Neuro Flashcards
What are the types of hydrocephalus and what causes them?
Hydrocephalus
- Communicating (no blockage-decreased absorption)
- Non-communicating (blockage in system )
COMMUNICATING HYDROCEPHALUS What does it look like on CT? What causes it? Can you use LP? Managment?
COMMUNICATING (normal pressure)
Appearance
-pressure increased in all areas of ventricles
-all ventricles enlarged on CT
Causes
-E.g. SAH/ meningitis/post op
LP: YOU CAN USE LP
Managment
-extra-ventricular drain or lumbar drain or permanent diversion (shunt)
NON COMMUNICATING HYDROCEPHALUS What does it look like on CT? What causes it? Can you use LP? Managment?
NON-COMMUNICATING (blockage in system)
Appearance
-pressure throughout not consistent (higher before blockage)
Causes
-Causes: mass/cyst/infection web/intraventricular haemorrhage
LP: DO NOT DO LP
Management: remove obstruction/permanent diversion (shunt)
Causes of encephalitis?
ENCEPHALITIS IS MOST OFTEN CAUSED BY VIRAL Viral -HSV most common inf. cause (type 1 ADULTS. type 2 neonates) -CMV -EBV -VZV -HIV -Measles -Mumps -Japanese B encephalitis
Non-viral
- bacterial meningitis, TB, malaria, legionella, listeria, schistosomiasis, typhus , toxoplasmosis (AIDS)
Presentation if encephalitis?
ENCEPHALITIS
Clinical hallmark is a TRIAD of:
- Fever
- Headache
- Altered mental status
- ↓GCS or odd “encephalopathic” behaviour (confusion)
Also common to have Infectious prodrome:
- Meningism (common) – fever, headache, neck stiff, photophobia, vomiting
- Cold sores (HSV)
- Fever, Rash
- Lymphadenopathy, Conjunctivitis
- History of travel or animal bite
*(if no prodrome, consider encephalopathy: hypoglyceamia, hepatic enceph, DKA, Wernikes)
Investigations for encephalitis?
ENCEPHALITIS Bloods -blood cultures -viral PCR (also throat swab and MSU) -toxoplasma IgM titre (AIDS/immunocompromised) -malaria film (thick and thin blood film) -Glucose – check not DKA -LFTS – Hepatic encephalopathy
Imaging
-Contrast enhanced CT (MRI if allergic to contrast)
LP – do after CT
↑↑Protein ↑↑Lymphocytes ↓Glucose
Send for Viral PCR = 95% specific for HSV1
EEG – lateralised periodic discharge (2Hz)
You do a contrast enhanced CT for encephalitis and see the following:
a) focal Bilateral temporal lobe involvement
b) meningeal enhancement
ENCEPHALITIS CT CONTRAST
a) HSV = focal B/L temporal lobe involvement
b) Meningingoencephalitis = meningeal enhancement
Treatment for encephalitis?
ENCEPHALITIS
-IV Aciclovir START WITHIN 30 MINS OF ARRIVAL
(for 14 days. 21 days if immunocompromised)
What does the 3rd cranial nerve do?
CN III
- Eye movements (NOT superior orbital and lactus rectus)
- Pupillary constriction
- Accommodation
- Eye lid opening
How does 3rd nerve palsy present?
Investigation?
Third nerve palsy (ocular motor)
- DOWN AND OUT (double vision)
- Ptosis
- Pupil dilated (mydriasis) (may be pupil sparing if caused by poor blood flow rather than compression-HTN/diabetes)
- Painful (sign of posterior communicating artery aneurysm)
MRI to identify cause
How does a 4th nerve palsy present?
how will they appear to look from end of bed
4th nerve palsy TROCHLEAR (affects superior oblique muscle-SO4)
- Head tilt AWAY from affected eye (chin depressed if bilateral)
- Downward gaze → vertical diplopia
- When adducted the eye will raise (when adducted, the superior oblique is the only muscle that can depress eye-it fails and so the eye raises)
*Can be congenital
How does a 5th nerve palsy present?
5th nerve palsy (TRIGEMINAL)
- Trigeminal neuralgia – shock paroxysms of U/L V1-V3
- Loss of corneal reflex (afferent)
- Loss of facial sensation
- Paralysis of muscles of mastication
- Deviation of jaw jerk to weak side
How does a 6th nerve palsy present?
6th nerve palsy (ABDUCENS)
- Defective ABduction → horizontal diplopia
- E.g. when looking to the left, the left eye wont move
How does a 7th nerve palsy present?
7th nerve palsy
- Flaccid paralysis of upper AND lower face
- Loss of corneal reflex (efferent)
- Loss of taste (because anterior2/3 tongue supplied)
- Ear numbess and pain (Hyperacusis - ↑sensitivity to certain frequencies)
- If caused by HSV (ramsy hunt)>painful rash/lesions
Bells palsy → high dose prednisolone may help in first 24hrs
Deviation of Tongue to LEFT-where is lesion?
Tongue deviation
- tongue=towards lesion
- e.g. left tongue deviation=left hypoglossal lesion (CN XII)
Deviation of uvula to LEFT-where is the lesion?
Uvular deviation
- uvular=away lesion
- e.g.right vagus nerve (X)
Easy pneumonic to help remember arm nerve palsies?
ARM-U(niversity) you should be able to NAMe SOME
Axillary nerve (C5-C6) -Neck of femur fracture
Radial nerve (C5-T1)
- Axilla (saturday nigh palsy or crutches)
- Midshaft fracture of humerous
Medial nerve (C5-T1) -Supracondylar fracture
Ulnar nerve (C8-T1)
- Outstreched hand fall
- Medial Epicondyl fracture
How does the axillary nerve injury present?
Mechanism of injury?
AXILLARY NERVE (axillary=abduction)
- Reduced ABDUCTION
- Flattened deltoid
- ↓sensation to reg badge
**Humeral neck fracture
What does radial nerve control?
How does radial nerve injury present?
Mechanism of injury?
RADIAL NERVE INJURY (radial=rist drop)
-Controls extension of forearm, wrist, fingers, thumb
**Axillary pressure or midshaft fracture
What does ulnar nerve control?
How does ulnar nerve injury present?
Mechanism of injury?
ULNAR NERVE INJURY (ulnar claw)
- Intrinsic hand muscles except LOAF
- Inability to abduct fingers and Claw hand
**Outstreched hand injury or Medial epicondyle fracture
How does a medical nerve injury present?
Mechanism of injury?
MEDIAL NERVE INJURY (medial=monkey)
- Monkey hand (inability to abduct thumb away from hand)
- inability to flex wrist
(because median nerve supplies LOAF-lateral 2 lumbricals, opponens pollis, abductor pollis brevis, flexor pollis brevis)
**supracondylar fracture
How does a musculocutaneous nerve injury present?
MUSCULOCUTANEOUS NERVE
Inability to flex and supinate arm @ elbow (Biceps Brachii)
How can you get long thoracic nerve injury?
What does it look like?
LONG THORACIC NERVE INJURY
- During high impact sport e.g. blow to the ribs
- Complication of mastectomy
- Presentation: winged scapula
What is Klumpke’s palsy
How can you get Klumpke’s palsy?
How does it present?
KLUMPKES PALSY
- What: Damage of LOWER trunk of bracial plexus (C8-T1)
- Why: shoulder dystocia or excessive stretching of arm
- How: claw hand and HORNERS syndrome (psosis, anhydrosis, miosis-constriction)
What is Erbs palsy
How can you get erbs palsy?
How does it present?
ERBS PALSY
- What: Damage to UPPER trunk of brachial plexus (C5-6)
- Why: Due to shoulder dystocia during birth
- How: Arm adducted, internally rotated, elbow extended (waiter’s tip)
Ramsy hunt vs bells palsy?
Ramsy hunt
- Burning sensation
- Involves vestibular cochlear nerve as well (vertigo)
- More severe paralysis at onset and are less likely to recover completely
Aciclovir and steroids
What is the pathophysiology of Multiple Sclerosis?
MULTIPLE SCLEROSIS
-Autoimmune inflammatory disorder of CNS (T cell mediated)
-Destruction of oigo-dendrocytes>demyelinated plaques> axon damage
(can heal intermittently-relapse and remitting)
-NEVER affects peripheral nerves
What virus is multiple sclerosis sometimes linked to?
MULTIPLE SCLEROSIS
-linked with EBV
(EBV antibodies produced by B cells + T cells directed also attack CNS myelin due to molecular mimicry)
Who is more likely to get MS?
MULTIPLE SCLEROSIS
- Females in their 30s
- Caucasians
- Vit D deficiency
What are the main categories of symptoms for MS?
What makes the symptoms WORSE?
MULTIPLE SCLEROSIS
- Visual
- Motor and coordination
- Sensory and automatic
- Psych and cognition
*Symptoms worsened by heat = Uhthoff’s phenomenon
What investigation is done for MS and what does it show?
MRI with contrast
- brain and spinal cord plaques in periventricular white matter
Sensitive but not specific
What are the types of MS?
- Relapsing and remitting (90%)
○ Recovery (may recover fully or still be functionally impaired during this process)
○ If 1st presentation, you need to observe to confirm if relapsing remitting
BEST PROGNOSIS - Primary progressive (no remissions, just progressively worse) WORST PROGNOSIS
- Secondary repressive (looks like relapsing remitting, then turns more progressive and have marked reduction in function)
What are the VISUAL symptoms of MS?
MS-VISION Sx:
• Optic neuritis (very mylinated nerve-risk of demylination)
○ Partial or total UNILATERAL blurred vision
○ Pain behind the eye
○ Pain on movement
○ Difficult to see red (compared to other eye)
○ ↓central vision
• Reduced eye movements and diplopia
○ When brainstem and CNerves are affected)
What are the MOTOR/COORDINATION symptoms of MS?
MS-MOTOR AND COORDINATION Sx:
-Weakness (lower>upper)
•UMN Sx (reduced power, hyper-reflexia, spasticity)
•Transverse myelitis. 1st exclude obstruction e.g. MSCC)
-Ataxia poor coordination
What are the SENSORY AND AUTOMATIC symptoms of MS?
MS-SENSORY AND AUTONOMIC Sx:
-Paraesthesia (tingling/itching/burning) + numbness in legs. lhermitte electric shock sign (on neck flexion)
-Loss of thermoregulation
•sweating
•pyrexia
•hypothermia
-Bladder, bowel and sexual dysfunction (incontinence, retention)
*ACUTE leg weakness and incontinence may indicate transverse myelitis
What are the COGNITION/PSYCH symptoms of MS?
MS COGNITION/PSYCH Sx:
• Cognitive impairment
• Depression (75% patients), may worsen attention, memory, concentration
• Fatigue
What is the diagnostic criteria for MS called?
McDonald Criteria is diagnostic
• 2 or more attacks (e.g. optic neuritis, cerebellar symptoms )
• 2 or more lesions
How do you treat an acute flare of MS?
MS MANAGMENT
-Prednisolone 500mg/day for 5 days (with omeprazole/ranitidine)
(shortens relapses)
-DMARDs (Alemtuzumab (1st line R&R) )
What is used in mild/moderate relapsing-remitting MS?
DMARDs
- Dimethyl fumarate
- Monoclonal antibodies (alemtuzumab/natalizumab)
What symptoms would you expect if MS effects the brainstem or cerebellum?
MS- Brainstem or Cerebellar Sx
- DANISH
- Diplopia (CN III, IV, VI) and Nystagmus
- Trigeminal neuralgia – paroxysmal shock like pain in
- Facial weakness – Bells palsy, Dysarthria
- Deafness + BPV → vomiting
- Headache
What is Intranuclear opthalmoplegnia (INO)?
Intranuclear opthalmoplegnia (INO)
• Conjugate gaze disorder (one eye moves, and one doesn’t follow)
• Failure of eye to ADDUCT to follow other eye
• Due to demylination of the medial longitudinal fasciculus (MLF)
• The ABDUCTING eye will have nystagmus
MLF connects 6th and 3rd cranial nerve nucleus (can abduct one eye via lateral rectus (6), but not adduct the medial rectus of other eye (3))
Investigations for MS?
MS -investigations
Bedside
-full CNS and PNS exam
Bloods
- FBC, ESR, CRP, LFT, U+E, HIV serology, confusion screen (Ca2+, glucose, TFT, B12)
Imaging
-MRI WITH CONTRAST shows disseminated “white plaques”
Special tests
- Useful when not sure based off MRI
- LP – Oligoclonal IgG bands in CSF
What medications can you do for symptom control in MS?
MS
- Spasticity – Baclofen or Dantrolene
- Tremor – Botulinum toxin type A
- Urgency/freq – catheterisation or tolterodine
- Neuro pain – TCAs, pregabalin, Duloxetine, Gabapentin
- Emotional lability – CBT/TCA
Important complication of MS?
Managment?
MS
Transverse myelitis
-acute episode of BILATERAL weakless/paralysis
-sensory loss, bowel and bladder incontinence
Managment
- Urgent hospital admission
- MRI to exclude obstructive cause
- IV steroids
What triad of symptoms might you see in MS?
Charcot’s neurologic triad (not pathoneumonic)
- nystagmus
- intention tremor (plaques in motor pathways)
- dysarthria (brainstem involvement-swallow/articulation)
What is a differential for MS?
How can you tell the difference?
whats it assosiated with
Neuromyelitis optica (or Devic disease)
• BILATERAL AND MORE SEVERE optic neuritis
•TRANSVERSE MYELITIS (more disabling)
Associated with: IgG antibody for anti aquaporin 4 (AQP4)
Note: Completely separate from MS
What is Myasthenia Gravis?
Myasthenia Gravis
-Autoimmune neuromuscular disorder categorised by WEAKNESS and FATIGUABILITY
Pathophysiology of Myasthenia Gravis?
Pathophysiology of Myasthenia Gravis?
-abnormal antibodies produced by B cells block Ach receptors at NM junction
Who gets Myasthenia Gravis?
Myasthenia Gravis
trimodal:
- NEONATAL
- YOUNG FEMALES
- OLD MALES
Symptoms of Myasthenia Gravis?
Myasthenia Gravis symptoms
-weakness worse at end of day/when tired (fatiguability)
Eye problems
-diplopia, ptosis, ophthalmoplegia-cant maintain gaze
Bulbar problems
-dysphagia/dysarthria/chewing fatiguability
Respiratory
-breathlessness/weak breathing/WEAK COUGH/ resp failure
Limbs/neck
-propped head/weakness arms>legs, proximal worse
***low threshold for intubation>due to deterioration
What investigations are diagnostic of Myasthenia Gravis?
Bedside/bloods/imaging/special
Myasthenia Gravis
Bedside
-ice pack test-IMPROVE with ice
-FVC <1L
Bloods
-serology (Anti-AchR-ab BEST! or Anti-MuSK Ab) also look for other autoimmune conditions
Imaging
-CT or MRI to exclude THYOMA (10%)
Special
-EMG nerve stimulation
Treatment for Myasthenia Gravis?
Myasthenia Gravis treatment
FIRSTLINE: acetyl choline esterase inhibitors
PYRIDO-STIGMINE
- treat relapses: prednisolone or DMARDS
- thymectomy (even if no thyoma)
What drugs worsen Myasthenia Gravis?
Myasthenia Gravis
-Gentamycin and beta blockers classically worsen Myasthenia Gravis
(loads of others-opiates, tetracycline, quinine)
How do you treat myasthenia graves crisis?
Myasthenia gravis crisis
-Plasma exchange and IV Immunoglobulin for crisis
Differentials for myasthenia gravis (and differences)
Lambert eaton
- Paraneoplastic syndrome (tumour)
- Improve with exercise
- Autonomic symptoms (dry mouth, constipation, impotence)
Guillain Barre
- post infective (e.g. campylobacter)
- dymylination of peripheral nerves
- symetrical glove and stocking ASCENDING weakness AND parasthesia
- Give IV IG
Management of fibromyalgia?
Fibromyalgia
- Aerobic exercise
- CBT
- Low dose medications may be effective e.g. amitriptyline or duloxetine if comorbid anxiety/depression
- Do not prescribe NSAIDS – no inflammation so not effective
What is motor neurone disease?
Motor neurone disease
-degenerative disease of MOTOR neurons → UMN/LMN dysfunction → progressive paralysis → death
ALS is the most common (amyotrophic lateral sclerosis)
Presentation of motor neurone disease?
Motor neurone disease
- Limb weakness most common
- Typically upper limbs
- Muscle wasting of hands – pts. drop objects
- Difficulty manipulating objects – turning key, writing, dressing
- FASCICULATIONS of muscles prior to weakness
- Foot drop , gait disorder, falls, fatigue whilst walking, difficulty rising from chair (prox myopathy) - Bulbar onset
- Slurred speech (1st sign)
- Wasting and fasciculations of tongue
- Dysphagia (late, w/ significant speech difficulty)
- Difficulty eating, drooling, dysarthria, dysphonia, choking, aspiration
- Emotional lability - Respiratory
- Dyspnoea, Orthopnoea, Hypoventilation, Chest inf/Aspir
MS vs MND?
Motor neurone disease you DO NOT get sensory disturbance/sphincter disturbance (unlike MS)
Managment of MND?
PALLIATIVE (mostly)
Riluzole – prolongs life by 3 months
Symptomatic
- Drooling -Glycopyrrolate (1st line if cognitive decline-can give SC)
- Feeding - PEG
- Cramps - Quinine (1st line)
- Spacisity- Baclofen,
- Pain – follow ladder
- Breathlessness – Opioids or Benzos (if a/w anxiety)
Who gets cluster headaches?
How long do cluster headaches last?
Cluster headaches
- Male and smoker
- last around 15min – 2hrs
Presentation of cluster headache
Cluster headaches
- Headache lasts 15min – 2hrs (often nocturnal and rapid onset)
- Intense sharp stabbing pain around eye (watery eye-lid swelling
- U/L rhinorrhoea
- Restless patient
- Patial hornets syndrome: Miosis + Ptosis (not common)
ACUTE management of cluster headaches?
ACUTE management of cluster headaches
- 100% oxygen non re breath mask
- S/C sumatriptan (or nasal spray)
PROPHYLACTIC managment of cluster headaches?
PROPHYLACTIC managment of cluster headaches
-verapamil
Treatment for trigeminal neuralgia?
Treatment for trigeminal neuralgia
-Crbamazepine
Acute managment of migraine?
MIGRAIN (acute)
acute: triptan + NSAID or triptan + paracetamol
(nasal triptan if age 12-17)
Prophylactic managment of migraine?
When would you give?
MIGRAINE (prophylactic)
-prophylaxis (if 2+ attacks a month): propranolol (not in asthma or topiramate (not in pregnancy or on pill)
What is the classic triad of normal pressure hydrocephalus?
Normal pressure hydrocephalus
- Ataxia
- Urinary incontinence
- Dementia
