Neuro Flashcards
What does left homonymous hemianopia mean?
Visual field defect to the left
Ie right optic tract lesion
A 42-year-old woman is admitted to the vascular ward for an endarterectomy. Her CT report confirms a left temporal lobe infarct.
Visual field defect?
Right superior quadranopia
Temporal lesions cause a contralateral superior quadranopia. Think temporal area is at the top of the head i.e. superior quadranopia
A 22-year-old man is referred to urology with possible urinary retention. He is passing huge amounts of urine. Post void bladder ultrasound is normal.
Visual field defect?
Lower bitemporal hemianopia
This patient has diabetes insipidus due to a craniopharyngioma. This causes a lower bitemporal hemianopia.
A 53-year-old man is admitted to the vascular ward for a carotid endarterectomy. His CT head report confirms a left parietal lobe infarct.
Visual field defect?
Right inferior quadranopia
Parietal lesions cause a contralateral inferior quadranopia.
How to remember homonymous quadranopias ?
PITS
Parietal Inferior
Temporal Superior
What is visual field defect when a pit adenoma compresses?
Bitemporal hemaniopia
With a bitemporal hemaniopia
If the defect is mostly Upper quadrant where is the compression?
Lower quadrant?
Upper - from inferior side
-Eg Pituitary adenoma
Lower - from superior
-Eg Craniopharyngioma
What condition do you see bilateral acoustic neuromas ? Ix?
Neurofribromatosis type 2
MRI of cerebellopontine angle
To stop antiepileptics
How long seizure free? How long do you spend stopping drugs?
Can be considered if seizure free for > 2 years, with AEDs being stopped over 2-3 months
Why do you not use carbamazepine in absence seizures?
Can exacerbate them
What happens in Wallenberg s?
Lateral medullary syndrome (posterior inferior cerebellar artery)
ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner’s
contralateral: limb sensory loss
Vessel with Contralateral hemiparesis and sensory loss, lower extremity > upper
Anterior cerebral
Vessel with Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral homonymous hemianopia
Aphasia
Middle cerebral
Contralateral homonymous hemianopia with macular sparing
Visual agnosia
Vessel?
Posterior cerebral artery
Vessel? Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity
Weber syndrome
Posterior cerebral
Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus
Vessel?
Posterior inferior cerebellar
Wallenberg syndrome
What is complex regional pain syndrome?
Often after minor injury
- > disproportionate Sx to original injury
- temperature and skin changes
- oedema and sweating
What needs to be considered before starting IV phenytoin? Why?
Cardiac monitoring
-proarrhythmogenic effects
When would you check phenytoin levels?
Before dose if:
1- adjustment in dose
2- suspected toxicity
3- suspected non adherence
Which drugs can -> myasthenia crisis?
penicillamine quinidine, procainamide beta-blockers lithium phenytoin antibiotics: gentamicin, macrolides, quinolones, tetracyclines
Usual cause of a painful CNIII palsy?
Posterior communicating artery aneurysm
Features of CNIII palsy?
Eye deviated down and out
Ptosis
Pupil may be dilated
What is Lennox-gastaut syndrome thought to perhaps follow? Usual age?
Seen on EEG? What may help?
May be extension of infantile spasms (50% have hx) onset 1-5 yrs atypical absences, falls, jerks 90% moderate-severe mental handicap EEG: slow spike ketogenic diet may help
Sodium valproate mechanism? Adverse effects?
Increases GABA
Appetite and weight gain P450 enzyme inhibitor (Eg think warfarin) Ataxia Tremor Hepatitis Pancreatitis Thrombocytopenia Alopecia Teratogenic - neural tube
Carbamazepine mechanism? Adverse effects
Binds to Na channels -> increases refractory period
P450 enzyme inducer Dizzy / ataxia Drowsiness Lecupenia and agranulocytosis SIADH Visual disturbances
Lamotrigine mechanism? Adverse effects ?
Na channel blocker
Stephen Johnson’s
Phenytoin mechanism? Adverse effects ?
Binds to Na channel -> increase refractory period
P450 inducer Dizzy and ataxia Drowsiness Gingival hyperplasia, hirtuism, coarsening of facial features Megaloblastic anaemia Peripheral neuropathy Increased vit d metabolism -> osteomalacia Lymphadenopathy
Which drug increased life span in MND
Riluzole
Key distinguishing features of Lewy body dementia
Progressive cognitive impairment
Parkinsonism
Visual hallucinations
SPECT scan can be used
First seizure and DVLA?
Inform
6 months off driving so long as no structural abnormalities and no eleptiform activity on EEG
If either of these -> 12 months seizure free
Following stopping epilepsy medication how long should people not drive
6 months after last dose
1st line anti thrombotic post TIA/stroke ?
Clopidogrel
Aspirin + dipyridamole for those who cannot tolerate
What are the features of syringomyelia ?
Strong association?
Slow progressing
Motor- Wasting and weakness of arms
Sensory - Spinothalamic sensory loss (pain and temp)
Loss of reflexes
Arnold-chiari malformation
Key feautres of guillian barre
Often post gastroenteritis
Ascending weakness
Areflexia
Autonomic - eg urinary retention
Cranial nerve involvement
MG associations
Thymic hyperplasia / thyromas
Autoimmune - Pernicious anaemia, autoimmune thyroid, SLE, Rhematoid arthritis
5 Ix in MG?
Nerve conduction studies CT thorax - exclude thyroma Creatine kinase - Normal Autoantibodies Tension test
3 key long term Mx of MG
Long acting anti-cholinesterase - Eg pyridostigmine
Immunosuppression - prednisolone
Thymectomy
Mx of MG crisis?
Plasmapheresis
IVIG
TS inheritance?
Autosomal D
Cutaneous / neurological features in TS?
Cutaneous
Ash leaf spots which fluoresce under UV light
Rough patches of skin over lumbar spine (shagreen patches)
Angiofibromas in butterfly distribution over nose
Fibromata under nails
Neurological
Developmental delay
Epilepsy
Intellectual impairment
Features of multi system atrophy
Parkinsonism
Autonomic - Atonic bladder, postural hypotension
Cerebellar signs
What happens in b12 deficiency
Subacute combined degeneration of the spinal cord
- dorsal colum usually affected first (Proprioception, vibration)
- > distal parathesia
Status epliepticus
1/2/3rd line Mx?
1 Buccal midazolam/ IV lorazepam
2 IV lorazepam
3 IV phenytoin (phenobarbital if already on regular phenytoin)
4 Rapid sequence induction of anaesthesia using thiopental sodium
Cranial nerves affected in acoustic neuroma
cranial nerve VIII: hearing loss, vertigo, tinnitus
cranial nerve V: absent corneal reflex
cranial nerve VII: facial palsy
Common reflex roots Ankle? Knee? Biceps? Triceps?
Ankle S1-S2
Knee L3-L4
Biceps C5-C6
Triceps C7-C8
Which anti-epileptic most associated with weight gain?
Valproate
Mid humeral fracture
Which nerve are you worried about?
How to test?
Radial
Extend the wrist
Migrane during pregnancy 1st and 2nd line
1 - paracetamol 1g
2- ibuprofen / aspirin if in 1st/2nd trimester
What class of drug used in Mx of chemo related nausea ? EG? Where do they act? Common Side effect?
5-HT3 antagonists
Odansetron
Medulla oblongata
Constipation
What can provoke an absence seizure? Seen on EEG?
Hyperventilation / stress
Bilateral symmetrical 3Hz spike and wave
Management of cervical myelopathy due to disk prolapse
Cervical decopressive surgery
-> ideally within 6 months of diagnosis for bet prognosis
Ix if cervical myelopathy is suspected?
MRI of spine
What is cataplexy? Association?
Sudden transient loss of muscular tone caused by strong emotion
2/3 of narcolepsy patients have cataplexy
What would you expect in raising eyebrow in Bell’s palsy
Inability to do so as it is a LMN palsy of facial nerve
Mx of Bell’s palsy
Prednisolone
Eye care - eg artificial tears
What Class of drug do you really need to avoid in LB dementia
Antipsychotics -> they are v sensitive and can lead to irreversible Parkinsonism
What is hereditary sensorimotor neuropathy also called?
Inheritance?
Features? Usual presentation?
Charcot-Marie-tooth disease
AD
Starts at puberty
Motor sx predominate
-Distal muscle wasting, clawed toes
-Foot drop, leg weakness are the usual presenting features
Eg of dopamine receptor antagonist for Parkinson’s? Big adverse effect? Other S/e?
Bromocriptine, ropinirole, carbegoline
Pulmonary / cardiac fibrosis
Impulse control disorders, daytime somnolence, hallucinations
What is often used to treat drug induced Parkinsonism? Eg?>
Anti muscarinic
Procyclidine, benzotropine
Which commonly used anaesthetic agent are people with MG resistant to?
Suxamethonium
Restless leg syndrome
What is it? Features? Associations?
Diagnosis? Mx?
Uncontrollable urge to move legs (akathisa)
- usually at night
- Can get parathesia / throbbing
- May occur during sleep
FHx Iron deficiency anaemia Uraemia Diabetes Pregnancy
Diagnosis is clinical although bloods to exclude Iron deficiency anaemia
Mx
Walking, stretching / massaging affected limbs
Treat iron deficiency
Dopamine agonists (Pramipexole / ropinirole)
Benzos
Gabapentin
Where is the defect ?
A 72-year-old man develops visual problems. He is noted to have a left homonymous hemianopia with some macula sparing.
Occipital cortex
[macular sparing]
Where is the defect?
A 30-year-old man with a family history of early blindness is concerned that he is developing ‘tunnel vision’.
What else could be seen on exam ?
Retina
This is probably retinitis pigmentosa
Extensive pigmentation seen on fundoscopy
What is miosis
Contracted pupil
Seen in CNIII palsy?
Eye down and out
Ptosis
Pupil may be dilated
Tremor worse when arms outstretched
Improved by alcohol and rest
Strong FHx
Essential tremor
Tremor with history of liver disease
Hepatic encephalopathy
Tremor with COPD hx
Carbon dioxide retention
Parkinsonism with Supra nuclear palsy has what distinguishing features ?
Dysarthria
Reduced verticals eye movements
Which drug used fro stroke thrombolysis ?
Altepase
Mx of ischemic stroke after 4.5hour window missed?
Aspirin
When do people develop a high stepping gait? What would you suspect if unilateral?
Peripheral neuropathy
Common peroneal nerve lesion
Loss of corneal reflex
Think acoustic neuroma
Nerve to deltoid
Axillary
Feaures of Bell’s palsy
Paralysis Forehead affected - LMN
Dry eyes, altered taste
Mx of Bell’s palsy
Prednisolone 10 days
Artificial tears
An 8-year-old boy falls onto an outstretched hand and sustains a supracondylar fracture. In addition to a weak radial pulse the child is noted to have loss of pronation of the affected hand.
Nerve?
Median
LMN/UMN in ALS, PLS, PMA
myotrophic lateral sclerosis (50% of patients)
typically LMN signs in arms and UMN signs in legs
in familial cases the gene responsible lies on chromosome 21 and codes for superoxide dismutase
Primary lateral sclerosis
UMN signs only
Progressive muscular atrophy
LMN signs only
affects distal muscles before proximal
carries best prognosis
Progressive bulbar palsy
palsy of the tongue, muscles of chewing/swallowing and facial muscles due to loss of function of brainstem motor nuclei
carries worst prognosis
Post shingles pain doesn’t respond to paracetamol and ibuprofen . Give what?
Amitriptyline
Essential tremor Better or worse with Alcohol? Hand outstretched ? 1st line?
Better with alcohol worse outstretched
Propranolol
Features of subacute degeneration of the spinal cord
- Bilateral spastic paresis
- Bilateral loss of proprioception and vibration sensation
- Bilateral limb ataxia
Syngomyella features
- Flacid paresis (typically affecting the intrinsic hand muscles)
- Loss of pain and temperature sensation
Neurosyphylis sensation features?
Loss of proioception and vibration
A 32-year-old rugby player is hit hard on the shoulder during a rough tackle. Clinically his arm is hanging loose on the side. It is pronated and medially rotated.
Brachial trunks c5-6
-Erbs palsy
A 42-year-old teacher is admitted with a fall. An x-ray confirms a fracture of the surgical neck of the humerus. Which nerve is at risk?
Axillary
A 63-year-old man is admitted with a severe headache, nausea and a recent epileptic fit. Fundoscopy shows papilloedema. He is also noted to have diplopia when asked to look laterally.
Nerve?
Abducens
A 32-year-old lady is admitted with weakness, visual disturbance and periorbital pain. On examination she is noted to have mydriasis and diminished direct response to light shone into the affected eye. The consensual response in the affected eye is preserved.
Nerve?
Optic
A 60 year-old male presents with clumsy hands. He has been dropping cups around the house. His wife complains he doesnt answer his mobile as he struggles to use it. His symptoms have been gradually deteriorating over the preceding months.
Sign ?
Hoffmans
[This patient is likely to have degenerative cervical myelopathy [DCM], which is associated with upper motor neuron signs. Hoffmans sign is elicited by flicking the distal phalaynx of the middle finger to cause momentary flexion. A positive result is exaggerated flexion of the terminal phalanyx of the thumb. Patients with DCM often have subtle signs that are easily missed [1], but as a progressive condition, these are likely to get worse [2]. Whilst the sensitivity of signs is low (i.e. their absence does not rule out a problem), their specificity is high (i.e. there will be a problem). Therefore, in order to diagnose early DCM and improve patient outcomes, a high index of suspicion, alongside a comprehensive neurological examination and monitoring for progression is required.]
A 32 year-old female presents with a 3 day history of altered sensation of her left foot and right forearm. She had an episode of visual loss a few months ago and says her friends have noted her eyes be flickery and jerky.
Sign?
Hoffmans
[This patient is likely to have Multiple Sclerosis (MS). As a disease of the central nervous system, MS is usually associated with only upper motor neuron signs such as Hoffmans sign (see above). The patients visual loss was probably secondary to optic neuritis, a common presentation of MS. Cerebellar signs are particularly common with MS and include nystagmus, which is likely to be the jerky eye movements noted by her friends.]
A 70 year old man has decompressive surgery for degenerative cervical myelopathy. Three years later he presents with neck pain and hand paraesthesias. Which one of the following management strategies is recommended?
Urgent referral -
[Postoperatively, patients with cervical myelopathy require ongoing follow-up as pathology can ‘recur’ at adjacent spinal levels, which were not treated by the initial decompressive surgery.
Recurrent symptoms should be treated with a high degree of suspicion. Although peripheral neuropathy can occur in any patient, this should not be the diagnosis that is the most strongly suspected as delays in diagnosis and treatment of DCM affect outcomes. ]
Common side effect of Triptans
‘triptan sensations’ - tingling, heat, tightness (e.g. throat and chest), heaviness, pressure
Triptans CI
patients with a history of, or significant risk factors for, ischaemic heart disease or cerebrovascular disease
Drug to reduce tremor in drug induced Parkinsonism
Procyclidine
Why don’t you get sensory loss over the distribution of the facial nerve in Bell’s palsy?
The facial nerve does not carry sensation
Why do you get hyperacusis in Bell’s palsy ?
Paralysis of stapedius
Facial nerve supplies?
Supply - ‘face, ear, taste, tear’
face: muscles of facial expression
ear: nerve to stapedius
taste: supplies anterior two-thirds of tongue
tear: parasympathetic fibres to lacrimal glands, also salivary glands
IIH associated medications?
contraceptives steroids levothyroxine lithium Tetracycline Abx
What condition do you see bilateral acoustic neuromas ?
Neurofibromatosis type 2
Ix in acoustic neuroma
MRI of cerebellopontine angle
You are examining a patient who complains of double vision. Whilst looking forward the patient’s right eye turns upwards and outwards. On attempting to look to the patient’s left the right eye elevates more as it moves medially. On looking right there is no obvious squint. What is the most likely underlying problem?
Right 4th nerve palsy
Supplies superior oblique
What is Webber syndrome
Pattern of stroke
- ipsilateral III palsy
- contralateral weakness
Useful in patients with absence seizures who are intolerant of sodium valproate
Ethosuximide
Mechanism of odansetron? Common side effect?
5-HT3 antagonist
Constipation
A 40-year-old man presents with a progressive deterioration in vision over the past 2 weeks. On examination, there is ophthalmoplegia, his gait is noticeably ataxic and there is a generalised loss of the deep tendon reflexes. He returned from Turkey two weeks ago where he describes having a simple viral illness involving a sore throat and fever that lasted for around 1 week and resolved shortly before his return home. He drank more alcohol than normal during the holiday, having around 3 glasses of wine each night. What is the cause of his poor vision?
Miller-Fisher variant
§ is a type of Guillain-Barre syndrome that starts by affecting the cranial nerves and therefore manifests with eye signs. Both Guillain-Barre syndrome and Miller-Fisher tend to be preceded by an infection, classically Campylobacter jejuni.
Ophthalmoplegia, areflexia and ataxia (of which the question has all three) are the major features of Miller-Fisher.
This alcohol consumption is a distractor as the question states he drank much more than usual this week and alcoholic polyneuropathy only comes from a chronic, heavy alcohol history.
Open angle glaucoma visual loss?
Peripheral vision loss in affected eye
What is gastroschisis ? Exomphalos? Associations?
Gastroschisis describes a congenital defect in the anterior abdominal wall just lateral to the umbilical cord
-Gastroschisis is associated with socioeconomic deprivation (maternal age <20, maternal alcohol/tobacco use)
In exomphalos the abdominal contents protrude through the anterior abdominal wall but are covered in an amniotic sac formed by amniotic membrane and peritoneum
What is Epstein’s pearl? Mx?
A congenital cyst found in the mouth. They are common on the hard palate, but may also be seen on the gums where the parents may mistake it for an erupting tooth.
No treatment is generally required as they tend to spontaneously resolve over the course of a few weeks.
When is mirtazapine particularly useful? Class?
specific serotonergic antidepressant
Increases appetite and sedative
[old people with insomnia and poor appetite]
Brocca vs wernickes
Wernickes - receptive dysphasia -
-fluent speech, but abnormal comprehension
Brocca - Expressive dysphasia
-Poor speech but normal comprehension
Sx of SSRI discontinuation?
Dizziness, electric shock sensations and anxiety
Cerebellar vermis vs hemisphere ataxia?
Cerebellar hemisphere lesions cause peripheral (‘finger-nose ataxia’)
Cerebellar vermis lesions cause gait ataxia
