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5thyr > Neuro > Flashcards

Neuro Flashcards

1
Q

What are the types of hydrocephalus and what causes them?

A

Hydrocephalus

  • Communicating (no blockage-decreased absorption)
  • Non-communicating (blockage in system )
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2
Q 
COMMUNICATING HYDROCEPHALUS 
What does it look like on CT?
What causes it?
Can you use LP?
Managment?
A

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)

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3
Q 
NON COMMUNICATING HYDROCEPHALUS 
What does it look like on CT?
What causes it?
Can you use LP?
Managment?
A

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)

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4
Q

Causes of encephalitis?

A 
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)

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5
Q

Presentation if encephalitis?

A

ENCEPHALITIS

Clinical hallmark is a TRIAD of:

  1. Fever
  2. Headache
  3. 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)

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6
Q

Investigations for encephalitis?

A 
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)

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7
Q

You do a contrast enhanced CT for encephalitis and see the following:

a) focal Bilateral temporal lobe involvement
b) meningeal enhancement

A

ENCEPHALITIS CT CONTRAST

a) HSV = focal B/L temporal lobe involvement
b) Meningingoencephalitis = meningeal enhancement

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8
Q

Treatment for encephalitis?

A

ENCEPHALITIS
-IV Aciclovir START WITHIN 30 MINS OF ARRIVAL
(for 14 days. 21 days if immunocompromised)

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9
Q

What does the 3rd cranial nerve do?

A

CN III

  • Eye movements (NOT superior orbital and lactus rectus)
  • Pupillary constriction
  • Accommodation
  • Eye lid opening
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10
Q

How does 3rd nerve palsy present?

Investigation?

A

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

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11
Q

How does a 4th nerve palsy present?

how will they appear to look from end of bed

A

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

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12
Q

How does a 5th nerve palsy present?

A

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
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13
Q

How does a 6th nerve palsy present?

A

6th nerve palsy (ABDUCENS)

  • Defective ABduction → horizontal diplopia
  • E.g. when looking to the left, the left eye wont move
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14
Q

How does a 7th nerve palsy present?

A

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

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15
Q

Deviation of Tongue to LEFT-where is lesion?

A

Tongue deviation

  • tongue=towards lesion
  • e.g. left tongue deviation=left hypoglossal lesion (CN XII)
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16
Q

Deviation of uvula to LEFT-where is the lesion?

A

Uvular deviation

  • uvular=away lesion
  • e.g.right vagus nerve (X)
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17
Q

Easy pneumonic to help remember arm nerve palsies?

A

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
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18
Q

How does the axillary nerve injury present?

Mechanism of injury?

A

AXILLARY NERVE (axillary=abduction)

  • Reduced ABDUCTION
  • Flattened deltoid
  • ↓sensation to reg badge

**Humeral neck fracture

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19
Q

What does radial nerve control?
How does radial nerve injury present?
Mechanism of injury?

A

RADIAL NERVE INJURY (radial=rist drop)
-Controls extension of forearm, wrist, fingers, thumb

**Axillary pressure or midshaft fracture

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20
Q

What does ulnar nerve control?
How does ulnar nerve injury present?
Mechanism of injury?

A

ULNAR NERVE INJURY (ulnar claw)

  • Intrinsic hand muscles except LOAF
  • Inability to abduct fingers and Claw hand

**Outstreched hand injury or Medial epicondyle fracture

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21
Q

How does a medical nerve injury present?

Mechanism of injury?

A

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

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22
Q

How does a musculocutaneous nerve injury present?

A

MUSCULOCUTANEOUS NERVE

Inability to flex and supinate arm @ elbow (Biceps Brachii)

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23
Q

How can you get long thoracic nerve injury?

What does it look like?

A

LONG THORACIC NERVE INJURY

  • During high impact sport e.g. blow to the ribs
  • Complication of mastectomy
  • Presentation: winged scapula
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24
Q

What is Klumpke’s palsy
How can you get Klumpke’s palsy?
How does it present?

A

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)
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25
Q

What is Erbs palsy
How can you get erbs palsy?
How does it present?

A

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)
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26
Q

Ramsy hunt vs bells palsy?

A

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

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27
Q

What is the pathophysiology of Multiple Sclerosis?

A

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

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28
Q

What virus is multiple sclerosis sometimes linked to?

A

MULTIPLE SCLEROSIS
-linked with EBV
(EBV antibodies produced by B cells + T cells directed also attack CNS myelin due to molecular mimicry)

29
Q

Who is more likely to get MS?

A

MULTIPLE SCLEROSIS

  • Females in their 30s
  • Caucasians
  • Vit D deficiency
30
Q

What are the main categories of symptoms for MS?

What makes the symptoms WORSE?

A

MULTIPLE SCLEROSIS

  1. Visual
  2. Motor and coordination
  3. Sensory and automatic
  4. Psych and cognition

*Symptoms worsened by heat = Uhthoff’s phenomenon

31
Q

What investigation is done for MS and what does it show?

A

MRI with contrast
- brain and spinal cord plaques in periventricular white matter

Sensitive but not specific

32
Q

What are the types of MS?

A
  1. 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
  2. Primary progressive (no remissions, just progressively worse) WORST PROGNOSIS
  3. Secondary repressive (looks like relapsing remitting, then turns more progressive and have marked reduction in function)
33
Q

What are the VISUAL symptoms of MS?

A

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)

34
Q

What are the MOTOR/COORDINATION symptoms of MS?

A

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

35
Q

What are the SENSORY AND AUTOMATIC symptoms of MS?

A

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

36
Q

What are the COGNITION/PSYCH symptoms of MS?

A

MS COGNITION/PSYCH Sx:
• Cognitive impairment
• Depression (75% patients), may worsen attention, memory, concentration
• Fatigue

37
Q

What is the diagnostic criteria for MS called?

A

McDonald Criteria is diagnostic
• 2 or more attacks (e.g. optic neuritis, cerebellar symptoms )
• 2 or more lesions

38
Q

How do you treat an acute flare of MS?

A

MS MANAGMENT
-Prednisolone 500mg/day for 5 days (with omeprazole/ranitidine)
(shortens relapses)

-DMARDs (Alemtuzumab (1st line R&R) )

39
Q

What is used in mild/moderate relapsing-remitting MS?

A

DMARDs

  • Dimethyl fumarate
  • Monoclonal antibodies (alemtuzumab/natalizumab)
40
Q

What symptoms would you expect if MS effects the brainstem or cerebellum?

A

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
41
Q

What is Intranuclear opthalmoplegnia (INO)?

A

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))

42
Q

Investigations for MS?

A

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
43
Q

What medications can you do for symptom control in MS?

A

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
44
Q

Important complication of MS?

Managment?

A

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
45
Q

What triad of symptoms might you see in MS?

A

Charcot’s neurologic triad (not pathoneumonic)

  1. nystagmus
  2. intention tremor (plaques in motor pathways)
  3. dysarthria (brainstem involvement-swallow/articulation)
46
Q

What is a differential for MS?
How can you tell the difference?

whats it assosiated with

A

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

47
Q

What is Myasthenia Gravis?

A

Myasthenia Gravis

-Autoimmune neuromuscular disorder categorised by WEAKNESS and FATIGUABILITY

48
Q

Pathophysiology of Myasthenia Gravis?

A

Pathophysiology of Myasthenia Gravis?

-abnormal antibodies produced by B cells block Ach receptors at NM junction

49
Q

Who gets Myasthenia Gravis?

A

Myasthenia Gravis

trimodal:
- NEONATAL
- YOUNG FEMALES
- OLD MALES

50
Q

Symptoms of Myasthenia Gravis?

A

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

51
Q

What investigations are diagnostic of Myasthenia Gravis?

Bedside/bloods/imaging/special

A

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

52
Q

Treatment for Myasthenia Gravis?

A

Myasthenia Gravis treatment
FIRSTLINE: acetyl choline esterase inhibitors
PYRIDO-STIGMINE

  • treat relapses: prednisolone or DMARDS
  • thymectomy (even if no thyoma)
53
Q

What drugs worsen Myasthenia Gravis?

A

Myasthenia Gravis
-Gentamycin and beta blockers classically worsen Myasthenia Gravis

(loads of others-opiates, tetracycline, quinine)

54
Q

How do you treat myasthenia graves crisis?

A

Myasthenia gravis crisis

-Plasma exchange and IV Immunoglobulin for crisis

55
Q

Differentials for myasthenia gravis (and differences)

A

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
56
Q

Management of fibromyalgia?

A

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
57
Q

What is motor neurone disease?

A

Motor neurone disease
-degenerative disease of MOTOR neurons → UMN/LMN dysfunction → progressive paralysis → death

ALS is the most common (amyotrophic lateral sclerosis)

58
Q

Presentation of motor neurone disease?

A

Motor neurone disease

  1. 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)
  2. 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
  3. Respiratory
    - Dyspnoea, Orthopnoea, Hypoventilation, Chest inf/Aspir
59
Q

MS vs MND?

A

Motor neurone disease you DO NOT get sensory disturbance/sphincter disturbance (unlike MS)

60
Q

Managment of MND?

A

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)
61
Q

Who gets cluster headaches?

How long do cluster headaches last?

A

Cluster headaches

  • Male and smoker
  • last around 15min – 2hrs
62
Q

Presentation of cluster headache

A

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)
63
Q

ACUTE management of cluster headaches?

A

ACUTE management of cluster headaches

  • 100% oxygen non re breath mask
  • S/C sumatriptan (or nasal spray)
64
Q

PROPHYLACTIC managment of cluster headaches?

A

PROPHYLACTIC managment of cluster headaches

-verapamil

65
Q

Treatment for trigeminal neuralgia?

A

Treatment for trigeminal neuralgia

-Crbamazepine

66
Q

Acute managment of migraine?

A

MIGRAIN (acute)
acute: triptan + NSAID or triptan + paracetamol
(nasal triptan if age 12-17)

67
Q

Prophylactic managment of migraine?

When would you give?

A

MIGRAINE (prophylactic)

-prophylaxis (if 2+ attacks a month): propranolol (not in asthma or topiramate (not in pregnancy or on pill)

68
Q

What is the classic triad of normal pressure hydrocephalus?

A

Normal pressure hydrocephalus

  1. Ataxia
  2. Urinary incontinence
  3. Dementia

5thyr (18 decks)

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