

grade 4 = glioblastoma multiforme

224
Q

pilocytic astocytoma?

Affects?

S/s?

Dx?

Tx?

A

truly benign

affects children

s/s = slow in schooling, walk with tip-toe gait, laughing seizures

Dx = CT

Tx = surgery (curative)

225
Q

grade 2 astrocytoma found?

presentation?

features on MRI?

A

temporal lobe, posterior frontal lobe, anterior parietal lobe

presentation = raised ICP, usually seizures

MRI = does not enhance, if it enhances it is a sign it is progressing from grade 2 to grade 3

226
Q

Tx grade 2 astrocytoma?

A

surgery + chemo/radiotherapy

227
Q

prognostic factors grade 2 astrocytoma?

A

poor prognosis (i.e. will progress to glioblastoma)

  • age >45
  • low performance score
  • large tumours >6cm diameter/crossing midline
228
Q

malignant astrocytomas?

features?

A

anaplastic astrocytoma (grade 3)

  • medial survival 2 years

glioblastoma multiforme

  • most common primary tumour
  • median survival <1 year
  • multiple gliomas = NF, TS, PML
229
Q

multiple gliomas a sign of?

A

neurofibromatosis

tuberous sclerosis

progressive multifocal leukoencephalopathy

230
Q

Tx grade 3 + 4 astrocytomas?

survival?

A

non-curative surgery +

post-op radiotherapy +

chemotherapy (temozolamide)

improves median survival to 14 months - so 2 extra months essentially

231
Q

what else is important to discuss with GBM patient?

A

must inform DVLA! - seizure risk post-op

232
Q

side effects radiotherapy brain tumour?

A

drops IQ by 10

skin changes

hair loss

tired

233
Q

tiptoeing, ataxia, vomiting + headache in children?

A

suspect pilocytic astrocytoma

234
Q

severe headache that wakes from sleep, plus nausea + vom?

A

suspect brain tumour

235
Q

meningioma s/s?

associated with?

A

s/s

  • majority asymptomatic
  • headache
  • cranial nerve neuropathies (CN VI)

Meningiomas associated with - neurofibromatosis type 2, breast cance

236
Q

classification meningioma?

A

majority benign

small percentage malignant - clear cell, choroid, rhabdoid, papillary

can also get radiation-induced meningiomas (e.g. after childhood leukemia)

237
Q

meningioma Dx?

A

CT - enhancing, skull “blistering”

MRI - dural tail

Angiography - may see occlusion of sagittal sinus

238
Q

meningioma Tx?

prognosis?

A

small meningioma = expectant

surgery

radiotherapy

prognosis = 90% 5 year survival

239
Q

nerve sheath tumours?

A

schwannomas (aka neruomas)

neurofibromas

240
Q

acoustic neuromas also called?

what are they associated with?

s/s?

complication?

A

vestibular schwannomas

associated with neurofibromatosis 2 (suspect in young people with bilateral sesnorineural hearing loss)

s/s

  • sensorineural hearing loss
  • tinnitus
  • vertigo

complication = hydrocephalus

241
Q

acoustic neuroma Tx?

A

expectant (hearing aid)

radiation

surgery

if develp hydrocephalus = shunt

242
Q

normal pressure hydrocephalus s/s?

A

triad

memory loss + urinary incontinence + ataxic gait

243
Q

Tx ischaemic stroke?

A

thrombolysis - IV TPA!!

  • limited to <4.5 hours from onset of symptoms
  • if >4.5 hours I think you use endovascular therapy

Aspirin 300mg (CT first to exclude bleed, wait 24 hours if thrombolysed)

DVT prevention - LMWH

start statins

244
Q

Tx haemorrhagic stroke?

A

anticoagulant reversal

  • warfarin = vit K
  • dabigatran = idarucizumab
  • factor Xa inhibitors = andexanet alpha
  • if unavailable = clotting factors
245
Q

acute spinal cord compression Ax?

A

Trauma

Tumours - haemorrhage or collapse (vertebrae)

Infection e.g. epidural asbscess

Spontaneous haemorrhage (AVM)

246
Q

brown sequard syndrome?

A

ipsilateral motor level

ipsilateral dorsal column sensroy level

contralateral spinothalamic sensory level

247
Q

central cord syndrome Ax?

S/s?

A

hyperflexion or extension injury to already stenotic neck (also syringomyelia)

s/s

  • distal upper limb weakness
  • “cape-like” spinothalamic sensory loss
  • lower limb power preserved
  • dorsal columns preserved
248
Q

tumours that can cause spinal cord compression?

A

extradural

  • metastasis from lung, breast, kidney, thyroid etc

intradural

  • meningioma, schwannoma

intramedullary

  • astrocytoma, ependymoma
249
Q

Tx spinal trauma?

A

immobilise

X-ray/CT

MRI to see cord!!

decompress + stabilise

250
Q

spinal epidural abscess Tx?

A

antibiotics + surgical drainage

251
Q

acute spinal cord compression?

A

EMERGENCY!!!

252
Q

Parkinson’s Ax?

Risk factors?

A

5% cases are familial, 95% sporadic

risk factors

  • age
  • men
  • rural living
  • (smoking is protective)
253
Q

drugs that can cause parkinson’s?

A

Haloperidol - dopamine blockers

Metaclopramide (oncology patients - can get secondary parkinsons)

  • And other anti-emetics like prochlorperazine
254
Q

Ix Parkinson’s?

A

DAT scan

(test bloods for Wilson’s disease)

255
Q

Tx Parkinson’s?

A

L-dopa

Dopamine agonists

Anticholinergics

Amantadine

COMT inhibitors (entacapone)

Apomorphine

256
Q

analgesic ladder?

257
Q

which areas of the brain are involved in analgesia?

A

periaqueductal grey (PAG)

locus ceruleus (pons)

nucleus raphe magnus (medulla)

258
Q

opoid receptor?

A

U (mu) - responsible for most of the analgesic action of opioids

259
Q

major adverse effects of opoids?

A

respiratory depression - apnoea

orthostatic hypotension

GI - nausea, vomiting, constipation, increased intrabillary pressure

CNS - confusion, hallucinations, dizziness, hyperalgesia (with excessive use)

260
Q

what drug should be avoided with pethidine?

A

MAO inhibitors

261
Q

tramadol avoided in?

A

patients with epilepsy

262
Q

1st line treatment for trigeminal neuralgia?

A

carbamazepine

263
Q

allodynia?

hyperalgesia?

A

Allodynia = pain from stimulus that is not normally painful e.g. cotton wool

Hyperalgesia = more pain than expected from a painful stimulus e.g. pin prick

264
Q

Tx neuropathic pain?

A

Tricyclic antidepressants

Anticonvulsants\opioids

NMDA antagonists e.g. ketamine

Sodium channel blockers e.g. lignocaine

Capsaicin

GABA agonists (e.g. Baclofen)

265
Q

MS?

Dx?

A

Autoimmune demyelinating disorder characterised by distinct episodes of neurological deficit, separated in time, and which correspond to spatially separated foci of neurological injury

Clinical diagnosis

  • 2 distinct neurological deficits occurring at different times
  • Multiple distinct (usually white matter) CNS lesions on MRI

Diagnosis can also be backed up by

  • IgG oligoclonal bands in CSF
  • MRI showing demylinated plaques
266
Q

Dx?

267
Q

clinical features MS?

A

Typically presents with focal neurological deficit

  • Optic nerve lesions (optic neuritis)
    • Unilateral visual impairment
  • Spinal cord lesions
    • Motor/sensory deficit in trunk and limbs
    • Spasticity
    • Bladder dysfunction
  • Brain stem lesions
    • Cranial nerve signs
    • Ataxia
    • Nystagmus
    • Internuclear ophthalmoplegia
268
Q

types MS?

A

Clinically isolated syndrome

Relapsing and remitting (most common)

Secondary progressive

Primary progressive

269
Q

risk of passing MS to child?

270
Q

dementia classification?

most common types?

A

most common types = alzhiemer’s disease + vascular dementia

271
Q

death Alzhiemer’s?

A

usually occurs due to secodary cause such as bronchopneumonia

272
Q

microscopic features Alzheimers?

A

plauques - amyloid angiopathy (amyloid AB)

neurofibrillary tangles (tau protein)

273
Q

risk factors Alzhiemer’s?

A

AGE

Down’s syndrome

presnillin 1 and 2

Apolipoprotein E

274
Q

amyloid angiopathy Dx?

Comp?

A

Stains with congo red - bright green

comp = intracerebral haemorrhage

275
Q

Tx Alzhiemer’s?

A

Anticholinesterase drugs (cholinesterase inhibitors)

  • e.g. donepezil, galantamine, rivastigmine

NMDA receptor blockers - memantine

276
Q

Lewy body dementia clinical features?

contrast with Alzheimers?

pathophys?

Dx?

A

Clinical features

  • Progressive dementia
  • hallucinations and fluctuating levels of attention/cognition
  • REM sleep behaviour disorder (acting out dreams)
  • Parkinsonism

in contrast to Alzhiemers, memory affected later

pathophys = degeneration of substantia nigra (like Parkinson’s) + lewy bodies

Dx = lewy bodies + amyloid in brain

277
Q

Parkinsonism seen in which conditions?

A

Idiopathic parkinson’s disease

Lewy body dementia

Drugs e.g. phenothiazines

Trauma e.g. dementia pugilistica

Multi-system atrophy (nystagmus)

Progressive supranuclear palsy

Cortico-basal degeneration

278
Q

macroscopic finding Huntington’s?

A

atrophy of caudate nucleus

279
Q

Front-temporal dementia (Pick’s disease)?

S/s?

A

Progressive dementia commencing in middle life (50-60) characterised by progresive changes in personality + behaviour

S/s

  • Personality and behavioural change
  • Speech and communication problems
  • Changes in eating habits
  • Reduced attention span
280
Q

histological hallmarks FTD?

A

Pick’s cells (swollen neurons)

Pick’s bodies

281
Q

Multi-infarct dementia (vascular dementia)?

distinguish from Alzhiemer’s?

Dx?

Tx?

A

Cumulative damage to brain through hypoxia as result of multiple blood clots in brain

distinguish from alzheimers = abrupt onset, stepwise progression

Dx = history of stroke/HTN, evidence of stroke on CT/MRI

Tx = cannot reverse damage that’s already happened

  • aim to prevent further strokes
    • lifestyle
    • statins
    • BP
    • Warfarin
282
Q

Dx?

clinical features?

Ax?

triggering factors?

A

Dx = transient global amnesia

clinical features

  • anterograde>retrograde amnesia (repetitive)
  • abrupt onset
  • preserved knowledge of self - they know name, DOB
  • always <24 hours!!

Ax = unknown

Triggering factors = emotion/changes in temperature

283
Q

Dx?

S/s?

Tx?

A

Dx = transient epileptic amnesia

S/s

  • short-lived
  • forgetful/repetative questioning
  • can carry out complex activities with no recollection of events

Tx = AEDs

284
Q
A

prion disease i.e. CJD

285
Q

Dx?

s/s?

Ix?

pathophys?

Tx?

A

Dx = limbic encephalitis

s/s = short term memory loss, seizures, behavioral change

Ix = anti-Hu antibodies

pathophys = underlying malignancy or autoimmune

Tx = treat tumour/immunosuppressants

286
Q

early onset AD?

A

<65 y/o, may have genetic influences

287
Q

Ix Alzheimers?

A

cognitive tests

MRI - frontal + temporal lobe atrophy

SPECT - decreased temperoparietal metabolism

CSF - decreased amyloid, increase tau protein

288
Q

Dx?

Features?

S/s?

Ax?

A

frontotemporal dementia

early onset <65 + Pick bodies

s/s

  • personality + behavioural changes
  • disinhibition, loss of empathy, hyperorality (can’t stop eating) and other addictive behaviours (online shopping)
  • early loss of insight (collateral history vital)

25% genetic cause - c9orf

289
Q

Ix FTD?

Tx?

A

MRI - trophy of frontal and temporal lobes

SPECT - decreased frontotemporal mentabolism

CSF - increased TAU but normal amyloid

Tx

  • trazadone/antipsychotics
  • safety management - controlled acess to food, money, internet
  • power of attorney
290
Q

vascular dementia onset?

core cliical features?

s/s?

Ax?

prognosis?

Tx?

A

late onset dementia >65 y/o

core clinical features = prescence of cerebrovascular disease + clear temporal relationship between dementia and cerebrovascular disease

s/s = decreased attention, executive dysfucntion, slowed processing

Ax = can be after stroke (easy), or small vessel disease (more difficult to prove)

prognosis same as Alzhiemers - ~8 years

Tx = reduce vascular risk factors + cholinesterase inhibitor

291
Q

lewy body dementia onset?

Ax?

core clinical features?

A

late onset >65 y/o

Ax = a-synuclein builds up and damages cells - causes disruption to cholinergic (memory) and dopaminergic pathways (parkinsonism)

clinical features = fluctuating cognition + visual hallucinations + extrapyramidal features (bradykinesia, rigidity, tremor)

292
Q

Ix Lewy Body dementia?

Tx?

A

Ix

  • DAT scan
  • diagnostic = a-synuclein in CSF/a-synucliein ligand imaging

Tx

  • levodopa
  • cholinesterase inhibitors
  • support - community nurse
293
Q

Parkinson’s disease dementia?

how to differentiate from lewy body?

s/s?

Tx?

A

late onset >65 y/o - occurs after 20 years of Parkinson’s

DLB <1 year presentation

PDD >1 year presentation

s/s

  • parkinson’s (bradykinesia, rigidity, temor)
  • dementia (decreased attention, impaired visuospatial function + memory)

Tx = same as DLB

  • levodopa + cholinesterase inhibitor
294
Q

Huntington’s disease dementia?

s/s?

Ix?

Tx?

A

early onset dementia (30-50 y/o)

s/s

  • changes in mood/personality
  • chorea
  • impaiment of memory
  • psychosis

Ix = genetic testing + MRI (loss of caudate heads)

Tx = mood stabilisers, drugs that suppress chorea

295
Q

proteinopathy associated with:

Alzhiemer’s?

vascular dementia?

Parkinson’s disease dementia?

Lewy body dementia?

CJD?

FTD?

Huntington’s?

A

Alzhiemer’s = amyloid

Vascular dementia = amyloid

PDD = a-synucluein

DLB = a-synuclein

CJD = prion

FTD = tau protein

HD = Huntingtin

296
Q

REM parasomnia associated with?

A

Parkinson’s disease - will act out dreams

297
Q

Narcolepsy pathophys?

s/s?

A

pathophys is unknown, usually begins as teenager

Daytime sleepiness

  • Involuntary somnolence during eating/talking

Cataplexy - loss of muscle tone triggered by emotion

Hypnagogic hallucinations (occur at sleep onset)

Sleep paralysis

RBD - act out dreams

298
Q

Ix narcolepsy?

A

overnight polysomnography

multiple sleep latency test

299
Q

origin of corticospinal tract?

parts?

300
Q

corticobulbar tract origins?

Function?

what does it innervate?

301
Q

eyebrow raise sign?

A

forehead sparing = LMN lesion

non-forehead sparing = UMN lesion

302
Q

rubrospinal tract originates from?

Function?

303
Q

reticulospinal tract originates from?

Function?

304
Q

which tract is active in decortiate rigidity?

decerebrate rigidity?

A

decorticate = rubrospinal tract still active

decerebrate = reticulospinal tract still active

305
Q

lesion in blue line?

red line?

A

blue line = both rubrospinal and reticulospinal tracts active

red line = reticulospinal tract still active

307
Q

central cord syndrome associated with?

disruption fo which tracts?

s/s?

A

syringomyelia

disrpution of corticospinal and spinothalamic tract

s/s

  • cape-like loss of pain and temperature
  • weakness and spasticity in upper limbs (worse than lower limbs)
308
Q

anterior cord syndrome disrupts which tracts?

A

all tracts except DCML

309
Q
A

syringomyelia

310
Q

what is syringomyelia associated with?

A

arnold chiari malformation

311
Q

where are sinuses in brain found?

A

dura mater

313
Q

diagnostic tests SAH?

A

CT angiogram then LP (blood)

314
Q
A

1 - subdural

2 - SAH

3 - extradural

316
Q

Dx?

associated features?

A

SAH

meningeal irritation can cause neck stiffness and photophobia

317
Q

symptoms cerebral herniation?

A

UMN signs - spatic paralysis, brisk reflex, upgoing plantars

Cushing’s triad (ICP) - HTN, bradycrdia + irregular breathing

unreative pupil (uncal hernation - CN III)

318
Q

Cushing’s triad?

A

signs of raised ICP

hypertension + bradycardia + irregular breathing

319
Q
A

degenerative cervical myelopathy

320
Q
A

1 - lumbar stenosis

2 - cauda equina

3 - mechanical back pain

322
Q

vascular territories of brain?

323
Q

anterior circulation stroke?

A

dysphasia

homonymous visual field defect

contralateral motor/sensory deficit of at least 2 areas (out of face, arm, leg)

324
Q

posterior circulation stroke?

A

cerebellar dysfunction (ataxia, dysdiadokinesia, nystagmus, intention tremor, slurred speech, heel-shin)

isolated homonymous vidual field defect

cranial nerve dysfunction

325
Q

lacunar stroke?

A

pure motor or pure sensory stroke

326
Q
A

1 - lacunar stroke

2 - partial anterior stroke

3 - posterior stroke

328
Q
A

brocas = 2

wernicke’s = 4

cerebellum = 6

329
Q
A

1 - cerebellum

2 - right temporal lobe

3 - left parietal lobe (numbers + writing)

330
Q

most common cause of non-communicating hydrocephalus?

A

cerebral aqueduct obstruction

331
Q
A

non-communicating hydrocephalus due to aqueduct stenosis

332
Q
A

normal pressure hydrocephalus

333
Q

triad normal pressure hydrocephalus?

A

gait disturbance + mild dementia + impaired bladder control

334
Q

Intracerebral haemorrhage Ax?

Ix?

A

Ax = trauma, hypertension, tumour, AVM, aneurysm, venous cavernoma, haemorrhagic stroke, venous sinus thrombosis

Ix

  • ABCDE
  • HPC
  • PMHx - anticoahulation? liver dysfunction? previous stroke? malignancy?
335
Q

s/s intracerebral haemorrhage?

A

Global

  • Headache
  • N + V
  • Reduced GCS
  • Pupils
  • → raised ICP

Focal

  • Paresis
  • Dysphasia
  • Numbness
  • Seizure
  • Visual symptoms
  • Cerebellar symptoms

Associated problems

  • SAH - photophobia, meningism
  • IVH - hydrocephalus (raised ICP)
  • Trauma - external trauma
336
Q

Dx intracerebral haemorrhage?

AVM?

aneurysms?

A

non-contrast CT

AVM = CTA

aneurysms = DSA (digital subtraction angiography)

338
Q

Tx subdural haematoma?

A 
reduce ICP (sit patient up?)
correct clotting

control BP

surgery

339
Q

cerebral perfusion pressure equation?

A

CPP = MAP - ICP

340
Q

what is major determinant of CPP?

341
Q

effect of CO2/lactic acid on cerebral arterioles?

A

dilate!!!

Increased CO2/increased BP → vasodilation

Decreased CO2/decreased BP → vasoconstriction

342
Q

Ax raised ICP?

A

SOL - tumour, haematoma, asbscess

brain swelling - liver failure, encephalopathy, hypercarbia

increased centrla venosu pressure - venous sinus thrombosis, obsruction of juglar veins

343
Q

causes of hydrocephalus

344
Q

normal ICP?

A

7-15 mmHg

(lower in children)

345
Q

s/s raised ICP?

A

Early signs (worst hangover ever)

  • Reduced level of consciousness
  • Headache
  • Pupillary dysfunction +/- papilloedema
  • Changes in vision
  • Nausea and vomiting

Later signs

  • Coma
  • Fixed, dilated pupils
  • Hemiplegia
  • Bradycardia → cushing’s triad
  • Hyperthermia
  • Increased urinary output
346
Q

Tx ICP?

A
  • Maintain head in midline (at 30-45 degrees elevation) to facilitate blood flow
  • Loosen collars etc
  • Avoid gagging, coughing
  • Treat hyperthermia
  • Maintain fluid balance and normal electrolytes
  • Maintain normocarbia
347
Q

Tx hydrocephalus?

A

Use diuretics (mannitol, furosemide)

Barbiturate coma

Antiepileptics

Surgical decompression (shunt?)

348
Q
A

arnold chiari malformation

(cause of obstructive hydrocephalus)

349
Q

Ix?

A

CT - DO NOT LP!!!

350
Q

Tx non-communicating hydrocephalus?

A

ventriculoperitoneal shunt

351
Q

Hakim’s triad?

A

normal pressure hydrocephalus

abnormal gait, urinary incontinence, and dementia

352
Q

Dx?

A

normal pressur ehydrocephalus - lateral sulcus is much thicker than sagittal

353
Q

Ax normal pressure hydrocephalus?

Ix?

Tx?

A

Ax - uncertain (can be due to venous sinus stenosis)

Ix

  • LP (remember not in other causes of hydrocephalus)

Tx

  • VP shunt
  • Medium or low pressure valve
354
Q

idiopathic intracranial hypertension?

features?

S/s?

A

Raised intracranial pressure of unknown cause

features = no ventricular dilation, mainly women of child-bearing age, obese

s/s

  • headache
  • double vision + visual blurring
  • tinnitus
  • radicular pain
  • papilloedema
355
Q

Ix idiopathic intracranial hypertension?

Tx?

A

Ix

  • LP
  • CT/MR head
  • CTV!! (venous pressure possible cause)
  • Fundoscopy + ophthalmology review

Tx

  • weight loss
  • carbonic anhydrase inhibitors (acetazolamide, topiramate)
  • diuretics
  • intracranial venous sinus stenting
356
Q

cervical myelopathy symptoms?

Tx?

A

s/s

  • clumsiness in hands
  • gait imbalance
  • numbness, tingling
  • neck pain and stiffness
  • UMN sings - brisk reflexes, babinski
  • hoffman’s sign

Tx = surgery!!

357
Q

most likely cause of non-communicating hydrocephalus in teenager?

6 month old?

A

arnold chiary presents in teenage years

aqueduct stenosis is congenital so would cause non-communicating hydrocephalus in 6 month old

358
Q

56 y/o man, headache 8/10, nausea + vomiting, ptosis, bilaterally constricted pupils

A

horner’s syndrome due to ICA dissection

359
Q

56 y/o man presents with progressive headache, 6/10 severity, right dilated unreactive eye

A

posterior communicating artery aneurysm

360
Q

10/10 severity headache, neck stiffness and photophobia

361
Q

Dx?

A

Periventricular white matter is very dark

Asymmetrical

Myelin is reason its white

So these are demyelinating plaques - multiple sclerosis

362
Q

UMN pattern of weakness?

Ax?

how to determine site?

A

pyramidal/corticospinal = weak extensors in arm, weak flexors in leg

Ax

  • stroke, SOLs, spinal cord lesions

determine site

  • hemispheric = contralteral pyramidal weakness in face, arm, leg
  • parasagittal frontal lobe lesion = paraparesis
  • spinal cord = pyramidal weakness below level of lesion
    • cervical = arms + legs
    • throacolumbar = legs
363
Q

Ax LMN signs?

A

Motor neuron disease

Spinal muscular atrophy

Lead poisoning, poliomyelitis etc

366
Q

neuromuscular junction s/s?

Ax?

how to differentiate

A

Neuromuscular junction = fatigable weakness, normal or decreased tone - no sensory symptoms!!

Ax = MG or Lambert Eaton

  • MG = have hyperreflexia
  • LEMS = absent reflexes
367
Q

patterns of sensory loss?

369
Q

cerebellar signs?

A

Cerebellar gait is broad-based and unsteady

Intention tremor + ataxia

Dysdiadochokinesia

Nystagmus and dysarthria are additional features

370
Q

s/s frontal lobe damage?

A
  • Personality dysfunction - disinhibition, apathy
  • Paraparesis
  • Paratonia (inability to relax muscles)
  • Grasp reflex
  • Frontal gait dysfunction (magnetic gait)
  • Cortical hand
  • Seizures
  • Incontinence
  • Visual field defects (optic chiasm beneath frontal lobe)
  • Expressive dysphasia (Broca’s area in frontal lobe)
  • Anosmia (olfactory pathway beneath frontal lobes)
371
Q

s/s temporal lobe damage?

A
  • Memory dysfunction - episodic memory
  • Agnosia (visual and sensory)
  • Receptive dysphasia (Wernicke)
  • Visual field defects (upper homonymous quadrantanopia)
  • Auditory dysfunction (Heschel’s gyrus)
  • Limbic dysfunction
  • Temporal lobe epilepsy
372
Q

parietal lobe damage s/s?

A

Visual field defect (lower homonymous quadrantanopia)

Sensory dysfunction (visual and sensory)

Gerstmann’s syndrome - dysgraphia, left-right disorientation, finger agnosia, alcalculia

Dyspraxia

Inattention

373
Q

Ix MS?

A

MRI with gadolinium contrast

oligoclonal bands in CSF

374
Q

acute relapse MS Tx?

3rd year medicine (13 decks)

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