neuro Flashcards
stroke thrombolysis - when can it be given?
up to 4.5 hours and haemorrhage exluded by CT
Tx stroke outside the thrombolytic window?
aspirin
If falls soon after dx of Parkinson’s disease, what is wrong?
Investigate neuro signs - CN3/4/6
could be Parkinson’s plus syndrome - PSP
what is the Parkinson’s plus disease: PSP
Progressive Supranuclear Palsy
How would PSP present?
impaired vertical gaze - down worse than up >difficulty reading/down stairs Parkisnonism slurred speech falls cognitive impairment
how do patients with PSP respond to L-Dopa?
Poorly
Mx of cervical myelopathy?
refer to spinal/neurosurgery
Decompressive surgery - prevents progression
when should surgery be done for cervical myelopathy?
within 6 months
symptom relief in cervical myelopathy?
Neuropathic analgesia
risk factors for degenerative cervical myelopathy?
smoking
genetics
occupation - axial loading
DCM symptoms?
pain - neck/UL/LL loss motor function sensory loss - numbness loss autonomic function - incontinence/impotence Hoffman's sign
what is Hoffman’s sign?
reflex test to assess for Cervical Myelopathy
flicking finger of patient’s hand
+ve - reflex twitching of other fingers on same hand in response
Ix: Cervical Myelopathy
what will it show?
gold standard - MRI (C-spine if UL+LL sx)
disc degeneration and ligament hypertrophy with cord signal change
which antiepileptic is most associated with weight gain?
Na Valproate
how does Na valproate work?
Increases GABA activity
Na Valproate adverse effects?
nausea increased appetite/weight gain alopecia ataxia tremor hepatotoxicity pancreatitis thrombocytopaenia teratogenic hyponatraemia hyperamonemic encephalopathy
what is paraesthesia?
abnormal sensation - tingling/pricking sensation caused by pressure on/damage of peripheral nerves
54yo male, 6/7 hx paraesthesia hands and feet.
Getting worse - can’t walk.
2/52 hx diarrhoea episode. resolved.
recent life stressors. no alcohol misuse.
Ex: 4/5 finger abductors, 3/5 ankle dorsiflexion+plantarflexion
loss soft touch sens up to ankles bilat
absent knee/ankle reflexes, plantars downgoing. T=N
reduced motor nerve conduction velocity on NCS 2nd to demyelination
GBS
Guillian Barre syndrome: define
progressive peripheral polyneuropathy with hyporeflexia is GBS
what recent infection is commonly associated with GBS?
Campylobacter
which visual field loss results from PG tumour?
Bilateral hemianopia, upper quadrant defect
what visual field loss from primary open angle glaucoma in R eye?
Unilateral peripheral vision loss
visual field loss from extensive stroke with R sided hemiplegia?
R sided homonynous hemianopia
in left honomymous hemianopia, where is lesion?
R sided optic tract
what does PITS refer to (visual fields)
homonymous quadrantanopias -
Parietal Inferior
Temporal Superior
where are lesions in incongruous defects?
optic tract lesion
where are lesions in congruous defects?
optic radiation lesion / occipital cortex
what does congruous defect mean?
complete/symmetrical defect
incongruous defect
incomplete/asymmetrical
in bitemporal hemianopia, where is the lesion>
Optic chiasm
UQ defect>LQ defect - inferior chiasmal compression - PG tumour
LQ>UQ - superior chiasmal compression - craniopharyngioma
which malformation is associated with Syringomyelia
Chari malformation
what are chari malformations causing?
disturbed CSF flow at foramen magnum
cape-like distribution of sensory loss?
Syringomyelia
migraine triggers:
CHOCOLATE chocolate orgasms hangovers cheese caffeine COCP lie-ins alcohol travel exercise
where is the lesion when patient presents with gait ataxia?
Cerebellum Vermis
what will the patient’s exam show with cerebellar hemisphere lesion?
Finger-nose ataxia
which type of LOC episodes are associated with a rapid recovery and short post-ictal period?
Vasovagal syncope
which neuro condition is of higher incidence at higher latitudes?
MS
risk factors MS:
female away from equator EBV smoking Vit D def
which drug shows a survival benefit in patients with MND?
Riluzole
3 months survival increase
What does Riluzole do?
prevents glutamate receptor stimulation in ALS
what non-pharma tx for MND has shown benefit?
BIPAP at night
In stroke mx, which pharma tx first?
aspirin then clopidogrel
what triggers pain in trigeminal neuralgia?
light touch, shaving, eating
what is the pain like in trigeminal neuralgia?
Brief electric shock like pain
first line tx trigeminal neuralgia?
Carbimazepine
sfx - sjs
what does pyridostigmine tx as 1st line?
MG - sx relief
what is pyridostigmine MOA?
Long acting AchI
what class of drugs treats cause of MG?
Immunosuppressants
The key feature is muscle fatigability extraocular muscle weakness: diplopia proximal muscle weakness: face, neck, limb girdle ptosis dysphagia
Myasthenia Gravis
what is MG highly associated with ?
Thymoma (15%)
MG Ix:
single fibre electromyography CT thorax - thymoma CK autoAbs - Tensilon test
Mx: myesthenic crisis:
plasmapharesis
IVIG
commonest MND:
ALS
Amyotrophic lateral sclerosis
ALS sx:
typically LMN signs in arms
UMN signs in legs
FHx cases: gene on ch21 and codes for superoxide dismutase
nerve lesion can cause weakness of foot dorsiflexion and foot eversion?
Common peroneal
where is common peroneal nerve running?
lateral knee
vertigo, hearing loss, tinnitus and an absent corneal reflex: which cranial nerves will be affected?
8, 5, 7
vertigo, hearing loss, tinnitus and an absent corneal reflex: Dx?
vestibular schwannoma / acoustic neuroma
Ix: acoustic neuroma:
MRI: cerebellopontine angle
what type of side effects with metroclopramide (antiemetic)
EPSEs in young people
gold standard test for dx : venous thrombosis?
MR venogram
risk factors for cerebral venous sinus thrombosis?
COCP
FHx VTE
presentation:
2/7 Hx gradual onset severe headache, n/v. Blunted and difficulty finding right words. No PMHx.
COCP. FHx - mother unprovoked DVT in her 30s
Venous thrombosis
what lesion would cause finger abduction weakness?
T1
damage to C5,6 roots
winged scapula
breech presentation
Erb-Duchenne paralysis
damage to T1
loss of intrinsic hand muscles
due to traction
Klumpke’s paralysis
A wide-based gait with loss of heel to toe walking - what gait?
Ataxic gait
cerebellar injury causes - PASTRY ?
P - Posterior fossa tumour A - Alcohol S - Multiple sclerosis T - Trauma R - Rare causes I - Inherited (e.g. Friedreich's ataxia) E - Epilepsy treatments S - Stroke
Mx: Bell’s palsy
Prednisolone
EYE CARE
Bell’s palsy define:
unilateral, idiopathic, facial nerve paralysis
peak incidence Bell’s palsy and who is more at risk?
20-40
pregnant women
which (LMN lesion) does NOT spare forehead?
Bell’s palsy
patients may also notice post-auricular pain (may precede paralysis), altered taste, dry eyes, hyperacusis
in which palsy?
Bell’s palsy
Triceps reflex nerve root?
C7-C8
Bicep reflex nerve root?
C5-C6
Ankle reflex nerve root?
S1-S2
Knee reflex nerve root?
L3-L4
change in her appearance. She finds removal of rings difficult, her shoe size has changed and photographs show a marked change in her appearance
Acromegaly
what causes acromegaly?
PG SOL
what is anterior white commisure?
Spinothalamic tracts
What do spinothalamic tracts do?
Temperature
pain
Dorsal coloumns - what do they carry sens?
proprioception
fine touch
vibration
hyperacusis
You can experience a heightened sensitivity to particular sounds that are not usually a problem for others
what causes hyperacusis?
Facial nerve palsy - VII
why can facial nerve palsy cause hyperacusis?
VII supplies the stapedius muscle
what does facial nerve supply?
Face, ear, taste, tear facial expression muscles, ear - nerve to stapedius taste - anterior 2/3 tear - parasymptathetic fibres to lacrimal glands
causes of bilateral facial nerve palsy?
sarcoidosis GBS Lyme disease bilateral acoustic neuromas Bell's
confabulation - which disease?
Korsakoff’s syndrome
nystagmus (the most common ocular sign) ophthalmoplegia ataxia confusion, altered GCS peripheral sensory neuropathy
all features of?
Wernicke’s encephalopathy
cause of congenital hydrocephalus?
Arnold-chiari malformation
what happens in Arnold-chiari malformation?
cerebellum herniates through the foramen magnum
plydactylyl
extra digits
achondroplasia
dwarfism type
if intracerebral haemorrhage due to thrombolysis - after stroke - mx?
stop aspirin and control BP
Charcot-Marie-Tooth - what is it?
inherited condition, damage to peripheral nerves
which nerves are affected by Charcot-Marie-Tooth?
both sensory and motor peripheral nerves
Unilateral Parkinsonism and severe autonomic disturbance (atonic bladder/postural Hypotension)- dx?
Multiple system atrophy
thymine deficiency - vitamin?
B1 deficiency
Tuberous sclerosis - inheritance?
autosomal dominance
depigmented ‘ash-leaf’ spots which fluoresce under UV light
roughened patches of skin over lumbar spine (Shagreen patches)
adenoma sebaceum (angiofibromas): butterfly distribution over nose
fibromata beneath nails (subungual fibromata)
café-au-lait spots* may be seen
Tuberous sclerosis
Tuberous sclerosis: neuro features?
developmental delay
epilepsy
intellectual impairment
what is the commonest psych illness of PD?
Depression!
adenoma sebaceum
Tuberous sclerosis
If mix of UMN and LMN signs, think?
Subactute combined degeneration of the SC
what causes SCDC?
b12 deficiency
what can precipitate SCDC?
giving folate to a b12 deficient patient
Damage to the posterior columns - loss of proprioception, light touch and vibration sense (sensory ataxia and a positive Romberg’s test).
Damage to lateral columns - spastic weakness and upgoing plantars (UMN signs).
Damage to peripheral nerves - absent ankle and knee jerks (LMN signs).
SCDC
which sign is: paraesthesiae in limbs on neck flexion
Lhermitte’s sign
MS
worsening of vision following rise in body temperature: which sign?
Uhtoff’s phenomenon
MS
what type of inherited condition is essential tremor?
AD
essential tremor made better by: (from history)
alcohol
what is first line tx intention tremor:
Propranolol
phonobhobia in which type of headache?
migraine
excessive watering of the eye: medical word
epiphora
which blood test can differentiate between seizure and pseudo-seizure?
Prolactin - raised in real seizure
Following a first seizure, patients must be seizure free for how long before driving?
6 months
If the patient has a formal diagnosis of epilepsy they must be seizure-free for at least ?? before driving
12 months
dose of Aspirin for someone with TIA <7days
300mg
ataxic gait and increased upper limb tone with cog-wheel rigidity. Blood pressure is 135/80 lying and 95/70 standing. Dx?
multiple system atrophy
thumb/index finger nerve root?
c6
middle finger palm nerve root?
c7
ring and little finger nerve root
c8
man had stroke. Started on aspirin. made a good recovery. what should he be changed onto after 14 days?
clopidogrel and statin
GCS: how many points for each section?
654.. MoVE
GCS motor response 1-6:
- Obeys commands
- Localises to pain
- Withdraws from pain
- Abnormal flexion to pain (decorticate posture)
- Extending to pain
- None
GCS: verbal response 1-5
- Orientated
- Confused
- Words
- Sounds
- None
GCS: eye opening 1-4
- Spontaneous
- To speech
- To pain
- None
Carotid bruit, previous TIA, atrial fibrillation and ischaemic heart disease are indications that the cause of a stroke is ??
Ischaemic!
penicillamine
quinidine, procainamide
beta-blockers
lithium
phenytoin
antibiotics: gentamicin, macrolides, quinolones, tetracyclines
these drugs can precipitate what kind of crisis?
Myesthenic crisis
which blood tests are performed in those under 55 with no obvious cause of a stroke??
Thrombophilia and autoimmune
Tongue fasciculations make you think of which condition?
Bulbar disease - MND
Wernicke’s (receptive) dysphasia - where is the lesion?
superior temporal gyrus
Conduction (associative) dysphasia - where is the lesion?
arcuate fasciculus
Broca’s (expressive) dysphasia - where is lesion?
inferior frontal gyrus
eye is deviated ‘down and out’
ptosis
pupil may be dilated
Which CN palsy?
3rd nerve palsy
causes of 3rd nerve palsy?
DM vasculitis e.g. temporal arteritis, SLE false localizing sign* due to uncal herniation through tentorium if raised ICP- trauma PCA aneurysm - pupil dilated - often associated pain cavernous sinus thrombosis Weber's syndrome: ipsilateral with contralateral hemiplegia -caused by midbrain strokes Amyloidosis, Multiple sclerosis
if epilepsy dx and drives a bus (group 2 vehicle) how much time before can reapply to DVLA ?
10 years seizure free
phenytoin MOA:
binds to sodium channels increasing their refractory period
When starting a phenytoin infusion what monitoring is required
Cardiac due to proarrhythmogenic effects
diminished response with repetitive stimulation to EMG - which condition?
MG
- unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphasia
If all 3 present, what syndrome type is this?
TACI
- unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphasia
If 2/3 present, what syndrome is this?
PACI
which circulation is affected TACI
Middle and anterior
Which circulation is affected PACI?
Anterior only
where does Lacunar stroke occur>
perforating arteries around the internal capsule, thalamus and basal ganglia
- unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
- pure sensory stroke.
- ataxic hemiparesis
if 1/3 present, what syndrome present?
Lacunar
involves vertebrobasilar arteries presents with 1 of the following: 1. cerebellar or brainstem syndromes 2. loss of consciousness 3. isolated homonymous hemianopia ???
PCI
Ptosis + dilated pupil =
3rd nerve palsy
ptosis + constricted pupil =
Horner’s syndrome
which is the ONLY cervical nerve root that comes out BELOW the vertebra?
c8
is symmetrical tremor normally caused by idiopathic Parkinsons?
no
55yof - posture stooped, slow, shuffling gait. She also freezes approaching doorways or trying to turn around. Face is expressionless and voice is quiet and lacks inflection. New bilateral pill-rolling tremor, exacerbated on distraction.
PMH schizophrenia, t2dm
drug-induced parkinsonism
what type of sx commonly more seen in children with migraines vs adults with migraines?
GI disturbance
65-year-old woman is admitted with proximal muscle weakness present in the face, neck, shoulder & pelvic muscle girdles. On examination, she has double vision present in her left eye and drooping of her left eyelid. She also has difficulty swallowing.
MG
65-year-old woman is admitted with proximal muscle weakness present in the face, neck, shoulder & pelvic muscle girdles. On examination, she has double vision present in her left eye and drooping of her left eyelid. She also has difficulty swallowing. Antibody tests show ???
antibodies to AchRs
Addensonian crisis tx:
IV hydrocortisone
IV fluids
glucose
Abx
migraine: acute tx:
triptan +NSAID with triptan / paracetamol
migraine prophylaxis:
propranolol or topiramate
Plucking of clothes smacking of lips dejavu aura is typically seen in which type of epilepsy?
Temporal lobe seizures
seizures associated with motor abnormalities and Jacksonian movements.
Frontal lobe seizures
seizures associated with sensory abnormalities?
parietal lobe seizures
Floaters/flashes seen in what seizures?
occipital lobe
how long does it take after starting on APs for neuroleptic malignancy syndrome to manifest?
short-term - just commenced on tx
pyrexia muscle rigidity autonomic lability: typical features include hypertension, tachycardia and tachypnoea agitated delirium with confusion raised CK leukocytosis after starting APs
Neuroleptic malignancy syndrome
neuroleptic malignancy syndrome tx:
stop antipsychotic
patients should be transferred to a medical ward if they are on a psychiatric ward and often they are nursed in intensive care units
IV fluids to prevent renal failure
dantrolene* may be useful in selected cases
bromocriptine, dopamine agonist, may also be used
seratonin syndrome features:
caused by SSRIs/MAOIs/ecstasy
fast onset
hyperreflexia, clonus, dilated pupils
mx of severe seratonin syndrome:
cyproheptadine
chlorpromazine
newly diagnosed Parkinson’s who have motor symptoms affecting their quality of life
first line tx?
Levodopa
newly diagnosed Parkinson’s who do not have motor symptoms affecting their quality of life:
first line tx?
Dopamine agonist
levodopa
MAO-B
risk factors for multiple sclerosis
smoking, previous infectious mononucleosis, genetics and hypovitaminosis D
Migraine during pregnancy: tx:
paracetamol 1g is first-line
aspirin 300mg or ibuprofen 400mg can be used second-line in the first and second trimester
migraine + menstruation ass. - tx:
mefanamic acid
? to treat idiopathic intracranial hypertension
WEIGHT LOSS
Acetazolamide
Topiramate
what type of drug is Acetazolamide?
carbonic anhydrase inhibitor
reduce CSF production
headache blurred vision papilloedema (usually present) enlarged blind spot sixth nerve palsy may be present Dx?
Idiopathic Intercranial Hypertension (IIH)
risk factors for IIH?
obesity
female sex
pregnancy
drugs*: oral contraceptive pill, steroids, tetracycline, vitamin A, lithium
thrombectomy window?
within 6 hours
carpel tunnel syndrome - which nerve?
median nerve
what % stenosis before considering a carotid endartectomy?
50 or 70% depending on which criteria followed
which anti-platelets should be used after TIA/ischaemic stroke?
clopidogrel
secondary prevention
Nausea and vomiting associated with chemotherapy or radiotherapy often respond to ??
- Ondansetron
2. dexamethasone
what type of drug is ondansetron?
5-HT3 receptor antagonist
collection of pus encapsulated by a pyogenic membrane
abcess
CT head with contrast reveals a rim-enhancing lesion with a central cavity and surrounding oedema within the left frontal lobe
brain abcess
what does high stepping gate indicate?
foot drop
unilateral foot drop cause:
common peroneal nerve lesion
bilateral foot drop cause:
peripheral neuropathy
peripheral neuropathy; predominantly motor loss: causes:
Guillain-Barre syndrome porphyria lead poisoning Charcot-Marie-Tooth chronic inflammatory demyelinating polyneuropathy (CIDP) diphtheria
peripheral neuropathy predominantly sensory loss causes:
diabetes uraemia leprosy alcoholism vitamin B12 deficiency amyloidosis
commonest complication following bacterial meningitis in 1yo?
sensorineural hearing loss
other cx meningitis:
other neurological: epilepsy, paralysis
infective: sepsis, intracerebral abscess
pressure: brain herniation, hydrocephalus
increased gamma GT is suggestive of
excessive alcohol consumption - alcohol related perihperal neuropathy
if ? TIA: immediate mx:
aspirin 300mg immediately and specialist review within 24 hours
22-year-old man presents with a one day history of a generalised headache. He prefers being in the dark and says he is ‘sleepy’. He has no neck stiffness. His temperature is 38.2C
meningitis
69-year-old woman presents with a 3 week history of a headache which is worse on the right side. She is generally unwell and feels ‘weak’, noting particular difficulty in getting up from a chair.
temporal arteritis
weakness in temporal arteritis is explained by:
polymyalgia rheumatica
