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
33-year-old woman presents due to a severe frontal headache. She developed a cold around 2 weeks ago but has now been left with a severe headache. The pain is worse when she bends forward.
sinusitis
craniopharyngioma can cause which disease?
Diabetes Insipidus
craniopharyngioma causes which visual field defect?
lower bitemporal hemianopia
Miller-Fisher syndrome triad:
opthalmoplegia
areflexia
ataxia
what type of paralysis in GBS?
ascending
what type of paralysis in Miller-Fisher?
descending
which antibodies are found in 25% GBS patients?
anti-GM1 Abs
which antibodies are associated with Miller-Fisher? (90%)
anti-GQ1b Abs
which nerve innervates the skin on the palmar aspect of the thumb?
median nerve
which nerve innervates the nailbed of the index finger?
Median nereve
which nerve innervates the skin overlaying the medial aspect of the hand?
ulnar nerve
is infarct seen in TIA?
no - tissue only TIA, not time
The combination of facial and contralateral body loss of pain sensation along with nystagmus and ataxia make up a common syndrome:
lateral medullary syndrome
what commonly causes lateral medullary syndrome?
PICA stroke (posterior inferior cerebellar artery)
which type of stroke causes locked in syndrome?
basillar artery
if similar presentation to lateral medullary syndrome except ipsilateral facial weakness and deafness, which type of stroke?
Anterior Inferior Cerebellar Artery stroke
anterior inferior cerebellar stroke (AICA) can cause which syndrome?
lateral pontine syndrome
MRI brain showing subependymal nodules is consistent with a diagnosis?
tuberous sclerosis
ass with West syndrome
6/12m episodes of ‘fits’. Tensing and relaxing suddenly and repeatedly several times in quick succession. Not reaching his developmental milestones. Patches of discoloured skin.
Ex: GDD and 12 depigmented macules on trunk+ limbs.
West syndrome
Phenytoin MOA:
binds to Na channels increasing their refractory period
sfx of phenytoin: acute
dizziness, diplopia, nystagmus, slurred speech, ataxia
later: confusion, seizures
chronic phenytoin sfx:
gingival hyperplasia, hirsuitism, coarsening of facial features, drowsiness megaloblastic anaemia peripheral neuropathy osteomalacia - enhanced vit D metabolism lymphadenopathy dyskinesia
what congenital abnormalities are associated with phenytoin use in pregnancy?
cleft palate and congenital heart disease
teratogenic
idiosyncratic sfx phenytoin:
fever rashes - toxic epidermis necrolysis hepatitis dupuytron's contracture aplasatic anaemia drug-induced lupus
sinusitis + focal neurology and fever ->
brain abscess
IV 3rd-generation cephalosporin + metronidazole
Ix: brain abscess?
CT head
Tx: brain abscess:
surgical craniotomy and debridement
IV 3rd-generation cephalosporin + metronidazole
53-yom difficulty speaking clearly and some swallowing difficulty. Overactive gag reflex on both sides, tongue spasticity and the tongue seems to be wasted with fasciculations. Dx:
MND
ALS with bulnbar onset
Patients with a GCS below 8 should be considered for :
review by anaesthetist and a view of intubation and ventilation
as well as dizziness and right sided hearing loss, how might an acoustic neuroma present:
loss of corneal reflex
what type of herniation causes 3rd nerve palsy (down and out) due to raised ICP?
trans-tentorial herniation
Autonomic dysreflexia can only occur if the spinal cord injury occurs
above T6
severe hypertension, flushing and sweating without a congruent response in heart rate in the context of spinal cord injury indicates. often caused by retention or impaction
autonomic dysreflexia
able to speak clearly, content of their speech is unrelated to the questions you ask them, and makes little to no sense. Unable to repeat phrases.
Which dysphasia?
Wernicke’s
where is the lesion in Wernicke’s ?
superior temporal gyrus
lesion to the temporo-occipital region would result in which kind of aphasia?
transcortical sensory aphasia
lesion to the arcuate fasciculus would result in which type of aphasia?
conduction aphasia
lesion to the angular gyrus would result in which aphasia?
Gerstmann syndrome
where is the lesion in Broca’s?
Inferior frontal gyrus
Global aphasia: what is it?
large lesion affecting wernicke’s, brocas and arcuate gyrus (connecting) leading to severe expressive and receptive aphasia
which artery supplies brocas area?
superior division of the MCA
which artery supplies wernicke’s area?
inferior division of the MCA
sentences that make no sense, word substitution and neologisms but speech remains fluent
Comprehension is impaired
Wernicke’s
Speech is non-fluent, laboured, and halting
Comprehension is normal. repetition impaired
Brocas
Speech is fluent but repetition is poor. Aware of the errors they are making
Comprehension is normal
Conductive aphasia
vertical diplopia - which lesion?
eg worse going down stairs
4th nerve palsy
trochlear, cn4
72yom. declining cognition. He was normally very well and independent until 3 months ago. He has lost no weight, has no headache but has been falling a lot. He also complains of urinary incontinence.
Normal Pressure Hydrocephalus
‘wet, wobbly and wacky’
Normal pressure hydrocephalus
Mx: normal pressure hydrocephalus?
ventriculoperitoneal shunting
there are no contraindications, which one of the following antiplatelet regimens is recommended following an acute ischaemic stroke?
aspiring 300mg 2 weeks, clopidogrel 75mg long term
which nerve does thumb opposition?
Median
45-year-old lady recovering from a mastectomy and axillary node clearance notices that sensation in her armpit is impaired.
which nerve?
intercostobrachial
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. which nerve
median
MS: most appropriate baseline ix:
MRI + contrast
What is the most important cause of status epilepticus to rule out first?
hypoxia
hypoglycaemia
Mx status:
- PR diazepam or IV lorazepam
if unresponsive after inital benzos in status, what is 2nd line tx:
phenytoin, sodium valproate, levetiracetam, or phenobarbital
headaches classically worse on standing and improve when lying flat:
spontaneous intracranial hypotension
caffeine and fluids = mx
what can cause spontaneous intracranial hypotension?
low CSF (post-LP) caffeine and fluids
Weakened dorsiflexion, inversion and eversion of the ankle indicates
L5 lesion
MG patients are typically resistant to which type of general anaesthesia?
depolarising neuromuscular blocking drugs (NMBDs) - suxamethonium
74-year-old male presents with sudden onset right-sided weakness. On examination you note weakness of the right face, upper and lower limbs. You also note that the left eye is in a ‘down and out’ position and the pupil is dilated.
What is the most likely diagnosis?
weber’s syndrome
what causes weber’s syndrome?
midbrain stroke syndrome that involves the fascicles of the oculomotor nerve resulting in an ipsilateral CN III palsy and contralateral hemiplegia
classical bacterial meningitis presentation, what is first investigation to do?
CT head to rule out raised ICP
diagnostic test;meningitis:
LP
Valsalva manoeuvre?
headache linked to cough
Episodic eye pain, lacrimation, nasal stuffiness occurring daily lasting 15m-2h??
cluster headache
what is a common trigger of cluster headaches?
alcohol
Mx : cluster headache acute:
100% o2, SC triptan
cluster headache: prophylaxis?
verapamil
who commonly gets cluster headaches?
smokers, men
42-year-old man presents with pain in the posterior and left side of his head. This came on over one minute and is now severe. The pain is worse when he bends his neck. His temperature is 37.3ºC
SAH
62-year-old woman presents with a one day history of pain around her right eye. She feels nauseated and has vomited once. On examination her right eye is red
acute glaucoma
22-year-old woman presents with recurrent headaches around the time of her periods. These are typically on the left-side and severe. When she gets a headache it lasts several hours and she usually goes to bed.
migraine
what is a CI of triptan use as prophylaxis for a migraine?
CVD
what dose of rectal diazepam given during status/
10mg
for power test, grade X indicates can hold against gravity>
3
13-yom difficulty walking. His legs are weak and he experiences severe muscle cramps on mild exercise. Pseudohypertrophy calf muscles and uses arms to help stand up from the floor. No intellectual impairment. His 4-year-old brother is well. Genetic testing excludes Duchenne muscular dystrophy.
What is the most likely diagnosis?
Becker’s muscular dystrophy
what is Gower’s sign?
patient that has to use their hands and arms to “walk” up their own body from a squatting position due to lack of hip and thigh muscle strength - prox LL weakness
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.
Median nerve entrapment
DCM
32 year-old female presents with a 3 day history of altered sensation on her left foot and right forearm. On examination she has clonus in both legs and has hyperreflexia in all limbs.
MS
Adhesive capsulitis: another name for
frozen shoulder
external rotation!
45 year-old female presents with stiffness and pain in her left shoulder, which started around a month ago. She had a similar episode that resolved by itself. Examination reveals limited external rotation.
adhesive capsulitis
Lip smacking + post-ictal dysphasia are localising features of what kind of seizure?
temporal lobe seizure
Temporal lobe seizures: HEAD
hallucinations
Epigastric rising/emotional
Automatisms
Dejavu/dysphasia post-ictal
which anti-parkinsons med is linked to change in behaviour (inhibition disorder)?
Dopamine agonists - carbidopa
What are jacksonian movements?
clonic movements travelling proximally
what is adjacent segment disease?
in DCM post-op, recurrence of the condition at adjacent spinal intervals
weakness of foot dorsiflexion and foot eversion - nerve?
common peroneal
nasopharyngeal malignancy has locally invaded the left cavernous sinus - what is this called?
cavernous sinus syndrome
70 year-old man has pain and weakness in both legs on walking. It settles with rest: Dx
lumbar canal stenosis
which sign differentiates organic and functional causes of stroke in LL?
Hoover sign
what is hoovers sign?
patient is genuinely making an effort, feel the ‘normal’ limb pushing down vs hand as the patient tries to lift the ‘weak’ leg = organic cause.
If fails to feel the ‘normal’ limb pushing down as they try to raise ‘weak’ leg, = functional, also known as ‘conversion disorder’.
Jendrassik manoeuvre: what is it?
compares a reflex with/without distraction e.g. clenching teeth
Romberg’s test: if positive what does this indicate?
sensory ataxia
same sided weakness and proprioception/vibration loss and loss of pain/temperature on the opposite side to the hemisection:
Brown-sequard syndrome
CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
How does this impact stroke management?
thrombectomy window extended from 6>24 hours as potential to salvage brain tissue
right eye fails to adduct and the left eye develops coarse nystagmus in abduction
Intranuclear Opthalmoplegia
where is the lesion in INO?
medial longitudinal fasciculus (MLF), a tract that allows conjugate eye movement
Causes of INO?
MS
Vascular disease
Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral homonymous hemianopia
Aphasia
where is stroke?
MCA
Contralateral hemiparesis and sensory loss, lower extremity > upper
Stroke where?
ACA
Contralateral homonymous hemianopia with macular sparing
Visual agnosia
where stroke?
PCA
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.
CN??
VI
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.
CN?
II
18-year-old man who has been stabbed in the neck is found to have an inability to contract the sternocleidomastoid and upper fibers of trapezius muscles on that side.
XI
what types of anti-emetics may exacerbate Parkinsons?
anti-histamines
cyclizine / prochlorperazine
which antiemetic should be prescribed in parkinson?
Domperidone
Doesn’t cross BBB - no EPSEs
what are fasciculations a common feature of?
MND
In trauma, to test if the fluid draining from the nose or ear is CSF:
check for glucose
gold standard test to prove clear fluid is CSF?
Beta-2-transferrin
CSF circulation:
- Lateral ventricles (via foramen of Munro)
- 3rd ventricle
- Cerebral aqueduct (aqueduct of Sylvius)
- 4th ventricle (via foramina of Magendie and Luschka)
- Subarachnoid space
- Reabsorbed into the venous system via arachnoid granulations into superior sagittal sinus
What is in CSF?
Glucose: 50-80mg/dl
Protein: 15-40 mg/dl
Red blood cells: Nil
White blood cells: 0-3 cells/ mm3
what type of cells make CSF and where do they do this?
ependymal cells of the choroid plexus
total vol CSF in brain approx?
150ml
total CSF produced per day?
500ml
what is found in the CSF of patients with MS?
oligoclonal bodies
Sudden onset of unilateral, blurred vision with pain on movement of that eye
optic neuritis
sinister headache signs which need urgent CT:
Vomiting more than once with no other cause.
New neurological deficit (motor or sensory).
Reduction in conscious level (GCS).
Valsalva (associated with coughing or sneezing) or positional headaches.
Progressive headache with a fever.
medial two lumbricals aDductor pollicis interossei hypothenar muscles: abductor digiti minimi, flexor digiti minimi flexor carpi ulnaris which nerve?
ulnar
when can you consider stopping seizure medication?
if seizure free > 2years and wean off AEDs over 2-3/12
MS acute relapse tx?
methylprednisolone
first choice MS drug to reduce relapse rate?
B-inferon
B-inferon criteria in MS:
relapsing-remitting disease + 2 relapses in past 2 years + able to walk 100m unaided
secondary progressive disease + 2 relapses in past 2 years + able to walk 10m (aided or unaided)
reduces number of relapses and MRI changes, however doesn’t reduce overall disability
Other MS relapse preventing drugs:
glatiramer acitate
natalizumab
fingolimod
23-year-old man is involved in a fight outside a nightclub and sustains a laceration to his right arm. On examination he has lost extension of the fingers in his right hand.
nerve?
Radial
which nerve supplies the extensor muscle group of the hands?
Radial
40-year-old lady trips and falls through a glass door and sustains a severe laceration to her left arm. Amongst her injuries it is noticed that she has lost the ability to adduct the fingers of her left hand
nerve?
ulnar
28-year-old rugby player injures his right humerus and on examination is noted to have a minor sensory deficit overlying the point of deltoid insertion into the humerus.
nerve?
axillary
progressive, disproportionate symptoms to the original injury/surgery allodynia temperature and skin colour changes oedema and sweating motor dysfunction
complex regional pain syndrome
when does complex regional pain syndrome commonly present?
after surgery or an injury
Mx: complex regional pain syndrome:
early physiotherapy is important neuropathic analgesia in-line with NICE guidelines specialist management (e.g. Pain team) is required only if fx on QOL severe
when testing GCS, if discrepency in reponse between both sides of body, which score is used?
use BEST response from both sides
does hoffman’s sign positive indicate UMN/LMN dysfunction?
UMN
roughened patches of skin over lumbar spine (Shagreen patches) - which condition?
tuberous sclerosis
67-yom to ED sudden onset dizziness and vomiting, 2 hours. He has a background of HTN and hypercholesterolaemia- ramipril and simvastatin.
Vertical nystagmus and difficulty standing without support.
what does he have?
cerebellar stroke
which type of seizure is carbimazepine ineffective vs?
Absence seizure
if pregnant woman on phenytoin, what given in last month of pregnancy?
Vit k to prevent clotting disorders
why is COCP CI in migraine with aura?
significant increase in risk of ischaemic stroke
what is the type of inheritance in Charcot-Marie-Tooth type 1?
AD
features often start at puberty
motor symptoms predominate
distal muscle wasting, pes cavus, clawed toes
foot drop, leg weakness often first features
Dx?
Charcot-Marie-Tooth 1
neuropathic pain Mx:
- Amitriptyline, duloxetine, gabapentin or pregabalin
- tramadol may be used as ‘rescue therapy’ for exacerbations
- topical capsaicin may be used for localised neuropathic pain
pain management clinics
what may provoke absence seizure?
hyperventilation/stress
first line tx: absence seizure?
Na Valproate or ethosuximide
elderly patient who presented to the emergency department with reduced consciousness after a fall, hitting the side of their head. Your consultant describes a unilateral crescentic lesion in the right frontoparietal area on CT.
Dx?
SDH
which vessel has been damaged in SDH?
bridging veins between cortex and venous sinus
Epidural haemorrhage (extradural) is associated with which vessel?
MMA
Subarachnoid haemorrhages are associated with vessels??
of circle of willis - basilar/ACA
Restless leg syndrome - management?
dopamine agonist - ropinirole
commonest type of MS?
relapsing-remitting disease
55-year-old woman complains she is losing weight. On examination her pulse is 102 bpm and she has a fine tremor when her hands are outstretched: cause?
thyrotoxicosis
Axillary freckles are indicative of
NF1
how are NF diseases type 1 and 2 inherited
AD
Café-au-lait spots (>= 6, 15 mm in diameter) Axillary/groin freckles Peripheral neurofibromas Iris hamatomas (Lisch nodules) in > 90% Scoliosis Pheochromocytomas
NF1
Bilateral vestibular schwannomas
Multiple intracranial schwannomas, mengiomas and ependymomas
NF2
cerebellar symptoms: DANISH
D - Dysdiadochokinesia, Dysmetria (past-pointing), patients may appear ‘Drunk’
A - Ataxia (limb, truncal)
N - Nystamus (horizontal = ipsilateral hemisphere)
I - Intention tremour
S - Slurred staccato speech, Scanning dysarthria
H - Hypotonia
Third nervy palsy presenting with a large pupil = Mx:
surgical case needs urgent brain imaging
adverse effects Levodopa:
dyskinesia 'on-off' effect postural hypotension cardiac arrhythmias nausea & vomiting psychosis reddish discolouration of urine upon standing
wrist drop: which nerve?
Radial
which # type causes radial nerve damage?
of shaft of humerus
following TIA: DVLA rules?
no need to inform, can restart driving after 1 month sx free
when should aspirin be given in stroke/tia??
only after ruled out haemorrhagic stroke
what will nerve conduction studies show in MND?
Normal motor conduction
First-line anti-epileptic in a 17-year-old girl with tonic-clonic seizures. She is not sexually active and does not use any form of contraception currently
lamotrigine
first-line treatment to children, young people and adults with newly diagnosed focal seizures.’
carbimazepine or lamotregine
both can cause sjs
1st line generalised tonic clonic tx:
Na valproate
Lamotrigine
(Valproate inappropriate in women and young girls)
Laughter → fall/collapse
cataplexy
what is cataplexy commonly associated with ?
narcolepsy
CT: hypodense collection around the convexity of the brain that is not limited to suture lines.
chronic SDH
trigeminal neuralgia: red flag sx?
<40yo
sensorineural hearing loss
sensory changes
hx of skin/oral lesions that could spread perineurally
pain only in the opthalmic division or bilaterally
optic neuritis
FHx of MS
what disease has weakness which initially improves after exercise?
Lambert-Eaton
Voltage-gated calcium-channel antibodies are suggestive of ??
Lambert-Eaton Myasthenic Syndrome
repeated muscle contractions lead to increased muscle strength* (in contrast to myasthenia gravis)
limb girdle weakness (affects lower limbs first)
hyporeflexia
autonomic symptoms: dry mouth, impotence, difficultly micturating
ophthalmoplegia and ptosis not commonly a feature (unlike in myasthenia gravis)
LEMS
what would EMG show in LEMS?
incremental response to repetitive muscle stimulation
Mx of Lambert Eaton?
treatment of underlying cancer
immunosuppression, (prednisolone +/ azathioprine
3,4-diaminopyridine currently trialled
IVIG and plasma exchange
Painful third nerve palsy =
posterior communicating artery aneurysm
complex focal seizure: how may it present?
Emotional disturbance and automatism are features of focal seizures with impaired awareness, which are followed by a post-ictal state during which the patient may be tired.
Toperimate (migraine prophylaxis) during pregnancy?
no - cleft lip and palate
also reduces effectiveness of hormonal contraception
first line radiological Ix for ?stroke?
Non-contrast CT head
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 nerve
32-year-old window cleaner is admitted after falling off the roof. He reports that he had slipped off the top of the roof and was able to cling onto the gutter for a few seconds. The patient has Horner’s syndrome.
Nerve?
Brachial trunks C8-T1
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
which palsy and which nerve?
Erb’s palsy
Brachial trunks C5-C6
43-year-old lady presents with symptoms of chronic ear discharge and a right sided facial nerve palsy. On examination she has foul smelling fluid draining from her right ear and a complete right sided facial nerve palsy.
cause?
cholestatoma
You suspect a stroke. Which tool is used to assess a patient in this situation?
Rosier
a stroke is likely if Rosier score >?
0
In adjacent segment disease - what is initial mx?
again, refer to spinal surgeons / neurosx
in syringomyelia, which sensory loss type commonly seen?
pain + temperature loss - spinothalamic
‘cape-like’ (neck and arms) loss of sensation to temperature but preservation of light touch, proprioception and vibration. Classic examples are of patients who accidentally burn their hands without realising.
syringomyelia
Ix: syringomyelia:
full spine MRI with contrast to exclude a tumour or tethered cord. A brain MRI is also needed to exclude a Chiari malformation.
Mx : syringomyelia:
underlying cause
shunt into the syrinx
TIA and intolerant of clopidogrel. What is the most appropriate therapy to help reduce his chance of having a further stroke?
aspirin and dipyridamole lifelong
essential tremor: when is it worse?
on outstreched arm
which test will be positive in MS (examination)
Hoffmans
Obese, young female with headaches / blurred vision think
idiopathic intracranial HTN
berry anuerysm>
SAH
which drugs are associated to idiopathic intracranial HTN?
drugs*: oral contraceptive pill, steroids, tetracycline, vitamin A, lithium
attacks of vertigo, tinnitus, sensorineural deafness and fullness of the ear.
Meniere’s
Widespread convulsions without conscious impairment
pseudoseizure
where do 5-HT3 antagonists (eg ondansetron) act?
medulla oblongata
which type of seizure gradually builds up?
pseudoseizure
with reduces Glasgow coma score, quadriplegia, miosis, and absent horizontal eye movements.
pontine haemorrhage
72-year-old man develops visual problems. He is noted to have a left homonymous hemianopia with some macula sparing. where is lesion?
occipital cortex
30-year-old man with a family history of early blindness is concerned that he is developing ‘tunnel vision’. lesion??
retina
While an essential tremor is classically associated with a tremor present with sustained muscle tone (i.e. postural tremor) in the hands, where can it also affect?
vocal cords
adhesive capsulitis initial mx:
refer to physios
post-ictal weakness AKA?
Todd’s paresis
who may experience todd’s paresis?
sufferers of focal seizures
Useful for managing tremor in drug-induced parkinsonism
procyclidine
Parksinson’s drug ass with pulmonary fibrosis:
cabergoline
which parkinsons drug decreases effectiveness over time?
Levodopa
which GCS would you intubate below?
8
cuffed endotracheal tube
‘port-wine stain’ of the forehead, learning disabilities, seizures and glaucoma.
Sturge weber syndrome
known MS struggling with spasticity of legs - mx:
first line is baclofen or gabapentin
74-year-old man presents to his GP with slowed movement and feeling off-balance. His wife has noticed that his right hand starts shaking when he is watching television.
What is the most appropriate action for the GP to take?
refer urgently to neuro
first line investigations for patients with a suspected diagnosis of vestibular schwannoma
audiogram and gadolinium-enhanced MRI
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
Lennox-Gastaut syndrome
Shingles dx, with post-herpatic neuralgia: mx:
amitriptyline, duloxetine, gabapentin or pregabalin first-line.
75-year-old female presents with sudden onset weakness of her left arm and leg. She also reports visual problems. On examination you note left sided face, arm and leg weakness, and a left homonymous hemianopia. There is no aphasia, no hemispatial neglect, and no other deficits of higher function. You suspect a stroke and send her for an urgent CT.
right sided partial anterior circulation stroke
which MND best prognosis?
progressive muscular atrophy
which MND worst prognosis?
Progressive bulbar atrophy
The tremor seen in Parkinson’s disease:
unilateral
improves on voluntary movement
first seizure presents to GP - mx:
refer to epilepsy clinic only
only rarely would prescribe drugs before specialist consult
which dementia is associated with MND?
FTD
typical migraine aura include:
spreading scintillating scotoma (jagged crescent)
62-year-old female inpatient, with a known history of epilepsy, who is having a seizure. The nurse who witnessed the seizure says it began by affecting her right hand before involving her entire right arm and then progressing to a loss of consciousness with her entire body shaking. What is the most likely diagnosis?
Jacksonian march with secondary generalisation
64-yom presents for his annual diabetic review. He reports that in last few months he has developed tingling and numbness in his right ring finger and little finger. On examination there is paraesthesia and numbness of the right fourth and fifth digit, a right sided foot drop and a left sided facial weakness.
What is the most likely diagnosis?
Mononeuritis multiplex
looking forward, the patient’s right eye turn is deviated upwards and rotated outwards. On attempting to look to the patient’s left the double vision worsens.
R 4th nerve palsy
11-year-old boy presents complaining of persistent headaches which have been getting progressively worse over the last few years. He mentions that he finds it difficult to concentrate in class as he is unable to see the board clearly. Visual examination reveals a bitemporal superior quadrantanopia. His parents are concerned as he is not growing in height. His height is calculated to be below the 10th centile for children in his age group. Which of the following is the most likely diagnosis?
pituitary adenoma
Confusion, ataxia, nystagmus/ophthalmoplegia→
give pabrinex urgently
‘Saturday night palsy’ -
compression of the radial nerve against the humeral shaft leading to wrist drop
which peripheral neuropathies have a glove and stocking distribution?
DM neuropathy,
GBS
CIDP
UMN signs (3)
- Hyperreflexia, Spasticity, Muscle weakness, Clonus, Babinski positive
LMN signs (3)
- Hyporeflexia, atrophy, flacid weakness, fasciculation, fibrillations, facial droop, slurred speech,
3 causes of UMN lesions?
Stroke CP TBI MS MND SOL Parkinson's Huntingtons
life expectancy MND?
2-3 years from dx
primary mechanism behind Parkinsons disease?
lewy body accumulation in the substantia nigra, leading to reduced dopamine – less ‘dopinergic neurons’
4 features of Parkinson’s disease? (TRAP)
Tremor
Rigidity
Akinesia (brady)
Postural instability
3 non-motor Parkinson’s sx:
dementia depression Rem-sleep disturbance constipation hallucinations orthostatic hypotension
3 causes of ataxia:
wernicke's miller-fisher lateral medullary sydnrome acute alcohol use li toxicity gluten intolerance meningitis/encephalitis b12 deficiency NPH
who’s criteria for MS and what is included?
McDonald’s
dissemination in time and space
4 investigations to dx MS:
- MRI non-contrast, GAD contrast one – spine and brain – high signal T2 lesion, periventricular plaques, dawsons fingers – FLAIR
- Visual evoked potentials – EEG on occipital cortex and shows images and one side is slower than other
- NCS – slower MCV, normal amplitude
- CSF – oligoclonal bands, intrathecal IgG increased
- Ddx – bloods – b12 deficiency
acute head injury - eg cricket ball. Convex lens haemorrhage on CT:
extradural haemorrhage
inferior homonymous quadrantanopia: where is the lesion?
Baum’s loop
marcus gunn pupil - ix?
swinging light test +ve
name a contraindication to thrombectomy?
oesophageal varices
thumb adduction nerve?
ulnar
Unilateral loss ddx:
CRAO - amaurosis fugax CRVO retinal detachment - floaters vitreous haemorrhage - floaters DM/macular degen acute glaucoma - pain/red n/v Optic neuritis GCA
Optic neuritis sx:
reduced acuity over days
opthalmoplegia (pain on movt)
Uhtoff’s
Afferent pupillary defect - Marcus Gunn
optic neuritis causes:
MS
DM
Syphilis
ON mx:
steroids - gets better over 6 weeks
features typical of MS:
ON pyramidal weakness, spastic paraparesis sensory disturbance cerebellar sx bladder/sex dysfunction fatigue
when do you give statin after stroke?
48 hours
when do you give aspirin after thrombolysis?
24 hours after
if stroke pt has AF, which drug give instead of clopidogrel?
NOAC - RIvaroxiban
Ix for stroke location??
MRI angio day 1
raised ICP mx?
mannitol IV - osmotic diuretic
raise bed to 30 degree (head)
muscles typically spared in MND?
occular muscles
typically presents with muscle wasting of the hands, numbness and tingling and possibly autonomic symptoms - eg swimmer getting tired more easily with known cervical rib?
neurogenic thoracic outlet syndrome
If there is a weakness to one side of the face with forehead sparing, this is typically caused by an?
upper motor neurone lesion of the contralateral side to the weakness
recommend for patients with an acute ischaemic stroke who present within 4.5 hours?
combo of thrombolysis AND thrombectomy
Controlled hyperventilation may be used in patients with raised ICP. ?mechanism?
hyperventilation > reduce co2 > vasoconstriction of cerebral arteries > reduce ICP
Drugs for neuropathic pain are typically used as?
monotherapy - switch - do not add
benign tumours that develop from the dura mater of the meninges? - well-defined border between the tumour and the brain parenchyma.
meningioma
62M neuro clinic worsening ataxia and paraesthesia in his feet. He describes losing his footing very easily and he has had multiple falls in the last few weeks. He has a past medical history of gout and hypertension. Loss of joint position and vibration sense. He has brisk knee reflexes and absent ankle jerks. There is no muscle weakness. dx?
SCDC
dorsal and lateral columns affected
widening pulse pressure
bradycardia
irregular breathing
triad?
cushings triad seen in ICP
worrying sign
If a patient is on warfarin/a DOAC/ or has a bleeding disorder and they are suspected of having a TIA - mx?
ED urgently for imaging to r/o haemorrhage
Barthel index is a scale that measures?
disability or dependence in ADLs in stroke pts
A 23-year-old male presents to you in neurology clinic complaining of excessive daytime somnolence. He describes episodes of sudden onset sleep during the day, and at night often wakes with episodes where he is unable to move his arms or legs and describes seeing figures in the far corner of his bedroom. dx, ix?
narcolepsy
first line - multiple sleep latency eeg
tx for cerebral oedema caused by brain tumour?
dedxamethasone
brain mets - commonest primary>
lung
38F medication review. Headaches were regular and debilitating but short-lasting (minutes) boring pain to the right side of her face, behind her eye. Right-sided tearing and nasal congestion, but no photophobia. The attacks had occurred over thirty times and could occur up to eight times a day. The neurologist recommended indomethacin. She would like a repeat prescription as since taking indomethacin the attacks have stopped. dx?
paroxysmal hemicrania
The definition of a TIA is now??
tissue based not time based - a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction
pt presented like meningitis but then had an absence seizure - on broad spec abx already - mx?
?encephalitis - start aciclovir IV in addition to abx
Progressively worsening headache with higher cognitive function impaired =
urgent imaging required - ca
isolated result of high protein in the CSF
GBS
A facial palsy caused by an upper motor neuron lesion ‘spares’ the upper face i.e. forehead. also otalgia?
ramsay hunt syndrome
hyponatraemia in post-op pt for subarachnoid haemorrhage pt given lots of IV fluids?
SIADH - cx of sah
A 21-year-old man is hit on the left side of his face during a rugby game. He complains of double vision when both eyes are open, and it is painful to open his mouth. dx?
depressed # of zygoma
NICE Head injury Head CT criteria: < 8hrs
with loss of consciousness or amnesia, and who are aged over 65 years old
bleeding or clotting disorder hx / on warfarin
dangerous mechanism of injury
NICE head injury head CT criteria <1h:
GCS < 13 on initial assessment
GCS < 15 at 2 hours post-injury
suspected open or depressed skull fracture.
any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).
post-traumatic seizure.
focal neurological deficit.
more than 1 episode of vomiting
Elderly, alcoholic, head injury, insidiuous onset symptom -
subdural haematoma
A 22-year-old male falls of a ladder. He complains of neck pain and cannot feel his legs. His GCS suddenly deteriorates and a CT head confirms an extradural haematoma. What is the best imaging for his neck?
ct c-spine
An 18-year-old student is shot in the back of the head.
imaging/mx?
NS review even before CT head
also this if GCS<8
will present with increased head circumferences, a bulging fontanelle and sunsetting of the eyes???
infants with hydrocephalus
A 25-year-old cyclist is hit by a bus traveling at 30mph. He was not wearing a helmet. He arrives with a GCS of 3/15 and is intubated. A CT scan shows evidence of cerebral contusion but no localising clinical signs are present. What is the most appropriate course of action?
insertion of ICP monitoring device
ICP should raise over next few days
diffuse axonal injury ix?
MRI brain
There are 6 tests to confirm brain death;
pupillary reflex, corneal reflex, oculo-vestibular reflex, cough reflex, absent response to supraorbital pressure, and no spontaneous respiratory effort
subarachnoid haemorrhage Ix?
CT head
if normal -> LP in 12h
Extradural or subdural haemorrhage?
Extradural = lucid period, usually following major head injury. Subdural = fluctuating consciousness, often following trivial injury in the elderly or alcoholics
Neonatal deterioration in premature babies is not infrequently due to?
intraventricular haemorrhage
periorbital bruising referring to the bruising around the eye that is otherwise known as Raccoon eyes, and post-auricular bruising referring to bruising of the mastoid otherwise known as Battle’s sign. dx?
basilar skull #
A 32-year-old rugby player is crushed in a scrum. He is briefly concussed but then regains consciousness. He then collapses and is brought to ED. His GCS on arrival is 6/15 and his left pupil is dilated. What is the best course of definitive management?
pariotemporal decompression
likely extradural
Patients with intracranial bleeds, who become unresponsive should be managed?
brain CT to check for hydrocephalus (particularly with intraventricular haemorrhage)
Following a subarachnoid haemorrhage, most intracranial aneurysms are now treated with a?
coil
A 33-year-old lady develops a thunderclap headache and collapses. A CT scan shows that she has developed a subarachnoid haemorrhage. She currently has no evidence of raised intracranial pressure. Which of the following drugs should be administered?
nimodipine
to prevent vasospasm in aneurysmal SAHs
presence of what in CSF indicates SAH?
breakdown of RBC - not RBC itself (traumatic tap)
eg bilirubin
number 1 priority in GCS of 8 pts?
AIRWAY
