Neuro Flashcards
Within how many hours of a stroke can alteplase be given?
After this time, what should be given?
4.5 hours
After this: 300mg Aspirin + 300mg Clopidogrel
Long term Rx given after a stroke if its not due to AF?
ACS
Antihypertensive
Clopidogrel 75mg
Statin (20mg Atorvastatin)
If someone is thought to have had a stroke 3 hours ago what test needs to be done before commencing treatment?
CT head to exclude a bleed
How does idiopathic parkinson’s typically present differently to vascular parkinsonism
Vascular parkinsonism- tends to be bilateral and affect lower limb worse
Idiopathic parkinson’s- tends to be unilateral and affect upper limb
Which symptom is most crucial to diagnose Parkinson’s?
Bradykinese
+ resting tremor/rigidity/postural instability
Which non-motor symptoms after often positive in early Parkinson’s disease?
Loss of smell
Lewy body in enteric NS- constipation, overactive bladder
What two symptoms make stroke less likely than other neuro diagnoses?
Loss of consciousness/syncope
Seizure activity
(Hemiplegic migrane, Todd’s palsy)
What are the RR, HR, peak flow values and symptoms characteristic of severe acute asthma?
RR above 25
HR above 110
Peak flow between 30-50% of patient’s best
Inability to complete a sentence in one breath
What signs, peak flow, PaO2 or SpO2 suggest life-threatening asthma?
When they are getting tired: Peak flow below 150L/min PaO2 below 8kPa SpO2 below 92% Silent chest, cyanosis, feeble respiratory effort Exhaustion, coma, confusion HR
What peak flow suggests moderate asthma?
50-70% of normal
What is the pyramidal distribution of weakness seen in upper motor neuron lesions?
Weakness of
Arm extensors
Leg flexors
So think of a stroke patient, flexed arms + straight legs
UMN lesion Vs LMN lesion
UMN: spastic
hyperreflexic
Babinski +ve, upgoing plantars
Pyramidal muscle weakness (arm extensors, leg flexors)
LMN: flaccid
Hyporeflexic
wasting
± fasciculation
A man has a cranial nerve palsy on his left side and weakness of arm movements on his right. Roughly where is the lesion?
Left brainstem
Pain and temperature nerves travel along which tracts of the spinal cord?
Anterolateral (spinothalamic) tract
AL for ALert for danger (heat/pain)
Joint position and vibration travels along which tracts of the spinal cord?
Dorsal columns
Door bell vibrates. Open close the door
What is the pattern of weakness in Guillain-Barré syndrome?
Proximal muscles first
Patient has lost vibration and proprioception on his left side and temperature and pain sense on his right side. Which side of the spinal cord is the hemi-cord lesion on?
Left side
Ipsilateral dorsal and contralateral anterolateral tracts affected
Dorsal (ring doorbell + open door, proprioception + vibration)
Anterolateral (ALert to pain + temp)
Patient has a stroke and is dizzy and deaf afterwards, which artery is affected?
Anterior inferior cerebellar artery
A patient has a stroke and is left feeling dizzy with inability to swallow and speech abnormalities, which artery has been affected?
PICA- posterior inferior cerebellar artery
Dizzy + Dysphasic + Dysphonic
Right homonymous hemianopia with macular sparing. Which artery is affected?
Left posterior cerebral artery
Locked in syndrome is caused by damage to which part of the brain?
Ventral pons
Pontine artery occlusion
Signs of cerebellar lesion?
DASHING Dysdiadokinesis (alternate clapping) Dysmetria (past pointing) Ataxia Slurred speech Hypotonia Intention tremor Nystagmus Gait abnormality
Patient has right-sided deafness, nystagmus, reduced corneal reflex, right sided cerebellar signs (DASHING). Where is the lesion?
Right (ipsilateral) cerebellopontine angle
Could be due to acoustic neuroma or vestibular Schwannoma
During a seizure an EEG pattern shows a 3s spike and wave pattern. What type of seizure is this associated with?
Absence seizures (a specific type of generalised seziure)
What is the main difference between complex and simple partial seizures?
Simple- remain aware
Complex- unaware/semi-conscious
A young man develops UMN signs, becomes withdrawn and has myoclonic jerking. What is the differential?
Dementia with myoclonus: creutzfeldt-jakob disease
Brain tumour
HIV- dementia
Wilson’s, Huntington’s
Wher does proprioception and vibration sense travel in the spinal cord?
Ring the doorbell (vibration), open (proprioception) the DOORsal columns
Where do pain and temperature small fibres travel within the spinal cord?
Pain + temperature = ALert
Anterolateral tract
Dorsal columns for proprioception and vibration large fibres
Where do motor fibres run in the spinal cord?
Ventral (front) and lateral (sides) corticospinal tract
Like an air hostess
What pattern of sensory and function loss occurs in a Brown Sequard picture (hemi-cord lesion)?
Dorsal column loss ipsilateral to the side of the lesion Spinothalamic loss (pain + temperature) contralateral- wants to run away fast so decussates across on entering cord
Spasticity gives way to what pattern of increased tone when tested?
Velocity dependent, clasp knife
From UMN lesions
What signs make a primary muscle wasting disease more likely than a LMN lesion?
Syemmetry, reflexes are lost later
No sensory loss
Anterior cerebral infarcts tend to affect upper or lower limb worse?
Lower
If the middle cerebral artery is infarcted on the dominant or non-dominant hemisphere, how will the symptoms differ?
Dominant- dysphasia (speech) or cognitive change
Non-dominant- visuospatial (cannot dress, gets lost)
Which cerebral arteries make give rise to a homonymous hemianopia if infarcted?
Posterior (macular sparing) or middle cerebral- hemianopia would be on the contralateral side
Dizziness following a stroke suggests involvement of which part of the brain?
Cerebellar
How do symptoms differ if a stroke occurs in the superior vs the anterior or posterior inferior cerebellar arteries?
infarction in inferior arteries gives worse symptoms
SCA- dizzy
AICA- dizzy and deaf
PICA- dizzy and dysphagic (swallowing) and dysphonic (sound production)
Which arteries if occluded give rise to a lateral medullary syndrome?
(Vertigo, vomiting, dysphagia, ipsilateral Horner’s, nystagmus, crossed sensory loss)
Posterior inferior cerebral artery or one vertebra; artery
Infarcting the lateral medulla and inferior cerebellum
If someone has Horner’s sign on their left, which post inferior cerebellar artery has been wiped out?
The left (ipsilateral)- cranial nerves do not really decussate (bar CNIV) Motor cortex fibres travel in the corticobulbar tracts and synapse in the midbrain, pons or medulla to form the nuclei of the CNs. The postganglionic nerves (CNs are on the side they innervate, do not really decussate unlike the corticospinal tract nerves which deucssate in the pyramids of the medulla
In locked in syndrome, which artery is affected?
Pontine artery occlusion causing ventral pons damage
BP is more than 20mmHg different in each arm, and after using his arm the patient finds it hard to remember things and where he is. Syndrome?
Subclavian steal syndrome, stenosis of the subclavian artery proximal to the branch of the vertebral artery leads to retrograde blood flow from the vertebral artery into the arm
Enhancing GABA inhibitory inputs is useful in the Rx of which conditions?
Epilepsy (valproate)
Neuropathic pain (gabapentin)
Spasticity (baclofen, benzodiazepines)
Name two 5-HT agonists?
5-HT1a = lithium 5-HT1d = sumitriptan
Ondansetron and clozapine antagonise which type of 5-Ht receptors?
Ondansetron: 5-HT 3
Cloazapine: 5-HT 2c
What are the different functions mediated by a, b1 and b2 adrenergic receptors?
Alpha- vasoconstriction and pupillary dilatation
Beta 1- pulse and stroke volume
Beta 2- bronchodilation, uterine relaxation and vasodilation
How do acamprosate and bupropion act in helping people give up addictions?
Acamprosate is a gluatamate antagonist, reducing cravings
Disulfiram produces a nasty reaction on drinking alcohol
Naltrexone reduces the pleasure and cravings of alcohol
When do you stop giving acamprosate to help someone quit drinking if they are still drinking?
After 4-6 weeks
Dermatome of nipples and umbilicus?
T4 nipples
T10 umbilicus
Sensory innervation to the back of the hand?
Ulnar 1.5 fingers
Mostly radial nerve, except fingertips (median nerve)
Sensory innervation of the palm?
Mostly median nerve
Except 1.5 fingers on ulnar side (ulnar nerve)
In dermatomes,
what is the knee?
what do i stand on?
What do i sit on?
L3 at the knee
Stand on S1
Sit on S3
Differential of acute severe headache with menigism?
Fever:
meningitis (purpuric rash)
encephalitis (odd behaviour)
Subarachnoid haemorrhage
Management in acute severe headache, with associated meningism?
CT head
If -ve, lumbar puncture for xanthochromia
In someone with a head injury, what 2 things would make you consider a CT head?
Drowsiness ± lucid interval
Focal neurology- weakness, visual changes
Aside from raised intracranial pressure, what other type of headache gets worse on bending forward?
Sinusitis
± postnasal drip
Mollaret’s meningitis- recurrent episodes of severe headache with meningism + fever is thought to be caused by?
Herpes simplex 2 - can PCR CSF for it
For someone with analgesia overuse headaches, how many days a month should they be allowed over-the-counter analgesics?
6
Rx for cluster headaches?
All the S’s and C’s
100% oxygen for 15 mins via non-rebreathe mask
Sumitriptan at onset
Prevention: Suboccipital Steroid injections intranasal Civamide (form of capsaicin)
Calcium channel inhibitors (verapamil)
Lithium, melatonin
Rx of trigeminal neuralgia?
Carbamazepine, lamotrigine, phenytoin
Or
Gabapentin
If a patient doesn’t get aura, what other criteria may be used?
>4 headaches lasting 4-72 hours with vomiting or nausea And 2 of: Unilateral Pulsating Impairs or worsened by routine activity
Acute Rx for migranes and the CI to this?
NSAIDs Sumitriptans- CI: as vasoconstrict somewhat IHD, coronary spasm Uncontrolled hypertension Recent lithium or SSRIs
CI to ergotamine (used in acute Rx of migranes and in the 3rd stage of labour)
The pill
Peripheral vascular disease, IHD, Raynaud’s, liver/kidney disease
Hemiplegic migrane
Prevention Rx of migrane?
If more than 2 a month
1. Propranolol, amitriptyline, topiramate
- Valproate, gabapentin
Rx for peri-menstrual migrane?
NSAID at onset of period
Oestradiol patches for 3 days before period
What is Uthoff’s phenomenon in multiple sclerosis?
worsening of vision following rise in body temperature
Which benzo is not given PR to abort seizures?
Lorazepam
Can give diazepam PR however
Flexor pollicis longus is innervated by?
Anterior interosseous nerve (median nerve branch)
= difficulty with pincer movements
Which structures travel in the anterior cubital fossa?
Medial to lateral: NAT Median nerve Brachial artery Biceps tendon
Cephalic vein over the top
Which symptoms are more common in an intra-cerebral bleed compared to a stroke?
Headache, nausea + vomiting
Would expect focal neurology in both
ABCD2 assessment for risk of stroke?
Age >60 (1)
BP >140.90 (1)
Clinical signs- facial weakness (2)
Speech disturbance, no weakness (1)
Diabetes (1)
Duration. >1 hour (2)
10-59 minutes (1)Management of someone coming in with a TIA
EHx for residual neuro deficit (= stroke)
IHx: bloods, glucose, fasting lipids, U+Es, platelets
ECG- exclude AF
Start aspirin 300mg
ABCD2 to determine risk- 4+ needs assessment withn 24 hours
3 or less within a week
Factors of the rosier scoring tool in determining likelihood of stroke?
Loss of consciousness/syncope = -1
Seizure = -1
Face (1), arm (1), leg (1), speech (1) if asymmetric
Visual field defect (1)
In suspected stroke what needs to be excluded via blood test?
Hypoglycaemia
Who is at high risk of subsequent stroke following a TIA?
2 TIAs in a week
TIA with a score of 4 on the ABCD2 scoring
Require 24 hour appointment + MRI
(Age >60, BP>140, face weakness or speech problem, diabetes, >1 hour or 10-59 mins)
What imaging modality is preferred in someone with a high risk TIA?
MRI within 24 hours (Score >4 on ABCD2 score or 2 in a week)
What features need to be present for the bamford classification of a total anterior circulation infarct?
3 of:
Higher dysfunction (decreased consciousness, dysphasia, visuospatial)
Homonymous hemianopia
Motor/sensory deficit (in 2 of face, arm or leg)
What features define a partial anterior circulation infarct in the bamford classification?
2 of:
Higher dysphagia (low gcs, dysphasia)
Motor/sensory deficit (in 2 of face, arms, legs)
Homonymous hemianopia
Or:
Higher dysfunction alone
Limited motor sensory deficit
What features define a posterior cerebral infarct in the bamford classification?
Any of:
Cranial nerve palsy + contralateral motor/sensory deficit
Bilateral motor or sensory deficit
Conjugate eye movement problems (can’t fix on a single object)
Cerebellar dysfunction
Homonymous hemianopia
In the bamford classification, what defines a lacunar infarct?
Affecting 2 of face, arm or leg Pure sensory deficit Pure motor deficit Sensorimotor deficit Ataxic hemiparesis
What signs suggest that vertigo is due to a cause located at the cerebello-pontine angle, cerebellum or brainstem rather than in the labyrinth?
Associated nystagmus and other CN lesions
Differential: acoustic neuroma, MS, stroke, migrane
What is the pathology of
A. benign positional vertigo
B. Menieres disease
C. Labyrinthitis
A. Displaced crystals in the inner ear
B. Excessive fluid in the inner ear
C. Inflammation of inner ear
Rx for benign positional vertigo?
Vertigo lasting 30 secs-30 mins
Should not have tinnitus
Epley manouvres (pt quickly forced into supine position, head turned ever minute x3 then back up)
Rx for menieres disease?
Bed rest
Antihistamine- cinnarizine if prolonged
Prochlorperazine if severe (for 7 days) -D2 antagonist
Which drugs cause ototoxicity = deafness ± vertigo
Aminoglycosides (gentamycin)
Loop diuretics
Cisplatin
In an abnormal Rinnes test are they rinne positive or negative?
Rinne negative
Management of sudden hearing loss?
ENT referral asap
Steroids may cure
Causes of pulsatile tinnitus?
Pulsatile = blood
Carotid artery stenosis or dissection
AV fistula
Glomus tumours (rare neoplasm of the AV shunt used for temperature regulation)
What’s the difference between symptoms in cauda equina/conus medallaris and cord compression higher up the cord?
Cauda equina + CM = flaccid and areflexic (as nerves are compressed at the LMN level)
Higher in the cord = spastic + hyperreflexic below the level of the lesion as UMN
What pattern of neurological deficit occurs in tertiary syphilis?
Tabes dorsalis (takes out the dorsal columns of proprioception and vibration-sense) Afferent pathways from muscle spindles are affected first with reduced tone and tendon reflexes (numb)
Later Taboparesis= pyramidal tracts become involved leading to spastic paraparesis
Which part of the cord is affected in subacute combined degeneration of the cord, occurring with B12 deficiency?
Lateral (motor) and dorsal (proprioception + vibration)
May cause spastic paraparesis or mixed UMN + LMN signs:
Absent knee jerks with extensor plantars
What’s the difference between an apraxic, ataxic and antalgic gait?
Apraxic- like being on an ice rink, very tentative + wide-based (normal pressure hydrocephalus
Ataxic- wide based, can’t heel-toe (cerebellar)
Antalgic- to reduce pain
Rx for tardive dyskinesia
Withdraw antipsychotic
After 3 months if still a problem, try tetrabenzine
What is the main genetic cause of stroke?
Notch 3 gene mutation =
CARDASIL cerebral autosomal dominant arteriopathy with subcortical infarcts & leukoencephalopathy
(Migrane, TIA, mood disorders, dementia)
What symptoms are characteristic of cardasil (cerebral autosomal dominant arteriopathy with subcortical infarcts & leukoencephalopathy)?
Genetic cause of stroke (Notch 3 gene mutation) TIA mood disorders Dementia Migrane From 40 years +
When BP drops more than 40mmHg what is the risk?
Strokes in watershed zones, often follows sepsis
Which type of stroke requires urgent neurosurgical referrals?
Cerebellar strokes with haemaniomas (require evacuation)
What aspects of the PC or recent tests would be a CI for thrombolysis following a stroke/heart attack?
○ PC: Mild deficit, seizures at presentation
○ INR >1.7
○ Platlets 220/130
What PMC would be a CI to thrombolysis in the event of a stroke or heart attack?
○ PMH: Recent birth, surgery, trauma or artery/vein puncture
○ Past CNS bleed
○ AV malformation or aneurysm
○ Severe liver disease/varices/portal hypertension
If someone has prosthetic or rheumatic valves, what factor about them would warrant lifelong anticoagulation?
If the abnormal valve in on the left side
Rx to give post stroke?
Clopidogrel
Statins
Antihypertensives
Rx for subarachnoid haemorrhage whilst waiting for neurosurgery?
Nimodipine (ca2+ antagonist reduces vessel spasm)
Rx of subdural haemorrhage?
May see midline shift on CT
Burr hole craniostomy to release pressure
Which artery is typically damaged in an extradural haemorrhage?
Middle meningeal artery, by the temporal bone
Nerves involved in an acoustic neuroma?
5,6, 9 + 10
Rx for idiopathic dystonia occuring in childhood that spreads from one place to another?
Benzhexol (a ACh antagonist)
Patient started on a new neuroleptic, their eyes become fixed staring upwards. Rx?
Oculogyric crisis (Acute dystonia) Benzhexol- anticholinergic
How would you expect someone with a myopathy to walk?
Waddling gait with weak hip girdle
Rx for alzheimers?
Cholinesterase inhibitors: donepezil, rivastigmine
NMDA antagonist- memantine
Rx for lewy body dementia?
Like alzheimers, can only use rivastigmine (cholinesterase inhibitors)
Rx for partial epilepsy in adults?
P for carbamazePine
Then valProate
Treatment for generalised epilepsy in adults?
GeneraLised:
vaLproate or Lamotrigine
Rx for parkinson’s disease?
Early on:
Dopamine agonist: ropinirole, pramipexole
MAO-B inhibitor: selegiline, rasagiline
Over 70 or low QoL:
L Dopa + carbidopa/benzeratide
Someone with Parkinson’s is getting end of dose effects, freezing etc, what Rx can help with this?
Apomorphine SC (in a rescue pen) for sudden freezes Comt inhibitors: entacapone, tolcapone (needs LFTs0
What is the name for the name in MS when neck flexion causes electric shocks?
Lhermitte’s sign
What findings on lumbar puncture might occur in someone with MS?
Oligoclonal IgG bands or increased IgG
Rx for relapsing and remitting MS?
Methylprednisolone- acute attack (doesn’t help prognosis)
Targeting T cells: alemtzumab, natulizumab
Azathioprine, IFN
Rx for progressing MS?
Mitoxantrone (acts as an immunosupressant, topoisomerase inhibitor)
Rx you can offer women with idiopathic benign intracranial hypertension?
Prednisolone, loop diuretics, weight loss
Rx for myaesthenia gravis?
Anticholinesterases- pyridostigmine
SE: salivation, sweats, lacrimation, miosis
What features of MS are definitive if present?
2 or more attacks with 2 or more objective clinical lesions
(Last > 1hour with 30 days between attacks)
MRI shows 3 out of the 4 of: Gadolium enhacning or 9 hyperintense lesions 1+ infratentorial lesion 1+ juxtacortical lesion 3+ periventricular lesions
What provides MRI evidence of dissemination in time in suspected MS>
Gd-enhancing lesion 3 months after onset of a clinical attack at a different site to the clinical attack.
Or if no Gd-enhancing lesion at 3 months, follow up scan 3 months later showing Gd-lesion or new T2 hyperintense lesion
What finding on evoked waveform is suggestive of MS?
Delayed but well-preserved waveform
Name the 5 parkinson’s plus syndromes:
- Supranuclear palsy (vertical gaze palsy ± falls)
- Multisystem atrophy (autonomic and cerebellar signs)
- Lewy body dementia (reduced cognition, hallucinations)
- Corticobasal degeneration (loss of 3D depth perception- cortical sensory loss)
- Vascular parkinsons (diabetic/hypertensive + gait problems)
IHx needed if someone has trigeminal neuralgia?
MRI
To exclude secondary causes of nerve compression like tumours or aneurysms
Where is the lesion in a lacunar infarct causing pure motor deficits?
Internal capsule
Where is the lesion in a lacunar infarct causing pure sensory deficits?
Thalamus
