Neuro Flashcards
Masked face is a typical sign of which condition ?
Parkinson’s disease
What are the 4 Cardinal signs of Parkinson’s disease ?
- tremor
- rigidity
- bradykinesia
- postural instability
Of visual hallucinations and dementia are present or occur within a year of Parkinsonism, what is the likely diagnosis ?
Lewy body dementia
Impaired vertical eye movements would suggest which diagnosis ?
Progressive supra nuclear palsy
When are tremors due to Parkinson’s worst ?
When distracting patients with mental tasks
Micrographia is typical of which condition ?
Parkinson’s disease
What are the main secondary motor symptoms of Parkinson’s (4)?
- freezing
- micrographia
- masked face
- unwanted accelerations
Others include: dystonia, dysphagia, sexual dysfunction, cramping etc
What are the early non motor symptoms experienced by those with Parkinson’s disease ? (4)
- loss of sense of smell/constipation
- REM behaviour disorder
- mood disorders
- orthodontic hypotension
What are the age peaks of epilepsy ?
First 15 and last 15 years of life
What are common characteristics of an aura before epileptic seizure ?
- strange feeling in gut
- feeling of déjà vu
- change in mood or behaviour
- strange smell
- flashing lights
What are the characteristic post octal symptoms of epilepsy?
- headache
- confusion
- myalgia
- sore tongue
Post ictal temporary weakness suggests a focal seizure where ?
Motor cortex (todds palsy)
Post ictal dysphagia suggests focal seizure where ?
Temporal lobe
Causes of epilepsy ?
- idiopathic/familial
- structural: cortical scarring e.g. Head injury, tumour, stroke
- tuberous sclerosis
- SLE
- sarcoidosis
What is epileptogenesis ?
- The process by which a normal brain becomes epileptic
- the sequence of events that turns a normal neuronal network into a hyper excitable one
What are the excitatory neurotransmitters that can cause seizures in excess ?
- glutamate
- aspartate
*stimulated by influx of sodium and calcium
Which are the inhibitory neurotransmitters which can reduce seizures ?
- GABA
* stimulated by inward ionic influx of chloride and efflux of potassium
What is status epilepticus ?
- life threatening condition, medical emergency
- brain in constant state of seizure
- > 30 min of activity or 2 or more seizures spanning this period without full recovery
What are partial seizures and what are the types of partial seizures ? (3)
Focal onset with features referable to a part of one hemisphere:
- simple partial:
- complex partial
- partial seizure with secondary generalisation
What is a simple partial seizure ?
- awareness unimpaired
- focal motor, sensory, autonomic or psychic symptoms
- no post ictal symptoms
What are complex partial seizures .
- awareness impaired
- may have simple partial onset (=aura) or impaired awareness onset
Where do complex partial seizures most commonly arise from .
Temporal lobe
What is common post ictal symptom following seizure arising from temporal lobe ?
Confusion
What is the common post ictal symptom followng seizure arising from frontal lobe ?
Rapid recovery
What is a partial seizure with secondary generalisation ?
Electrical activity starts vocally (as either simple or complex partial seizure) then spreads widely causing a secondary generalised seizure which is usually convulsive
What are primary generalised seizures and what are the different types ? (4)
Simultaneous onset of electrical discharge throughout cortex, with no localising features referable to only one hemisphere:
- absence seizure
- tonic clonic seizure
- myoclonic seizure
- atonic seizure
What are absence seizures ?
Brief (
What are tonic clonic seizures ?
- loss of consciousness
- limbs stiffen (tonic), then jerk (clonic)
- may have one and not the other
- post ictal confusion and drowsiness
What are myoclonic seizures ?
- Sudden jerk of limb, face or trunk
- patient may be thrown to ground, or have a violently disobedient limb
What are atonic seizures ?
- Sudden loss of muscle tone causing a fall
- no loss of consciousness
First line treatment for generalised tonic clonic seizures ?
Sodium valproate or lamotrigine
- usually better tolerated and less teratogenic
Second= carbamazepine
Drug treatment for absence seizures ?
Sodium valproate, lamotrigine or ethosuximide
Carbamazepine and oxcarbazepine should be avoided in which types of seizures and why ?
Tonic, atonic and myotonic - may worsen seizures
Use sodium valproate or lamotrigine
Which drug treatment is first line for partial seizures ?
Carbamazepine
What are the causes of Parkinsonism
- idiopathic Parkinson’s disease
- drugs (neuroepileptics, metoclopramide, prochlorprerazone)
- trauma/boxing (rare)
- encephalopathy post flu
- manganese or copper toxicity (Wilson’s disease)
- HIV
Pathogenesis of Parkinson’s disease
Mitochondrial DNA dysfunction causes degeneration of dopaminergic neurons in substantia nigra pars compacta (associated with Lewy bodies), hence decreased striatal dopamine levels
Management of Parkinson’s
- postural exercises and weight lifting show to improve disability and cognition
- dopamine agonists or MAO-B inhibitors can push back use of levodopa
- anticholinergics may help tremor but cause confusion in the elderly
- levodopa
What are the Parkinson plus syndromes? (5)
- supra nuclear palsy
- multiple systems atrophy
- Lewy body dementia
- cortico-basal degeneration
- vascular Parkinsonism
What are the red flags for progressive supra nuclear palsy? (6)
early postural instability AND vertical gaze eye palsy +/-:
- falls
- rigidity of trunk > limbs
- symmetrical onset
- speech and swallowing problems
- little tremor
Red flag symptoms for multiple systems atrophy
- early autonomic features e.g. Impotence/incontinence
- postural hypotension
- cerebellar + pyramidal signs
- ## rigidity > tremor
Red flag symptoms for Lewy body dementia
- fluctuating cognition
- visual hallucinations
- early dementia
Rad flag symptoms for corticobasal degeneration
- akinetic rigidity involving one limb
- cortical sensory loss e.g. Astereognosia (inability to recognise object by active touch)
- apraxia (e.g. Alien limb syndrome)
Red flag signs for vascular Parkinson’s
- pyramidal signs (legs) e.g. Ataxia (no festination)
E.g. In diabetic/hypertensive patient with falls or has gait problems
Cause if multiple sclerosis
- discrete plaques of demyelination occur at multiple sites in CNS
- due to T cell mediated immune response
- demyelination heals poorly causing remitting and relapsing disease
- prolonged demyelination causes axonal loss and clinically progressive symptoms
Who is most likely to present with MS ?
Females 30 yrs
Presentation of MS?
usually monosymptomatic:
- unilateral optic neuritis (pain on eye movement and rapid decrease in central vision)
- numbness and tingling in limbs
- leg weakness
- brainstem and cerebellar symptoms (diplopia, ataxia)
- symptoms may worsen with with heat or exercise
Treatment of MS
- steroids e.g, methylprednisolone reduce acute attack
- interferons: decrease no. Of relapses
- monoclonal antibodies: e.g. Alemtuzumab acts against T cells in relapsing-remitting MS
- no good drugs for primary progressive MS
What is a tension headache ?
- bilateral, non pulsatile headache +/- scalp muscle tenderness
- NO vomiting or sensitivity to head movements
- stress relief, massage and antidepressants may help
Characteristic signs and symptoms of raised ICP
- pain worse on waking, lying, bending forward or coughing
- vomiting, papilloedema, seizures, false localising signs,
- odd behaviour
*imaging to exclude space occupying lesion, consider idiopathic raised intracranial hypertension
Which analgesics are common causes of episodic headache becoming chronic daily headache ?
- cocodamol
- ergotamine
- triptans
Characteristic signs/symptoms of cluster headaches
- rapid onset excruciating pain around one eye that may become watery or bloodshot with lid swelling, lacrimation, facial flushing, rhinorrhoea, miosis +/- ptosis
- pain strictly unilateral and almost always affects the same side
- lasts 15-60 mins
- occurs once or twice a day and often nocturnal
- clusters last 4-12 weeks and followed by pain free periods of few months
- sometimes chronic and non episodic
Symptoms of trigeminal neuralgia
- paraoxysms of intense, stabbing pain, lasting seconds in trigeminal nerve distribution
- unilaterally, usually affecting mandibular or maxillary divisions
- face screws up in pain
Classical and alternative symptoms of migraine
Classically:
- visual or other aura lasting 15-30 mins followed within 1hr by unilateral, throbbing, headache
OR
- isolated aura with no headache
- episodic severe headache without aura, often premenstrual, unilateral , with nausea, vomiting +/- photophobia/phonophobia
- may also be allodynia- all stimulus painful
What is a migraine prodrome ?
Precedes headache by hours/days e.g. Yawning, cravings, mood/sleep changes
Common migraine auras:
- Visual: chaotic, cascading, distorted , melting and jumbling lines, dots, zigzags, scotomata, or hemianopia
- somatosensory: parathesiae spreading fingers to face
- motor: dysarthria, ataxia, opthalmoplegia, hemiparesis
Partial triggers of migraine seen in >50% of cases
CHOCOLATE:
C- chocolate H- hangovers O- orgasms C- cheese O- oral contraceptives L- lie-ins A- alcohol T- tumult E- exercise
Pharmacological prophylaxis of migraine ?
If frequency >2/month or not responding to as needed NSAIDS:
1st line: propanolol, amitriptyline, topiramate or Ca channel blockers
2nd line: valproate, gabapentin, pregablin
Causes of subarachnoid haemorrhage ?
- ruptured saccular aneurysm
- arteriovenous malformation
- no cause found in 15%
Typical age presenting with subarachnoid haemorrhage
35-65
Risk factors for subarachnoid haemorrhage
- smoking
- alcohol abuse
- hypertension
- bleeding disorders
- family history
Common sites for berry aneurysms ?
- junction of posterior communicating with internal carotid
- anterior communicating with anterior cerebral artery
- bifurcation if mid cerebral artery
Which conditions are associated with berry aneurysms ?
- polycystic kidneys
- coarctation of aorta
- ehlers-danlos syndrome
Symptoms of SAH ?
- Sudden, devastating, typically occipital headache
- vomiting
- collapse
- seizure
- coma
Signs if SAH ?
- neck stiffness
- kernig’s sign (6h to develop)
- retinal, subhyaloid and vitreous bleeds (=Terson’s syndrome)
- focal neurology suggesting site e.g. Pupil changes indicating 3rd nerve palsy with a posterior commutating artery aneurysm
Differential diagnosis of ‘thunderclap’ headache?
- SAH
- meningitis
- migraine
- intra cerebral bleeds
- cortical vein thrombosis
Investigations and findings in SAH ?
- CT detects >90% SAH within 48h
- if CT -ve after 12h do LP
- CSF in SAH usually bloody early on and becomes xanthochromic (yellow) - this finding confirms SAH
Management of SAH
Refer to neurosurgery immediately!
- maintain cerebral perfusion by keeping well hydrated, only treat high BP if severe
- nimodipine prevents vasopasm and so reduces cerebral Ischaemia
- endo vascular coiling preferred over surgical clipping
- CT angiography to identify aneurysms before operating
Complications of SAH ?
- rebleeding
- cerebral Ischaemia
- hydrocephalus
- hyponatraemia q
What are the cardiac causes of stroke ? (7)
- non-valvular AF
- external cardioversion
- prosthetic values
- acute MI
- paradoxical systemic emboli - via venous circulation in those with patent foramen ovale and atrial/ventricular septal defects
- cardiac surgery
- valve vegetations e.g. Infective endocarditis
Define TIA
Sudden onset of focal CNS phenomena due to temporary (
Signs of anterior cerebral artery stroke
- weak, numb, contralateral leg +/- similar arm symptoms
- face unaffected
*supplies frontal and medial part of cerebrum
Patient presents with: hemiplegia/hemiparesis of face, sensory loss, hemianopia and dysphagia. Where is this patient likely to have had a stroke ?
Middle cerebral artery/internal carotid, in dominant hemisphere (as presents with dysphagia, non dominant = Visuo-spatial disturbance
- hemisphere affected is contralateral to side with deficits
*this type of stroke usually consciousness preserved, and limbs begin weak and areflexive but return within few days and become exaggerated, headache unusual
Stroke presenting with homonymous hemianopia with macula sparing is likely to have affected which part of the brain ?
Contralateral posterior cerebral artery
How can you tell the difference between cerebral haemorrhage and infarct ?
You can’t tell the difference clinically, requires imaging
- haemorrhage more likely to produce headache. But unreliable
Signs of lacunar infarct (I.e. Occlusion of one of the deep penetrating arteries of the brain)
- pure motor stroke
- pure sensory stroke
- sudden unilateral ataxia and sudden dysarthria with a clumsy hand
Which cranial nerve nuclei are in the midbrain ?
- occult motor (3)
- Trochlear (4)
Which cranial nerve nuclei are in the pons ?
Trigeminal (5)
Abducens (6)
Facial (7) (on border of pons and medulla)
Which cranial nerve nuclei are in The medulla ?
Glossopharyngeal (9)
Vagus (10)
Accessory (11)
Hypoglossal (12)
What is amaurosis fugax ?
Sudden transient loss of vision in one eye due to passage of small emboli through the retinal arteries
- often first sign of carotid artery stenosis
Treatment following stroke
- control CV risk factors e.g. BP, cholesterol etc
- anti platelet: clopidogrel, aspirin
- warfarin if mural emboli
- carotid endarterectomy if stenosis >70%
What is the most common cause of meningitis ?.
Viral infection
Risk factors for meningitis
- patients with CSF shunts or dural defects
- spinal procedure
- DM,
- alcoholism
- splenectomy, sickle cell disease (encapsulated organisms)
- crowding
Most common organisms causing meningitis in neonates ?.
- group B strep
- listeria monocytogenes
- E. coli
Most common organisms causing meningitis in infants and young children ?
H influenzae
If under 4 and unvaccinated: N meningitidus and strep pneumoniae
Most likely organism causing meningitis in adults
- s pneumoniae
- H influenzae
Most common organisms causing meningitis in elderly and immunocompromised ?
- S pneumoniae
- L monocytogenes
- TB
Most common organisms causing hospital acquired meningitis ?
- Klebsiella pneumoniae
- E. coli
- pseudomonas aeruginosa
- staph aureus
Signs of meningitis in neonate?
- non specific
- fever
- respiratory distress
- episodes of apnoea and bradycardia
- feeding difficulty
- irritability
- reduced activity
Who is at risk of fungal meningitis ?
- AIDS
- leukaemia
- immunosuppressed
Which fungi are likely to cause meningitis?
- cryptococcus
- histoplasma
- coccidioides
What is the most common cause of eosinophilic meningitis ?
Angiostrongyliasis - parasitic infection by nematode (from consuming raw giant African snail)
What is mollarets meningitis ?
Chronic recurrent, benign, inflammation of meninges
What are the non infective causes of meningitis ?
- malignant cells e.g. Leukaemia, lymphoma
- chemical meningitis e.g. Intrathecal drugs
- drugs e.g. NSAIDs, trimethoprim
- sarcoidosis
- SLE
- Behçet’s disease
Conditions presenting similarly to meningitis
- malaria
- encephalitis
- septicaemia
- SAH
- dengue
- tetanus
Early features of meningitis ?.
- headache
- leg pains
- cold hands and feet
- abnormal skin colour
Later features of meningitis?
- meningism (neck stiffness, photophobia, kernig’s sign)
- reduced consciousness level
- seizures +/- focal CNS signs
- non blanching petechial rash
Signs of galloping sepsis (e.g. In meningitis)
- slow cap refill
- DIC
- ,hypotensive
- raised temp and pulse
Signs of disease causing meningitis
- HSV: cold sore/genital vesicle
- HIV: lymphadenopathy, dermatitis, candiasis, uveitis
- leptospirosis: bleeding +/- red eye
- mumps: parotid swelling
Prophylaxis for those who have been in close contact with someone who has developed meningitis
Rifampicin OR ciprofloxacin
Tests for bacterial meningitis ?
- CRP
- WCC
- CSF (LP) - inc. WCC, total protein and glucose concentrations, gram stain and microbial culture
- PCR (LP) - N meningitidis, S pneumoniae (only do PCR if CSF culture negative)
If CRP and WCC normal and CSF not available to interpretable then treat as confirm bacterial meningitis anyway
Treatment for bacterial meningitis
- empiric antibiotics: cefotaxime + (if
Pathogenesis of bacterial meningitis ?
- pia-arachnoid congested with polymorphs
- layer of pus forms, may organise to form adhesions causing CN palsy and hydrocephalus
- cerebral oedema in any bacterial meningitis
- mortality 15%
Pathogenesis of viral meningitis
- lymphocytic inflammation if CNS
- no pus formation, polymorphs or adhesions
- little or no cerebral oedema unless encephalitis develops
When do most meningococcal infections occur ?
Winter and early spring
Causes of mononeuropathies?
- Trauma
- entrapment
Causes of mononeuritis multiplex ?
= if 2 or more peripheral nerves are affected , causes tend to be systemic: WARDS PLC
W- wegeners A- aids / amyloidosis R- rheumatoid D- diabetes P- pan ? L- leprosy C- carcinomatosis
What investigation can help find site of lesions in mononeuritis multiplex ?
Electromyography
Muscles supplied by median nerve (C6-T1)?
LOAF- muscles of precision grip
L- lumbricals
O- opponens pollicis
A- abductor pollicis brevis
F- flexor pollicis brevis
Pathogenesis of carpal tunnel syndrome
Mononeuropathy of median nerve due to compression at the wrist (increased pressure in the carpel tunnel)
- characterised by tingling, numbness or pain on distribution of median nerve (thumb, index and middle fingers and medial half of ring finger on palmar aspect)
- often worse at night and causes wakening
- weakness in hand grip and opposition of the thumb
- muscle wasting In thenar eminence
Damage to the median nerve at elbow or forearm causes what symptoms ?
- inability to flex index finger and distal phalanx of thumb
- weak flexion of Middle finger
- defective opposition of thumb
Treatment for carpel tunnel
- likely to resolve in 6 months if
Signs of ulnar nerve compression (C7-T1)
- weakness/wasting of ulnar side wrist flexors, interossei (can’t cross fingers) and medial two lumbricals (claw hand)
- hypothenar wasting -> weak little finger abduction
- sensory loss over medial 1.5 fingers
Wrist drop is caused by which peripheral mononeuropathy ?
Radial nerve compression
What is Guillain-Barré syndrome ?
- Acute, predominantly motor, inflammatory, demyelination neuropathy
- symmetrical, ascending muscle weakness begins few weeks after an infection
- progressive phase up to 4 weeks followed by recovery
- proximal muscles more affected
What is thoracic outlet syndrome?
Mononeuropathy of brachial plexus
- pain in arm
- paraesthesia in arm and hand (usually C8 and T1 dist)
- weakness in arm
