Neuro Flashcards
Treatment for cluster headache?
Subcut sumatriptan and 100% O2
Cranial nerve signs ipsilateral and motor signs contralateral is what type of stroke?
A brainstem infarct
Migrain treatment in acute event and for prophylaxis?
acute: triptan + NSAID or triptan + paracetamol
prophylaxis: topiramate or propranolol
If you’re able to lift the upper eyebrow area is that a lower or upper motor neurone issue?
Upper
If you’re unable to lift the upper eyebrow area is that a lower or upper motor neurone issue?
Lower
Wasting and paralysis of hypothenar eminence is as a result of dysfunction in what nerve?
Ulnar
When can you be considered seizure free in epilepsy?
> 2 years no seizure and 2-3 months without medication.
Spinal tracts involved in descending motor control?
Corticospinal (body) Corticobulbar (Head)
Tracts involved in proprioception and vibration?
DCML (conscious)
Spinocerebellar (unconscious)
Tracts involved in pain and temperature?
Lateral Spinothalamic (conscious)
Dorsal root is for sensory or motor information?
Sensory
Ventral root is for sensory or motor info?
Motor (somatic and autonomic)
Triad in normal pressure hydrocephalus?
Ataxia, urinary incontinence and dementia.
Dietary management for kids with epilepsy?
The ketogenic diet is a high fat, low carbohydrate, controlled protein diet. It is an established treatment for children with epilepsy that is hard to control and is generally unresponsive to antiepileptic medications.
Mid shaft humeral fracture associated with what nerve, how would you test this?
Radial nerve, test by doing wrist extension.
Subdural haemorrhage is caused by?
Bleed of bridging veins from sinus to cortex.
What is the sylvian fissure, what does it contain?
Separates the frontal and temporal lobe
Contains branches of the MCA
CSF ventricles of the cranium?
2 lateral ventricles 3rd ventricle (below them) 4th Ventricle (below that)
Openings into the 4th ventricle?
Paired lateral foramina of Lushka
Median foramen of magendie
Small pupil is caused by what (miosis)?
Impaired sympathetic function e.g. horners
Large pupil (mydriasis), is caused by what?
Impaired parasympathetic function e.g. 3rd nerve palsy (will also have ptosis) - could be posterior comm artery aneurysm.
RAPD is a sign of dysfunction of what nerve?
Optic nerve.
Action of the obliques?
Inferior: elevates in ADDUCTION
Superior: depress in ADDUCTION
What muscle (and nerve) is responsible for elevation of abducted eye?
Superior rectus (CN II)
Parasympathetic fibres (for pupil constriction carried in what nerve?)
CN III
What symptoms do you get in 3rd nerve palsy?
Eye in down and out position - can only abduct and intort (elevate in adduction)
Pupil is fixed and dilated
Complete ptosis
If painful the posterior communicating artery aneurysm.
What are some causes of a third nerve palsy?
Aneurysm, diabetes, Cavernous sinus lesion, tentorial herniation.
6th Nerve palsy presentation? Causes?
Can’t abduct
Pupils and eyelid normal
Raised ICP, diabetes
4th Nerve palsy presentation?
Can’t depress in adduction
Pupils normal, eyelid normal
Head trauma
Corneal reflex af/efferent aspect nerves?
Afferent - trigeminal (opthalmic)
Efferent - Facial
What muscles are controlled by the trigeminal nerve?
muscles of mastication:
- Temporalis, masseter pterygoids
Rinnes test abnormal result?
BC > air = conductive loss
Role of the IX CN ?
Glossopharyngeal:
Gag reflex and palatal sensation
X CN function?
Motor to palate and larynx
XI CN function?
Accessory (traps and sternocleidomastoid)
XII CN function?
Hypoglossal
Motor to tongue (will deviate to side of lesion in palsy)
What is bulbar palsy?
Bulbar palsy is a lower motor neurone dysarthria.
A condition in which the lower cranial nerves (8-12) are dysfunctional.
Causes, w/ assoc. feats:
- Wasting and fasciculation of masticatory muscles (MND)
- Fatiguable dysarthria (MG)
- Facial weakness (GBS)
- Brainstem stroke
What is psuedobulbar palsy?
Upper motor neurone dysarthria
CNS dysfunction of the corticobulbar tract.
May have extensor plantar response, brisk jaw reflex, dysphagia.
In a UMN/LMN lesion what type of wasting is observed?
UMN: Late, disuse atrophy
LMN: Early, neurogenic wasting.
Does fasciculation occur in UMN or LMN lesions?
LMN
Tone in UMN and LMN lesions?
Hypotonia (LMN)
Spasticity (UMN)
Pattern of weakness in UMN and LMN lesions?
UMN:
- yes, flexors stronger than extensors in upper limb and reverse in lower
LMN:
- Yes, may follow single nerve, may be predominantly distal.
Plantar reflex in UMN/LMN lesions?
UMN: extensor
LMN: flexor or absent
What tracts decussate at the level in the spinal cord?
Spinothalamic
Reflex dysfunction in radial nerve dysfunction?
Biceps reflex loss
What is brown sequard’s syndrome?
Hemisection of the spinal cord - so the spinothalamic tract has not decussated yet and is affected contralaterally
loss of pain and temperature contralaterally, and all others ipsilaterally
Signs are UMN, SO spasticity and upwards going plantars.
Median nerve compression at wrist Motor, sensory and reflex changes?
Motor:
- Thenar muscles
Sensory:
- Thumb, index, middle and half of ring
Reflex:
- Nil
Ulnar nerve compression at elbow: motor, sensory and reflex changes?
Motor:
hypothenar, interossei and flexor carpi ulnaris (wrist flexion)
Sensory:
- medial 1 and 1/2 fingers
Nil reflex dysfunction
Radial nerve compression at upper arm: motor, sensory and reflex changes?
Motor:
Wrist extension,
Sensory anatomical snuffbox (very little)
Triceps reflex may be lost (if higher then biceps I guess)
Peroneal nerve compression at neck of fibula motor, sensory and reflex changes?
Motor:
tibialis anterior - foot flexion
Sensory :
lateral calf and foot dorsum
nil reflex loss
C7 nerve root loss motor, sensory and reflex changes?
Motor: Triceps, wrist extensors
Sensory: central strip of forearm
Reflex: loss of triceps
L5 nerve root loss motor, sensory and reflex changes?
MotorL Extensor hallucis longus (toe extension)
Sensory: sole of foot
Nil reflex loss
S1 nerve root loss motor, sensory and reflex?
Gastrocnemius, soleus
sole of foot
loss on ankle reflex
What nerve does knee reflex?
Femoral
What nerve does ankle reflex?
Sciatic
Key finding on LP for SAH?
bilirubin
LP done at what level?
L3/4
LP elevated protein differential?
VERY HIGH:
- GBS
- TB/fungal Meningitis
HIGH:
- encephalitis
- malignancy
- meningitis
LP low glucose finding DDx?
Meningitis
HSV encephalitis
LP lymphocytes finding DDx?
Lymphoma/leukaemia
SLE
Viral encephalitis/meningitis
LP oligoclonal bands in CSF?
MS
CNS Lymphoma
SLE
GBS
Dysfunction in complete spinal cord lesion?
Motor:
LMN at site of lesion
UMN below lesion
Sensory dysfunction below lesion
Bladder involvement
Brown sequard dysfunction, motor and sensory?
Motor:
Ipsilateral UMN below lesion
Sensory:
Contraleral loss of pain and temp
Ipsi loss of everything else
Central cord lesion motor and sensory dysfunction?
Motor:
LMN at site, UMN below
Sensory:
Loss of pain and temp, others may be preserved
Migraine features?
throbbing (60% unilateral) moderate-severe pain. Nausea and vomiting, photophobia, visual, sensory, motor and speech disturbance FH, better ON SLEEP.
Tx for acute migraine attack?
Paracetamol/NSAID/Aspirin
Triptan (HT1 antag)
NO OPIOIDS
Tx for prophylaxis of migraines?
Beta blocker
Topiramate
Riboflavin Candeartan
Cluster presentation and Tx?
15-2 and a half hours pain (behind eye) intense unilateral.
Have clusters of headaches for a week or so then better for a while (months).
rhinnorhoea, redness of eye, can have horners
Acute: High flow O2 Triptans, prednisolone
Prophylaxis: Lithium, topiramate, verapamil
Venous sinus thrombosis symptoms?
Severe headache w/ nausea and vomiting +/- seizures, focal neurological signs.
Papilloedma is common
Recent infection, dehydration or immobility
Presentation of carotid artery dissection?
Unilateral headache, traumatic or spontaneous, can have cranial nerve signs such as (horners), pulsatile tinnitus
Classic triad (<1/3rd)
- Ipsilateral pain
- Horner’s syndrome
- Delayed ischaemia
Typical pt with subdural haematoma? Prognosis?
Old, alcoholic, bad prognosis
Typical pt with extra dural haematoma?
young, good prognosis
Most common meningitis agent in UK?
Neisseria meningitidis, (meningococcus) B is most common.
Frontal lobe seizure pres?
progression of clonic sezure over one side of the body
Temporal lobe seizure pres?
De ja vu, then wide eyed stare and automatisms
What epilepsy drugs can’t you take with COCP?
Carbemazepine and phenytoin
Management of status epilepticus?
Prehospital:
- diazepam rectally or midazolam buccally
Then lorazepam
then phenytoin or phenobarbitone
Can go on to give anaesthesia (propofol)
Clinical presentation of tumour?
Focal neurological deficit
Symptoms of raised ICP e.g. early morning headache
Seizures
MS treatment?
Interferon B and glatiramer
Biologics e..g Nataluzimab
polyneuropathy normal presentation?
distal sensorimotor deficits w/ hyporeflexia
Causes of polyneuropathy?
GBS, Cancer, Diabetes
Presentation of myopathy?
Proximal symmetrical weakness without sensory or autonomic symptoms
Cauda equina syndrome typical pres?
Bilateral leg pain w/ sensory disturbances
Incontinence
saddle anaesthesia
Needs decompression
What is radiculopathy and spondylosis?
Radiculopathy - compression of nerve root normally causes pain with weakness and sensory disturbance
Spondylosis - degeneration of spine, may cause radiculopathy
Signs/symptoms of raised ICP?
Signs:
- Papilloedema (after 48 hours)
- ptosis/3rd and 6th nerve palsy (can’t abduct - diplopia)
Symptoms
- Headache, worse on lying down, or after sleeping
- Vomiting
What can caused raised ICP?
SOL:
- tumour
- Abscess
Haemorrhage
- Extra dural
- Subdural
- Sub arachnoid
- Intracranial (HTN - cocaine)
Hydrocephalus
- Communicating and non-communicating (ventricular blockage)
Presentation in brain tumour?
New onset headache, worse in mornings
Nausea and vomiting
Seizures
Focal neurological signs
Types of brain tumour?
From brain itself:
- Glioma (e.g. astrocytoma)
- Microglioma (primary lymphoma)
- Pituitary gland
From lining:
- meningioma
From nerves:
- vestibular schwannoma
Ankle reflex nerve root value?
S1-2
Knee reflex nerve root value?
L3-L4
Biceps reflex nerve root value?
C5-6
Triceps reflex nerve root value?
C7-8
LMN lesion presentation?
Symptoms:
- Pain
- Tingling
- Weakness
Signs:
- Hyporeflexia
- Early wasting
- Fasciculation
UMN lesion presentation?
Symptoms:
- weakness
- spasticity
Signs:
- Hypertonia
- Hypereflexia
- upwards going plantars
Tract involved in crude touch?
Spinothalamic
Tract involved in fine touch?
DCML
What gene is implicated in ALS?
SOD1
Lumbar puncture normal findings?
8-20 pressure <5 lymphocytes No red cells 0.15-0.5 g/L protein Glucose 60-80% of blood glucose
What nerve roots supply the pelvic floor?
S3 S4
MS presentation?
20-40, more common in women
Depends on location
- Optic neuritis - optic nerve will cause blurred vision, pain on eye movement, impaired colour vision
- Cervical cord: get transverse myelitis, ascending numbness and parasthesia, often asymmetrical
- Brainstem: vertigo, dyscoordination, diplopia
UMN signs on examination
Types of multiple sclerosis
Relapse-remitting
- 65% of cases
- after 10 years 50% will go on to get secondary progressive
Primary-progressive
- No relapses
- Patients become progressively disabled from onset
Relapsing-progressive
- 15% of cases, a combination of the above two
What would you see on an MRI for an MS patient?
Multiple T2 high signal lesions, seen as white dots.
Old lesions may be seen on T1 as black holes
LP findings for MS?
Oligoclonal bands
Mild WBC rise (<10)
Normal protein and glucose
High IgG index
What is an evoked potential and what would an evoked potentials investigation say in MS?
Assess brainstem and somatosensory pathways, if these regions have been damaged or delayed the potentials may be delayed.
What are the different stroke syndromes and their presentations?
General presentation:
- Focal loss of function
- No warning, sudden / rapid onset
- Maximal loss in all parts, no gradual spread
The following criteria should be assessed:
- contralateral hemiparesis and/or hemisensory loss of the face, arm and leg
- contralateral homonymous hemianopia
- higher cognitive dysfunction e.g. dysphasia (not dysarthria)
Total anterior circulation infarcts (TACI, 15%)
involves middle and anterior cerebral arteries
all 3 of the above criteria are present
Partial anterior circulation infarcts (PACI, 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, 25%) involves perforating arteries around the internal capsule, thalamus and basal ganglia presents with 1 of the following: 1. Complete contralateral hemiparesis (and/or sensory deficit)
Posterior circulation infarcts (POCI, . 25%) involves vertebrobasilar arteries presents with 1 of the following: 1. Ipsilateral cerebellar signs 2. Contralateral homonymous hemianopia 3. Brainstem stroke
Management of ischaemic stroke?
Blood glucose, hydration, oxygen saturation and temperature should be maintained within normal limits
300mg aspirin
VTE prophylaxis: intermittent pneumatic compression
Cholesterol >3.5 then start statin
Thrombolysis within 4.5 hours, when haemorrhagic stroke excluded:
- Alteplase
Mechanical thrombectomy - can do, may be better, with stent
Secondary prevention :
- Clopidogrel recommended ahead of aspirin and dipyramole
- Carotid artectomy if significant stenosis and suffered TIA or Stroke
Stroke risk factors?
Age - the biggest risk factor of all
Sex - a small male excess
BP - most important modifiable risk factor
Diabetes – doubles risk, but better glycaemic control doesn’t seem to lower this
Cholesterol – complex: observational data show no overall impact, but statins clearly lower risk
Other cardio-vascular disease – AF, MI, PVD, AAA
Smoking – dose response effect
Alcohol
Diet – high salt, low F+V, low fish
Obesity & lack of exercise
Social deprivation
Common causes of ischaemic stroke?
AF Mitral stenosis MI Endocarditis Prothetic valve
Atheroma in large artery
Micro-atheroma and atherosclerosis in small arteries
Common causes of haemorrhagic stroke?
Arteriosclerosis
Amyloid angiopathy
Anticoagulation
Uncommonly: berry aneurysm, tumour
Management of haemorrhagic stroke?
Surgery in select patients
BP control (<140)
VTE prophylaxis Intermittent pneumatic compression
Definition of epilepsy, and of epileptic seizure?
Epileptic seizure:
Synchronous, excessive discharge of neurones in the cerebral cortex causing a clinically discernable event
Epilepsy
- Tendency to recurrent epileptic seizures (2 or more)
Causes of epilepsy?
Identifiable cause in about 50% of cases
Structural causes
- Perinatal
- Head injury
- Stroke
- Tumours
Infection
Genetic
Autoimmune
Metabolic
Investigations for seizure?
Clinical diagnosis, but to aid classification and to determine aetiology
ECG
EEG
Neuroimaging
Principles of epilepsy management?
Focal seizures
- Lamotrigine
- Carbamazepine
Generalised seizures
- Valproate
- Lamotrigine
SAH presentation?
Sudden onset very very severe headache that reaches peak intensity within 5 minutes
Associated brief LOC, nausea and vomiting
Neck stiffness and photophobia
May have focal neurological signs
Investigations for SAH?
First CT scan - this does not rule it out, but can rule it in
Then LP >12 hours after
Bilirubin peak = SAH
Investigations and diagnosis of cerebral venous sinus thrombosis?
Plain non-contrast CT brain
CT venogram
MR venogram
Treatment of venous sinus thrombosis?
Treat underlying infection plus anticoagulation
Presentation of vertebral artery dissection
Vertebral artery dissection
- Posterior neck pain
- Headache
- Different to migraine or musculoskeletal pain
- Lateral medullary syndrome (ataxia, dyspagia)
Pituitary apoplexy presentation and Tx?
SAH mimic with thunderclap headache:
- Neurosurgical emergency
Focal neurological signs
Rapid progressive visual loss
Extra-ocular nerve palsies
Acute pituitary insufficiency
Addisonian crisis, hypotension:
- Metabolic acidosis
- Hypoglycaemia
What is hypokinesia?
Akinesia / Bradykinesia = Lack of / Slowness of movement
Types of hyperkinetic movement?
Tremor
- involuntary, repetitive, rhythmic oscillation of a body part,
Dyskinesia
- Excessive involuntary non-rhythmic jerking
Myoclonus
- Sudden jerk
Dystonia
- Abnormal posturing
What is incoordinated movement called?
Ataxia
Idiopathic Parkinsons disease presentation?
Tremor - worse with distraction, better with movement
Rigidity
Bradykinesia
Postural instability
Micrographia
Difficulty terning over in bed
Difficulty with fine manual tasks
Parkinsons disease treatment?
Motor symptoms
- Levodopa, carbidopa
- Amantadine (NMDA antag)
- Entacapone (COMT inhibitor)
- Selegiline (MOB inhibitor)
- benhexedol (anticholinergic)
What are the different causes of tremor?
Resting tremor
- Parkinsons
- Benign essential - can be genetic, worse on movement
Dystonic tremor
- asymmetric, rhythmic, action tremor, bilateral
Intention tremor
- tries to get to target and then when you get there that’s when problems arise
C5 nerve root (C4/C5 disc level) compression in cervical radiculopathy symptoms?
Pain from neck to shoulder and numbness over deltoid, biceps diminished reflex.
C6 nerve root (C5/C6 disc level) compression in cervical radiculopathy symptoms?
Pain over lateral arm and forearm, sensory distrubance in lateral forearm thumb and index finger
Motor weakness in biceps and brachioradialis
Biceps and supinator reflex damage
C7 nerve root (C6/C7 disc level) compression in cervical radiculopathy symptoms?
Pain down middle forearm and middle, sometimes ring finger
Motor weakness in wrist and finger extensors
Diminished triceps reflex
C8 nerve root (C7/8 disc level) compression in cervical radiculopathy symptoms?
Pain medial forearm to hand, sensory disturbance in medial forearm and hand
Hand grip and intrinsic muscle weakness
No reflex changes
Presentation of cervical spondylotic myelopathy
Numb clumsy hands
Unsteady gait
Bladder symptoms, should do MRI cervical spine
Myasthenia gravis presentation and treatment?
Autoimmune (to ach receptors)
Fatigueability is key
- In talking
- look up at finger
Weakness in proximal muscles
No muscle wasting, fasciculations, tone is normal
Treat with acetylcholinesterase
- pyridostigmine
If they don’t respond then corticosteroids, azathioprine and thymectomy are options
What is syringomyelia?
Cystic cavitation of the spinal cord caused by a number of things such as post trauma, cancer and chiari malformation
Sensory loss (loss of pain and temp and preserved vibration sense and proprioception)
Normally do decompressive surgery
Meningitis presentation?
Fever, headache, neck stiffness, photophobia nause and vomiting and reduced GCS
Encephalitis presentation, normally caused by?
Inflammation of the brain parenchyma, normally viral almost always HSV in the UK
Present with
- Non-specific headache, malaise and myalgia with fever
- Can either then be mild and self-limiting or progress to meningism, personality change and confusion
How does sporadic CJD present, how does variant CJD?
Rapidly progressive dementia with akinetic mutism (don’t move, don’t talk) cortical blindness and myoclonus
Variant presents with behaviour change ataxia and involuntary movements
Causes of hydrocephalus?
Increased CSF production
- very rare, choroid plexus cancer
Obstruction to CSF pathways
- can either be communicative or non-communicative
- Communicative in subarachnoid space obstruction, all 4 ventricles will be dilated, this could be post SAH or infective
- Non-communicative could be a tumour, post-infectious, post-haemorrhagic or congenital malformations
Impaired absorption
presentation of hydrocephalus in kids?
Head will expand as kids bones have not fused, OFCircumference would be crossing centiles, may have be failure to thrive and stuff later on
tension headache presentation?
Bilateral dull persistent headache, episodic or chronic - not affected by physical activity, can last from 30 mins to days or weeks
pressure or tightness - may be associated with the neck
Tension headache Tx?
Acupuncture or amitryptiline
