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Sheff 3a > Neuro > Flashcards

Neuro Flashcards

1
Q

Cause of a gradual vs sudden onset temporal lobe lesion? Other causes? Presentation?

A

Sudden - Cerebrovascular event
Gradual - space occupying lesion
Trauma, frontotemporal dementia

[Like dementia / psychosis]
Sensory aphasia - language comprehension
Contralateral upper quadrantanopia
Disturbance of auditory/Visual sensation / perception
Altered sexual behaviour
Altered personality
Impaired long term memory

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2
Q

Presentation of a frontal lobe lesion ?

A

Change in personality
Anosmia - loss of sense of smell
Motor aphasia - language production
Contralateral hemiparesis

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3
Q

Presentation of a parietal lobe lesion ?

A

Hemiparesis
Decreased 2-point discrimination
Astereognosis - inability to recognise familiar object in hand
Sensory inattention - ignoring Half of body Eg. Will only draw half a clock face

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4
Q

What lobe affected in gerstmann’s syndrome? What 4 characteristic feautes?

A

Parietal
Inability to write - dysgraphia
Inability for mathematics - acalculia
Inability to identify own finger - finger agnosia
Inability to distinguish left and right side of body

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5
Q

Presentation of occipital lobe lesion

A

Contralateral homonymous hemaniopia

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6
Q

Presentation of a midbrain lesion

A

Unequal pupil sizes
Inability to direct eyes up/down
Short term amnesia + confabulation
Somnolence - strong desire to sleep

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7
Q

Causes of cerebellar lesion? Presentation?

A

CVE, space occupying lesion, infection
Nutritional - wernickes, vitamine E, gluten ataxia

DANISH
Dysdiadochokinesia - can do rapid alternating movements (turn hand on hands )
Ataxia
Nystagmus
Intention tremor + dysmetria (past-pointing)
Staccato speech
Hypotonia + pendular reflexes

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8
Q

Damage to the posterior inferior cerebellar artery causes? Sx?

A

Wallenberg’s syndrome

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9
Q

Which tumour do you get in the cerebellar pontine angle? Presentation?

A

Acoustic neuroma

Ipsilateral deafness / tinnitus
Facial / trigeminal palsy’s -> facial numbness, reduce corneal reflex
Cerebellar -> Eg ataxia, nystagmus

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10
Q 
Vision in lesion to (all on right side) 
1 - optic nerve 
2- optic chiasm (central)
3 - optic chiasm (peripheral) 
4- optic tract 
5-
A

1- blindness of right eye
2- bipolar hemianopia due to midline lesion
3- right nasal hemaniopia due to lesion involving right perichiasmal area
4- left homonymous hemaniopia (blind on left side of both eyes)

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11
Q

Glasgow coma scale parts?

A

Best eye movement
Best verbal response
Best motor response

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12
Q

DDs of headache

A 
Subarachnoid Haemorrhage
Migraine
Cluster Headache
Meningitis, Encephalitis
Tension-Type Headache
Medication-Induced Headache
Giant Cell Arteritis
Subarachnoid Haemorrhage
Migraine
Cluster Headache
Meningitis, Encephalitis
Tension-Type Headache
Medication-Induced Headache - analgesics / Tristan’s >17days/month 
Giant Cell Arteritis
Sinusitis
Raised ICP
CVE/TIA
Idiopathic Intracranial Hypertension
Cervical Spondylosis
Temporomandibular Joint Dysfunction
Dental Abscess
Glaucoma
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13
Q

Headache red flags

A 
Change in pattern of headache 
New headache >50yrs 
Seizures 
Systemic illness (myalgia, fever, malaise , weight loss) 
Personality change 
Acute onset of worst headache ever 
Scalp tenderness / jaw claudication 
Focal neurological finding s s
Symptoms of raised ICP - eg vomiting
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14
Q

Symptom and sign triad of meningism

A

Sx - Headache, photophobia, nuchal rigidity (stiff neck)

Signs - kernigs - hip flexion and knee extension = pain
Brudzinski - lift head off couch -> involuntary lifting of legs
Nuchal rigidity -> inability to flex neck forward

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15
Q

RF for meningitis? Usual causes? Non infective causes?

A

CSF shunts, spinal anaesthetics, Diabetes, alcoholism, IVDU, malignancy, crowding

Viral - mumps, HSV, HIV
Fungal - crytococcus (usually immune compromised)
Bacterial
-neonate - group B strep
- young children - h influenza type b
- Adults - s. Pneumoniae, h influenza type b, n meningitidis
- elderly / immune compromised - s pneumonia, listeria
- hospital aquired - klebsiella pneumonae, E. coli

Non infective - malignancy, sarcoidosis, SLE.

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16
Q

Presentation of meningitis

A 
Menigism (no nuchal rigidity in neonate) 
Fever 
Bulging fontanelle (neonates) 
Opisthotonos (arching of back) 
Altered mental state 
Shock
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17
Q

Investigations in meningitis

A

Lumbar puncture - gram stain, Ziehl neelsen, cryology, glucose, protein, culture, rapid antigen screen

Blood - FBC, CRP, culture, coagulation, glucose, U&E, ABG

Urine, nasal swab, stool culture

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18
Q

Sx of raised ICP

A

Vomiting, reduced consciousness, headache, fits

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19
Q 
LP normal 
Pressure
Appearance 
Cell count 
Protein g/L 
Glucose mmol/L
A 
10-20 
Clear 
5/mm2
0.2-0.4 
>1/2 plasma
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20
Q 
Bacterial 
Pressure
Appearance 
Predominant cell 
Cell count 
Protein g/L 
Glucose mmol/L
A 
High 
Turbid 
Polymorphism - neutrophils 
>1000 (high) 
>1.5 
<1/2 plasma
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21
Q 
Vial LP 
Pressure
Appearance 
Predominant cell 
Cell count 
Protein g/L 
Glucose mmol/L
A 
±high 
Clear 
Mononuclear - lymphoctes 
10-1000 (high) 
±high 
± < 1/2 plasma
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22
Q 
Tb LP 
Pressure
Appearance 
Predominant cell 
Cell count 
Protein g/L 
Glucose mmol/L
A 
High 
Fibrin web 
Mononuclear - lymphocytes 
50-1000 (high) 
>1.5 - usually higher than bacteria 
<1/2 plasma
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23
Q

CI to doing LP?

Complications?

A

Raised ICP (GCS <9, focal neurology, age relative bradycardia + hypertension)
Shock
Coagulation abnormalities

Complications - post LP headache, infection, bleeding, cerebral herniation

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24
Q

Mx of meningitis for all?
Viral?
Bacterial?

A

Fluids, antipyretic, antiemetics

HSV -> acyclovir CMV -> ganciclovir

Bacterial 
Blind/meningococcus/h influenza -> IV ceftriaxone 
Pneumococci -> vancomycin + ceftriaxone 
Grou B strep -> IV cefotaxime 
Listeria -> IV amoxicillin + gentomycin

+ dexamethasone in children

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25
Q

Complications of meningitis?

A 
Sepsis, septic shock, DIC
Seizures, coma, raised ICP,
Septic arthritis
Haemolytic anaemia (h influenzae) 
SIADH 
Deafness / hydrocephalus
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26
Q

Prevention of meningitis

A

Vaccination (h influenzae, meningococcus, strep pneumonia)

Ciprofloaxacin prophylaxis (meningococcal ) 
Rifampicin prophylaxis
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27
Q

Usual organism for menigicoccal septicaemia ? Type ?

A

Neisseria menigitidus
Gram -ve diplococcus, sero groups A/B/C/Y/W
Often found in nasopharynx

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28
Q

Presentation of meningococcal septicaemia ? Pre-hospital management?

A

Non blanching Petachial rash + sepsis (cold peripheries, Cap refil >2s, hypotensive)
±meningitis presentation
Paed - cold peripheries, Leg pain, unusual skin colour

Suspected + non blanching rash -> IV/IM benzylpenicillin

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29
Q

Meningococcal septicaemia investigations

A 
Blood cultures 
FBC, U&amp;E, LFT, CRP 
DIC - raised PT / apTT, Low platelets / fibrinogen 
Pharyngeal swab 
LP - ±CT to exclude raised ICP
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30
Q

Mx of meningococcal septaemia in hospital?

A 
Resuscitation 
<3months - cefotaxime + amoxicillin 
>3 months - ceftriaxone 
Travel - add vancomycin 
Later on -> dialysis
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31
Q

Complications of meningococcal septicaemia

A

Seizures , raised ICP
DIC, adrenal failure
Later - deafness, hydrocephalus

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32
Q

Prevention of meningococcal septicaemia

A

Ciprofloaxcin ± menigicoccal vaccine prophylaxis

MenACWY vaccine - Uni students / pilgrims

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33
Q

What is encephalitis? Usual cause? Other ? Presentation? Presentation in neonate

A

Inflammation of brain parenchyma
HSV-1 (often in temporal/ frontal lobe -> temporal lobe epilepsy)
HSV-2 -> usually in neonates , CMV -> usually immunocompromised
bacterial - TB, mycoplasma, listeria

Meningitis presentation - fever, headache, altered mental state
Raised ICP - severe headache, vertigo, seizures

Neonate - legarthy, irritability, poor feeding, building Fontanelle, seizures

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34
Q

Encephalitis investigations? Mx? Why do you have to be careful with fluids

A

Bloods - leukocytosis, culture, LFTs, ESR/CRP
CT head - exclude stroke / SOL / basilar fracture
- raised ICP for LP
LP - Viral picture -> viral PCR.
EEG
MRI

IV/IM benzylpenicillin
IV acyclovir
IV fluid -> good but be careful as risk of cerebral oedema

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35
Q

Complications of encephalitis ?

A 
SIADH 
DIC 
Cardiac/resp arrest 
Epilepsy 
Personality change
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36
Q

Usual cause of subarachnoid haemorrhage? Other? RF?

A

Berry aneurysm
Non aneurysm haemorrhage, Arteriovenous malformation, vasculitis

HTN, smoking, cocaine, alcohol, ADPKD, Ehlers-Danlos, Marfans, neurofibromatosis

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37
Q

Usual presentation of SAH? Other pres?

A

Sudden occipital severe headache, vomiting, acute confusion, seizure

10% have sentinel bleeds

  • ~3ks prior to SAH due to small leaks in aneurysm
  • headache (SAH like but resolve), dizziness, orbital pain, sensory/motor disturbance
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38
Q

Most common place for berry aneurysm? Other 2 most common?

A

Junction of anterior communicating artery and anterior cerebral artery

Middle cerebral artery bifurcation

Posterior communicating - internal carotid junction

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39
Q

Signs of SAH?

A

Meningism - 6hr after headache
Altered GCS
Intraoccular haemorrage (15% -> ophthalmoscopy)
Focal neurology

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40
Q

If the patient with SAH had CNiii palsy where would you guess the aneurism was?

A

PCOMA-ICA junction

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41
Q

Ix for SAH? What would you find?

A

CT head non contrast ± Lumbar puncture
LP may have xanthochromia (yellowish discolouration of CSF after 12 hrs

Cerebral angiography -> locate aneurism

ECT - QT prolongation, Q waves, dysthymia

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42
Q

Where is CSF produced? Which layer of meningies and how? Absorbed where?

A

Choroid plexus in ventricles
Ventricles and flows into Subarachnoid space through median and lateral apertures
Dural venous sinuses

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43
Q

Mx of SAH ? Complications ?

A

Resuscitation
Nimodipine -> reduce vasospasm
Nitroprusside / labetalol -> control HTN
Coiling (through femoral catheterisation) OR clipping (craniotomy)

Complications - rebleeding, cerebral ischemia (vasospasm), hydrocephalus, cardiac arrest

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44
Q

Causes of raised ICP

A

Neoplasm - mets, hliomas, pituitary adenomas, acoustic neuromas
Haematoma - extra/sub dural, intra cerebral, SAH
Abscess / cysts
Oedema - trauma, infection, trauma (Diffuse oedema - SAH, encephalitis, meningitis)
Obstructive / communicating hydrocephalus
Cerebral venous thrombosis
Idiopathic intracranial hypertension

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45
Q

Mets to brain, where is the most likely place its from

A

Lung > breast > colon > melanoma

Top 4

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46
Q

Presentation of raised ICP ? What could be a false localising sign?

A

Headache - nocturnal, worse on waking / coughing / bending forward / lying
Papilloedema - bilateral
Vomiting - no nausea
Altered mental state - lethargy, irritable, abnormal behaviour -> COMA

Unilateral pupil irregularity / dilation
6th nerve palsy ->Diplopia (false localising sign)

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47
Q

What would you see looking at papilloedema ?

A

Blurred disk margins

Venous engorgement, loss of venous pulsation, venous haemorrhage

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48
Q

Ix of ICP? Mx?

A

CT/MRI head
ICP monitoring - using catheters into different spaces Eg subdural, epidural, SA, ventricular …

Resuscitation if needed - bed head elevation
If seizures -> anticonvulsants
CSF drainage - ventriculostomy
Analgesia ± sedation ± neuromuscular blockade
Mannitol (diuretic used in ICP)

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49
Q

What 3 false localising signs do you get with a space occupying lesion ?

A

6 nerve palsy - 1 eye is turned inwards due to limited abduction of lateral rectus

Horner’s syndrome - sympathetic trunk damage - ipsilateral miosis (constricted pupil), ptosis (weak eyelid) and anhydrosis (decreased sweating)

Cerebellar signs - DANISH

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50
Q

Where is the blood in an extra dural haematoma? Causes? Which vessel?

A

Blood in the potential space between bone and dura

Fracture of temporal/parietal bone, middle meningeal artery / vein damage
Acute (60%), sub acute (30%), chronic (10%)

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51
Q

Presentation of an extra dural haematoma

A

1 - Trauma + LOC
2 - Lucid interval
3- Deterioration

Headache (severe and progressive) N+V, seizures, bradycardia ± HTN, CSF otorrhoea/ rhinorrhoea, altered GCS

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52
Q

Extra dural Ix? Mx?

A

Blood - FBC U&E coagulation
X-RAY skull - fractures
X-ray cervical - injury must be excluded
CT head - haematoma

Resuscitation
Mannitol / hypertonic saline
Burr hole / craniotomy + clot evacuation

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53
Q

Complications of extra dural? Prevention?

A

Neurological deficits, post traumatic seizures

Helmets - bikes, boxing, horse riding
Alcohol

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54
Q

CT of extra dural, what do you see?

A

Lens shaped haematoma NOT crossing suture lines
Midline shift
Soft tissue swelling

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55
Q

Pathology of subdural haematoma? usual cause?

A

Blood in space between dura and arachnoid
Bridging vein tear (cortex -> Venus sinus), cortical artery damage
Acute, subacute (3-7d post trauma), chronic (2-3wk post trauma)

Trauma - if in paeds / elderly think of physical abuse

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56
Q

Rf for subdural

A

Paeds
Elderly - cerebral atrophy -> tension on veins
Alcoholism - prolonged bleeding
Anticoagulation

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57
Q

Subdural acute presentation? Chronic? Other signs?

A

Acute

  • trauma ± LOC
  • lucid interval (few hrs)
  • decreasing GCS -> LOC

Chronic

  • 2-3wk post trauma
  • gradually progressive Sx - anorexia, N&V, headache, focal limb weakness, speech impairment, confusion

Raised ICP, skull brushing, purpura

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58
Q

Ix for subdural? Mx? Complications?

A

Blood - FBC, U+E, LFT, coag
CT NON contrast

Resuscitation, mannitol / hypertonic saline
Burr hole / craniotomy + clot evacuation

Raised ICP, cerebellar herniation, cerebral oedema, recurrent haematoma, seizures, permanent neurological deficit

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59
Q

Seen on CT of subdural

A

Crescent shaped haematoma crossing suture lines, mid line shift

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60
Q

What is a basilar skull fracture? What happens? Signs?

A

Fracture of the base of skull - temporal, occipital, sphenoid/ethmoid
Fracture -> tear in meninges -> CSF leakage

Panda eyes
Battles sign - bruising over mastoid process (behind ear)
Haemotypanum - blood in the middle ear
CSF - rhinorrhoea / otorrhoea

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61
Q

Triggers of migraine? Mnemonic

A 
CHOCOLATE 
CHeese 
Oral contraceptive 
Caffeine 
AlcohOL 
Anxiety 
Travel 
Exercise
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62
Q

Types of migraine ?

A 
1- migraine without aura 
2 migraine with aura 
3 migraine aura without headache 
4 Hemiplegic migrane - hemiplegia ± aphasia 
5 menstural migrane
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63
Q

Presentation of migrane

A

Premonitory phase: fatigue, irritable, depressed
Aura - 1/3rd
Before headache and usually <60mins
Visual - scintillating Scotoma, geometric patterns
Somatosensory - unilateral, numbness, paraesthesia hand-> arm -> face

Migrane
Headache - unilateral, pulsating, severe 4-72 hrs
N+V
Photophobia, phonophobia (sounds)

Resolution phase - fatigue, irritable, depressed

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64
Q

Signs of migrane? Management during?

A

Nothing between attacks
During attack -> facial oedema, scalp tenderness

Attack + trigger migraine diary -> identify and address triggers
Acute, severe -> pharma
1 - Analgesic (paracetamol / aspirin) + Triptan
2- rectal analgesic (diclofenac) + anti-emetic (domperidone)
3- anti migrane drugs - triptan / ergotamine

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65
Q

What are CI to Triptans? What receptor do they act on?

A

CI - uncontrolled hypertension, CHD/CVD (or RF for these), angina

5-hydroxytryptamine agonist

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66
Q

How many migranes usually before preventative pharma used? What is it?

A

> /= 2 attacks / month + >/= 3days disability per attack
Medication use >2d per week

Triptans and if CI/ ineffective
1- b-blocker (atenolol / propranolol) OR topiramate
2- acupuncture
3 - gabapentin

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67
Q

CI to use of b blockers

A

PVD, asthma, depression, myasthenia gravis

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68
Q

Complication of migrane

A

Depression, bipolar, anxiety
Status migrainous (>72hrs)
Migrainous infarct
Increased risk or ischemic / haemorrhagic stroke

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69
Q

Why/ When is COCP CI with migraine ?

A

Due to additive risk of ischemic stroke

Migrane with aura
Migrane without aura but RF (DM, obesit, smoking , HTN, FH)
Status migrainous
Migraine treated with ergotamine

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70
Q

Mx of migraine when pregnant / breast feeding ? What can you not?

A

Ibuprofen (<30wks)
Promethazine
Propranolol

No aspirin (Reyes), no Triptans

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71
Q

Who usually gets cluster headaches? What is the usual headache pattern?

A

Male 20-40yrs

45-90mins 1-2 times in a day over 6-12 weeks
Usually every year / other year

Often at night 1-2 hrs after falling asleep

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72
Q

Presentation of cluster headaches

A

Headache - rapid onset, sharp, localised around eye

Ipsilateral autonomic feautes - lacrimation, rhinorrhoea, facial flushing, eyelid swelling, partial horners

Restless - can’t keep still, banging head (opposite of migrane )

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73
Q

Common trigger for cluster? Mx of acute?

A

Alcohol
Histamine, nitroglycerine (vasodilator used to treat angina that doesn’t respond to oral)

Subcutaneous sumatriptan + O2

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74
Q

Prevention of cluster?

A

Stop smoking / no alcohol
1- verapamil ± prednisolone
2- lithium

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75
Q

Presentation of tension type headaches

A

Headache - gradual onset, generalised, bilateral, band-like, fronto-occipital, neck radiation
May have mild nausea

NO - photophobia, phonophobia, visual/sensory/motor disturbance

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76
Q

Mx of tension type headache

A

Identify + address stress, anxiety, depression
Exercise + posture
Pharma = NSAID / paracetamol, amitriptyline

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77
Q

Pathology of trigeminal neuralgia ? Who normally gets it? Triggers? Cause?

A

Neuropathic disorder of trigeminal nerve (maxillary / mandibular branches)
Females 50-60
Shaving, washing, brushing teeth, eating

Compression by loop of artery / vein
5-10% is tumour, ms, avm, cavernous sinus mass

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78
Q

Pain pattern in trigeminal neuralgia? Presentation?

A

Seconds - few mins
Some people can get 100s of attacks / day
Often have a remission of months -> years

Facial pain - sudden unilateral, sharp/shock like
Often -> precedes parathesia
Tic doloureux (face skewing up)

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79
Q

Ix / mx in trigeminal neuralgia

A

MRI - to exclude other causes of compression

Education / pain referral
Pharma
- carbamazepine / lamotrigine
Surgery - rhizotomy, gamma knife, micro vascular decompression

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80
Q

Pathology of giant cell arteritis? RF?

A

Systemic immune mediated vasculitis of medium / large sized arteries

Age - 60-80yrs
Female
European

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81
Q

Presentation of GCA

A

Headache - temporal, severe
Scalp tenderness
Jaw claudication - pain during chewing / talking
Visual disturbance - diplopia, AMAUROSIS FUNGAX, blurred vision
Systemic - malaise, myalgia, malaise, fever weight loss

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82
Q

Investigation / mx in GCA ?

A

Raised ESR ± CRP
Normocytic, normochromic anaemia, thrombocytosis
Temporal artery biopsy / US

Prednisolone (PO high dose_
Aspirin low dose
PPi

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83
Q

3 Complications of GCA

A

Aortic (thoracic) aneurysm / dissection
Loss of vision (20% in severe)
CNS - seizures
Complication of steroid use

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84
Q

Prolonged high dose of steroids complications

A

Skin - thinning
Soft tissue - truncal obesity, buffalo hump, moon face, hirtuism, oedema
Neuro - neuropathy
Cardio - HTN
MSK - osteoporosis
Endocrine - adrenal cortex suppression, diabetes
Immune suppression
Development - growth retardation
Ophthalmic - cataract, narrow angle glaucoma.

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85
Q

Pathology of TIA? What is it called when you have 2 or more in 1. Week? RF?

A

Temporary inadequacy of part of brain circulation
Crescendo TIA

Black, age, male

86
Q

Usual cause of TIA

A

Embolism - carotid, AF, mitral/arotic valve disease, post MI mural thrombus
Carotid 80%, vertebrobasilar 20%

87
Q

Presentation of TIA ? Carotid vs vertebrobasilar ?

A

10-15 min duration usually with quick onset

Carotid - Hemiparesis, motor dysphasia, amaurosis fungax

Vertebrobasilar - homonymous hemianopia, hemiparesis, hemisensory loss, cerebellar signs

No global symptoms alone (syncope / seizure)

88
Q

Rf for stroke / TIA

A

HTN, smoking, diabetes, heart disease (ischemic, valvular, AF), peripheral artery disease, carotid artery occlusion (bruit), COCP, alcohol, polycythemia Vera (too many RBC produced)

89
Q

DDx of stroke

A 
SOL (subdural haematoma / tumour)
Seizure (post-ictal Todd’s paresis / paralysis) 
Syncope - arrhythmia 
GCA 
Migraine - hemiparesis 
Hypoglycaemia
90
Q

Signs that you might notice o/e which could be the cause of TIA ?

A

AF
HTN
Carotid bruit
Heart murmur

91
Q

TIA ix in primary care? Secondary care? When would you want to do investigations in secondary care?

A

1 - Blood - FBC, ESR, U+E, glucose, LFT, TFT
Urinalysis (glucose)
ECG - AF, MI, ischemia

2 - want to do <1wk post symptoms

  • Diffusion weighted MRI if vascular territory is uncertain / ABCD2 >4
  • ECG abnormality -> echo
  • Carotid Dopplers
92
Q

Mx of tia?

Complications?

A

Aspirin + dipyridamole ± statin
Secondary prevention
AF -> anticoagulation
Carotid endarterectomy

DRIVING - car/bike -> no notification but don’t drive for 1 month
Lorry/bus - licence revoked for 1 year

CVE, MI

93
Q

When would you send TIA for specialist assessment?

A

Crescendo

ABCD2 >4/7

94
Q

What are parts of ABCD2 ? What is it used for?

A

Score for risk of stroke post TIA
Age >60
Blood pressure >140/90 (either part above)
Clinical features - speech disturbance =1, unilateral weakness =2
Duration - >60mins = 2, >10 = 1
Diabetes

Indicates prognosis and choice of doing diffusion weighted MRI

0-3 -> low risk, 4-5 moderate risk, 6-7 high risk (8%) of stroke in 2days

95
Q

Types of stroke ?

Cause in young/old?

A

Cerebral infarction - 70%
Primary haemorrhage - 15%
SAH - 5%

Young - vasculitis, thrombophilia, SAH

Old - thrombosis in situ, athero-thromboembolism Eg carotid
Heart emboli - AF, IE, mi
CNS bleed - HTN, trauma, aneurysm rupture

96
Q

Signs of ischemic stroke ? Haemorrhagic?

A

Ischemia - carotid bruit, AF, hx of TIA

Haem - menigism, severe headaches, coma within hours

97
Q

Areas and Presentation of stroke

A 
Cerebral hemisphere - 50% 
Contralateral hemiplegia - flaccid->spastic 
Contralateral sensory loss 
Homonymous hemaniopia 
Dysphasia

Brainstem 25%
Quadriplegia, vision changes
Cerebellar signs
Locked in syndrome, Wallenberg syndrome, dejerine’s syndrome

Lacunar 25%
Pure motor / sensory OR mixed OR ataxia
Intact cognition / consciousness

98
Q

What is locked in / Wallenberg / dejerine syndromes?

A

Locked in - patient aware but cannot move bar eyes and blinking

Wallenberg (lateral medullary) - loss of pain/temperature on ipsilateral side of face and contralateral side of body

  • difficulty swallowing /speech
  • spinothalamic tract

Dejerine (medial medullary) - involved anterior spinal artery

  • deviation of tongue
  • contralateral limb weakness, loss of discriminative touch, proprioception and vibration
  • pain and temperature preserved
99
Q

Stroke diagnosis score?

A

ROSIER
Exclude hypoglcaemia then asses
Score >0 means stroke is likely

100
Q

What system for stroke classsification?
Which Sx should be assessed?
Types and which vessel involved? Sx ?

A

BAMFORD
The following criteria should be assessed:
1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
2. homonymous hemianopia
3. higher cognitive dysfunction e.g. dysphasia

Total anterior circulation infarcts (TACI, c. 15%)
involves middle and anterior cerebral arteries
all 3 of the above criteria are present

Partial anterior circulation infarcts (PACI, c. 25%)
involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
2 of the above criteria are present

Lacunar infarcts (LACI, c. 25%)
involves perforating arteries around the internal capsule, thalamus and basal ganglia
presents with 1 of the following:
1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
2. pure sensory stroke.
3. ataxic hemiparesis

Posterior circulation infarcts (POCI, c. 25%)
involves vertebrobasilar arteries
presents with 1 of the following:
1. cerebellar or brainstem syndromes
2. loss of consciousness
3. isolated homonymous hemianopia
101
Q

Investigations in stroke

A

Bloods - glucose, ESR, platelets

CT head non contrast - exclude haemorrhage

102
Q

Management of stroke acute? Long term?> who is involved?

A

O2, glucose, BP (exclude haemorrhage)

Aspirin 300mg + clopidogrel 75mg in <4.5 hrs
Thrombolysis - alteplase
Surgery - decompresive hemicraniectomy = MCA

Long term
Secondary prevention
Cerebrovascular event rehab
- consultant, nurses, physio, SALT’s, social workers, psychologist, orthoptist

103
Q

Stroke complications

A

Stroke
Mi
Long term impairment -motor, communication, dysphasia mood, cognition
-> aspiration pneumonia, malnutrition, dehydration, bed sores, constipation, depression, incompetence

104
Q

CI to thrombolysis in stroke

A 
Seizure at stroke onset 
SAH sx 
<3m stroke / head injury 
<3wk GI/uro bleed 
<2wk major surgery / trauma 
Hx of intracranial haemorhhage 
AVM / aneurysm 
Anticoagulation - INR>1.7 
Thrombocytopenia - PI<100 
Hypoglycaemia (GLu<2.7 
Severe HTN >185/11- 
Acute pericarditis
105
Q

Prevention of stroke

A

Lifestyle
Blood pressure
AF - anticoagulation
TIA/ischemic with no AF - 1:clopidogrel, 2: aspirin + dipyridamole
Statin
Carotid endarterectomy (correct stenosis), within 2 weeks

106
Q

Need to assess baseline cognition in a patient presenting with delirium ?

A

Use a collateral hx

107
Q

RF for delirium

A

Age, male, pre existing cognitive impairment, severe comorbidity, post op, benzo/alcohol, Hx of delirium

108
Q

Causes of delirium

A

Acute infection - UTI pneumonia sepsis
Drugs - benzo, anticholinergics, anticonvulsants, antiparkinsons…
Surgical - post op
Toxic - alcohol, withdrawal
Vascular - CVE, IHD, haemorrhage
Metabolic - hypoxia, hyper/po glycaemia, hypercalaemia
Vit deficiency - B1/B12
Endo - hyper/po Thyroidism, hyper/po parathyroidism, cushings
Trauma - head
Epilepsy
Malignancy - CNS

109
Q

Presentation of delirium?

A 
Acute onset + fluctuating course 
DELIRIUM
Disordered thinking - slow / irrational 
Euphoric /fearful / angry 
Language - gabbling, repetitive 
Illusions / delusions / hallucinations 
Reversal of sleep wake 
Inattention 
Unaware  (consciousness) 
Memory deficits - short term
110
Q

Two types of delirium and sx?

A

Hypoactive - apathy, quiet, confusion (depression like)

Hyperactive - agitation, delusions, disorientation (schitz like)

Mixed

111
Q

Ix and mx for delirium

A

Abbreviated mental test score / Confusion assessment method for ICU (CAM-ICU)
Bloods - FBC, U&E, glucose, LFT, TFT, cardiac enzymes (troponin), B12, folate, CRP
Urine dipstick / microscopy
Blood culture
ECG
CXR

Mx
Supportive - communication, clock, familiar objects, staff consistency
Environmental - control noise, temp, sleep, space, lighting, nutrition
Medical - stop drugs, haloperidol
Post discharge

112
Q

Complications and prevention of delirium

A

Hospital acquired infection - Eg c diff, MRSA
Pressure sores
Fracture - falls
Cognitive impairment

Prevention
MDT 24hr assessment
Manage cognitive impairment, pain, hypoxia, poly pharmacy

113
Q

3 sx groups of dementia

A

Cognitive impairment - ST memory, language, attention, orientation

Psychiatric disturbance - depression, delusions, hallucinations

Difficulties with ADLs - driving, shopping, dressing

114
Q

Assessment of dementia? Ix?

A

GPCOG
MMSE
AMT - abbreviated mental test

Blood - FBC,ESR/CRP, U&amp;E, LFT, TFT, glucose, b12, folate, calcium 
MSU 
Blood cultures 
CXR 
MRI head 
Psychometric testing
115
Q

Mx of dementia

A

Care coordinator - MDT, respite, carer’s groups, tax
Carer- psychoeducation, psychological therapy
Advance statements, lasting power of attorney, MCA
Mobility
DVLA informed
Routines and planning
Therapy - music, art, dancing, masssage, aromatherapy
Challenging behaviour - lorazepam, haloperidol
Depression
Palliative care

Avoid anticholinergics (tricyclic antidepressant) and antipsychotics

116
Q

Pathology of Alzheimer’s

A

Progressive degeneration of cerebral cortex
Widespread cortical atrophy
Increased beta amyloid peptide
Amyloid plaques + neurofibrillary tangles
Neuron damage - decreased Ach

117
Q

RF for dementia

A

Ageing, Caucasian, FHx, female, apolipoprotein E4 variant, head injury
Vascular RF

118
Q

Early and later presentation of dementia

A

Early
ST memory loss, difficulty finding words

Later
Apraxia, language difficulty, confusion

Later
Disorientation, wandering, apathy
Depression, hallucinations, delusions
Disinhibition, aggression

119
Q

DD of dementia ? Ix?

A 
Normal ageing
other types of dementia
normal pressure hydrocephalus
 Parkinson’s
Hypothyroidism 
Vit b12 deficiency 
Depression, schitzophrenia 
Delirium

MRI head
HMPAO SPECT - differentiate AD vs vascular vs frontotemporal

120
Q

Vascular dementia… pathology, cause, RF

A

Cognitive impairment due to ischemia ± haemorrhage from CVD

Stroke related - multiple infarcts / single infarct
Subcortical - small vessel disease
Mixed

Hx of stroke / TIA, Atrial fibrillation
HTN, DM, hyperlipidaemia, smoking, obesity

121
Q

Diagnosis of vascular dementia

A

1 - Dementia - memory loss + 2 impaired cognitive domains
2 - CVD - based on clinical / brain imaging
3- Relationship between 1 and 2
-onset of dementia within 3 month of stroke
- abrupt deterioration in cognition
- fluctuating STEPWISE progression of cognitive decline

122
Q

Investigations / MX of vascular dementia ?

A

Dementia investigations
MRI head - in facts, cortical lacunae, white matter changes

Dementia management
Address cardio RFs
Donepezil / galatamine

123
Q

Pathology of dementia with Lewy bodies?

A

Lewy bodies in brainstem and neocortex

LB = eosinophilic intracytoplasmic neuronal inclusion bodies

124
Q

Dementia with LB ix? Diagnosis? Mx?

A

Dementia IX
SPECT / PET scan - low dopamine transporter uptake in basal ganglia
MIBG scintigraphy

Diag
1- dementia 
2 - 2/3 core features 
-Fluctuating attention / concentration 
-recurrent well formed visual hallucinations 
- Spontaneous Parkinsonism 
[recurrent falls]

Mx
Dementia mx
AChR inhibitor - rivastigmine

125
Q

Pathology of frontotemporal dementia? Associated ?

A

Frontal / temporal lobe atrophy
Loss of neutrons, no increase in plaques
Protein inclusions (Tau) in cells

Progressive supranuclear palsy
Corticobasal syndrome
MND

126
Q

Presentation, ix and mx of fronto temporal ?.

A

3 presentations
[insidious progression, memory / visual spatial remain intact]
1- behavioural - loss of inhibition, motivation, empathy, change in preferences
2- Semantic - loss of vocabulary / recognition
3- progressive non-fluent aphasia (difficult slow speech, grammar errors)

Ix
Dementia ix 
HD genetics + Wilson’s ix
LP - tau, beta amyloid 
MRI head - frontal / temporal atrophy 
SPECT, FDG-PET

Mx
Dementia mx

127
Q

Presentation of Parkinsonism? Causes?

A

Tremor - resting, ‘pill rolling’, absent during activity
Rigidity - increased tone, ‘leadpipe’
Bradykinesia - mask like face (reduced expression), reduced arm swing, shuffling, difficulty stopping

Idiopathic PD
Multiple cerebral infarcts
Parkinson plus syndromes - Lewy body dementia, Progressive supranuclear palsy, multiple system atrophy
Drugs - antipsychotics, metoclopramide (dopamine agonist)
Toxin - Wilson’s

128
Q

Presentation of Parkinson’s? Pathology? RF? Diagnosis?

A

Insidious, unilateral onset, persistent asymmetry
Parkinsonism pres
Normal reflexes
Anosmia, visual hallucinations, depression, dementia

Pars compacta of substantia nigra
Reduction of dopamine
Reduced basal ganglia -> cortex communication

RF - age, male, pesticide

Diagnosis
1- bradykinesia
2- muscular rigidity OR 4-6Hz resting tremor OR postural instability

129
Q

DDx of Parkinson’s?

A

Benign essential tremor (worse on movement, less on rest)
Drug / toxin induced
HD, WD, vascular / LB / FT dementia
Progressive supranuclear palsy - vertical gaze abnormalities
Multiple system atrophy - postural hypotension, ataxia
Cortical based degeneration - alien limb phenomena

130
Q

Parkinson’s ix?

A

Trail of dopaminergic agent (L-dopa failure -> CT/MRI )

Transcranial sonography - Differentiate PD from secondary causes

PET with flurodopa - can localise dopamine deficiency in basal ganglia

Genetic testing

131
Q

Mx of Parkinson’s

A

Nursing assessment
Carer support
Patient inform DVLA / insurers
MDT

Pharma
1 Levodopa + dopa-decarboxylase inihibitor
[Carbidopa]

2 dopamine agonist (pramipexole / ropinirole)
OR MAO-Bi (selegiline)

3 COMTi (entacapone) OR antimuscarinic OR Apomorphine (rescue agent and potent DA agnoist)

4 surgery, deep brain stimulation

132
Q

General complications of Parkinson’s? Complications or levodopa ? Other specific complications and their management?

A

Infections, aspiration pneumonia, pressure sores, malnutrition, falls

L-dopa 
-wearing off phenomenon 
On-off fluctuations 
Dyskinesias 
Mx - add dopamine agonist, smaller frequent doses of l-dopa

Depression - tricyclics / SSRIs
Dementia - AChEi
Compulsive behaviours
Hallucinations / psychosis - clozapine / slow treatment withdrawal
Parkinson’s crisis
Axial degeneration - balance, speech, gait is not improved by Parkinson’s medication

133
Q

What is a Parkinson’s crisis?

A

Acute akinesia -> sudden worsening of motor sx

134
Q

Normal pressure hydrocephalus triad? Ix? Mx?

A

Urinary incontinece
Dementia
Gait abnormality (similar to PD)

Ix
MRI/CT head - hydrocephalus with enlarged 4th ventricle

Mx 
Ventriculoperitoneal shunting (VP shunt)
135
Q

Pathology of Huntington’s? Usual age of onset? How many CAG repeats for onset?

A

Autosomal dominant, chromosome 4, CAG repeats
Progressive neurodegenerative
30-50 yrs onset

<27 normal
<35 future onset
<39 late onset
>40 abnormal

136
Q

Presentation of HD

A

Early - personality change, self neglect, apathy, clumsiness, depression

Later - chorea ->dystocia -> Parkinsonism
Dementia

Later - dysarthria, dysphagia, abnormal eye movements, aggressiveness

137
Q

Ix? And mx of HD?

A

Exlcude - SLE, WD, thyroid disease, antiphospholipid syndrome

MRI/CT head - loss of striata volume, increased frontal horn size of lateral ventricles

Genetic testing/ counselling

Mangement
MDT

Chorea -> benzodiazepines

Parkinsonism - L-dopa / dopamine agonist

Depression - SSRIs

Psychosis - clozapine

Surgery - deep brain stimulation

138
Q

Left hemiparesis and sensory loss
Legs >arms
Which vessel?

A

Right ACA

139
Q

Right hemiparesis and sensory loss
Arms >legs
Right homonymous hemaniopia
Which vessel?

A

Left MCA

140
Q

Visual agnosia
Right homonymous hemaniopia
Which vessel?

A

Left PCA

141
Q

Amaurosis fungax

Which vessel?

A

Retinal / opthalmic

142
Q

Locked in syndrome

Which vessel?

A

Basilar

143
Q

Initial stroke management

A

ABCDE
Immediate neuro imaging
Haemorrhagic -> consider surgery
Ischemia -> thrombolysis within 4.5 hours and no CI
-Aspirin 300mg stat for 2 weeks then long term thrombolysis therapy

144
Q

Driving post stroke?

A

Group 1 licence (normal) - no driving for 4 weeks, no need to notify unless deficit persists

Group 2 (heavy goods / passenger) - no driving for 12 months, need to notify DVLA

145
Q

Stroke management long term

A

Lifestyle - smoking, exercise, salt, alcohol

Drugs 
Antiplatelet - clopidogrel 75mg daily (or low dose aspirin + modified release dipyridamole) 
Statin- after 48 hours 
Consider carotid endarterectomy 
Manage AF, DM, and HTN <140/90
146
Q

Pharmacological management for high risk TIA (score >3 on ABCD2)

A

Refer for specialist assessment
Statin eg simvastatin 40mg
Anti-platelet drug - clopidogrel 300mg OR aspirin 300mg

Advise not to drive until after seeing specialist

147
Q

Managing low risk TIA patients (ABCD2 <3)

A

Refer for specialist assesssment within 1 week
Statin Eg simvastatin 40mg daily
Antiplatlet - clopidogrel / aspirin 300mg loading dose then 75mg daily until reviewed
Manage CVD risk factors

Don’t drive until seen specialist

148
Q

TIA long term management

A 
Follow up within 1 month 
Lifestyle 
Drugs - for AF, DM, HTN 
-Antiplatelet 
-statin

Driving
Annual - BP and lipid profile
-flu vaccine

149
Q

25yr old female, feels as though there is a tight band across her forehead, the pain came on over 20 minutes and eases after a couple of hours.

What type of headache?
What is the acute treatment?
What is the prophylactic treatment?

A

Tension
Feeling of tightness, pressure behind eyes, throbbing sensation.
Acute treatment: Aspirin, Paracetamol or NSAID
Prophylaxis: 10 sessions of Acupuncture

150
Q

25 year old lady, has recurrent throbbing headaches around the time of her period. She knows it is about to start as she feels nauseated and has wiggly lines across her vision. Lying in a dark room for several hours helps.

What type of headache is this?
What is the acute treatment?
What are the prophylactic treatment option?

A 
Migraine with Aura
Acute treatment (for migraine +/- aura)
oral triptan and NSAID or Paracetamol
Consider antiemetic too
Prophylaxis
1st line = topiramate or Propanolol
2nd line = Amitriptylline
3rd line = 10 sessions of Acupunture
151
Q

What do you need to consider with topiramate ?

A

It is teratogenic so offer suitable contraception / alternative if of child bearing age

152
Q

40 year old male, smoker. Develops excruciating unilateral pain around one eye which starts to tear up and go red. The pain subsides after 30 mins but comes back later in the day and daily for the next 4 weeks.
What type of headache?
What is the acute treatment?
What can be offered as prophylaxis?

A 
Cluster 
Pain almost always unilateral
Eye signs – watery, bloodshot, lid swelling, lacrimation.
Clusters last 4-12 weeks, followed by pain free intervals of up to 2 years.
Acute treatment
Oxygen =/- subcutaneous or nasal Triptan
Prophylaxis
Verapamil
153
Q

28 year old male sustains a head injury during a fight. Police take him in to the station where he complains of nothing but a headache, and then they notice that he goes unconscious for ten minutes. He regains consciousness but then begins to behave unusually – he slumps down on the seat, complains of feeling nauseous, and then stops talking.
Which bleed?
Which artery most commonly involved

A

Extra dural

Middle meningeal - trauma in temporal region

154
Q

42 year old female with no history of headaches is taking a shower when suddenly she is struck by a severe pain at the back of her head. She describes this to be the worst pain she has ever experienced.
Which bleed?
Where do berry aneurysm usually occur?

A

SA

Terminal portion of the internal carotid artery, and the branching sites in the anterior portion of the circle of Willis

155
Q

82 year old male with a history of COPD and alcoholism has had a headache for the past couple of weeks, along with the following:
Difficulty with walking
Decreased balance
Memory loss
They have been worsening over the past few weeks
He can’t remember any injury (but then again his memory is pretty poor…)
Which bleed?

A

Subdural
Can be acute or chronic
One half of chronic have no known history of trauma

156
Q

Investigations for epilepsy

A

EEG
MRI
12 lead ECG

157
Q

Why do you do EEG? What does a standard EEG involve? Next line?

A

Used to support clinical suspicion of epilepsy
Involved photic stimulation and hyperventilation
Sleep EEG

158
Q

When would you do an MRI for epilepsy ?

A

Illness onset before 2 years old or in adulthood
OR if you suspect focal onset
OR if illness continues despite first line meds

159
Q

When do you do an ECG for epilepsy

A

All adults with suspected eplilepsy

160
Q 
Epilepsy 1st line  treatment for 
Focal Seizures
Generalised tonic-clonic seizures
Absence seizures
Myoclonic seizures
Tonic/atonic

Bar anticonvulsants what other treatment options?

A

Focal Seizures
1st line Carbamazepine or Lamotrigine

Generalised tonic-clonic seizures
1st line Sodium Valproate

Absence seizures
1st line Sodium Valproate or ethosuximide

Myoclonic seizures
1st line Sodium Valproate

Tonic/atonic
1st line Sodium Valproate

Surgery
Deep nerve stimulation (vagus)
Ketogenic diet - body made to burn fat instead of carbs
->ketone bodies used by brain instead of glucose

161
Q

Which drug can be used 1st line for all seizure types bar focal seizures? What consideration do you have to make?

A

Sodium valproate

Teratogenicity

162
Q

What do you NOT use in absence seizures?

A

Carbamazepine

163
Q

Status epilepticus 1st, 2nd line, in hospital?

A

1- buccal midazolam
2 - rectal diazepam
Hospital - IV lorazepam

164
Q

Name some motor tracts? Sensory tracts?

A

Motor
Pyramidal - corticospinal
Extrapyrmidal - reticulospinal, vestibulospinal

Sensory
Dorsal column medial leminniscus
Spinocerebellar
Anterolateral - spinothalamic

165
Q

What is brown-sequard syndrome?

Which tracts are affected?

A

The presentation of a spinal injury that is an incomplete lesion

Lateral corticospinal
Dorsal columns
Lateral spinothalamic

166
Q

Corticospinal tract functions ? Where does it cross? Deficit?

A

Motor
Pyramidal - decussate in the medulla
Voluntary movement

Defective -> loss of voluntary movement, spasticity, hemiplegia

167
Q

Dorsal column (posterior column) functions? Deficit?

A

Sensory
Vibration, proprioception, light touch, two-point discrimination

Deficit -> tingling, clumsiness, numbness, electric shock like, position and vibration sense lost

168
Q

Lateral spinothalamic tract functions? Where does it cross? Deficit?

A

Sensory
Crude touch, pain, temperature,
Synapse with dorsal horn in cord, cross within the cord

Deficit -> contralateral loss of pain and temp sensation

169
Q

Clinical signs of corticospinal, dorsal column and spinothalamic lesions?

A

Corticospinal:
Ipsilateral spastic paresis below the lesion
Babinski sign ipsilateral

Dorsal column:
Ipsilateral loss of proprioception and vibration sensation

Spinothalamic
Contralateral loss of pain and temperature sensation
Usually 2-3 segments below the level of the lesion

170
Q

Other word for corticospinal tract?

What can be used interchangeably with pyramidal

A

Pyramidal tract

Upper motor neruon

171
Q

Anatomy of pyramidal / corticospinal tract ? Diseases of this cause what kind of lesions?

A

Cerebral cortex to the spinal cord anterior horn cell
The nerve fibres conjugate in the internal capsule and cross in the medulla to the contralateral spinal cord to form the lateral corticospinal tracts

Disease -> UMN lesions

172
Q

Where are UMN from - to? LMN?

A

UMN - cerebral cortex to anterior horn cell

LMN - anterior horn cell (or cranial nerve nucleus) via peripheral nerve to neuromuscular junction

173
Q

UMN lesion signs

A 
Pronator drift 
Weakness 
Hypertonia 
Hyperreflexia 
Positive babinski
174
Q

Are UMN lesions usually above the decussation or below? Features of pyramidal weakness in upper vs lower limb?

A

Above -> weakness in contralateral limbs

Upper - flexor stronger than extensor
Lower limb - extensor stronger than flexor

175
Q

Umn LESION

What causes hypertonia (spasticity)? What else do you get?

Cause of hyperreflexia

A

Loss of inhibitory effects of the corticospinal pathway
Clonus

Again due to loss of inhibition

176
Q

What is a positive babinski sign?

A

Normal flexor plantar becomes extensor

177
Q

Signs of LMN lesions

A

Muscle wasting
Fasiculation
Hyperreflexia

178
Q

What causes fasiculation

A

Contractions of denervated single motor units

179
Q 
28 year old female with no serious medical history (other than a Campylobacter infection causing diarrhoea, three weeks ago) notices some pain and weakness in her legs developing over a few days. A couple of days later, her hands are affected, and then her arms and shoulders. Both sides are affected equally. 
Diagnosis? What is it? Features? 
Ix?
Complication?
Treatment?
A

Gillian-barre syndrome
Acute inflammatory demyelinating polyradiculopathy
- immune attack on peripheral nerves

Reduced power + hyporeflexia

Ix
Nerve conduction studies
LP - raised protein
Spirometry if respiratory involvement

25% develop weakness of breathing muscles -> watch out for resp failure

Oxygen and IVIg 
Plasma exchange 
SC heparin (VTE prophylaxis)
180
Q 
32 year old woman with Rheumatoid Arthritis notices some progressive but fluctuating weakness in her torso, some changes to her speech, and her friends say that her facial expressions seem more muted. Her eye movements have decreased and she finds chewing to be quite tiring… 
Diagnosis?
Pathology? Features?
Diagnostic tests?
Treatment?
A

Myasthenia gravis

Pathology - anti-AChR antibodies (also get anti-MuSK antibodies)

Weakness and fatigue of proximal limb, bulbar and ocular muscles
Muscle pain is usually ABSENT
Thymic hyperplasia in 70%

Tests - nerve stimulation
-tensilon (edrophonium) test
[give edrophonium -> substantial improvement in weakness within seconds]

Treat - pyridastigmine, immunosuppressive

181
Q

What is anti-AChR? Anti-MuSK? Edrophonium ? Pyridostigmine / neostigmine

A

Anti-AChR: antibodies to acetylcholine receptor protein
anti-MuSK antibodies (muscle-specific receptor tyrosine kinase)

Edrophonium: short acting acetylcholinesterase inhibitor (prevents breakdown of acetylcholinesterase)
Pyridostigmine and neostigmine: acetylcholinesterase inhibitors

182
Q

60 year old man attended the dentist as he is experiencing intense stabbing pain on the right side of his face when chewing and talking. It only lasts a few seconds and he wonders if he needs a filling.
Diagnosis?
Treatment?

A

Trigeminal neuralgia

Carbamazepine / surgery if drugs fail

183
Q 
80 year old lady who has lost vision in her right eye over the last 20 mins, she is on her way to the doctors but combing her hair on the way out and the cold wind is causing tenderness over her scalp.
Diagnosis?
Investigations?
Treatment?
Associated disease?
A

Amaurosis fugax due to GCA

Investigation
ESR and CRP
Temporal artery biopsy – skip lesions

Treatment
Prednisolone

Associated disease
Polymyalgia Rheumatica

184
Q

What does the cerebellum do?

A

Acts as the coordinator for all movements IPSILATERALLY

185
Q

Common causes of cerebellar dysfunction?

A

Infarct
MS
Alcohol abuse - chronic
Compression - tumour / abbess

186
Q

General principles of management for cerebellum

A

Treat underlying cause

  • SALT
  • physio
  • OT
187
Q

2 scoring systems to decide weather to anticoagulate?

A

CHADSVASC

HASBLED

188
Q

Score for stroke following tia?

A 
Age >60
BP >140-90
Clinical features of TIA -unilateral weakness = 2, Speech disturbance without unilateral weakness = 1
Duration of sx 10-59minutes =1, >60 =2 
Diabetes

ABCD2

189
Q

What are you likely to see on a diffusion weighted MRI in exam question about stroke?

A

Cerebral oedema

190
Q

What is a Jacksonian seizure?

A

Partial seizure just in the motor cortex

191
Q

Features to identify a pseudo seizure?

A 
Hip thrusting 
Tiring and restarting 
EEG videotelemetry 
Serum lactate 
Awareness / post ictal
192
Q

1st line treatment for generalised seizure? 2nd?

A

Sodium valproate / lamotrigine

Carbamazepine

193
Q

1st line treatment of partial then generalised seizure?

A

Carbamazepine

194
Q

Why would a patient be bettter suited to lamotrigine over valproate

A

Safer in pregnancy

195
Q

Driving with epilepsy

A

Can’t drive until seizure free for 1 year

For HGV / buses, horse boxes …. must be seizure free and off meds for 10 years

196
Q

Sx/ signs of myasthenia gravis?

A

Increasing muscular fatigue

  • Extraocular
  • Bulbar (chewing / swallowing)
  • Face and neck
  • Limbs (proximal)

Signs

  • Ptosis, diplopia
  • myasthenic snarl
  • ‘Peek sign’ (on sustained forced eyelid closure)
  • Altered speaking
197
Q

Myasthenia gravis IX

A

Serum antibodies

  • Anti ACh-R
  • Anti MuSK

CT thorax - Thymic enlargement

Tensilon (edrophonium test
-short acting anti-cholinesterase -> improvement in strength following administration

Ice test - crushed ice improves ptosis

198
Q

Mx of myasthenia gravis

A

Acetylecholinesterase inhibitors - Pyridostigmine

Immunosupressants
-Steroids, methotrexate, azathioprine

Thymectomy

IvIg for exacerbations

199
Q

What is a myasthenic crisis? When does it usually occur?
Mx?
Triggers?
How do you distinguish between this and a cholinergic crisis?

A

Severe weakness including respiratory muscles
20-30% of patients have one in first year of disease

Intubation and mechanical ventilation

Infection
post-surgery

Endrophonium test

200
Q

A 58 yr old man reports that for the past couple of months he has struggled to do things with right hand, such as picking up his keys and turning them in the door. It has been gradually getting worse and he ahs now also recently started dropping a few glasses in the pub he works at.
On examination you notice wasting of the intrinsic muscles of the hand.
You also elicit brisk reflexes in the affected limb.

Diagnosis?
What does it not affect?

A

MND

No sensory

Never affects eye movements

201
Q

Rare familal cause of MND

A

SOD-1 gene

202
Q

4 types of MND

A

Amyotrophic Lateral Sclerosis

  • Amyotrophic – muscle atrophy (LMN)
  • Lateral – lateral corticospinal tract (UMN)

Progressive Bulbar Palsy
-Affecting lower CN (VII – XII)

Progressive Muscular Atrophy
-Pure LMN

Primary Lateral Sclerosis
-Pure UMN

203
Q

Where are motor neurones lost in ALS ?

Signs?

A

Motor cortex and Anterior horn cells

LMN signs
-Progressive limb weakness (often upper limb and asymetrical), wasting, fasciculations

UMN signs
-Hypertonia, brisk reflexes, upgoing plantars

204
Q

Bulbar palsy MND features?

What is pseudobulbar palsy?

A

Muscles of talking, chewing and swallowing

Bulbar palsy – flaccid, fasciculating tongue

Pseudobulbar palsy – tongue paralysed, no fasciculations

205
Q

PMA and PLS forms of MND are far less common but what are the key features of each?

A

Progressive muscular atrophy
Wasting, often in small muscles of hand
May be unilateral start – soon bilateral

Primary lateral sclerosis
Weakness, spasticity

206
Q

Ix of MND?

A

Evidence of UMN / Mn lesions
-progressive spread of sx/signs within a region / to other regions

Nerve conduction studies

207
Q

Mx of MND ? What for drooling?

spacticiy?

A

Conservative

  • Respiratory support
  • OT / SALT
  • Feeding support

Pharmacological
Anti-depressants
Riluzole

Drooling - hyosine
Spacticy - Baclofen

208
Q

What are parkinsons plus syndromes? How to differentiate?

A

Multiple system atrophy (Will have nystagmus)

Progressive supranuclear palsy (Up and down eye movements restricted)

SPECT to differentiate

209
Q

Ix (what would be seen on bloods) and Mx of GCA

A

Raised ESR, CRP, platelets,
Reduced hB

Temporal artery biopsy (will be negative in 10%)

Steroids, and gastric / bone protection
-PPI, Bisphosphonates

210
Q

Ix . Mx guillain barre

A

Nerve conduction studies - slow
CSF - raised protein, normal WCC
Anti-GM1 antibodies (25% of pts)

IV immunoglobulin
Plasma exchange

Sheff 3a (30 decks)

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