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
2
Q
Presentation of a frontal lobe lesion ?
A
Change in personality
Anosmia - loss of sense of smell
Motor aphasia - language production
Contralateral hemiparesis
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
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
5
Q
Presentation of occipital lobe lesion
A
Contralateral homonymous hemaniopia
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
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
8
Q
Damage to the posterior inferior cerebellar artery causes? Sx?
A
Wallenberg’s syndrome
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
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)
11
Q
Glasgow coma scale parts?
A
Best eye movement
Best verbal response
Best motor response
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
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
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
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.
16
Q
Presentation of meningitis
A
Menigism (no nuchal rigidity in neonate) Fever Bulging fontanelle (neonates) Opisthotonos (arching of back) Altered mental state Shock
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
18
Q
Sx of raised ICP
A
Vomiting, reduced consciousness, headache, fits
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
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
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
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
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
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
25
Complications of meningitis?
```
Sepsis, septic shock, DIC
Seizures, coma, raised ICP,
Septic arthritis
Haemolytic anaemia (h influenzae)
SIADH
Deafness / hydrocephalus
```
26
Prevention of meningitis
Vaccination (h influenzae, meningococcus, strep pneumonia)
```
Ciprofloaxacin prophylaxis (meningococcal )
Rifampicin prophylaxis
```
27
Usual organism for menigicoccal septicaemia ? Type ?
Neisseria menigitidus
Gram -ve diplococcus, sero groups A/B/C/Y/W
Often found in nasopharynx
28
Presentation of meningococcal septicaemia ? Pre-hospital management?
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
29
Meningococcal septicaemia investigations
```
Blood cultures
FBC, U&E, LFT, CRP
DIC - raised PT / apTT, Low platelets / fibrinogen
Pharyngeal swab
LP - ±CT to exclude raised ICP
```
30
Mx of meningococcal septaemia in hospital?
```
Resuscitation
<3months - cefotaxime + amoxicillin
>3 months - ceftriaxone
Travel - add vancomycin
Later on -> dialysis
```
31
Complications of meningococcal septicaemia
Seizures , raised ICP
DIC, adrenal failure
Later - deafness, hydrocephalus
32
Prevention of meningococcal septicaemia
Ciprofloaxcin ± menigicoccal vaccine prophylaxis
| MenACWY vaccine - Uni students / pilgrims
33
What is encephalitis? Usual cause? Other ? Presentation? Presentation in neonate
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
34
Encephalitis investigations? Mx? Why do you have to be careful with fluids
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
35
Complications of encephalitis ?
```
SIADH
DIC
Cardiac/resp arrest
Epilepsy
Personality change
```
36
Usual cause of subarachnoid haemorrhage? Other? RF?
Berry aneurysm
Non aneurysm haemorrhage, Arteriovenous malformation, vasculitis
HTN, smoking, cocaine, alcohol, ADPKD, Ehlers-Danlos, Marfans, neurofibromatosis
37
Usual presentation of SAH? Other pres?
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
38
Most common place for berry aneurysm? Other 2 most common?
Junction of anterior communicating artery and anterior cerebral artery
Middle cerebral artery bifurcation
Posterior communicating - internal carotid junction
39
Signs of SAH?
Meningism - 6hr after headache
Altered GCS
Intraoccular haemorrage (15% -> ophthalmoscopy)
Focal neurology
40
If the patient with SAH had CNiii palsy where would you guess the aneurism was?
PCOMA-ICA junction
41
Ix for SAH? What would you find?
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
42
Where is CSF produced? Which layer of meningies and how? Absorbed where?
Choroid plexus in ventricles
Ventricles and flows into Subarachnoid space through median and lateral apertures
Dural venous sinuses
43
Mx of SAH ? Complications ?
Resuscitation
Nimodipine -> reduce vasospasm
Nitroprusside / labetalol -> control HTN
Coiling (through femoral catheterisation) OR clipping (craniotomy)
Complications - rebleeding, cerebral ischemia (vasospasm), hydrocephalus, cardiac arrest
44
Causes of raised ICP
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
45
Mets to brain, where is the most likely place its from
Lung > breast > colon > melanoma
| Top 4
46
Presentation of raised ICP ? What could be a false localising sign?
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)
47
What would you see looking at papilloedema ?
Blurred disk margins
| Venous engorgement, loss of venous pulsation, venous haemorrhage
48
Ix of ICP? Mx?
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)
49
What 3 false localising signs do you get with a space occupying lesion ?
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
50
Where is the blood in an extra dural haematoma? Causes? Which vessel?
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%)
51
Presentation of an extra dural haematoma
1 - Trauma + LOC
2 - Lucid interval
3- Deterioration
Headache (severe and progressive) N+V, seizures, bradycardia ± HTN, CSF otorrhoea/ rhinorrhoea, altered GCS
52
Extra dural Ix? Mx?
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
53
Complications of extra dural? Prevention?
Neurological deficits, post traumatic seizures
Helmets - bikes, boxing, horse riding
Alcohol
54
CT of extra dural, what do you see?
Lens shaped haematoma NOT crossing suture lines
Midline shift
Soft tissue swelling
55
Pathology of subdural haematoma? usual cause?
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
56
Rf for subdural
Paeds
Elderly - cerebral atrophy -> tension on veins
Alcoholism - prolonged bleeding
Anticoagulation
57
Subdural acute presentation? Chronic? Other signs?
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
58
Ix for subdural? Mx? Complications?
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
59
Seen on CT of subdural
Crescent shaped haematoma crossing suture lines, mid line shift
60
What is a basilar skull fracture? What happens? Signs?
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
61
Triggers of migraine? Mnemonic
```
CHOCOLATE
CHeese
Oral contraceptive
Caffeine
AlcohOL
Anxiety
Travel
Exercise
```
62
Types of migraine ?
```
1- migraine without aura
2 migraine with aura
3 migraine aura without headache
4 Hemiplegic migrane - hemiplegia ± aphasia
5 menstural migrane
```
63
Presentation of migrane
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
64
Signs of migrane? Management during?
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
65
What are CI to Triptans? What receptor do they act on?
CI - uncontrolled hypertension, CHD/CVD (or RF for these), angina
5-hydroxytryptamine agonist
66
How many migranes usually before preventative pharma used? What is it?
>/= 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
67
CI to use of b blockers
PVD, asthma, depression, myasthenia gravis
68
Complication of migrane
Depression, bipolar, anxiety
Status migrainous (>72hrs)
Migrainous infarct
Increased risk or ischemic / haemorrhagic stroke
69
Why/ When is COCP CI with migraine ?
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
70
Mx of migraine when pregnant / breast feeding ? What can you not?
Ibuprofen (<30wks)
Promethazine
Propranolol
No aspirin (Reyes), no Triptans
71
Who usually gets cluster headaches? What is the usual headache pattern?
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
72
Presentation of cluster headaches
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 )
73
Common trigger for cluster? Mx of acute?
Alcohol
Histamine, nitroglycerine (vasodilator used to treat angina that doesn’t respond to oral)
Subcutaneous sumatriptan + O2
74
Prevention of cluster?
Stop smoking / no alcohol
1- verapamil ± prednisolone
2- lithium
75
Presentation of tension type headaches
Headache - gradual onset, generalised, bilateral, band-like, fronto-occipital, neck radiation
May have mild nausea
NO - photophobia, phonophobia, visual/sensory/motor disturbance
76
Mx of tension type headache
Identify + address stress, anxiety, depression
Exercise + posture
Pharma = NSAID / paracetamol, amitriptyline
77
Pathology of trigeminal neuralgia ? Who normally gets it? Triggers? Cause?
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
78
Pain pattern in trigeminal neuralgia? Presentation?
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)
79
Ix / mx in trigeminal neuralgia
MRI - to exclude other causes of compression
Education / pain referral
Pharma
- carbamazepine / lamotrigine
Surgery - rhizotomy, gamma knife, micro vascular decompression
80
Pathology of giant cell arteritis? RF?
Systemic immune mediated vasculitis of medium / large sized arteries
Age - 60-80yrs
Female
European
81
Presentation of GCA
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
82
Investigation / mx in GCA ?
Raised ESR ± CRP
Normocytic, normochromic anaemia, thrombocytosis
Temporal artery biopsy / US
Prednisolone (PO high dose_
Aspirin low dose
PPi
83
3 Complications of GCA
Aortic (thoracic) aneurysm / dissection
Loss of vision (20% in severe)
CNS - seizures
Complication of steroid use
84
Prolonged high dose of steroids complications
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.
85
Pathology of TIA? What is it called when you have 2 or more in 1. Week? RF?
Temporary inadequacy of part of brain circulation
Crescendo TIA
Black, age, male
86
Usual cause of TIA
Embolism - carotid, AF, mitral/arotic valve disease, post MI mural thrombus
Carotid 80%, vertebrobasilar 20%
87
Presentation of TIA ? Carotid vs vertebrobasilar ?
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
Rf for stroke / TIA
HTN, smoking, diabetes, heart disease (ischemic, valvular, AF), peripheral artery disease, carotid artery occlusion (bruit), COCP, alcohol, polycythemia Vera (too many RBC produced)
89
DDx of stroke
```
SOL (subdural haematoma / tumour)
Seizure (post-ictal Todd’s paresis / paralysis)
Syncope - arrhythmia
GCA
Migraine - hemiparesis
Hypoglycaemia
```
90
Signs that you might notice o/e which could be the cause of TIA ?
AF
HTN
Carotid bruit
Heart murmur
91
TIA ix in primary care? Secondary care? When would you want to do investigations in secondary care?
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
Mx of tia?
| Complications?
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
When would you send TIA for specialist assessment?
Crescendo
| ABCD2 >4/7
94
What are parts of ABCD2 ? What is it used for?
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
Types of stroke ?
| Cause in young/old?
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
Signs of ischemic stroke ? Haemorrhagic?
Ischemia - carotid bruit, AF, hx of TIA
Haem - menigism, severe headaches, coma within hours
97
Areas and Presentation of stroke
```
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
What is locked in / Wallenberg / dejerine syndromes?
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
Stroke diagnosis score?
ROSIER
Exclude hypoglcaemia then asses
Score >0 means stroke is likely
100
What system for stroke classsification?
Which Sx should be assessed?
Types and which vessel involved? Sx ?
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
Investigations in stroke
Bloods - glucose, ESR, platelets
| CT head non contrast - exclude haemorrhage
102
Management of stroke acute? Long term?> who is involved?
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
Stroke complications
Stroke
Mi
Long term impairment -motor, communication, dysphasia mood, cognition
-> aspiration pneumonia, malnutrition, dehydration, bed sores, constipation, depression, incompetence
104
CI to thrombolysis in stroke
```
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
Prevention of stroke
Lifestyle
Blood pressure
AF - anticoagulation
TIA/ischemic with no AF - 1:clopidogrel, 2: aspirin + dipyridamole
Statin
Carotid endarterectomy (correct stenosis), within 2 weeks
106
Need to assess baseline cognition in a patient presenting with delirium ?
Use a collateral hx
107
RF for delirium
Age, male, pre existing cognitive impairment, severe comorbidity, post op, benzo/alcohol, Hx of delirium
108
Causes of delirium
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
Presentation of delirium?
```
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
Two types of delirium and sx?
Hypoactive - apathy, quiet, confusion (depression like)
Hyperactive - agitation, delusions, disorientation (schitz like)
Mixed
111
Ix and mx for delirium
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
Complications and prevention of delirium
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
3 sx groups of dementia
Cognitive impairment - ST memory, language, attention, orientation
Psychiatric disturbance - depression, delusions, hallucinations
Difficulties with ADLs - driving, shopping, dressing
114
Assessment of dementia? Ix?
GPCOG
MMSE
AMT - abbreviated mental test
```
Blood - FBC,ESR/CRP, U&E, LFT, TFT, glucose, b12, folate, calcium
MSU
Blood cultures
CXR
MRI head
Psychometric testing
```
115
Mx of dementia
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
Pathology of Alzheimer’s
Progressive degeneration of cerebral cortex
Widespread cortical atrophy
Increased beta amyloid peptide
Amyloid plaques + neurofibrillary tangles
Neuron damage - decreased Ach
117
RF for dementia
Ageing, Caucasian, FHx, female, apolipoprotein E4 variant, head injury
Vascular RF
118
Early and later presentation of dementia
Early
ST memory loss, difficulty finding words
Later
Apraxia, language difficulty, confusion
Later
Disorientation, wandering, apathy
Depression, hallucinations, delusions
Disinhibition, aggression
119
DD of dementia ? Ix?
```
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
Vascular dementia... pathology, cause, RF
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
Diagnosis of vascular dementia
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
Investigations / MX of vascular dementia ?
Dementia investigations
MRI head - in facts, cortical lacunae, white matter changes
Dementia management
Address cardio RFs
Donepezil / galatamine
123
Pathology of dementia with Lewy bodies?
Lewy bodies in brainstem and neocortex
| LB = eosinophilic intracytoplasmic neuronal inclusion bodies
124
Dementia with LB ix? Diagnosis? Mx?
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
Pathology of frontotemporal dementia? Associated ?
Frontal / temporal lobe atrophy
Loss of neutrons, no increase in plaques
Protein inclusions (Tau) in cells
Progressive supranuclear palsy
Corticobasal syndrome
MND
126
Presentation, ix and mx of fronto temporal ?.
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
Presentation of Parkinsonism? Causes?
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
Presentation of Parkinson’s? Pathology? RF? Diagnosis?
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
DDx of Parkinson’s?
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
Parkinson’s ix?
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
Mx of Parkinson’s
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
General complications of Parkinson’s? Complications or levodopa ? Other specific complications and their management?
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
What is a Parkinson’s crisis?
Acute akinesia -> sudden worsening of motor sx
134
Normal pressure hydrocephalus triad? Ix? Mx?
Urinary incontinece
Dementia
Gait abnormality (similar to PD)
Ix
MRI/CT head - hydrocephalus with enlarged 4th ventricle
```
Mx
Ventriculoperitoneal shunting (VP shunt)
```
135
Pathology of Huntington’s? Usual age of onset? How many CAG repeats for onset?
Autosomal dominant, chromosome 4, CAG repeats
Progressive neurodegenerative
30-50 yrs onset
<27 normal
<35 future onset
<39 late onset
>40 abnormal
136
Presentation of HD
Early - personality change, self neglect, apathy, clumsiness, depression
Later - chorea ->dystocia -> Parkinsonism
Dementia
Later - dysarthria, dysphagia, abnormal eye movements, aggressiveness
137
Ix? And mx of HD?
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
Left hemiparesis and sensory loss
Legs >arms
Which vessel?
Right ACA
139
Right hemiparesis and sensory loss
Arms >legs
Right homonymous hemaniopia
Which vessel?
Left MCA
140
Visual agnosia
Right homonymous hemaniopia
Which vessel?
Left PCA
141
Amaurosis fungax
| Which vessel?
Retinal / opthalmic
142
Locked in syndrome
| Which vessel?
Basilar
143
Initial stroke management
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
Driving post stroke?
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
Stroke management long term
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
Pharmacological management for high risk TIA (score >3 on ABCD2)
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
Managing low risk TIA patients (ABCD2 <3)
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
TIA long term management
```
Follow up within 1 month
Lifestyle
Drugs - for AF, DM, HTN
-Antiplatelet
-statin
```
Driving
Annual - BP and lipid profile
-flu vaccine
149
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?
Tension
Feeling of tightness, pressure behind eyes, throbbing sensation.
Acute treatment: Aspirin, Paracetamol or NSAID
Prophylaxis: 10 sessions of Acupuncture
150
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?
```
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
What do you need to consider with topiramate ?
It is teratogenic so offer suitable contraception / alternative if of child bearing age
152
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?
```
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
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
Extra dural
| Middle meningeal - trauma in temporal region
154
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?
SA
| Terminal portion of the internal carotid artery, and the branching sites in the anterior portion of the circle of Willis
155
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?
Subdural
Can be acute or chronic
One half of chronic have no known history of trauma
156
Investigations for epilepsy
EEG
MRI
12 lead ECG
157
Why do you do EEG? What does a standard EEG involve? Next line?
Used to support clinical suspicion of epilepsy
Involved photic stimulation and hyperventilation
Sleep EEG
158
When would you do an MRI for epilepsy ?
Illness onset before 2 years old or in adulthood
OR if you suspect focal onset
OR if illness continues despite first line meds
159
When do you do an ECG for epilepsy
All adults with suspected eplilepsy
160
```
Epilepsy 1st line treatment for
Focal Seizures
Generalised tonic-clonic seizures
Absence seizures
Myoclonic seizures
Tonic/atonic
```
Bar anticonvulsants what other treatment options?
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
Which drug can be used 1st line for all seizure types bar focal seizures? What consideration do you have to make?
Sodium valproate
| Teratogenicity
162
What do you NOT use in absence seizures?
Carbamazepine
163
Status epilepticus 1st, 2nd line, in hospital?
1- buccal midazolam
2 - rectal diazepam
Hospital - IV lorazepam
164
Name some motor tracts? Sensory tracts?
Motor
Pyramidal - corticospinal
Extrapyrmidal - reticulospinal, vestibulospinal
Sensory
Dorsal column medial leminniscus
Spinocerebellar
Anterolateral - spinothalamic
165
What is brown-sequard syndrome?
| Which tracts are affected?
The presentation of a spinal injury that is an incomplete lesion
Lateral corticospinal
Dorsal columns
Lateral spinothalamic
166
Corticospinal tract functions ? Where does it cross? Deficit?
Motor
Pyramidal - decussate in the medulla
Voluntary movement
Defective -> loss of voluntary movement, spasticity, hemiplegia
167
Dorsal column (posterior column) functions? Deficit?
Sensory
Vibration, proprioception, light touch, two-point discrimination
Deficit -> tingling, clumsiness, numbness, electric shock like, position and vibration sense lost
168
Lateral spinothalamic tract functions? Where does it cross? Deficit?
Sensory
Crude touch, pain, temperature,
Synapse with dorsal horn in cord, cross within the cord
Deficit -> contralateral loss of pain and temp sensation
169
Clinical signs of corticospinal, dorsal column and spinothalamic lesions?
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
Other word for corticospinal tract?
| What can be used interchangeably with pyramidal
Pyramidal tract
| Upper motor neruon
171
Anatomy of pyramidal / corticospinal tract ? Diseases of this cause what kind of lesions?
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
Where are UMN from - to? LMN?
UMN - cerebral cortex to anterior horn cell
LMN - anterior horn cell (or cranial nerve nucleus) via peripheral nerve to neuromuscular junction
173
UMN lesion signs
```
Pronator drift
Weakness
Hypertonia
Hyperreflexia
Positive babinski
```
174
Are UMN lesions usually above the decussation or below? Features of pyramidal weakness in upper vs lower limb?
Above -> weakness in contralateral limbs
Upper - flexor stronger than extensor
Lower limb - extensor stronger than flexor
175
Umn LESION
What causes hypertonia (spasticity)? What else do you get?
Cause of hyperreflexia
Loss of inhibitory effects of the corticospinal pathway
Clonus
Again due to loss of inhibition
176
What is a positive babinski sign?
Normal flexor plantar becomes extensor
177
Signs of LMN lesions
Muscle wasting
Fasiculation
Hyperreflexia
178
What causes fasiculation
Contractions of denervated single motor units
179
```
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?
```
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
```
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?
```
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
What is anti-AChR? Anti-MuSK? Edrophonium ? Pyridostigmine / neostigmine
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
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?
Trigeminal neuralgia
Carbamazepine / surgery if drugs fail
183
```
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?
```
Amaurosis fugax due to GCA
Investigation
ESR and CRP
Temporal artery biopsy – skip lesions
Treatment
Prednisolone
Associated disease
Polymyalgia Rheumatica
184
What does the cerebellum do?
Acts as the coordinator for all movements IPSILATERALLY
185
Common causes of cerebellar dysfunction?
Infarct
MS
Alcohol abuse - chronic
Compression - tumour / abbess
186
General principles of management for cerebellum
Treat underlying cause
- SALT
- physio
- OT
187
2 scoring systems to decide weather to anticoagulate?
CHADSVASC
| HASBLED
188
Score for stroke following tia?
```
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
What are you likely to see on a diffusion weighted MRI in exam question about stroke?
Cerebral oedema
190
What is a Jacksonian seizure?
Partial seizure just in the motor cortex
191
Features to identify a pseudo seizure?
```
Hip thrusting
Tiring and restarting
EEG videotelemetry
Serum lactate
Awareness / post ictal
```
192
1st line treatment for generalised seizure? 2nd?
Sodium valproate / lamotrigine
Carbamazepine
193
1st line treatment of partial then generalised seizure?
Carbamazepine
194
Why would a patient be bettter suited to lamotrigine over valproate
Safer in pregnancy
195
Driving with epilepsy
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
Sx/ signs of myasthenia gravis?
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
Myasthenia gravis IX
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
Mx of myasthenia gravis
Acetylecholinesterase inhibitors - Pyridostigmine
Immunosupressants
-Steroids, methotrexate, azathioprine
Thymectomy
IvIg for exacerbations
199
What is a myasthenic crisis? When does it usually occur?
Mx?
Triggers?
How do you distinguish between this and a cholinergic crisis?
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
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?
MND
No sensory
Never affects eye movements
201
Rare familal cause of MND
SOD-1 gene
202
4 types of MND
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
Where are motor neurones lost in ALS ?
| Signs?
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
Bulbar palsy MND features?
| What is pseudobulbar palsy?
Muscles of talking, chewing and swallowing
Bulbar palsy – flaccid, fasciculating tongue
Pseudobulbar palsy – tongue paralysed, no fasciculations
205
PMA and PLS forms of MND are far less common but what are the key features of each?
Progressive muscular atrophy
Wasting, often in small muscles of hand
May be unilateral start – soon bilateral
Primary lateral sclerosis
Weakness, spasticity
206
Ix of MND?
Evidence of UMN / Mn lesions
-progressive spread of sx/signs within a region / to other regions
Nerve conduction studies
207
Mx of MND ? What for drooling?
| spacticiy?
Conservative
- Respiratory support
- OT / SALT
- Feeding support
Pharmacological
Anti-depressants
Riluzole
Drooling - hyosine
Spacticy - Baclofen
208
What are parkinsons plus syndromes? How to differentiate?
Multiple system atrophy (Will have nystagmus)
Progressive supranuclear palsy (Up and down eye movements restricted)
SPECT to differentiate
209
Ix (what would be seen on bloods) and Mx of GCA
Raised ESR, CRP, platelets,
Reduced hB
Temporal artery biopsy (will be negative in 10%)
Steroids, and gastric / bone protection
-PPI, Bisphosphonates
210
Ix . Mx guillain barre
Nerve conduction studies - slow
CSF - raised protein, normal WCC
Anti-GM1 antibodies (25% of pts)
IV immunoglobulin
Plasma exchange
