Neuro Flashcards
Which drugs can cause Parkinsonism?
Anti psychotics - clozapine, quietapine, haloperidol, risperidone
Anti emetics - Metoclopramide and prochlorperazine
Methyldopa (BP)
Calcium channel blockers - cinnarizine and flunarizine
Amiodarone
Sodium valproate
Lithium
What is juvenile Parkinson’s?
Diagnosis under age 20
What is early onset Parkinson’s?
Diagnosis under age 40
What are the Parkinson’s plus syndromes?
Multiple system atrophy
Progressive supranuclear palsy
Corticobasal degeneration
What are signs and symptoms of multiple system atrophy?
Autonomic dysfunction
Parkinsonism
Ataxia
What is a DaTSCAN?
Dopamine transporter SPECT scan used in diagnosis of PD
If a GP suspects early stages of PD, how soon should the pt see a specialist (neurologist or geriatrician)?
Within 6 weeks
If a GP suspects late stages of PD, how soon should the pt see a specialist (neurologist or geriatrician)?
Within 2 weeks
How is a diagnosis of Parkinson’s made?
Usually clinical diagnosis
Likely PD if at least 2 of: resting tremor, bradykinesia, rigidity
If symptoms improved by levodopa - more likely
DaTSCAN can be used to aid diagnosis
What are the groups of causes of Parkinsonism?
Idiopathic
Drug induced
Cerebrovascular
Other progressive brain conditions - Parkinson’s plus
What development assessment tool is used for children?
SOGS II - birth to 5 years
Schedule of growing skills
Screening tool
What 9 areas are assessed in SOGS II?
Passive posture Active posture Locomotor Manipulative Visual Hearing and language Speech and language Interactive social Self care social
What factors contribute to idiopathic intracranial hypertension?
Pregnancy
Combined oral contraceptive therapy
Obesity
Oral tetracycline therapy
How do you treat idiopathic intracranial hypertension?
Weight reduction
Stopping the offending drug
More serious where sight is threatened - cerebrospinal fluid removal of shunting may be required
What is recommended for carotid artery stenoses greater than 70% diameter?
Carotid endarterectomy
What are complications of subarachnoid haemorrhage?
Recurrent SAH
Vasospasm
Stroke
Hydrocephalus
What are features of subarachnoid haemorrhage?
Acute onset severe headache Meningeal irritation Low grade fever Localising neuro signs Neurogenic pulmonary oedema ST elevation on ECG
What problems does maternal narcotic addiction cause in a neonate?
Neonatal abstinence syndrome: tremors, irritability, sleep problems, high pitched crying, hypertonia, hyperreflexia, seizures, mottled skin, fever, slow weight gain
Symptoms usually 1 to 3 days after birth
What might convulsions occurring in first 24 hours of life signify?
Placental insufficiency
Cerebral palsy
What are some causes of horners syndrome?
Pancoast tumour Cervical rib Goitre Syringomyelia Lateral medullary syndrome - brainstem stroke
Which is the best choice of antiepileptic drug for generalised epilepsy in women of child bearing age? What supplement should be given alongside during pregnancy? And what screening is required?
Lamotrigine
High dose folate supplements
Vitamin K given to mother prior to delivery
Alpha fetoprotein and second trimester USS screening
Why would phenytoin and valproate not be sensible choices for antiepileptic treatment in a woman of child bearing age?
Teratogenic effects
What is Patterson Kelly Brown syndrome?
Plummer Vinson syndrome
Triad of microcytic hypochromic anaemia
Atrophic glossitis
Oesophageal webs/stricture
What is Webers syndrome?
Infarction of the midbrain
Contralateral hemiplegia
Ipsilateral oculomotor nerve palsy and diplopia
What is Charcot Marie tooth disease?
Autosomal dominant inherited condition
Wasting of lower limbs and small muscles of hands
What is diabetic amyotrophy?
Weakness, wasting and pain usually in quadriceps
Paraesthesia of the proximal lower limbs - thigh, hip, buttock
Symptoms begin on one side but usually spread to other
Vasculitic changes, microvascular insufficiency and ischaemia followed by axonal degeneration and demyelination
What is friedreichs ataxia? What are features of it?
Progressive ataxia, dysarthria, decreased proprioception, ascending muscle weakness, pes cavus, scoliosis, cardiomyopathy, arrhythmias, diabetes
Inheritance autosomal recessive, decreased synthesis of frataxin - mitochondrial protein
Onset before 20 years
What is von Hippel Lindau disease?
Mutation in tumour suppressor gene
Multiple tumours in CNS and viscera
Most commonly retinal, haemangioblastomas, renal cell carcinoma, phaeochromocytoma
May be diagnosed from FH and genetic testing
What causes should be considered for prolonged hiccup?
CNS disease - posterior fossa tumour, brain injury, encephalitis
Phrenic nerve or diaphragm irritation - tumour, pleurisy, pneumonia, intrathoracic adenopathy, pericarditis, GORD, oesophagitis
What are causes of dilated pupils?
Holmes adie pupil
Third nerve palsy
Drugs and poisons - atropine, CO, ethylene glycol
What are causes of small pupils?
Horners syndrome Old age Pontine haemorrhage Argyll Robertson pupil Drugs and poisons - opiates, organophosphates
What are features of neuroleptic malignant syndrome?
Fever Rigidity Altered mental status Autonomic dysfunction Elevated creatine phosphokinase
Concomitant use of which drugs may increase the risk of neuroleptic malignant syndrome?
Lithium or Anticholinergics alongside antipsychotic drugs
What is the treatment for neuroleptic malignant syndrome?
Withdrawal of the offending drug
Reduction of body temperature with antipyretics
Bromocriptine and amantadine - dopaminergic drugs
Dantrolene sodium - muscle relaxant
You are referred to a 40 year old woman in a psych ward who has a long history of schizophrenia resulting in multiple hallucinations in the past. She gives a several week history of feeling generally unwell associated with increasing stiffness affecting the jaws and arms. Over the last few years she has been on haloperidol with good symptom control. Her temp was 38.5 and BP 175/85. What does she have and what is the most important investigation to be performed?
Neuroleptic malignant syndrome
Creatine phosphokinase
What causes meralgia paraesthetica?
Damage to the lateral cutaneous nerve of the thigh
Usually due to entrapment at the lateral inguinal ligament, trauma, ischaemia or a retroperitoneal lesion
What is alports syndrome?
Inherited condition of sensorineural deafness and renal dysfunction - glomerulonephritis
Defect in type IV collagen
What are features of an acoustic neuroma?
Hearing loss - sensorineural Unilateral tinnitus Vertigo Pressure in ear Facial numbness and tingling Loss of corneal reflex
What is the alternative name for an acoustic neuroma? What cells does it affect?
Vestibular schwannoma
Schwann cells
What is the triad of features of wernickes encephalopathy?
Acute mental confusion
Ataxia
Opthalmoplegia
What are the oculomotor findings in wernickes encephalopathy?
Weakness of abduction
Gaze evoked nystagmus
Internuclear opthalmoplegia
Vertical nystagmus in primary position
What are some causes of wernickes encephalopathy?
Chronic alcohol abuse Dialysis patients Advanced malignancy AIDS Malnutrition
What is the urgent treatment for wernickes encephalopathy?
100mg fresh thiamine IV followed by 50-100mg daily
What can cause cerebral abscess?
Untreated or partially treated meningitis
TB
Pyogenic ear infections
Facial/orbital cellulitis
What is treatment for cerebral abscess?
Surgical drainage
Abx
What are signs and symptoms of cluster headache?
Severe unilateral pain in temple and periorbital region Attacks lasting a few moments to two hours Ipsilateral lacrimation Nasal congestion Conjunctival injection Miosis Ptosis Lid oedema
What is the first choice of Abx in meningitis for different patient groups?
For infants 3m - adults 50 years, cefotaxime/ceftriaxone
If been outside UK recently or multiple Abx in last 3 months - add vancomycin
Under 3m and over 50, add amoxicillin to cover for listeria
What might be possible causes of a post op seizure out of the blue?
Severe hyponatraemic encephalopathy Hypoglycaemia Sepsis Hypoxia Drug induced
What are sequelae of trigeminal nerve herpes zoster?
Trigeminal neuralgia
Corneal ulceration
Postherpetic neuralgia
Why might MS patients get urgency of urine?
Spastic paraparesis caused by demyelination in SC
Why might MS patients get episodes of visual disturbance?
Optic neuritis
A 63 year old hypertensive male presents with sudden onset vertigo, ataxia, diplopia and dysarthria. What is the problem?
Vertebrobasilar ischaemia
A 55 year old woman complains of recurrent severe stabbing pain in left cheek and jaw. The episodes last 5-10 secs and frequently occur during meals and showers. Examination of the cranial nerves is unremarkable. What is the drug of choice?
Carbamazepine
What medications should be used for prophylaxis of migraine?
Propranolol
Pizotifen
Topiramate
What medications can be used for acute attacks of migraine?
Sumatriptan
Ergotamine
A 53 year old administrator attends her GP complaining of pain in her R hand which is worse at night and relieved by hanging her arm off the side of the bed. What is the most likely diagnosis?
Carpal tunnel syndrome
Which nerve is implicated in carpal tunnel syndrome?
Median nerve
By what mechanism is the nerve affected in carpal tunnel syndrome?
Compression, traction, pinching, squeezing or irritation of the median nerve as it runs through the transverse carpal ligament
What structures form the carpal tunnel?
Scaphoid
Lunate
Triquetrium
Flexor retinaculum
Which tendons run through the carpal tunnel?
Flexor digitorum profundus x 4
Flexor digitorum superficialis x 4
Flexor pollicis longus
In which canal does the ulnar nerve run?
Guyons canal
What findings would you expect on examination of a person with carpal tunnel?
Scars from previous release surgery
Sensory loss lateral 3 and a half digits
Wasting and weakness of LOAF: first and second lumbricals, opponens pollicis, abductor pollicis brevis, flexor pollicis Brewis
Positive Phalens: tingling in median nerve distribution induced by full flexion of the wrists for 60 secs
Positive Tinels: tapping over median nerve at wrist generates tingling in nerves distribution
What conditions can predispose to carpal tunnel syndrome?
Diabetes Hypothyroidism RA Pregnancy Obesity Wrist fracture/trauma
What investigations can be done for carpal tunnel syndrome? What will they show?
EMG: electromyography shows focal slowing of conduction velocity in the median nerve across carpal tunnel, prolongation of the median distal motor latency, decreased amplitude of median sensory and/or motor nerves
USS wrist: space occupying lesion may be identified
MRI wrist: space occupying lesion may be identified, useful pre op
Describe EMG as you would to a patient
Electrodes attached to skin one which emits a signal, one which records
Electrical impulses given to nerve - feel like sharp tapping sensation on skin, bit unpleasant but doesn’t last long
Time it takes for muscle to contract is recorded - conduction velocity
If you take muscle relaxants or anti cholinergics, may need to stop them
Tell person doing test if you have a pacemaker or defibrillator
Avoid hand lotions/creams
Wear loose fitting clothing that can be rolled above elbow
What are management options for carpal tunnel syndrome?
Avoid activities which make symptoms worse
Treating underlying condition
Wrist splint: improvement in 4 weeks
Corticosteroid injection into wrist
Carpal tunnel release surgery when other treatments have failed
What are possible complications of carpal tunnel release surgery?
Infection Persisting symptoms Bleeding Nerve injury Scarring Persistent wrist pain different from original Complex regional pain syndrome
What advice should be given after carpal tunnel release surgery?
Keep hand bandaged and raised for 2 days - sling
Gentle finger, shoulder and elbow exercise to prevent stiffness
Avoid using hand to do demanding activities until it is completely recovered which might take several weeks
A 35 year old man attends his GP complaining of severe pain in his L leg and numbness in his foot. His symptoms began suddenly 2 days ago when he bent down to pick up his child. He is otherwise fit and well. He also has back pain but less severe than his leg. What is the likely cause of his symptoms?
Sciatic nerve compression
What anatomical change causes sciatica?
Vertebral disc prolapse which causes compression on the sciatic nerve
What clinical test can you do to diagnose sciatica? What sign does this elicit?
Straight leg raise
Lasegues sign: pain in distribution of sciatic nerve reproduced with passive flexion of straight leg between 30 and 70 degrees
What is the management for sciatica?
Keeping active - exercise Physio NSAIDs Amitriptyline and duloxetine Gabapentin and pregabablin Corticosteroid injections Muscle relaxants Surgery: Open discectomy, microdiscectomy
A patient with a sciatic pain returns to the GP 3 days later with pain in both legs. What diagnosis needs to be urgently excluded and why? How do exclude it?
Cauda equina syndrome
Needs to be excluded quickly as can lead to paralysis, sensory changes, bladder bowel and sexual dysfunction
MRI
What questions do you need to ask to exclude cauda equina syndrome?
Unilateral or bilateral sciatica Saddle and perineal anaesthesia Urinary retention/incontinence Faecal incontinence Lower extremity motor weakness and sensory deficits
What examination findings would you expect in cauda equina syndrome?
Back tenderness to palpation Radicular sensory loss Saddle anaesthesia Asymmetrical paraplegia Loss of tendon reflexes Poor anal sphincter tone
What is the management for cauda equina?
Urgent spinal decompression
A 54 year old dentist attends her GP complaining of cramps and weakness in her R hand which are starting to affect her work. On examination there is general wasting of the hand muscles with muscle fasciculation and a brisk wrist reflex. What is the most likely diagnosis? Why?
Motor neurone disease - mixed upper and lower motor neurone signs
ALS
Which nerve cells are affected in motor neurone disease?
Motor neurones in the ventral spinal cord
What is the likely prognosis for ALS?
Life expectancy 2 to 5 years
What symptoms do you see with progressive bulbar palsy?
Progressive dysphagia Dysphonia Dysarthria Wasted tongue with fasciculations Drooling
What are symptoms of psuedobulbar palsy?
Slow and slurred speech Dysphagia Spastic tongue Brisk jaw jerk Dysarthria
A fit and well 25 year old woman attends A and E complaining of weakness in her legs. 2 weeks ago she had an episode of food poisoning from which she made a full recovery. 5 days ago she started to get numbness in her toes which has spread to her feet ankles and shins. This morning she woke up and was unable to move her feet. She is very anxious. She has a mild low back ache. On examination tone is reduced in her lower limbs, there is sensory loss, weakness, reduced knee and absent ankle reflexes. What is the differential?
Guillain Barre syndrome Cauda equina and conus medullaris syndromes Chronic inflammatory demyelinating polyradiculoneuropathy Myasthenia gravis Heavy metal toxicity Lyme disease MS Botulism
What is the pathological process involved in Guillain barre syndrome?
Post infective immune mediated
Antibodies that cross react with glycolipids and gangliosides distributed through myelin in peripheral nervous system
What investigations can be used to confirm guillain barre syndrome?
Nerve conduction studies: slowed conduction
LP: elevated CSF protein
LFT: elevated AST and ALT
Spirometry: reduced vital capacity, max inspiratory pressure
Antiganglioside antibody
What is the management for guillain barre syndrome?
IV immunoglobulin 400mg/kg/day for 5 days
Plasma exchange if IgA deficiency or renal failure
DVT prophylaxis
Intubation and ventilation
Gabapentin or carbamazepine for pain
Fluid boluses if hypotensive
What are the characteristic features of myasthenia gravis?
Skeletal muscle weakness
Increased fatigability
What thymus problems do people with myasthenia gravis have?
65% hyperplasia of thymus
12% thymoma
How do you treat myasthenia gravis?
Rest
Pyridostigmine - acetylecholinesterase inhibitor
Prednisolone
Azathioprine, mycophenolate or methotrexate
Thymectomy - 25% chance remission, 50% improve symptoms
Severe/life threatening - plasmapheresis, IV immunoglobulin
What is the charity which provides useful information and support to people living with myasthenia gravis?
Myaware
What are side effects of pyridostigmine?
Cholinergic crisis if overdose Diarrhoea Urinary frequency Meiosis Excessive salivation and lacrimation
What might cause a myasthenic crisis?
Drug omission
Infection
Stress
What are indications for an immediate CT head after head injury?
GCS < 13 on initial assessment
GCS < 15 at 2 hours post-injury
Suspected open or depressed skull fracture
Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
Post-traumatic seizure
Focal neurological deficit
More than 1 episode of vomiting
What are indications for a CT head within 8 hours of head injury?
Adults with risk factors who have experienced loss of consciousness or amnesia since injury:
Age 65 years or older
Any history of bleeding or clotting disorders
Dangerous mechanism of injury (pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs)
More than 30 minutes’ retrograde amnesia of events immediately before the head injury
Patient on warfarin
Which nerve is at risk during a carotid endarterectomy procedure?
Ipsilateral hypoglossal
What haemodynamic combination is most likely to be seen prior to coning? What is this reflex called?
Hypertension and bradycardia
Cushing’s reflex - pre terminal event
What are causes of primary brain injury?
Focal: contusion, haematoma
Diffuse: diffuse axonal injury
What are causes of secondary brain injury?
Cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation
What are risk factors for subdural haematoma?
Old age
Alcoholism
Anticoagulation
A 22-year-old mechanic is involved in a fight. He is hit on the head with a hammer. On examination he had clinical evidence of an open depressed skull fracture and a GCS of 6/15. What imaging is indicated?
Urgent neurosurgical review (even before CT head performed)
GCS less than 8
A 67-year-old retired lawyer falls down the stairs. His GCS is 15/15 and he has some bruising over the mastoid. What imaging is indicated?
CT head within an hour
Basal skull fracture, indicated by a positive Battle’s sign
A 52-year-old secretary falls down ‘10-11’ stairs. She complains of neck pain. She has a GCS of 15/15 and no neurology. She is unable to rotate her c-spine 45 degrees to the left and right. What imaging is indicated?
C spine immobilisation and CT c spine
What is Kernigs sign?
Positive when the thigh is flexed at the hip and knee at 90-degree angles and subsequent extension of the knee elicits pain. This can be indicative of meningism of subarachnoid haemorrhage
An elderly patient with a precious history of spinal canal stenosis sustains an extension injury of the cervical spine. The upper limbs are more affected than the lower and perianal sensation is preserved. What is the likely diagnosis?
Central core syndrome - motor and sensory loss, upper limbs mainly
What are some causes of a spastic paraparesis?
Metastatic infiltration of the spine
Vascular disorders
Osteoporotic collapse of vertebrae
What are some causes of facial nerve palsy?
Intracranial: brain stem tumour, stroke, ms, acoustic neuroma
Intratemporal: otitis media, Ramsay hunt, cholesteatoma
Infratemporal: parotid tumour, trauma
Other: sarcoidosis, guillain barre, diabetes, Bell’s palsy
In a patient presenting with amaurosis fugax but is otherwise fit and well, what treatment should they be started on?
Clopidogrel 75mg od
OR
Aspirin 75mg od plus dipyridamole mr 200mg bd if intolerant to clopidogrel
In a patient presenting with amaurosis fugax and af, what treatment should they be started on?
Warfarin - stroke risk
What are the layers of the scalp?
S: Skin from which head hair grows. Contains numerous sebaeceous glands and hair follicles
C: Connective tissue. A dense subcutaneous layer of fat and fibrous tissue containing nerves and vessels
A: Aponeurosis (epicranial or galea aponeurotica). Tough layer of dense fibrous tissue which runs from frontalis anteriorly to occipitalis posteriorly
L: Loose areolar connective tissue layer, easy plane of separation between upper three layers and pericranium. Referred to as danger zone because of ease by which infectious agents can spread through it to emissary veins which drain into the cranium. Made up of collagen I, collagen III, glycosaminoglycans
P: Pericranium is the periosteum of skull bones and provides nutrition to bone and the capacity for repair
What is Hutchinson’s sign?
Vesicles on tip or side of the nose, precedes the development of ophthalmic herpes zoster - sight threatening
Nasociliary branch of the trigeminal nerve innervates both the cornea and the lateral dorsum of the nose as well as the tip of the nose
What is the Le Fort fracture classification?
Fractures of midface, which involve separation of all or a portion of the midface from the skull base. In order to be separated from the skull base the pterygoid plates of the sphenoid bone need to be involved as these connect the midface to the sphenoid bone dorsally
Le Fort 1 is a horizontal maxillary fracture, separating the teeth from the upper face (floating palate)
Le Fort 2 is a pyramidal fracture, with the teeth at the pyramid base, and nasofrontal suture at its apex (floating maxilla)
Le Fort 3 is craniofacial dysjunction (floating face)
What is the Monroe Kellie principle?
Pressure-volume relationship that aims to keep a dynamic equilibrium among the essential non-compressible components inside the rigid compartment of the skull
Average intracranial volume in an adult is around 1700 mL, composed of brain tissue (1400 mL), CSF (150 mL), and blood (150 mL). The volume of these three components remains nearly constant in a state of dynamic equilibrium. Thus, a decrease in one component should be compensated by the increase in other and vice-a-versa
What should be given to prevent vasospasm in a subarachnoid haemorrhage?
Nimodipine - CCB
What complications are we aiming to prevent in management of SAH?
Rebleeding Vasospasm Hydrocephalus Hyponatraemia Seizures Acute pulmonary oedema Cardiac dysfunction
What is the difference between a communicating and obstructive hydrocephalus?
Communicating: impaired cerebrospinal fluid reabsorption in absence of any CSF-flow obstruction between the ventricles and subarachnoid space - SAH, meningitis. Functional impairment of the arachnoidal granulations
Obstructive: CSF-flow obstruction. Foramen of Monro obstruction may lead to dilation of lateral ventricles
Aqueduct of Sylvius, normally narrow to begin with, may be obstructed and lead to dilation of both lateral ventricles as well as the third ventricle
Fourth ventricle obstruction will lead to dilatation of the aqueduct as well as the lateral and third ventricles
Foramina of Luschka and foramen of Magendie may be obstructed due to congenital malformation
How is brain stem death confirmed?
Preconditions: apnoeic coma, defined cause of severe and irreversible brain damage, core temperature above 34
Tests by 2 doctors, repeated
Fixed unresponsive pupils with absence of direct and consensual light reflexes
Absent corneal reflexes
Absent vestibulo ocular reflexes
Absent motor activity after painful stimuli
Absent gag reflex
Absent spontaneous respiration
What are causes of neck stiffness?
Meningitic conditions
Tumours
Subarachnoid haemorrhage
Bony abnormalities: cervical spondylosis
What are features of benign essential tremor?
Postural tremor worse if arms outstretched
Improved by alcohol and rest
Cause titubation
What is the management for essential tremor?
Propranolol
Primidone
What are the criteria for ABCD2 for prognosis in TIA?
Age > 60
Blood pressure >140/90
Clinical features: unilateral weakness (2), speech disturbance (1)
Duration of symptoms: >60 mins (2), 10-59 mins (1)
Diabetes
What does an ABCD2 score of 4 or above tell you?
Had TIA and are at higher risk of stroke
Need aspirin started immediately
Specialist assessment and investigations within 24 hours of symptoms
Secondary prevention
What needs to be done if an ABCD2 score is 3 or below?
Specialist assessment within 1 week of symptoms
If vascular territory or pathology uncertain, refer for imaging
What should be done with patients with crescendo TIAs? (Two or more episodes in a week
Treated as high risk of stroke even if ABCD2 score is 3 or less
Why does myeloma increase risk of stroke?
Paraproteinaemia - hyperviscosity of blood
Which drugs are used for migraine prophylaxis?
Topiramate or propranolol
Which migraine prophylaxis drug is preferable in a woman of child bearing age?
Propranolol preferable to topiramate due to teratogenic effects and reduced effectiveness of hormonal contraceptives
What is first line management for an acute migraine?
Combination therapy with oral triptan and NSAID/paracetamol
An 18 year old female presents with tremor and dysarthria, there is a family hx of early onset liver disease. Blood tests show a raised ALT. What is the most likely diagnosis?
Wilson’s disease
How is Wilson’s disease inherited?
Autosomal recessive
What is the defect in Wilson’s disease?
ATP7B gene on chromosome 13 leading to excessive copper deposition in tissues due to increased absorption and decreased hepatic excretion
What are features of Wilson’s disease?
Liver: hepatitis, cirrhosis
Neuro: basal ganglia degeneration, speech and behavioural problems, asterixis, chorea, dementia
Kayser-fletcher rings
Renal tubular acidosis (fanconi syndrome)
Haemolysis
Blue nails
How is a diagnosis of Wilson’s disease made?
Reduced serum caeruloplasmin
Reduced serum copper
Increase 24h urinary copper excretion
What is the management of Wilson’s disease?
Penicillamine (chelates copper)
Trientine hydrochloride
What is the preferred benzodiazepine to give IV in the presence of ongoing seizures?
Lorazepam
What is the preferred benzo to give in a child with ongoing seizures?
Buccal midazola,
What is the next line of management if seizures were to continue despite two doses of benzodiazepine?
Phenytoin
Senior help as intubation and ventilation may be required
What is Charcots triad in the context of MS?
Suggestive of cerebellar lesions in MS
Nystagmus
Intention tremor
Staccato speech
In a patient presenting with headache and amenorrhoea combined with some visual field loss, what needs to be investigated and how?
Pituitary lesion
Assessment of pituitary function, MRI and serum prolactin
What are the International Headache Society diagnostic criteria for migraine without aura?
At least 5 attacks fulfilling:
Headache lasting 4-72 hours
Headache that is: unilateral, pulsating, moderate to severe, aggravated by activity
During headache: nausea/vomiting, photo/phonophobia
Not attributed to another disorder
Give examples of typical auras that precede migraines
Transient hemianopic disturbance
Spreading scintillating scotoma (jagged crescent)
Develop over at least 5 mins and last 5-60 mins
What is the oxford stroke classification? (Bamford)
Total anterior circulation infarct: middle and anterior cerebral arteries. Hemiparaesis/hemisensory loss, homonymous hemianopia, higher cognitive dysfunction
Partial anterior circulation infarct: smaller artistes of anterior circulation. 2 of above criteria
Posterior circulation infarct: vertebrobasilar arteries. Cerebellar/brainstem syndromes, loss of consciousness, isolated homonymous hemianopia
Lacunar: perforating arteries around internal capsule, thalamus, basal ganglia. Unilateral weakness/sensory deficit, pure sensory, ataxic hemiparesis
What is lateral medullary syndrome?
Posterior inferior cerebellar artery stroke
Wallenbergs syndrome
Ipsilateral ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy - horners
Contralateral limb sensory loss
What is webers syndrome?
Ipsilateral III palsy
Contralateral weakness
Which conditions are associated with berry aneurysms?
Adult polycystic kidney disease
Ehlers-Danlos syndrome
Coarctation of the aorta
What are some causes of subarachnoid haemorrhage?
Berry aneurysm rupture
AV malformations
Trauma
Tumours
How should subarachnoid haemorrhage be investigated?
CT
Lumbar puncture after 12 hours (time for xanthochromia to develop)
What are complications of subarachnoid haemorrhage?
Rebleeding
Obstructive hydrocephalus
Vasospasm leading to cerebral ischaemia
What is the management of subarachnoid haemorrhage?
Neurosurgical opinion
Post op nimodipine 60mg/4h if BP allows
What is an Adie pupil?
Tonically dilated pupil
Slowly reactive to light with more definite accommodation response
Damage to parasympathetic innervation of eye due to viral or bacterial infection
Accompanied by absent knee or ankle jerks
What is a Marcus-Gunn pupil?
Relative afferent pupillary defect seen during swinging light examination
Pupil constricts less and therefore appears to dilate when like swung from unaffected to affected eye
Damage to optic nerve or severe retinal disease
What signs does horners produce?
Miosis (pupil constriction)
Ptosis (droopy eyelid)
Apparent enopthalmos
Anhydrosis
What is Hutchinsons pupil?
Unilaterally dilated pupil unresponsive to light
Compression of oculomotor nerve by intracranial mass
What is an Argyll Robertson pupil?
Bilaterally small pupils that accommodate but don’t react to bright light
Prostitutes pupil - neurosyphilis
Diabetic neuropathy
Which infection classically triggers Guillain Barre?
Campylobacter jejuni
What are characteristic features of Guillain Barre?
Progressive weakness of all 4 limbs, ascending
Proximal muscles before distal
Very few sensory signs
Areflexia
Cranial nerve involvement - diplopia
Autonomic involvement - urinary retention
Aneurysm where needs to be ruled out with an acute onset painful third nerve palsy?
Posterior communicating artery
Which type of motor neurone disease carries the worst prognosis?
Progressive bulbar palsy
What is the most common presentation of MS?
Optic neuritis
In which tubes from a lumbar puncture should red blood cell count be determined?
4 tubes altogether
RBC count in 1 and 4
What features of CSF suggest SAH?
Elevated opening pressure
RBC that does not diminish between tubes 1 and 4
Xanthochromia after 12 hours
What are the different forms of motor neurone disease?
Amyotrophic lateral sclerosis
Primary lateral sclerosis
Progressive muscular atrophy
Progressive bulbar palsy
What is a rosier scale assessment?
Differentiate patients with stroke and stroke mimics LOC -1 Seizure -1 Facial weakness +1 Arm weakness +1 Leg weakness +1 Speech disturbance +1 Visual field defect +1 Stroke likely if score >0
Which medications are associated with IIH?
Tetracycline antibiotics Isotretinoin Contraceptives Steroids Levothyroxine Lithium Cimetidine
What are risk factors for IIH?
Obesity
Female
Pregnancy
Drugs: OCP, steroids, tetracycline, vit A, lithium
What are features of IIH?
Headache Blurred vision Papilloedema Enlarged blind spot Sixth nerve palsy
What is the management of IIH?
Weight loss Diuretics - acetazolamide Topiramate Repeated lumbar puncture Surgery - optic nerve sheath decompression and fenestration, lumboperitoneal or ventriculoperitoneal shunt
In a patient with a stroke and AF with a slow ventricular response, what is the management?
Aspirin 300mg OD for 2 weeks then lifelong anti coagulation
