Neuro Flashcards
How might you investigate MS?
Bloods: anti NMO
MRI; would show inflammation in periventricular white matter
LP: would show IgG oligoclonal bands
Evoked potentials: would show delayed auditory, visual and sensory
6th nerve palsy presentation
failure to abduct, cross eyed appearance
Can be a sign of raised ICP due to it having the longest course, so it goes first
causes of horner’s syndrome?
central/1st order neurones: MS, vascular disease
pre ganglionic/2nd order: pancoast’s tumour, T1 nerve root lesion, carotid endarterectomy
post ganglionic/3rd order: cavernous sinus thrombus
Management of stroke?
Acutely…ABCDE approach and call for help
Haemorrhagic:
Conservative: neuro obs
Medical: BP control, correct INR
Surgical: Neurosurgery referral
Ischaemic:
If <4.5 hours
Thrombolysis, repeat CT and start aspirin after 24h
If >4.5 hours
Aspirin 300mg
Then aspirin with clopidogrel lifelong
After initial acute management, admit to stroke unit for full investigation and neuro rehab with MDT and “secondary prevention mx”
homonymous hemianopia - lesion?
optic tracts
Causes of a bulbar palsy?
Motor neurone disease
Myasthenia gravis
Brainstem lesions: stroke/tumour
macular sparing homonymous quadrantinopia - lesion?
striate cortex
Define multiple sclerosis
A chronic inflammatory condition of the CNS characterised by multiple plaques of demyelination disseminated in time and space
Causes of complex opthalmoplegias?
Diabetes
Multiple sclerosis
Myasthenia graves
Thyrotoxicosis
Mimics of 3rd nerve palsy?
Thyrotoxicosis
Raised ICP
Myasthenia
4th nerve palsy presentation
nasal upshoot, failure to depress during adduction
causes of enlarged blind spot?
Optic neuritis
Papilloedema
Effect of stroke in anterior cerebral artery?
Contralateral motor/sensory loss in the legs > arms
Face is spared
Effect of stroke in middle cerebral artery?
Contralateral motor/sensory loss in face and arms >legs
Contralateral homonymous hemianopia
Cognitive changes; aphasia, neglect, apraxia
What is the Mx of Parinson’s?
MDT approach; neurologist, specialist nurse, physio, OT, GP, carers
Medical:
- Dopamine agonists: Bromocriptine, cabergolhne
- L-DOPA or peripheral DOPA decarboxylase inhibitor (carbidopa)
- MAO-B inhibitors and COMT inhibitors
Give anti emetics, anti psychotics and anti depressants
Causes of peripheral neuropathy?
INVITED MD
Infective; Guillan-Barre [Neoplastic/Vascular/Inflammatory & AI] Trauma Endocrine: Hypothyroidism, DM [Degenerative] Metabolic: B12, lead Drugs: Alcohol, chemotherapy
How might MS present?
“SATO”
Spastic parapesis
Ataxia
Tingling
Optic neuritis
Posterior circulation stroke presentation?
Cerebellar syndrome
Brainstem syndrome
Homonymous hemianopia
secondary prevention of ischaemic stroke?
Aspirin 300mg initially for 2 weeks, then reduce dose
Clopidogrel
Statin
Address risk factors e.g. DM and HTN
Causes of 3/4/6th nerve palsies?
Central NS: MS, vascular, SOL
Peripheral: DM (mononeuritis), compression, trauma
What are poor prognostic signs in MS?
Older female
Motor signs at onset
Many relapses early on
Many MRI lesions
Causes of cerebellar syndrome?
DAISIES
Demyelination Alcohol Infarct; brainstem stroke Space occupying lesion Inherited; e.g. Frederich's Ataxia/Wilson's disease Epilepsy medications: Phenytoin System atrophy, multiple
Ddx for Parkinsonism?
Progressive supra nuclear palsy
Corticobasilar degeneration
Lewy Body Dementia
causes of unilateral vs bilateral ptosis?
bilateral: myasthenia gravis, myotonic dystrophy, congenital
unilateral: 3rd nerve palsy, horner’s syndrome
Risk factors for stroke?
Hypertension Smoking AF DM Vascular disease Family history
homonymous quadrantinopia - lesion?
optic radiations
Clinical picture of Charcot Marie Tooth
Inspection: Bilateral pes cavus, Inverted champagne bottle, distal wasting & weakness
Tone:
Power: Weakness of ankle dorsiflexion & toe extension
Sensation:+/- Glove and stocking sensory neuropathy
Reflexes: Absent ankle jerk and plantar response
Gait: Stamping gait with foot drop, broad based. Positive Romberg sign (due to lack of proprioception)
Classify the types of MS
Relapsing remitting (80%)
Secondary progressive
Primary progressive
Progressive relapsing
Eye problems in MS?
Optic neuritis
INO
diplopia
Causes of 3rd nerve palsy?
Mononeuritis
MS
Tumours
Aneurysms
What medications are commonly used in MS?
Methylprednisolone - acute attacks
Interferon beta - disease modifying
Natalizumab - biologics preventing relapse
Baclofen - spasticity
Causes of unilateral facial nerve palsy?
Categorised by anatomical level:
Supranuclear: SOL, vascular, MS
Brainstem: haemorrhage, infection
Cerebellopontine angle: acoustic neuroma, meningioma
Facial canal: Ramsay-Hunt, trauma
Systemic: DM
Other causes of Parkinson presentation?
Parkinson plus syndromes:
Multi system atrophy:
- autonomic dysfunction, parkinsonism, cerebellar ataxia
Progressive supranuclear palsy:
- vertical gaze palsy, pseudobulbar palsy, parkinsonism
Lewy body dementia
What is lateral medullary syndrome/ Wallenberg’s
Occlusion of vertebral artery or PICA; signs are ipsilateral apart from body anaesthesia to pain "DANVAH" Dysphagia Ataxia Nystagmus Vertigo Anaesthesia Horner's syndrome
Features of vestibular schwannoma?
sensorineural hearing loss, tinnitus, vertigo, headache, facial anaesthesia and facial nerve palsy
Features of Friedrich’s ataxia?
Autosomal recessive mitochondrial disorder
PAWAH
Pes cavus Ataxia Wasting in legs Areflexia in legs but extensor planters HOCM
Myasthenia gravis features on inspection
Thymectomy scar Bilateral ptosis Complex ophthalmoplegia Myasthenic snarl Nasal voice +deterioration
Ix for myasthenia gravis?
Bloods
Abs:Anti AChR, Anti MuSK
Spirometry:
EMG: reduced response to titanic train of impulses
!!! Tensilon test: improvement with edrophonium
Imaging:
CT mediastinum: thymoma
Management of myasthenia gravis?
Acute: ABCDE approach! If rest dysfunction, ITU
- Plasmapheresis
- IVIg
Chronic
- Anti muscarinics, e.g pyrdostigmine
Classification of tremors
Active
- Postural tremor (benign essential, anxiety)
- Intention tremor
Passive
- Parkinsonian
Benign essential: Postural tremors get worse with lack of sleep and caffeine and better with alcohol
Tx of acute delirium
Haloperidol or olanzipine
Difference between HSMN1 and 2?
1: demylination - reduced conduction velocity
2. decreased amplitude - axonal degeneration
Mutated peripheral myelin protein
NMO vs MS?
NMO can be more severe, is not progressive in nature
NMO attacks aquaporin 4 protein in the CNS
Medical vs surgical 3rd nerve palsy
Medical: pupil sparing (e.g. diabetes, MS)
Surgical: pupil dilated (e.g. tumour)
Classification of LMN lesions
Anterior horn (old polio) Nerve itself (diabetes) Neuromuscular junction (Myasthenia)
Syringomyelia presentation
Syrinx = tubular cavity in spinal cord
Cape distribution: loss of pain and temperature
wasting/weakness of hands, loss of UL reflexes, charcot joints
