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Yr 6 PACES knowledge COPY RJ Challenger > Neuro > Flashcards

Neuro Flashcards

1
Q

General inspection of Parkinson’s disease

A

Hypomimia
Resting tremor - exacerbated by counting backwards
Stooped posture

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2
Q

Eye exam in parkinson’s disease

A

Nystagmus –> MSA?

Vertical gaze palsy –> PSP?

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3
Q

Gait in parkinson’s disease

A

Stooped
Shuffling
ABSENT ARM SWING
Slow initiation

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4
Q

Extras to an examination of PD patient

A
  • Assess for micrographia
  • Assess gait
  • BP lying + standing
  • MMSE
  • Drug chart
  • Abdominal examination
  • Abdo exam (Wilson’s disease = liver failure)
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5
Q

Causes of parkinsonism

A
  • Idiopathic
  • Parkinson + (MSA, PSP, Lewy body)
  • Multiple SNigra infarcts
  • Wilson’s disease
  • Antipsychotics
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6
Q

What parts of the Hx may point you towards a cause for parkinsonism?

A
  • Lewy body: visual hallucinations, memory problems
  • Infarcts in SN: sudden onset
  • MSA: postural hypotension, bladder/bowel problems
  • Antipsychotics: drug Hx
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7
Q

Ix in ?PD?

A

It’s a clinical dx!

but must do CT/MRI to exclude a vascular cause

  • DaTscan (iodine isotope injection which binds to DAergic neutrons in SNigra)
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8
Q

Medical Tx of Parkinsons

A

L-DOPA + DDCinhibitors

  • DA agonists (ropinirole)
  • MAO-B inhibitors (Selegiline)
  • COMT inhibitors (entacapone)
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9
Q

Unwanted side effects of L-DOPA?

A
  • Dyskinesias (occur in peak therapeutic effect)
  • On-off effect
  • Psychosis
  • Nausea/GI upset
  • Hypotension
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10
Q

Features of parkinsonism

A
  • Bradykinesia
  • Rigidity
    • Tremor
      Gait: slow to start, festinating, absent arm swing, shuffling
  • Hypomimia
  • Micrographia
  • SLEEP disorder
  • Depression
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11
Q

Sleep disorder in PD patients

A
  • Insomnia + frequent waking
  • Restless legs + early morning dystonia
  • Nocturia (from auto- dysfunction)
  • Violent enactment of dreams
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12
Q

Features of PSP?

A

Postural instability –> falls
Vertical gaze palsy
Speech + swallow problems (pseudo bulbar palsy)

Tremor is unusual

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13
Q

Features of Lewy body dementia

A

Parkinsonism precede memory loss

Visual hallucinations!

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14
Q

Ddx for tremor

A

Intention tremor = cerebellar

Resting tremor = parkinsonism

Postural (i.e. worse w arms outstretched)=

  • Thyroid
  • EtOH withdrawal
  • SABA/LABA use
  • Anxiety
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15
Q

Features of multi system atrophy

A

Autonomic dysfunction: postural hypo, bladder/bowel dysfunction

Cerebellar syndrome!!!
- nystagmus

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16
Q

how many cervical nerves and cervical vertebrae

A

Cervical nerves: C1-8
Cervical vertebrae: C1-7

All cervical nerves arise from ABOVE their corresponding vertebrae BUT C8 nerve arises from between C7 and T1 vertebrae

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17
Q

symmetrical + distal LMN signs = where is the lesion?

What are the differential

A

Peripheral motor polyneuropathy

  • Charcot Marie Tooth
  • Paraneoplastic
  • Guillain-Barré syndrome
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18
Q

Findings on examination in Charcot Marie Tooth?

A
  • Champagne bottle legs
  • Highs stepping gait w foot drop
  • High- arched foot
  • Sensory loss in stocking distribution
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19
Q

Investigations in Charcot Marie Tooth

A

Nerve conduction studies

Genetic testing

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20
Q

Mx of Charcot Marie tooth

A

Supportive
MDT: GP, physio, neurologist, specialist nurse OT
- foot care + special shoe choice
- ankle braces

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21
Q

Define GBS

A

autoimmune demyelinating polyneuropathy

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22
Q

Features of GBS

A

preceding infection (campylobacter)

  • ascending hypotonia + weakness
  • paraesthesia
  • breathing + swallowing probs
  • Autonomic probs: labile BP, urinary retention
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23
Q

Pathophysiology of GBS

A

cross-reactivity of antibodies to infection –> attacks gangliosides

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24
Q

Ix for diagnosis of GBS

A
  • Look for infection eg stool culture
  • Anti-ganglioside antibodies
  • Nerve conduction studies (low conduction velocity due to demyelination)
  • LP: high CSF protein levels!
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25
Q

Mx of GBS

A

Supportive:
AIRWAY: ITU if FVC<1.5L
ANALGESIA
AUTONOMIC: catheter +/- inotropes

Definitive:
IVIG, plasma exchange

Physio

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26
Q

Ddx for bilateral + symmetrical proximal muscle weakness

A

Proximal myopathy

Endocrine:
DM, hyperthyroidism, cushings, acromegaly

EtOH, statins, steroids

Paraneoplastic

Inherited: MD

Inflammatory: Dermato/polymyositis

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27
Q

Ddx for Hand wasting

A

Muscle atrophy - think LMN

AHC: MND, old polio, Charcot Marie Tooth

Nerve root (C8T1): Spondylosis

Plexus: cervical rib compression

Neuropathy: Charcot, DM

Muscle: RA (disuse), myotonic dystrophy

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28
Q

Ix for proximal myopathy

A 
Glucose/HbA1c
TSH
9am cortisol
LFTs - alcohol
CK (statins)
Anti-jo1
CXR
EMG
Genetic analysis
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29
Q

CN7 palsy - forehead involvement = ? causes?

A

Forehead involvement = LMN lesion

Cerebellopontine angle tumour
Bells palsy
Otitis media, RH syndrome
Parotid malignant tumour
Trauma

Systemic = DM, HIV, sarcoid

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30
Q

CN7 palsy - forehead sparing = ? causes?

A

UMN lesion

CVA
MS
SOL

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31
Q

Features of cerebellopontine angle tumour

A

CN 5678 involvement:

  • DANISH
  • loss of corneal reflex
  • facial muscle weakness
  • vertigo, tinnitus, sensorineural deafness
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32
Q

Mx of Bells palsy

A 
Conservative:
Protect eye - dark glasses, artificial tears, tape eye @ night
Medical:
PREDNISOLONE w/i 72 hours
(if ?VZV give valaciclovir)

(Surgery: plastics if no recovery)

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33
Q

Prognosis of Bells Palsy

A

Full recovery = 80%

Remainder: delayed recovery or permanent neuro/cosmetic changes

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34
Q

Myasthenia Gravis - Ix?

A
  • Tensilon test (improvement w anticholinesterase)
  • anti-cholinesterase antibodies
  • EMG
  • CT thorax (thymoma!!!)
  • TFTs (graves is common)
  • Spirometry - esp FVC
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35
Q

Findings on inspection of myasthenia gravis

A

Thymectomy scar
Bilateral ptosis
Snarl

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36
Q

3 ways to assess fatiguability in myasthenia gravis

A
  1. Repeatedly flap arm
  2. Ask to count down from 50
  3. Ask them to look up –> bilateral ptosis
37
Q

Management of myasthenia gravis

A

Acute: IVIG/plasmapharesis
Chronic: PYRIDOSTIGMINE

Thymectomy - of benefit even if no thymoma

38
Q

Important investigation in bilateral proximal muscle weakness that improves on testing

A

Anti-VGCC

CT thorax: usually a paraneoplastic syndrome due to SCLC!!!

39
Q

In any patient with CN3 palsy, what investigation would u do in all patients

A

CT angiogram = a sign of a PCA aneurysm

40
Q

Dangerous differentials for Horners syndrome

A

Apical lung tumour

Carotid artery dissection/aneurysm

41
Q

secondary prevention for stroke/TIA

A

Optimise RFs (smoking, wt loss, HTN, DM)

STATIN (everyone)

Clopidogrel 75mg OD for everyone unless on anticoagulation

Warfarin/NOAC: if cardioembolic stroke/AFib/venous sinus thrombosis/dissection

42
Q

Causes of foot drop?

Associated sensory features

A

Fibular head trauma
Sitting cross legged

Loss of sensation along lateral lower leg

43
Q

What nerve is at risk of damage in distal humerus fracture?

Presentation?

A

Ulnar nerve

Weakness of finger abduction
Ulnar claw - flexed 4th and 5th finger - ONLY if lesion is close to rist
Can’t do ‘good luck’ sign

Loss of sensation in ulnar 1.5 fingers

44
Q

Weak elbow extension

wrist drop

A

Radial nerve damage at the axilla

45
Q

Wrist drop + finger drop

A

Lesion is of radial nerve, at the humerus

46
Q

Waiters tip - where is the lesion? cause?

A

C56 i.e. higher brachial plexus

- shoulder dystocia

47
Q

Ulnar paradox

A

Ulnar claw is worse the more distal the lesion is:

close to wrist: medial lumbricals weakened – > 4+5th fingers flexed

More proximal: Flexor dig prof weakened –> 4+5th fingers less flexed!

48
Q

Wasting of dorsal muscles of hand
Claw hand

Lesion? Cause?

A

Lower brachial plexus injury (C8T1)

Cause: trauma from suddenly arm is pulled superiorly (tree)
OR Apical lung tumour –> T1 involvement

49
Q

Causes of a raised hemidiaphragm - where is the lesion? what causes it?

A

Phrenic nerve palsy (C3-5)

Neoplasm:
- lung, thymoma, myeloma
Mechanical: 
- Cervical spondylosis
Infective:
- Zoster, HIV, TB, Lyme
50
Q

2 or more peripheral nerve palsies - what is this phenomenon called?

And what can cause it?

A

Mononeuritis multiplex

WARDS PLC (most common = DM)
Wegeners, Amyloid, RA, DM, Sarcoid, PAN, Leprosy, Cancer
51
Q

Ddx for vertigo

A

IMBALANCE

  • Infection: Ramsay Hunt, labrynthitis (post URTI)
  • Meniere’s (tinnitus, SNHL, N+V)
  • BBPV (positional)
  • Amino glycosides (gent)
  • Arterial: Stroke, migraine
  • Nerve: Acoustic Neuroma
  • Central: MS, SOL
  • Epilepsy
52
Q

TACS criteria for stroke - what is it for? what are the criteria?

A

Anterior circulation stroke

  • Homonymous hemianopia
  • Hemparesis OR sensory deficit
  • Higher cortical dysfunction: dysphasia or hemispatial neglect
53
Q

Define a posterior circulation stroke

A

Haemorrhage or infarct of the vertebral arteries or basilar artery or its branches

54
Q

Presentations of posterior circulation stroke

A

Cerebellar syndrome
Brainstem syndrome
Homonymous hemianopia (occipital lobe involvement)

55
Q

Define lacunar stroke (i.e. what structures are affected

A

Small infarcts in blood supply to internal capsule, basal ganglia, thalamus

absence of brainstem signs/higher cortical dysfunction/drowsiness/homonymous hemianopia

56
Q

Absent corneal reflex in R eye
+ Loss of pain sensation in L arm and leg

diagnosis? other features?

A

R sided lateral medullary syndrome

i.e. infarct in post inf cerebellar artery or vertebral artery

Other features: dysphagia, dysarthria, ataxia, nystagmus, Horners syndrome

57
Q

Pupil - constricted
+ doesn’t react to light
+ DOES accommodate

A

Argyll Robertson pupil

DM or neurosyphilis

58
Q

Pupil - fixed and dilated + doesn’t respond to light or accomodation

A

Holmes Adie

Often viral cause

59
Q

Features of temporal lobe- focal seizure

A

Automatisms (lip smacking)
Hallucinations (olfactory)
Emotional disturbance
Deja vu/jamais vu

60
Q

ITP - platelet count? clotting times?

A

Low platelets

Normal APTT and PT

61
Q

Common long term complication o meningitis

A

SN hearing loss

62
Q

Pt takes metoclopramide for post-op nausea

  • retracted eyelids, fixed upward gaze, neck writhing –> dx? mx?
A

Oculogyric crisis

Mx = procyclidine

63
Q

Why be careful of rapid correction of hyponatremia

A

Central pontine myelinolysis

-

64
Q

Ring enhancing lesions on CT

A

toxoplasmosis

65
Q

ROmbergs test - what does it tell you?!

A

+ve = sensory ataxia
defect w vision/vestibular system/proprioception

-ve = ataxia is likely due to cerebellar syndreom

66
Q

Bilateral cerebellar signs - likely cause?

A

global cause

  • EtOH
  • MS
  • phenytoin
67
Q

Causes of cerebellar syndrome

A 
Vascular: posterior circulation stroke
MS
EtOH
SOL: CPA tumour
Wilsons
Phenytoin
MSA
68
Q

Nystagmus in cerebellar syndrome

A

Nystagmus is worse when looking towards the same side as lesion

69
Q

Differentials for conductive deafness

A

Outer ear: FB, wax
TM perforation: trauma, infection
Middle ear: effusion

70
Q

Differentials for SN hearing loss

A
  • Presbycusis (age related)
  • Drugs: gentamicin, vancomycin
  • Infection: meningitis, measles
  • Menieres
  • Malignancy: CPA lesion
  • Paget’s (CN8 invasion)
71
Q

Fx of CN4 palsy

A

Failure to depress the eye on adduction

Diplopia is v bad on looking down + in

72
Q

Failure to depress the eye on adduction

Dx? what else may be seen on inspection

A

CN4 palsy

Ocular torticollis

73
Q

Intranuclear ophthalmoplegia = explain

A

Lesion in MLF (v myelinated)

Ipsilateral eye fails to adduct, contralateral eye has nystagmus on abduction

MLF connects CN3 + CN6 nuclei - on lateral gaze, output to CN3 and CN6 is initiated via MLF

74
Q

Causes of CN3 palsy

A

PCA aneurysm
MS
SOL

DM, compression

75
Q

Ix in simple palsies –> opthalmoplegia

A

FBC (infection)
Glucose, HbA1c (DM)
MRI head (aneurysm)
CT head (haemorrhage)

76
Q

Type of imaging for MS?

A

gadolinium enhancing MRI

77
Q

Presentation of MS

A

Paraesthesia
Optic neuritis (loss of central and colour vision + painful eye)
Ataxia + cerebellar signs
Motor: spastic paraparesis

78
Q

Features of MS

A 
Paraesthesia
Spastic paraparesis
Transverse myelitis --> bilateral sensory, motor + autonomic Sx
Urinary retention, constipation
Optic neuritis, INO
CEREBELLAR: falls, ataxia, tremor
79
Q

Ix in MS

A

Bloods: autoantibodies MOB and MBP
Imaging: Gadolinium enhancing MRI
LP: IgG oligoclonal bands
Evoked potentials

80
Q

Mx of MS

A

Acute attack: methylprednisolone

Preventing attacks:
- IFNbeta + mAbs = alemtezumab

Symptomatic:

  • Amitryptiline (pain)
  • Clonazepam (tremor)
  • Self catheterisation/oxybutynin
  • Physio + baclofen (spasticity)
81
Q

Glucose levels in CSF: normal? Bacterial meningitis? TB meningitis?

Protein levels in CSF>?

A

Normal = 60-70% plasma glucose. Protein <1

Bacterial <50% of plasma glucose. protein >1

TB <50% of plasma glucose. protein 1-5!!!

82
Q

LP in encephalitis

LP in viral meningitis

A

Encephalitis:
moderately low glucose
high protein + lymphocytes

Viral meningitis:
Normal glucose (>50% plasma)
Protein <1
high WCC

83
Q

Surgical Mx of subdural

A

Burr Hole Craniostomy

84
Q

Surgical mx of extradural

A

Craniectomy

85
Q

Mx of SAH

A

1) urgent neurosurgical referral
2) monitor Obs + repeat CT head if deteriorating
3) aim for SBP >160
4) NIMODIPINE 60mg/4 hrs for 3 weeks
5) CT angio –> Surgical CLIPPING or COIL EMBOLISATION
6) STOOL SOFTENERS, analgesia, antitussives

86
Q

RFs for intracranial venous thrombosis

A 
Young
Malignancy
Thrombophilia
Pregnancy, OCP
Local infection - otitis, sinusitis, meningitis
87
Q

Why does cerebral venous thrombosis –> increased ICP?

Why does CVT present like a stroke?

A

Cerebral veins lie in the subarachnoid space. therefore when they thrombose + occlude –> reduced CSF drainage –> raised ICP

When cerebral veins thrombus –> increased pressure in veins + blood stasis –> less oxygen to brain tissue and cerebral edema

88
Q

clinical features of Cerebral venous thrombosis

A
  • Raised ICP: headache, visual changes, papilloedema
  • Focal deficits: hemiparesis (reduced oxygenation of brain tissue)
  • Seizures
  • Encephalopathy
89
Q

Ix for ?cerebral venous thrombosis

A

CT head
MRI head - T2 weighted
CT venography
LP

Yr 6 PACES knowledge COPY RJ Challenger (16 decks)

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