Neuro Flashcards
discharge management of a stroke
clopidogrel over aspirin. Statin if cholesterol over 3.5
neuroleptic malignant syndrome, what seen on invesgtigations
raised WCC, raised CK
sodium valproate adverse effects
p450 inhibitor alopceia weight gain, hepatitis, teratogenicity
indications for thrombolysis in stroke
within 4.5 hours
haemorrhage excluded
thrombolyse with alteplase
cranial nerve pathologies with acoustic neuroma
cranial nerve VIII: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
cranial nerve V: absent corneal reflex
cranial nerve VII: facial palsy
GCS M
- Obeys commands
- Localises to pain
- Withdraws from pain
- Abnormal flexion to pain (decorticate posture)
- Extending to pain
- None
GCS V
- Orientated
- Confused
- Words
- Sounds
- None
GCS E
- Spontaneous
- To speech
- To pain
- None
management of nausea
Ondansetron for chemotherapy-induced nausea
Haloperidol for intracranial causes (raised ICP, direct effect of tumour)
Prochlorperazine for vestibular causes
Metoclopramide for gastrointestinal causes
management of acute relapse of MS
high dose methyl pred
for spasticity baclofen and amitryptiline are first line
uhthoff’s phenomenon
uti leading to flare in MS symptoms
multiple system atrophy features
Shy-Drager syndrome is a type of multiple system atrophy.
Features
parkinsonism
autonomic disturbance (atonic bladder, postural hypotension, erectile dysfunction)
cerebellar signs
test for CSF in trauma leakage
glucose
beta 2 transferrin (gold std)
when to treat epilepsy
following a second epileptic seizure. NICE guidelines suggest starting antiepileptics after the first seizure if any of the following are present:
the patient has a neurological deficit
brain imaging shows a structural abnormality
the EEG shows unequivocal epileptic activity
the patient or their family or carers consider the risk of having a further seizure unacceptable
painful 3rd nerve palsy
posterior communicating artery aneurysm
3rd nerve palsy
eye is deviated ‘down and out’
ptosis
pupil may be dilated (sometimes called a ‘surgical’ third nerve palsy)
causes of 3rd nerve palsy
diabetes mellitus
vasculitis e.g. temporal arteritis, SLE
false localizing sign* due to uncal herniation through tentorium if raised ICP
posterior communicating artery aneurysm (pupil dilated)
cavernous sinus thrombosis
Weber’s syndrome: ipsilateral third nerve palsy with contralateral hemiplegia -caused by midbrain strokes
other possible causes: amyloid, multiple sclerosis
causes of foot drop
L5 radiculopathy
sciatic nerve lesion
common peroneal nerve lesion
superficial or deep peroneal nerve lesion
other possible includes central nerve lesions (e.g. stroke) but other features are usually present
klumpke paralysis trunks and muscles
c8-t1. weakness of intrinsic hand muscles. traction injuries
erbs palsy trunks
c5-6
Lateral medullary syndrome
posterior inferior cerebellar artery PICA
aka Wallenberg’s syndrome
ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner’s
contralateral: limb sensory loss
Lacunar infarcts presents with
- unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
- pure sensory stroke.
- ataxic hemiparesis
carpal tunnel syndrome nerve and muscles
median LOAF lat lumbricals opponens pollicis, abductor pollicis brevis flexor pollicis brevis
roughened patches of skin over lumbar spine + seizures
shagreen patches found in tuberous sclerosis
subungual fibroma also seen
management of migraines
acute: triptan + nsaid/ paracetamol
prophylaxis: topiramate or propranolol(child bearing age)
neurolaptic malignant syndrome pentad
hyperthermia, muscle rigidity, autonomic instability, altered mental status
c8 dermatome and myotome
medial side of the hand over little finger
flexion of DIP and MCP joints
(elbow extension is weak as contains roots from C7 and C8)
NF2 associated with
bilateral vestibular schwannomas
roots for reflexes
ankle, knew, biceps, triceps
Ankle S1-S2 Knee L3-L4 Biceps C5-C6 Triceps C7-C8
30 yo with tunnel vision
retinitis pigmentosa.
metoclopramide side effects
extrapyramidal side effects common in children and young adults
management of trigeminal neuralgia
carbamazepine or urgent referral if red flags present
what to avoid in lewy body dementia
Avoid neuroleptics in Lewy body dementia- may cause irreversible parkinsonism
Lip smacking + post-ictal dysphasia are localising features of
temporal lobe seizure
window for thrombectomy
6 hours
facial nerve complication due to paralysis of stapedius muscle
hyperacusis
most common complication of meningitis
sensorineural hearing loss
side effects of pheytoin
lymphadenopathy, peripheral neuropathy, gingival hyperplasia
todd’s paresis
post ictal weakness, common in focal seizures
Internuclear ophthalmoplegia features
impaired adduction of the eye on the same side as the lesion
horizontal nystagmus of the abducting eye on the contralateral side
EEG features of absence seizure
EEG: bilateral, symmetrical 3Hz spike and wave pattern
Brain abscess on imaging
parenchymal
ring enhancing
restricted diffusion on weighted imaging
Sinusitis + focal neurology and fever →
?brain abscess
Hereditary sensorimotor neuropathy features
includes charcot marie tooth
type 1:
autosomal dominant
due to defect in PMP-22 gene (which codes for myelin)
features often start at puberty
motor symptoms predominate
distal muscle wasting, pes cavus, clawed toes
foot drop, leg weakness often first features
precipitating factors for migraines
Chocolate Hangovers Orgasms Cheese Caffeine The oral contraceptive pill Lie-ins Alcohol Travel Exercise
Temporal lobe seizures HEAD
Hallucinations (auditory/gustatory/olfactory), Epigastric rising/Emotional, Automatisms (lip smacking/grabbing/plucking), Deja vu/Dysphasia post-ictal)
temporal arteritis associated with
polymyalgia rheumatica (proximal weakness)
Relative Afferent Pupillary Defect where is pathology
retina or optic nerve
horners syndrome triad and cause
miosis (contriction), ptosis, anhidrosis (no sweating). Sympathetic nerves of face affected
syringomyelia features
first cause compression of the spinothalamic tract as they decussate in the anterior white commissure.
associated with chiari malformations
autonomic dysreflexia lowest lesion level
T6
indications for CT head in headache
Vomiting more than once with no other cause.
New neurological deficit (motor or sensory).
Reduction in conscious level (as measured by the Glasgow coma score).
Valsalva (associated with coughing or sneezing) or positional headaches.
Progressive headache with a fever.
homonymous quadrantanopias: PITS
Parietal-Inferior, Temporal-Superior) contralateral to defect
high pituitary= lower bitemporal loss and vice cersa
ulnar nerve function
Overview
arises from medial cord of brachial plexus (C8, T1)
Motor to medial two lumbricals aDductor pollicis interossei hypothenar muscles: abductor digiti minimi, flexor digiti minimi flexor carpi ulnaris
Sensory to
medial 1 1/2 fingers (palmar and dorsal aspects)
Hoffman’s sign
examiner should flick the patients distal phalanx (usually of the middle finger) to cause momentary flexion. A positive sign is exaggerated flexion of the thumb.
Hoffmans sign is a sign of upper motor neuron dysfunction and points to a disease of the central nervous system
depigmented ‘ash-leaf’ spots which fluoresce under UV light
tuberous sclerosis
DVLA advice with
-TIA/stroke
-epilepsy
epilepsy and category c
- 1 month off may not need to inform DVLA if no residual neurological deficit. If defecit, DVLA do assessment
- 6 months seizure free
- 10 years seizure free
Contra indications to triptans
ischaemic heart disease and risk factors
stoppin of anti epileptic drugs
seizure free for >2 years, AEDs stopped over 2-3 months
Useful for managing tremor in drug-induced parkinsonism
procyclidine
parkinsons drug associated with pulmonary fibrosis
cabergoline
parkinsons drug with reduced effectiveness over time
levodopa
normal pressure hydrocephalus triad
wet, wobbly and whacky
urinary incontinence
dementia and bradyphrenia
gait abnormality (may be similar to Parkinson’s disease)
charcot marie toot inheritance
autosomal dominant
pmp-22 gene which codes for myelin
friedrich waterhouse syndrome
rare complication of meningococcal sepsis involving bilateral adrenal haemorrhage. This would be a patient who is extremely unwell, or who has been recently treated for meningitis and presents with collapse and salt-wasting
side effects of levodopa
dyskinesia 'on-off' effect postural hypotension cardiac arrhythmias nausea & vomiting psychosis reddish discolouration of urine upon standing
pontine haemorrhage presentation
quadriplegia, miosis, absent horizontal eye movements
LES vs MG
strength improves with activity, in MG it’s the opposite
MG associated with thymomas
mx seizures
Generalised tonic-clonic seizures
sodium valproate
second line: lamotrigine, carbamazepine
Absence seizures* (Petit mal)
sodium valproate or ethosuximide
sodium valproate particularly effective if co-existent tonic-clonic seizures in primary generalised epilepsy
Myoclonic seizures**
sodium valproate
second line: clonazepam, lamotrigine
Focal seizures
carbamazepine or lamotrigine
second line: levetiracetam, oxcarbazepine or sodium valproate
Laughter → fall/collaps
cataplexy
mid shaft humeral fracture. nerve and test
radial. extend wrist
jacksonian march and type of seizure
starts peripherally and spreads (focal aware)
frontal lobe
degenerative cervical myelopathy presentation
Pain (affecting the neck, upper or lower limbs)
Loss of motor function (loss of digital dexterity, preventing simple tasks such as holding a fork or doing up their shirt buttons, arm or leg weakness/stiffness leading to impaired gait and imbalance
Loss of sensory function causing numbness
Loss of autonomic function (urinary or faecal incontinence and/or impotence) - these can occur and do not necessarily suggest cauda equina syndrome in the absence of other hallmarks of that condition
Hoffman’s sign: is a reflex test to assess for cervical myelopathy. It is performed by gently flicking one finger on a patient’s hand. A positive test results in reflex twitching of the other fingers on the same hand in response to the flick.
?meningitis with altered mental state and aura jamais vu
encephalitis start aciclovir to cover HSV1
myotonic dystrophy vs beckers dystrophy
myotonic muscles do not relax
CTZ is where
medulla oblongata
falls soon after new dx of parkinsons
progressive supranucear palsy (park plus) test eye movements (diplopia)
restless leg syndrome mx
management includes dopamine agonists such as ropinirole
raised ICP and third nerve palsy
transtentoral herniation
LES antibodies
voltage gated calcium channel antibodies
anterior circulation infarct
- unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphasia
all for total, 2 for partial
posterior circulation
presents with 1 of the following:
- cerebellar or brainstem syndromes
- loss of consciousness
- isolated homonymous hemianopia
An isolated result of high protein in the CSF
GBS
lamotrigine s/e
SJS
mx of bell’s palsy
prednisolone (more common in pregnancy)
lubricating eye drops and tape eyes shut
numb armpit nerves
intercostobrachial nerve - axillary clearance surgery
loss of pronation nerve
median nerve
essential tremor mx
propranolol
MND mx
Riluzole
prevents stimulation of glutamate receptors
used mainly in amyotrophic lateral sclerosis
prolongs life by about 3 months
Respiratory care
non-invasive ventilation (usually BIPAP) is used at night
studies have shown a survival benefit of around 7 months
blood test to differentiate true and pseudoseizure
prolactin
spontaneous intracranial hypertension
Spontaneous intracranial hypotension is a very rare cause of headaches that results from a CSF leak. The leak is typically from the thoracic nerve root sleeves.
Risk factors include connective tissue disorders such as Marfan’s syndrome.
hoovers sign
true and fake leg weakness
neuropathic pain 1st line tx
amitriptyline, duloxetine, gabapentin or pregabalin.
subdural vessel
bridging veins between cortex and venous sinus
complex regional pain syndrome
Complex regional pain syndrome (CRPS) is the modern, umbrella term for a number of conditions such as reflex sympathetic dystrophy and causalgia. It describes a number of neurological and related symptoms which typically occur following surgery or a minor injury. CRPS is 3 times more common in women.
phenytoin s/e
peripheral neuropathy
proarrhythmic
anterior cerebral artery vs mca infact
Anterior cerebral artery stroke causes leg weakness but not face weakness or speech impairment
idiopathic intracranial hypertension mx
weight loss
acetazolamide
when to perform carotid endarterectomy
50 or 70 percent stenosis
cluster headache prophylaxis
verapamil
(acute- o2 and sub cut triptan)
(alcohol is a trigger)
syringomyelia
collection of csf in cord
‘cape-like’ (neck and arms) loss of sensation to temperature but preservation of light touch
3rd nerve palsy, lesion ipsi or contralateral
ipsilateral
stroke ct with or without contrast
without contrast
anti emetic that can be used in parkinsons
domperidone- does not cross BBB
congruous vs incongruous homonymous hemianopia
contralateral optic radiation/cortex vs contralateral optic tract
ondansetron MOA
5HT3 blocker
cerebellar vermis vs hemisphere lesion
hemisphere causes finger nose ataxia
ix in young stroke
autoimmune and thrombophilia screening if stroke <55
mx neuroleptic malignant syndrome
stop antipsychotic, dantrolene or bromocriptine
types of MS
Relapsing-remitting disease
most common form, accounts for around 85% of patients
acute attacks (e.g. last 1-2 months) followed by periods of remission
Secondary progressive disease
describes relapsing-remitting patients who have deteriorated and have developed neurological signs and symptoms between relapses
around 65% of patients with relapsing-remitting disease go on to develop secondary progressive disease within 15 years of diagnosis
gait and bladder disorders are generally seen
Primary progressive disease
accounts for 10% of patients
progressive deterioration from onset
more common in older people
initial mx of stroke in a chadvasc high pt
still high dose aspirin, move to anticoag after 14 days rather then low dose clopi for secondary prevention
Lhermitte’s sign
tingling in her hands which comes on when she flexes her neck
indicates disease near the dorsal column nuclei of the cervical cord. It is also seen in subacute combined degeneration of the cord and in cervical stenosis
dermatome aid memoirs
c6- make a six with index and thumb t4- teat pore t10- belly butTEN L1- Ligament 1nginal L4- on aLL 4s (knee caps) L5- Largest of 5 toes S1- small 1 (little toe)
Cushing reflex
response to increased intracranial pressure (ICP) that results in hypertension and bradycardia
Mx of stroke in GP within 7 days
High dose aspirin immediately- specialist review within 24 h
Cavernous sinus syndrome
Diagnosis is based on signs of pain, opthalmoplegia, proptosis, trigeminal nerve lesion (opthalmic branch) and Horner’s syndrome.
intracranial venous thrombosis ix
MR venogram
parkinsons drug (1st one for motor symptoms affecting qol)
levodopa
associated with bilateral vestibular schwannomas
NF2 (mri cerebellar pontine angle)
dementia associated with MND
frontotemporal
MRC scale
Grade 0 No muscle movement
Grade 1 Trace of contraction
Grade 2 Movement at the joint with gravity eliminated
Grade 3 Movement against gravity, but not against added resistance
Grade 4 Movement against an external resistance with reduced strength
Grade 5 Normal strength
adenoma sebaceum
(angiofibromas): butterfly distribution over nose found in tuberous sclerosis
