Neuro Flashcards
Epilepsy
Epilepsy: Recurrent, unprovoked seizures
Seizures: Overactive electrical activity in the brain
Sx: dyspahgia (
Causes:
Idiopathic, head injury, stroke, SOL, vascular malformations
Generalised: Originates at one point, and spread bilaterally Genetic aetiology Alcohol/stress trigger Photosensitivity Myoclonus No aura EEG abnormal
Subtypes:
Absence: <10s pauses. Presents childhood
Generalised-tonic-clonic: LOC, limb stiffness (tonic) then jerky movements (clonic)
Myoclonic: sudden jerk of limb
Focal
Originates in one hemisphere, often underlying structural disease
History trauma/birth injury Focal aura Post-confusion Temporary hemiparesis, aphasia postictal Automatisms (unconscious movements)
Subtypes:
Without impairment of conciousness (simple) - awareness remains, no post-ictal sx
With impairment of concousness (complex) - awareness impaired. Commonly from temporal lobe. Post-ictal confusion.
Temporal lobe: automatisms, deja vu, emotional disturbance
Frontal lobe: motor disturbance, dysphasia
Parietal: sensory disturbance
Occipital: visual disturbances
DDx: syncope, migraine, narcolepsy
Ix: EEG BM FBC (raised WCC - CNS infection) Electrolytes (hypo/hypernatraemia, uraemia can cause seizures) MRI
Tx:
DVLA (seizure free >1 yr)
Acute:
A-E
Lorazopam or rectal diazepam
Generalised:
1st line: Sodium valproate (not used in females reproductive age) or Lamotrigine
2nd line: Levetiracatam
Focal:
1st line: Lamotrigine or Cabamazepine
2nd line: Levetiracatam
Other:
CBT
Surgical - resection (if single cause identified)
Status epilepticus
Life threatening neurological emergency, continuous seizures for more than 5 mins or without regaining consciousness
Triggers: Not taking anti-convulsant medication Electrolyte imbalance Infection Alcohol Drugs
Ix:
FBC, UEs, Ca2+, Mg+, CRP (infection), Tox screen, BM, ECG, anti-convulsant medication levels
Tx: A-E
1st line: IV lorazopam or IM midazolam (if no access)
2nd line: Phenytoin
3rd line: Phenobarbital
Stroke
Acute neurological deficit lasts more than 24 hrs, caused by cerebrovascular aetiology.
Ischaemic (vascular occlusion or stenosis) or hemorrhagic (vascular rupture, or subarachnoid haemorrhage)
Risk fx: Age, HTN, Diabetes, AF
Ischaemic (85%)
Episode of neurological dysfunction due to focal cerebral, spinal or retinal infarction.
Total Anterior Circulation Syndrome (TACS)
Higher cortical dysfunction + contra. hemiparesis + contra. hemianopia
- Proximal MCA/ICA
Partial Anterior Circulation Syndrome (PACS)
Isolated higher cortical dysfunction or any 2 of:
Higher cortical dysfunction, contra. hemiparesis, contra. hemianopia
- branch of MCA
Posterior Circulation Syndrome (POCS)
Isolated contra. hemianopia (macular sparing) or brainstem syndrome e.g.
Lacunar medullary syndrome (ipsilateral Horner’s, loss of pinprick sensation ipsilateral face+contralateral trunk/limbs)
- PCA or cerebellar a
Lacunar Circulation Syndrome (LACS)
Pure motor OR pure sensory OR sensorimotor OR ataxic hemiparesis OR clumsy hand dysarthria (dysarthria, dysphagia, facial weakness, mild weakness+clumsiness)
- Peforating artery or small vessel disease
Haemorrhagic (Intra-cerebral) stroke
Neuro dysfunction due to collection of blood in brain parenchyma or ventricular system not due to trauma
Ix: CT within 1 hr (hypoattentuation (darkness) of brain parenchyma)
MRI (T2 weighted: hyperintense signal)
BM (exclude hypoglycaemia for focal neuro signs)
ECH (arrhythmia)
FBC (anaemia, thrombocytopenia)
Coagulation screen
Tx: Ischaemic IV thrombolysis: Alteplase, within 4.5 hrs+no contraindication Thrombectomy (6-8 hrs) Stroke Unit NBM SALT
If contra-indicated to thrombolysis: aspirin+stroke unit+SALT+heparin
Contra-indications thrombolysis: Haemorrhagic stroke, intracranial neoplasm, clotting disoder, seizures at presentation, severe liver disease
Secondary prevention:
Aspirin for 2 weeks then Clopidogrel (not until 24 hrs of thrombolysis and CT head (exclude haemorrhage)
2nd line: Aspirin+dipyridamole
Anti-coagulants: DOACs or warfarin (2 weeks after)
Ix:
HTN
Cardiac source of emboli (24-hr ECG for AF, Echo)
Carotid a. stenosis (Doppler US +/- CT angio)
Complications: aspiration pneumonia, pressure sores, constipation, DVT, depression
MDT team: Physio/OT/SALT
Haemorrhagic
Primary (spontaneous): cerebral amyloid angiopathy, HTN, anti-coagulants
Secondary: underlying disease that promotes vascular rupture e.g. cerebral tumour, AVMs, drug abuse
Sx: headache, neck stiffness, sensory loss, aphasia, visual changes (hemianopia: occipital lobe haemorrhage, diplopia: brain stem haemorrhage )
Ix:
CT head
BM, electrolytes, intoxication (exclude mimics stoke)
FBC (thrombocytopenia may be secondary cause)
Coagulation screen
BP control
Stroke Unit
Neurosurgical review
TIA
Transient episode of neurological dysfunction caused by focal brain, spinal cord, retinal ischaemia, without infarction. Usually resolves within 1 hr.
Causes: In-situ thrombus or embolus Cardio-embolic Small vessel occlusion Occlusion due to hypercoagulability
Sx:
focal neuro deficit
absence of positive sx e.g. seizures, migraine, spasm (implies something else)
DDx: hypoglycaemia, migraine, seizure with (Todd’s) post-seizure paralysis, SOL
Ix: BM, electrolytes (Low Na: seizure, high Ca: weakness) FBC (anaemia - weakness) Coagulation profile ECG (AF) Diffusion weighted MRI
Tx: Aspirin Statin Lifestyle changes Control BP (if HTN) Carotid enderectomy (if 70-99% stenosis) Driving prohibited 1 mnth
ABCD2 score: risk stratify pts at higher risk of stroke
SAH
Bleeding into subarachnoid space. Neurosurgical emergency.
Causes: Trauma Non-trauamtic: Berry aneurysms (80%) - junction of posterior communicating and ICA or anterior communicating and anterior cerebral or bifurcation of middle cerebral AV malformations Arterial dissections
Risk fx:
HTN, smoking, family hx, autosomal dom polycystic kidney disease, Ehlers Danlos
Sx: sudden-onset, occipital headache. Vomiting, photophobia, LOC, 3rd cranial n. palsy (pCOMa aneurysm compressing 3rd n)
Signs: Neck stiffness (Kernig's sign), Terson's syndrome (vitreous haemorrhage eye)
DDx: meningitis, migraine, intracerebral bleed, cortical vein thrombosis
Ix:
CT (>95% within 24hrs) (hyperdense in basal cisterns)
LP if CT -ve but history suggestive (after 12 hrs - xanthochromia (yellow - bilirubin)
U&Es (hyponatraemic)
FBC (leukocytosis)
ECG (arrhythmia, prolonged QT)
Tx:
Neurosurgery rv
Nimodipine (Ca+ channel blocker reduces vasospasm)
Endovascular coiling or surgical clipping
Complications: Rebleeeding Cerebral ischaemia due to vasospasm Hyponatraemia Hydocephalus
Anti-epileptic agents
Lamotrigine
1st line for both
Inhibits voltage gated Na channels - decreased AP
SE: maculopapular rash, SJS/TEN
Sodium valproate
1st line for Generalised
Weak Na channel inhibitor. Inhibits GABA degrading enzymes, increases GABA - stop AP
SE: teratogenic (not used in reproductive females), nausea, liver failure, pancreatitis
Carbamezapine:
1st line for Focal
Inhibits voltage gated Na channels
SE: drowsiness, hyponatraemia, SJS
Levetiracetam
2nd line for both
SV2A (synaptic vesicle protein allows NT release) inhibitor
SE: psych sx: depression, anxiety, drowsiness
Phenytoin
Sodium channel blocker
SE: depression, coarse facial features, gum hypertrophy
MS
Demyelinating CNS condition defined by 2 episodes of neuro dysfunction separated in time and space (brain, SC, optic nerves)
Sx: visual disturbance, sensory loss, urinary incontinence, bowel dysfunction, fatigue
Signs: ankle clonus, wide based gait
Ix: MRI brain+spine CSF (oligoclonal bands, elevated CSF IgG) Visual evoked potentials Vit B12 (exclude other causes)
Tx:
Acute
Methylprednisolone
Plasma exchange
Disease modifying (relapsing-remitting)
1st line: Dimethyl fumerate
2nd line: Fingolimod
3rd line: Alemtuzumab (autoimmune SEs), Natalizumab (risk of PML if JC virus)
Primary progressive:
Ocrelizumab
Other tx:
Modafinil - faitgue
Oxybutynin - bladder
Physiotherapy - gait/mobility
PD
Chronic neurodegenerative disorder characterised by rigidity, bradykinesia and resting temor
Causes:
Genetic - PINK1, Parkin
Toxins - MPTP
Vascular PD
Patho: loss of dopaminergic neurons in SNc, presence of Lewy bodies (a-synuclein)
Sx: resting tremor, rigidity, bradykinesia (slow to start movements, slower upon repetitive movements), postural instability, micrographia, hypophonia (reduced volume of voice)
Non-motor sx: urinary frequency, constipation, depression
Signs: masked facies, shuffling gait, stooped posture
Ix:
Clinical diagnosis
Parkinson Plus syndromes;
Progressive supranuclear palsy
Vertical gaze palsy, postural instability +/- falls
Multiple system atrophy
Sx: autonomic dysfunction (constipation, hypotension, urinary incontinence), speech/bulbar dysfunction
Dementia with Lewy bodies:
Sx: dementia then motor (dementia <1yr before motor sx), recurrent visual hallucinations, cognitive fluctuation, REM sleep behaviour disorder.
Tx:
1st line:
MAOB-inhibitors - Rasagiline
SE: postural hypotension, AF
Dopamine agonist - Ropinirole, Rotigotine transdermal
SE: hallucinations, pathological gambling, nausea
Levodopa
Crosses BBB and converted to dopamine
SE: dyskinesias, hallucinations, tolerance (need to increase dose eventually)
Domperidone for vomiting
Carbidopa: Inhibits dopa-decarboxylase (converts L-dopa into dopamine in the periphery), increases dopamine reaching CNS and decreases SE
COMT-I: Entacaptone (added with Levodopa) (inhibits peripheral breakdown of L-dopa)
SE: dyskinesia, nausea, brown urine
Anticholingergics: Benzhexol
(Confusion in elderly. Only given to younger pts, (not 1st line)
Cervical spondylosis
OA of spine inc. degeneration of disc or facet joints
Causes: wear and tear, family hx
Sx: asymptomatic. Axial neck pain, cervical muscle pain, headache/occipital pain, weakness/numbness
Signs: limited neck movement
Cervical spondylotic meylopathy (most common) “SC compression”
Neurological deficits in upper and lower peripheries e.g. clumsiness, loss fine motor function.
Involves disc and facet degeneration + changes in alignment of spine (kyphosis) + osteophyte formation. Causes narrowed spinal canal, compression on SC.
Cervical spondylotic radiculopathy - “root compression” radiating arm pain follows a single nerve root distribution. Due to mechanical compression of nerve root (spinal nerve exits cord) e.g. herniated disc
C5 root (C4/C5 disc) - weakness in deltoid. Pain from neck to elbow C6 root (C5/C6 disc) - weakness in biceps. Pain in shoulder to below elbow C7 root (C6/C7 disc) - weakness in triceps. Pain in upper arm down dorsal forearm C8 root (C7/C8) - weakness in finger flexors, small muscles of hand. Pain from upper arm to medial forearm
Ix: cervical MRI (bone destruction, SC compression) cervical XR (degenerative joint disease)
Tx:
Cerivcal spondylotic myelopathy: surgical decompression
NSAIDs, physio, diazepam (muscle relaxant)
Cervical spondoylotic radiculopathy: NSAIDs, prednisolone, physiotherapy
Headache
Primary: headache and underlying cause is the disorder: migraine, tension, cluster
Secondary: underlying cause: SAH, SOL, meningitis, drug-induced
Red flag features suggesting secondary headache:
Thunderclap headache, worse on lying down/straining, neuro deficit, systemic sx: weight loss, fever, meningism
Myasthenia Gravis
Autoimmune condition, antibodies against nicotinic AchR antibodies on post-synaptic NMJ
Sx: increasing/relapsing muscle fatigue (in order: extraocular, bulbar, face, neck, limb girdle)
NO sensory loss
Signs: ptosis, diplopia, dysphonia
Sx worse upon: hypokalaemia, infection, opiates
DDx: polymyositis, SLE
Assoc. with other autoimmune e.g. RA, SLE, thymic hyperplasia (if <50), thymic tumour (>50yrs)
Ix:
Anti-AchR (90%0
Anti-MUSK (muscle specific tyrosine kinase)
EMG (decreased response to repetitive nerve stimulation)
CT (thyoma)
Tx: Acetycholinesterase inhibitor: Pyridostigmine
SE: sweating, lacrimation, salivation
Relapses: prednisolone
Thymectomy
Myasthenic crisis:
Life threatening weakness of respiratory muscles
Tx: plasmapharesis, IVIG
Lambert-Eaton syndrome
Assoc. with SCLC or autoimmune
Antibodies against voltaged gated Ca channels
Sx: weakness/hyporeflexia (improves after exercise) autonomic: constipation, dry mouth
Ix: EMG (amplitude increases after exercise)
Tx: Pyridostigmine, IVIG
MND
Group of neurodegenerative diseases, characterised by loss of neurons in motor cortex, cranial nerve nuclei, anterior horn cells
Upper and lower motor neurons can be affected. NO sensory loss
ALS (amytrophic lateral sclerosis) (80%)
Loss of motor neurons in motor cortex and ant. horn
Sx: UMN+LMN
UMN: damage along corticospinal tract to anterior horn of SC. Groups of muscles affected.
Spasticity, increased tone, brisk reflexes, +ve plantar repsonse
LMN: damage along anterior horn to peripheral nerves
Decreased tone, muscle weakness, fasiculations, reduced/absent reflexes. Plantars remain flexor.
Progressive bulbar palsy
Only affects cranial nerves IX-XII (9-12)
LMN tongue, muscles for talking/swallowing: flaccid tongue fasicultations, speech quiet
Progressive muscular atrophy
Ant. horn lesion
LMN
Affects distal muscle groups before proximal
Primary lateral sclerosis
Loss of Betx cells in motor cortex
Mostly UMN signs - spastic leg weakness. No cognitive decline
Sx: <40 yrs, foot drop, proximal myopathy, weak grip, aspiration pneumonia
Signs: UMN/LMN signs, fronto-temporal dementia
Ix:
MRI head/spine (exclude other causes)
LP (exclude inflammatory cause)
Tx:
MDT: neurologist, palliative nurse, OT/physio, SALT, dietician, GP
Rizuole (NMDA antagonist) - imrpoves survival
Excess saliva: suctioning, oral care
Spasicity: exercise, orthotics
Communication: communication equipment
Palliative care
Peripheral neuropathy
Mononeuropathy
Radial:
“Saturday night palsy”
Sx: “wrist drop” - can’t extend wrist and fingers, painless
Extensor carpi radialis, extensor digitorum
Ulnar:
hx elbow trauma, sensory disturbance to 4th and 5th digit, weak grip (so can’t aDDuct thumb), “claw hand”
Weakness in: flexor carpi ulnaris (wrist flexion), adductor policis (thumb adduction)
Medial:
Most common mononeuropathy
Entrapment at carpal tunnel
Sx: intermittent pain, can radiate from wrist to arm, worse at night, numbness/tingling (first 3 1/2 digits on palmar surface)
Sign: +ve Tinel’s sign (tap on carpel tunnel (where median n. is, causes pins and needles)
Weakness: Lumbricals I and II Opponens pollicis Adductor pollicis brevis Flexor pollicis brevis
Anterior interosseous branch
Branch of median nerve which supplies ant. forearm
C8-T1
Sx: forearm pain, can’t make OK sign
Sign: +ve Tinel’s sign
Weakness: flexor digitorum, flexor pollicis
Peroneal L4-S2 Branch of sciatic n. Entrapment at fibular head Hx of trauma, surgery Sx: Acute onset foot drop, painless, foot inversion not affected (differentiates it from L5 nerve root neuropathy)
Weakness: Tibilias anterior (ankle dorsiflexion)
Femoral n
Due to trauma, haemorrhage
Weakness in quads, hip flexion, numbness in medial shin
Quadriceps femoris (extend knee), illiopsoas (hip flexion)
Mononeuritis multiplex
Hetergenous group of disorders involving motor and sensory deficits, involvement of each nerve occurs simultaneously or sequentially
Causes: vasculitis (most common) - primary vasculitis or from other disease e.g. Hep C/HIV, diabetes, sarcoidosis, Lyme disease, drug (allopurinol)
Sx: numbness, weakness, pain
Signs: dry mouth (Sarcoidosis, Sjogren’s), parotid gland enlargement (HIV)
Signs of granulomatosis with polyangiitis (upper and lower resp, haematuria)
Types of fibres involved in peripheral neuropathy
Motor:
Large myelinated fibres
Vibration, proprioception
Damage leads to sensory ataxia (loss of propioception), vibration sense
Sensory:
Thinly myelinated: temp, pain, light touch
Unmyelinated: temp, pain, light touch
Impaired pinprick, temp sensation
Autonomic: postural hypotension, abnormal sweating
