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)
2
Q
Dx DMD?
A
raised CK
genetic testing (dystrophin gene)
EMG
muscle biopsy
3
Q
is DMD inherited?
A
2/3rds inherited from asymptomatic mother 1/3rd sporadic
4
Q
huntington’s disease onset?
S/s?
Ax?
A
30-50 years
S/s
* dementia
* chorea
Ax = autosomal dominant CAG42
5
Q
appearance of Huntington brain
A
flattening of normal convex curve of lateral ventricles - due to loss of ganglia from caudate nucleus
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
7
Q
Alzheimers brain appearance genes?
A
neurofibrillary tangles + amyloid plaques
AD (presenilin) in 5% of cases - usually multifactorial
8
Q
ApoE4?
A
carriers more likely to get Alzhiemer’s in old age
9
Q
classification meningitis
A
acute pyogenic (bacterial)
acute aseptic e.g. viral
chronic bacterial - TB
acute encephalitis
10
Q
pyogenic meningitis dx?
A
suppurative exudate
neutrophils in subarachnoid space
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
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)
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
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
15
Q
Ax encephalitis
Ix
Tx?
A
Ax = herpes simplex
Ix = LP, EEG (abnormalities), MRI (temporal lobe)
Tx = IV aciclovir
16
Q
Ax brain asbcess?
Tx?
A
strep + bacteroides
Tx = ceftriaxone
* if penicillin allergic = vancomycin
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
18
Q
complications meningitis?
A
exudate around CN III + VI
brain abscess
cerebral oedema
communicting hydrocephalus
19
Q
sources of infection meningitis
A
nasopharyngeal colonisation (sinusitis, otitis media)
remote foci of infection - endocarditis, pneumonia, UTI
20
Q
when should lumbar puncture be avoided?
A
increased ICP
GCS <12
21
Q
bacterial vs viral CSF
A
22
Q
PCR meningitis?
A
used for viruses
23
Q
are you more likely to see neisseria or haemophilus as cause of meningitis in children?
A
neisseria meningitidis because Hib vaccine?
24
Q
most common cause of meningitis?
A
strep pneumo
25
tuberculous meningitis Tx?
isoniazid + rifampacin key
| (pyrazinamide + ethamutol too)
26
Ax aseptic meningitis
Viral
malignancy
sarcoidosis
vasculitis
dural venous sinus thrombosis
drugs - co-trimox, NSAIDs
27
Tx listeria?
if penicillin allergic?
amoxicillin
if penicillin allergic = co-trimoxazole
28
contact prophylaxis meningitis?
500mg ciprofloxacin
29
vaccines meningitis?
neisseria - ACYW
Haemophilus - Hib
strep pneumo
30
glial cells CNS?
astrocytes - BBB
oligodendrocytes - myelin
epdenymal cells - ventricles
microglia - macrophages
31
red neuron?
hallmark of acute neuronal injury due to hypoxia e.g. stroke
32
example of inclusions?
neurofibrillary tangles in Alzheimer's
33
oligodendrocite damage is a feature of?
demyelinating disorders
34
Gliosis?
astrocytes - scarring
**most important indicator of CNS injury**
35
types of microglia
M1 = acute
M2 = chronic
36
why does hypxoxia afect brain so much?
needs 20% total body oxygen
can only increse bloodflow 2-fold in response to hypoxia
37
excitotoxcity?
makes ischaemia worse
38
when can autoregulary brain mechanisms not compensate for BP?
when MAP falls below **50 mmHg**
39
where in the brain are thromboembolic events most common?
middle cerebral artery
40
which areas of the brain are particularly sensitive to ischaemia?
watershed areas - zone between 2 arterial territories i.e. parieto-occipital
41
stroke?
sudden disturbance of cerebral function of vascular origin that causes death or lasts over 24 hours
42
cerebral infarction Ax
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
43
risk factors stroke
atheroma
hypertension
cholesterol
obesity
diabetes
drugs
smoking
septal defects
44
stroke after 12 hours
48 hours
a week
few weeks
12 hours = red neuron
48 hours = lots of micoglia
a week = gliosis begins
few weeks = gliotic scar
45
symptoms carotid artery infarct?
**contra-lateral** weakness or sensory loss
sometimes aphasia/apraxia
sudden severe headache
sudden vision loss
46
symptoms middle cerebral artery infarct?
weakness of contralateral face and arm
47
anterior cerebral artery infarct?
weakness and sensory loss in contralateral leg
48
vertebro-basilar artery infarct?
vertigo
ataxia
dysarthria
dysphasia
complex brain stem syndromes
49
lacunar infarcts Ax?
Affect?
multiple lacunar infarcts?
atherosclerosis/thrombus or distal embolism
affect basal ganglia
multiple = multi-infarct dementia
50
hypertensive encephalopathy symptoms?
signs?
symptoms
\* severely hypertensive
\* symptoms of raised ICP - headache, vomiting, altered balance, fits
signs
\* global cerebral oedema
\* tentorial and tonsillar herniation
\* petechiae
51
types of intracrnaial haemorrhage
extradural haematoma = does not cross suture line
subdural haematoma = crosses suture line
subarachnoid hemorrhage
intracerebral haemorrhage
52
Ax intracerebral haemorrhage
causes of vascular injury - hypertension, amyloid angiopathy, diabetes, drugs (cocaine, alcohol), vasculitis
aneurysms
vascular malformations
coagulation disorders/iatrogenic anticoagulation
neoplasms
53
amyloid angiopathy Ax?
complication?
most commobly due to Alzheimers
complication = intracereberal haemorrhage (amyloid deposited in vessels causes rupture)
54
examples of vascular malformations in the brain
complications?
which are most likely to cause these complications?
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
55
most common vascular abnormality?
where are they found?
arteriovenous malformation
MCA
56
subarachnoid haemorrhage Ax?
areas effected?
associated with?
most common cause is rupture of berry aneurysm
90% in territory of carotid artery
associated with ADPKD
57
subarachnoid haemorrhage risk factors
S/s?
common complication?
smoking, hypertension, drugs
s/s
\* severe thunderclap headache
\* vomiting
\* loss of consciousness
complication = hydrocephalus
58
what seperates the 2 hemispheres?
what covers cerebellum
falx cerebri seperates 2 hemispheres
tentorium cerebelli covers cerebellum
59
normal CSF cytology
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
60
hydrocephalus Ax
obstruction to CSF - inflammation, pus, tumours
decreased reabsorption of CSF - SAH, meningitis
overproduction of CSF - tumours of choroid plexus (very rare)
61
hydrocephalus classification
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
62
timing of hydrocephalus
63
hydrocephalus ex vacuo
dilation of ventricular system + increase in CSF volume secondary to loss of brain parenchyma - **Alzheimer's disease**
64
Ax raised ICP
increased CSF (hydrocephalus)
SOL
oedema
increased venous volume
physiological (hypoxia, hypercapnia, pain)
65
consequences raised ICP
intracranial shifts + herniations (e.g coning)
midline shift
pressure on cranial nerves
impaired cerebral blood flow
66
examples of herniations
tonsillar through foramen magnum
67
signs of raised ICP
papilloedema
headache
nausea + vomiting
neck stiffness
reduced consciousness
68
examples of SOLs
tumours
abscesses
haematomas
localised brain swelling i.e. oedema around infarct
69
symptoms + signs brain tumour
symptoms = heaahce (worse in morning), vomiting, seizures, visual disturbances
signs = focal deficit, papilloedema
70
brain tumours children?
adults?
children = below tentorium cerebelli
adults = above tenorium cerebelli
71
brain metastases
from?
far more common than primary brain tumours
\* breast
\* bronchus
\* kidney
\* thyroid
\* colon
\* melanoma
72
commonest primary brain tumour in adults?
children?
adults = astrocytoma
children = medulloblastoma
73
astrocytoma grading
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
74
medulloblastoma?
found?
complication
Tx
most common tumour in children followed by pilocytic astrocytoma
occur in midline of cerebellum i.e. **below tentorium cerebelli**
complication = hydrocephalus
Tx = surgery + radiotherapy
75
brain abscess Ax
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**)
76
appearance brain abscesses
S/s?
Dx?
Tx?
central necrosis, oedema, fibrous capsule
S/s = fever, raised ICP
Dx = CT, MRI (ring enhancing)
Tx = aspiration + antibiotics
77
brain abscess organisms?
strep, bacteriodes, staph
immunocompromised patients = fungi, **toxoplasma in AIDS**
78
why do contra-coup injuries tend to be worse despite being non-impact side?
denser CSF moves to coup side first
79
most common intracranial haematoma?
epidural
80
"burst lobe"
subdural + intracerebral haematoma
occurs mostly in frontal + temporal lobe
81
Ax epidural haematoma?
fracture of tempero-parietal region = **midle meningeal artery**
82
subdural haemorrhage Ax
disruption of bridging veins
(blood accumulates between dura and arachnoid mater)
83
acute vs chronic subdural haemorrhage
acute = elderly, cleat history of trauma
chronic = commin in injury but often no clear history of trauma
84
B - juvenile myoclonic epilepsy is **generalised epilepsy** so not associated with hippocampal sclerosis (focal)
85
important features in epilepsy history
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
86
what drug can make epilepsy worse
tramadol
87
Ix for epilepsy?
MUST DO ECG - prolonged Qt syndrome (most common presentation is episode of collapse)
CT to screen for injury
EEG
88
differential diagnoses epilepsy?
syncope
pseudoseizures, psychogenic
panic attacks
TIA
migraine
hypoglycaemia
parasomnia
paroxysmal movement disorders
cataplexy
tonic spasms of MS
89
driving rules epilepsy
1st seizure = 6 months (car), 5 years (HGV)
epilepsy = 1 year or 3 years during sleep (car), 10 years off medication (HGV)
90
types of epilepsy?
further classification?
focal + generalised (cortical network)
focal
\* simple = without impaired consciousness
\* complex = with impaired consciousness
generalised
\* absence - petit mal
\* myoclonic
\* atonic
\* tonic
\* tonic clonic - grand mal
91
focal seizure locations + symptoms
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
92
generalised epilepsy onset?
tx?
e.g.?
onset = childhood + teens
Tx = sodium valproate
e.g. juvenile myoclonic epilepsy
\* early monring jerks
\* generalised seizures
\* risk factors - sleep deprivation, flashing lights
93
focal epilepsy onset?
Ax?
Tx?
any age
Ax = underlying structural cause e.g. **hippocampal sclerosis**
Tx = carbamazepine
94
how to AEDs work?
activate GABA system
95
side effects sodium valproate?
weight gain, hair loss, fatigue
teratogenic!!
96
what drug is avoided in primary generalised epilepsy?
carbamazepine - can make way worse!
97
which AEDs induce hepatic enzymes?
carbamazepine, phenobarbital + phenytoin
(so avoid in POP and COCP)
98
status epilepticus?
Ax?
medical emergency - seizure activity \>30 mins
Ax = hyponatraemia, pyridoxine (B6) deficiency, infection, head trauma, SAH, abrupt withdrawal of anticonvulsants, treating absence seizures with **carbamazepine**
99
convulsive status?
Complications?
Tx?
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!!
100
Tx epileptic seziure
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
101
patient presenting with acute confusional state?
always suspect **partial status epilepticus** in addition to septic encephalitis (as they are difficult to distinguish)
102
functional attacks?
Ax?
Dx?
not epilepsy but patient has no control of attacks
related to trauamatic events, physical/sexual abuse, other stress, anxiety/depression
Dx = EEG + history
103
types of aura
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)
104
Tx functional attacks?
removal of epiletpic drugs
CBT
Tx of anxiety or depression
105
motor neurone disease?
s/s?
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**
106
most common subtype MND?
ALS
107
prognosis MND?
average survival time = 3 years
108
Ax MND?
Types?
features of these types?
90% sporadic, 10% familial
types = ALS, PLS, progressive musclar atrophy, progressive bulbar palsy
109
ALS with fronto-temporal dementia associated with?
c9orf72 gene
110
upper vs lower motor signs in MND?
111
ALS symptoms?
PLS symptoms?
PBP symptoms?
ALS = mixed UMN and LMN signs
PLS = pure UMN
PBP (LMN) = wasting of the tongue, dysphagia, difficulty speaking (slurring)
112
progressive bulbar palsy will eventually become?
ALS
113
split hand syndrome?
ALS
114
C9orf72 mutation?
ALS with FTD
115
which subtype of MND has best prognosis?
primary lateral sclerosis
116
Ix MND?
EMG
neurological exam
117
Tx MND?
riluzole - gives an extra 3 months
communication needs
nutritional needs (dietician, gastrostomy) - metabolic rate in MND is doubled so weight loss expected
respiratory needs
118
sialorrhoea tx MND?
muscle cramps?
muscle spasms?
sialorrhoea = hyoscine/buscopan, glycopyronium (esp in cognitive impairment), botox
muscle cramps = quinine, **baclofen**
muscle spasms = **baclofen**, gabapentin
119
SOB MND?
lorezepam
120
S/s MND?
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
121
hypokinetic vs hyperkinetic movement disorder
hypokinetic (too little movement) = parkinsons
hyperkinetic (too much movement) = tremor, tics, chorea, myoclonus, dystonia, athetosis
122
important points in history for movement disorders?
birth history - anoxia, perinatal problems, milestones
family history
drug and toxin history - neuroleptics, antiepileptics, illicit substances, toxins
123
s/s parkinsonism/akinetic rigid syndrome?
TRAP
tremor
rigidity
akinesia/bradykineasia
postural disturbances (flexed posture, postural instability)
124
how to distinguish rigidity from spasticity?
rigidity = no increase with higher mobilising speed
spacticity = yes!
125
positive froment's maneuver?
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)
126
camptocornia?
extreme anterior truncal flexion sometimes seen in Parkinson's
127
parkinsonian gait?
slow shuffling steps
decreased arm swing
slow turning with multiple small steps
festination
postural instability (pull test)
128
types of tremor?
resting - occurs when body part at rest
postural - occurs when arms outstretched
kinetic - occurs during movement of body part
129
dystonia?
Ax?
sustained intermittent muscle contractions
130
chorea?
Ax?
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
131
Myoclonus
electric shock like jerks
caused by brief activation of a group of muscles leading to jerk of affected body part
132
ballism?
suggestive of?
severe type of chorea
involves proximal joints resulting in large movements
strongly suggestive of contralateral lesion involving striatum of subthalamic nucleus
133
essential tremor?
seen when?
what makes better?
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
134
pathological hallmarks of parkinson's?
lewy bodies
loss of dopaminergic neurons from substantia nigra
135
non-motor symptoms Parkinson's?
hypomimia
sleep disorders
hallucinations
GI dysfunction (constipation)
bladder problems
depression
congitive imapirment/dementia
anosmia
136
3 subtypes parkinsons
tremor-dominant (slower rate of progression)
non-tremor dominant (akinetic-rigid syndrome + postural instability gait disorder)
mixed
137
leadpipe vs cogwheel
Lead pipe = constant resistance throughout passive movement
Cogwheel = jerky resistance throughout movement as muscles contract and relax
138
Dx Parkinsons
DAT scan (SPECT)
139
does parkinsons reduce life expectancy?
barely - by 1 or 2 years
140
greatest risk factor parkinsons?
what decreases risk?
advancing age
smoking and alcohol decreases risk
141
Tx parkinsons?
levodopa
dopamine agonists
monamine oxidase B inhibitors
amantadine
anticholinergics for tremor
142
side effects parkinsons Tx?
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
143
red flag symptoms PD?
i.e. suggests not Parkinson's
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
144
differential diagnoses Parkinson's?
vascular Parkinsons
drug induced Parkinsons
tremor disorders
multi system atrophy
progressive supranuclear palsy
fragile X tremor ataxia syndrome
145
vascular parkinsonism features?
Dx?
affects predominantly lower limbs
rest tremor uncommon
poor levodopa response
Dx = brain imaging
146
drug induced parkinsonism?
symmetrical
coarse postural tremor
presence of other drug-induced disorders - orolingual dyskinesias, tardive dystonia, akathasia
usually narcoleptic/antipsychotic drugs
147
essential tremor vs parkinsons?
symmetrical, higher frequency (12Hz)
infrequently observed at rest
alcohol responsiveness
head tremor (mild)
148
multi system atrophy vs parkinsons?
Dx?
**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
149
progressive supraneuclear palsy vs parkinsons
**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**
150
fragile X tremor ataxia syndrome (FXTAS) vs Parkinsonism?
late onset (\>50 years) neurodegenerative disorder
cerebellar gait ataxia
postural tremor
parkinsonism
dysautonomia
cognitive decline
periperal neuropathy
151
"where" history brain injury
152
"where" examination brain injury
153
CNS
diagnosis = MS
154
neuromuscular junction problem so either lambert-eaton or myesthenia gravis
lambert eaton = absent deep tendon reflexes
myestheia gravis = hyperreflexia
so Dx = MG
155
PNS problem
acute = GBS
chronic = diabetes/alcohol
so Dx = GBS
156
peripheral neuropathy
157
pseudoathetosis?
Abnormal writhing (usually of fingers) - due to failure of proprioception
Indicates disruption of proprioceptive pathway
158
bilateral foot drop + high stepping gait
deep fibular nerve
159
...
160
...
161
Guillain barre syndrome
Tx?
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
charcot marie tooth disease?
hereditory sensory motor neuropathy
163
vasculitis often associated with which neuropathy?
mononeuritis complex
164
causes of peripheral neuropathy
vasculitis - mononeuritis multiplex
myeloma
hepatitis B/C, HIV, syphillis, Lyme
alcohol
amiodarone, phenytoin, chemo
diabetes
B12/folate deficiency
acute = GBS, porphyria
165
complication guillain barre syndrome?
autonomic failure (autonomic neuropathy) - cardiac
also respiratory failure
166
Tx peripheral neuropathy?
treat cause i.e hep C, diabetes
vasculitis = prednisolone + cyclophosphamide
guillain barre = IV immunoglobulin
neuropathic pain relief - gabapentin etc
167
168
169
170
multiple sclerosis?
most common type?
inflammatory demyelinating disorder in CNS
90% of people will have relapsing remitting MS
171
clinical features MS?
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
pyramidal dysfunction?
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
optic neuritis?
**painful** vision loss
1-2 weeks
**RAPD!!!**
174
cerebellar dysfunction?
(DANISH + PP)
Dysarthria
Ataxia
Nystagmus
Intention tremor
Past pointing
Pendular reflexes
Dysdiadokinesis
175
internuclear opthalmoplegia?
associated with MS in young people
medial longitudinal fasciculus
lid lag, nystagmus, failure of adduction (diplopia)
176
urinary tract dysfunction MS?
Frequency
Nocturia
Urgency
Urge incontinence
Retention
177
Dx MS?
DDx?
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
Tx MS?
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
1st line Tx relapsing remitting MS?
tecfidera
40% reduction in relapse rate
180
lambert eaton myesthenic syndrome (LEMS) associated with?
pathophys?
small cell lung cancer
antibodies to presynaptic calcium channels
181
myesthenia gravis?
associated with?
autoimmune anitbodies to AChR
association with thymoma
182
clinical features MG?
Tx?
fatiguable weakness
extraocular, facial + bulbar weakness
limb weakness typically proximal
Tx = **pyridostigmine** (anticholinesterase), IV immunoglobulin, **thymectomy**
183
drug to avoid MG?
gentamicin - makes MG worse
also avoid macrolide antibiotics
184
muscle power grading?
185
polymyositis?
Ix?
Tx?
dermatomyositis?
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
commonest muscular dystrophy?
S/s
myotonic dystrophy - autosomal dominant
s/s = myotonia, weakness, cataracts, ptosis, frontal balding, cardiac defects
187
drugs that can cause myopathies?
statins + corticosteroids
188
rhabdomyolysis triad?
complications
traid = myalgia, muscle weakness + myoglobinuria
comps = acute renal failure + DIC
189
traumatic brain injury Tx?
ABCDE
GCS, pupils
check c-spine
190
head injury severity scale?
Mild = 14 or 15, brief LOC
Moderate = 9-13
Severe = 3-8
191
NICE guidelines CT scan head injury?
\>65 y/o
coagulopathy
RTA or fallen from large height
192
Dx?
Battle sign = base of skull fracture
193
Dx?
classical presentation
Epidural haematoma
classic presentation:
Injury with LOC
“Lucid interval”
Deteriorating GCS
hemiparesis
Unilateral fixed and dilated pupil
Apnoea and death
194
Dx?
acute subdural haematoma
195
chronic subdural haematoma
196
Dx?
intracerebral haematoma
197
Dx?
diffuse axonal injury
198
Tx raised ICP?
sedation - benzos, propofol
head of bed tilt
mannitol
if all of this fails = **decompressive craniectomy**
199
brainstem death?
200
what MRI sequence do you use for water?
T2 hyperintense
201
supect haemorrhage?
CT!!
202
Dx?
subarachnoid haemorrhage
203
Dx?
diffuse haemorrhage - VERY BAD
204
Dx?
subdural haematoma with midline shift
205
extra-axial (outside brain parenchyma) tumours?
meningioma
pituitary adenoma
dermoid/epidermoid tumour
acoustic schwannoma
206
intra-axial brain tumours?
glioma
glioblastoma
metastases
207
either metastases or abscesses
208
chiari malformation?
complication?
s/s?
cerebellum herniates through foramen magnum
complication = can cause obstructive hydrocephalus
S/s = headaches, neck stiffness, seizures etc
209
cortical dysplasia - presents with seizures
210
schizencephaly (slit from ventricles)
211
arachnoid cyst
212
demyelination - MS
usually see lesions in spinal cord as well
213
encephalitis
Tx = aciclovir
214
classification brain tumours?
Supratentorial (usually adults) = above tentorium cerebelli
Infratentorial (usually in children)
Extrinsic (bone, meninges)
Intrinsic (glioblastoma)
215
presentation brain tumour?
neurological deficit
motor weakness
headache (**wakes up from sleep and associated with nausea + vomiting**)
seizures
216
raised ICP triad?
S/s?
cushing's triad = hypertension, irregular breathing, bradycardia
s/s
* headaches
* vomiting
* mental changes
* seizures
217
which nerve is most likely to be dysfunctional with tumour?
with uncal herniation?
6th cranial nerve (abducens) most likely to be dysfunctional with tumour
uncal herniation = occulomotor nerve (CN III)
218
cerebellar examination?
DANISH
## Footnote
Dysdiadokinesia
Ataxia (gait and posture)
Nystagmus
Intention tremor
Slurred, staccato speech
Hypotonia/heel-shin test
219
investigation of choice for brain tumour?
MRI scan
220
commonest brain tumour?
metastasis
221
commonest **primary** brain tumour?
glioma (glioblastoma)
222
neuroepithlial tissue?
astrocytes
oligodendroglial cells
epednymal cells/choroid plexus
neuronal cells
pineal cells
223
astrocytic tumours grading
grade 1 = pilocytic
grade 2 = low grade astrocytoma
grade 3 = anaplastic astrocytoma
grade 4 = glioblastoma multiforme
224
pilocytic astocytoma?
Affects?
S/s?
Dx?
Tx?
truly benign
affects **children**
s/s = slow in schooling, walk with tip-toe gait, laughing seizures
Dx = CT
Tx = surgery (curative)
225
grade 2 astrocytoma found?
presentation?
features on MRI?
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
Tx grade 2 astrocytoma?
**surgery** + chemo/radiotherapy
227
prognostic factors grade 2 astrocytoma?
poor prognosis (i.e. will progress to glioblastoma)
* age \>45
* low performance score
* large tumours \>6cm diameter/crossing midline
228
malignant astrocytomas?
features?
anaplastic astrocytoma (grade 3)
* medial survival 2 years
glioblastoma multiforme
* most common primary tumour
* median survival \<1 year
* multiple gliomas = NF, TS, PML
229
multiple gliomas a sign of?
neurofibromatosis
tuberous sclerosis
progressive multifocal leukoencephalopathy
230
Tx grade 3 + 4 astrocytomas?
survival?
non-curative surgery +
post-op radiotherapy +
chemotherapy (temozolamide)
improves median survival to 14 months - so 2 extra months essentially
231
what else is important to discuss with GBM patient?
must inform DVLA! - seizure risk post-op
232
side effects radiotherapy brain tumour?
drops IQ by 10
skin changes
hair loss
tired
233
tiptoeing, ataxia, vomiting + headache in children?
suspect pilocytic astrocytoma
234
severe headache that wakes from sleep, plus nausea + vom?
suspect brain tumour
235
meningioma s/s?
associated with?
s/s
* majority asymptomatic
* headache
* cranial nerve neuropathies (CN VI)
Meningiomas associated with - neurofibromatosis type 2, breast cance
236
classification meningioma?
majority benign
small percentage malignant - **clear cell, choroid, rhabdoid, papillary**
can also get radiation-induced meningiomas (e.g. after childhood leukemia)
237
meningioma Dx?
CT - enhancing, skull "blistering"
MRI - dural tail
Angiography - may see occlusion of sagittal sinus
238
meningioma Tx?
prognosis?
small meningioma = expectant
surgery
radiotherapy
prognosis = 90% 5 year survival
239
nerve sheath tumours?
schwannomas (aka neruomas)
neurofibromas
240
acoustic neuromas also called?
what are they associated with?
s/s?
complication?
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
acoustic neuroma Tx?
expectant (hearing aid)
radiation
surgery
if develp hydrocephalus = shunt
242
normal pressure hydrocephalus s/s?
triad
memory loss + urinary incontinence + ataxic gait
243
Tx ischaemic stroke?
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
Tx haemorrhagic stroke?
anticoagulant reversal
* warfarin = vit K
* dabigatran = idarucizumab
* factor Xa inhibitors = andexanet alpha
* **if unavailable = clotting factors**
245
acute spinal cord compression Ax?
Trauma
Tumours - haemorrhage or collapse (vertebrae)
Infection e.g. epidural asbscess
Spontaneous haemorrhage (AVM)
246
brown sequard syndrome?
ipsilateral motor level
ipsilateral dorsal column sensroy level
contralateral spinothalamic sensory level
247
central cord syndrome Ax?
S/s?
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
tumours that can cause spinal cord compression?
extradural
* metastasis from lung, breast, kidney, thyroid etc
intradural
* meningioma, schwannoma
intramedullary
* astrocytoma, ependymoma
249
Tx spinal trauma?
immobilise
X-ray/CT
**MRI to see cord!!**
decompress + stabilise
250
spinal epidural abscess Tx?
antibiotics + surgical drainage
251
acute spinal cord compression?
EMERGENCY!!!
252
Parkinson's Ax?
Risk factors?
5% cases are familial, 95% sporadic
risk factors
* age
* men
* rural living
* (smoking is **protective**)
253
drugs that can cause parkinson's?
Haloperidol - dopamine blockers
Metaclopramide (oncology patients - can get secondary parkinsons)
* And other anti-emetics like prochlorperazine
254
Ix Parkinson's?
DAT scan
| (test bloods for **Wilson's disease**)
255
Tx Parkinson's?
L-dopa
Dopamine agonists
Anticholinergics
Amantadine
COMT inhibitors (entacapone)
Apomorphine
256
analgesic ladder?
257
which areas of the brain are involved in analgesia?
periaqueductal grey (PAG)
locus ceruleus (pons)
nucleus raphe magnus (medulla)
258
opoid receptor?
U (mu) - responsible for most of the analgesic action of opioids
259
major adverse effects of opoids?
respiratory depression - apnoea
orthostatic hypotension
GI - nausea, vomiting, constipation, increased intrabillary pressure
CNS - confusion, hallucinations, dizziness, hyperalgesia (with excessive use)
260
what drug should be avoided with pethidine?
MAO inhibitors
261
tramadol avoided in?
patients with epilepsy
262
1st line treatment for trigeminal neuralgia?
carbamazepine
263
allodynia?
hyperalgesia?
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
Tx neuropathic pain?
Tricyclic antidepressants
Anticonvulsants\opioids
NMDA antagonists e.g. ketamine
Sodium channel blockers e.g. lignocaine
Capsaicin
GABA agonists (e.g. Baclofen)
265
MS?
Dx?
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
Dx?
MS
267
clinical features MS?
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
types MS?
Clinically isolated syndrome
Relapsing and remitting (most common)
Secondary progressive
Primary progressive
269
risk of passing MS to child?
approx 5%
270
dementia classification?
most common types?
most common types = alzhiemer's disease + vascular dementia
271
death Alzhiemer's?
usually occurs due to secodary cause such as bronchopneumonia
272
microscopic features Alzheimers?
plauques - amyloid angiopathy (amyloid AB)
neurofibrillary tangles (tau protein)
273
risk factors Alzhiemer's?
AGE
Down's syndrome
presnillin 1 and 2
Apolipoprotein E
274
amyloid angiopathy Dx?
Comp?
Stains with congo red - bright green
comp = intracerebral haemorrhage
275
Tx Alzhiemer's?
Anticholinesterase drugs (cholinesterase inhibitors)
* e.g. donepezil, galantamine, rivastigmine
NMDA receptor blockers - memantine
276
Lewy body dementia clinical features?
contrast with Alzheimers?
pathophys?
Dx?
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
Parkinsonism seen in which conditions?
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
macroscopic finding Huntington's?
atrophy of caudate nucleus
279
Front-temporal dementia (Pick’s disease)?
S/s?
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
histological hallmarks FTD?
Pick's cells (swollen neurons)
Pick's bodies
281
Multi-infarct dementia (vascular dementia)?
distinguish from Alzhiemer's?
Dx?
Tx?
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
Dx?
clinical features?
Ax?
triggering factors?
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
Dx?
S/s?
Tx?
Dx = transient epileptic amnesia
S/s
* short-lived
* forgetful/repetative questioning
* can carry out complex activities with no recollection of events
Tx = AEDs
284
prion disease i.e. CJD
285
Dx?
s/s?
Ix?
pathophys?
Tx?
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
early onset AD?
\<65 y/o, may have genetic influences
287
Ix Alzheimers?
cognitive tests
MRI - frontal + temporal lobe atrophy
SPECT - decreased temperoparietal metabolism
CSF - decreased amyloid, increase tau protein
288
Dx?
Features?
S/s?
Ax?
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
Ix FTD?
Tx?
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
vascular dementia onset?
core cliical features?
s/s?
Ax?
prognosis?
Tx?
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
lewy body dementia onset?
Ax?
core clinical features?
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
Ix Lewy Body dementia?
Tx?
Ix
* DAT scan
* diagnostic = **a-synuclein in CSF**/a-synucliein ligand imaging
Tx
* levodopa
* cholinesterase inhibitors
* support - community nurse
293
Parkinson's disease dementia?
how to differentiate from lewy body?
s/s?
Tx?
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
Huntington's disease dementia?
s/s?
Ix?
Tx?
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
proteinopathy associated with:
Alzhiemer's?
vascular dementia?
Parkinson's disease dementia?
Lewy body dementia?
CJD?
FTD?
Huntington's?
Alzhiemer's = amyloid
Vascular dementia = amyloid
PDD = a-synucluein
DLB = a-synuclein
CJD = prion
FTD = tau protein
HD = Huntingtin
296
REM parasomnia associated with?
Parkinson's disease - will act out dreams
297
Narcolepsy pathophys?
s/s?
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
Ix narcolepsy?
overnight polysomnography
multiple sleep latency test
299
origin of corticospinal tract?
parts?
300
corticobulbar tract origins?
Function?
what does it innervate?
301
eyebrow raise sign?
forehead sparing = LMN lesion
non-forehead sparing = UMN lesion
302
rubrospinal tract originates from?
Function?
303
reticulospinal tract originates from?
Function?
304
which tract is active in decortiate rigidity?
decerebrate rigidity?
decorticate = rubrospinal tract still active
decerebrate = reticulospinal tract still active
305
lesion in blue line?
red line?
blue line = both rubrospinal and reticulospinal tracts active
red line = reticulospinal tract still active
306
...
307
central cord syndrome associated with?
disruption fo which tracts?
s/s?
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
anterior cord syndrome disrupts which tracts?
all tracts except DCML
309
syringomyelia
310
what is syringomyelia associated with?
arnold chiari malformation
311
where are sinuses in brain found?
dura mater
312
...
313
diagnostic tests SAH?
CT angiogram then LP (blood)
314
1 - subdural
2 - SAH
3 - extradural
315
...
316
Dx?
associated features?
SAH
## Footnote
**meningeal irritation can cause neck stiffness and photophobia**
317
symptoms cerebral herniation?
UMN signs - spatic paralysis, brisk reflex, upgoing plantars
Cushing's triad (ICP) - HTN, bradycrdia + irregular breathing
unreative pupil (uncal hernation - CN III)
318
Cushing's triad?
signs of raised ICP
hypertension + bradycardia + irregular breathing
319
degenerative cervical myelopathy
320
1 - lumbar stenosis
2 - cauda equina
3 - mechanical back pain
321
...
322
vascular territories of brain?
323
anterior circulation stroke?
dysphasia
homonymous visual field defect
contralateral motor/sensory deficit of at least 2 areas (out of face, arm, leg)
324
posterior circulation stroke?
cerebellar dysfunction (ataxia, dysdiadokinesia, nystagmus, intention tremor, slurred speech, heel-shin)
isolated homonymous vidual field defect
cranial nerve dysfunction
325
lacunar stroke?
pure motor or pure sensory stroke
326
1 - lacunar stroke
2 - partial anterior stroke
3 - posterior stroke
327
...
328
brocas = 2
wernicke's = 4
cerebellum = 6
329
1 - cerebellum
2 - right temporal lobe
3 - left parietal lobe (numbers + writing)
330
most common cause of non-communicating hydrocephalus?
cerebral aqueduct obstruction
331
non-communicating hydrocephalus due to aqueduct stenosis
332
normal pressure hydrocephalus
333
triad normal pressure hydrocephalus?
gait disturbance + mild dementia + impaired bladder control
334
Intracerebral haemorrhage Ax?
Ix?
Ax = **trauma**, hypertension, tumour, AVM, aneurysm, venous cavernoma, haemorrhagic stroke, venous sinus thrombosis
Ix
* ABCDE
* HPC
* PMHx - anticoahulation? liver dysfunction? previous stroke? malignancy?
335
s/s intracerebral haemorrhage?
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
Dx intracerebral haemorrhage?
AVM?
aneurysms?
non-contrast CT
## Footnote
AVM = CTA
aneurysms = DSA (digital subtraction angiography)
337
...
338
Tx subdural haematoma?
```
reduce ICP (sit patient up?)
correct clotting
```
control BP
**surgery**
339
cerebral perfusion pressure equation?
CPP = MAP - ICP
340
what is major determinant of CPP?
ICP
341
effect of CO2/lactic acid on cerebral arterioles?
dilate!!!
## Footnote
Increased CO2/increased BP → vasodilation
Decreased CO2/decreased BP → vasoconstriction
342
Ax raised ICP?
SOL - tumour, haematoma, asbscess
brain swelling - liver failure, encephalopathy, hypercarbia
increased centrla venosu pressure - venous sinus thrombosis, obsruction of juglar veins
343
causes of hydrocephalus
344
normal ICP?
7-15 mmHg
| (lower in children)
345
s/s raised ICP?
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
Tx ICP?
* 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
Tx hydrocephalus?
Use diuretics (**mannitol**, furosemide)
Barbiturate coma
Antiepileptics
Surgical decompression (shunt?)
348
arnold chiari malformation
| (cause of obstructive hydrocephalus)
349
Ix?
CT - DO NOT LP!!!
350
Tx **non-communicating** hydrocephalus?
ventriculoperitoneal shunt
351
Hakim's triad?
normal pressure hydrocephalus
abnormal gait, urinary incontinence, and dementia
352
Dx?
normal pressur ehydrocephalus - lateral sulcus is much thicker than sagittal
353
Ax normal pressure hydrocephalus?
Ix?
Tx?
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
idiopathic intracranial hypertension?
features?
S/s?
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
Ix idiopathic intracranial hypertension?
Tx?
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
cervical myelopathy symptoms?
Tx?
s/s
* clumsiness in hands
* gait imbalance
* numbness, tingling
* neck pain and stiffness
* UMN sings - brisk reflexes, babinski
* **hoffman's sign**
Tx = surgery!!
357
most likely cause of non-communicating hydrocephalus in teenager?
6 month old?
arnold chiary presents in teenage years
aqueduct stenosis is congenital so would cause non-communicating hydrocephalus in 6 month old
358
56 y/o man, headache 8/10, nausea + vomiting, ptosis, bilaterally constricted pupils
horner's syndrome due to ICA dissection
359
56 y/o man presents with progressive headache, 6/10 severity, right dilated unreactive eye
posterior communicating artery aneurysm
360
10/10 severity headache, neck stiffness and photophobia
SAH!!
361
Dx?
Periventricular white matter is very dark
Asymmetrical
Myelin is reason its white
So these are demyelinating plaques - multiple sclerosis
362
UMN pattern of weakness?
Ax?
how to determine site?
pyramidal/corticospinal = weak **extensors** in _arm_, weak **flexors** in **_le_**g
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
Ax LMN signs?
Motor neuron disease
Spinal muscular atrophy
Lead poisoning, poliomyelitis etc
364
...
365
...
366
neuromuscular junction s/s?
Ax?
how to differentiate
Neuromuscular junction = fatigable weakness, normal or decreased tone - no sensory symptoms!!
Ax = MG or Lambert Eaton
* MG = have hyperreflexia
* LEMS = absent reflexes
367
patterns of sensory loss?
368
...
369
cerebellar signs?
Cerebellar gait is broad-based and unsteady
Intention tremor + ataxia
Dysdiadochokinesia
Nystagmus and **dysarthria** are additional features
370
s/s frontal lobe damage?
* 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
s/s temporal lobe damage?
* 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
parietal lobe damage s/s?
Visual field defect (**lower** homonymous quadrantanopia)
Sensory dysfunction (visual and sensory)
**Gerstmann’s syndrome - dysgraphia, left-right disorientation, finger agnosia, alcalculia**
Dyspraxia
Inattention
373
Ix MS?
MRI with gadolinium contrast
oligoclonal bands in CSF
374
acute relapse MS Tx?
steroids
