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NAM: med / surg / specialties > neuro > Flashcards

neuro Flashcards

1
Q

RFs subarachnoid haemorrhage

A 
PKD 
smoking
alcohol 
HTN
cocaine
connective tissue disesase: Marfan's, Ehlers-Danlos
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2
Q

thunderclap heaedache

A

subarachnoid

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3
Q

high impact trauma → brain haemorrhage

A

extradural

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4
Q

oculomotor nerve palsy presentation

A 
eye "down + out"
ptosis
dilated pupil (mydriasis)
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5
Q

horner’s syndrome presentation

A

ptosis (partial)
constricted pupil (miosis)
anhydrosis
same side as lesion

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6
Q

cerebellar signs

A 
ipsilateral 
dysdiadochokinesia + dysmetria 
ataxia
nystagmus
intention tremor
slurred staccato speech 
hypotonia
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7
Q

presentation parkinson’s disease

A 
bradykinesia
resting pill-rolling tremor 
stooped posture 
cogwheel rigidity 
hypomimesis
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8
Q

CT scan lenticular vs crescent shape hyperdensity

A 
lenticular = extradural 
crescentic = subdural
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9
Q

UMN signs

A

weakness
hyperreflexia (Babinski’s, clonus)
hypertonia (spasticity)

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10
Q

LMN signs

A 
weakness + wasting
hyporeflexia 
hypotonia 
flaccidity 
fasciculations
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11
Q

facial nerve palsy presentation

A

idiopathic LMN facial nerve palsy
facial weakness (NOT forehead sparing), drooling
hyperacusis (stapedius paralysis)
loss of taste (anterior 2/3 of tongue)
inability to close eye (tearing / drying)
loss of corneal reflex
Bell’s phenomenon: eyeball rolls up but eye remains open when trying to close eyes
normal sensation

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12
Q

myasthenia gravis vs lambert eaton

A

MG: muscle fatigue w use
ocular involvement
assoc w thymoma
AChR Ab

LE: may have autonomic involvement
anti-VGCC Ab
assoc w small cell lung cancer

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13
Q

investigations multiple sclerosis

A

bloods: FBC, ESR / CRP, LFTs, U+Es, B12
Gadolinium enhanced MRI brain + spinal cord (gold standard)
lumbar puncture → electrophoresis → IgG Ab in CSF form oligoclonal bands
visual evoked potentials → delayed conduction velocity

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14
Q

causes of parkinson’s plus

A 
Lewy body dementia 
multiple system atrophy 
progressive supranuclear palsy
corticobasal degeneration
vascular parkinsonism
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15
Q

Parkinson’s disease management

A

medical:
dopamine agonists e.g. bromocriptine
L-dopa e.g. sinemet + domperidone / carbidopa (reduce peripheral SEs e.g. N&V)
COMT / MAO-B inhibitors (dopamine degrading enzymes)
surgical: deep brain stimulation

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16
Q

causes of cerebellar syndrome

A

demyelination: MS
alcohol
infarct: stroke / TIA
space-occupying lesion e.g. vestibular schwannoma
inherited: Friedrich’s ataxia, wilson’s disease
epilepsy medication: phenytoin
multiple system atrophy

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17
Q

management multiple sclerosis

A

conservative: MDT approach, stress reduction, smoking cessation, pt education
medical:
acute: IV methylprednisolone 3-5days
relapse prevention (disease modifying drugs DMDs): β-IFN, biologics (natulizumab, rituximab), mitoxantrone
symptomatic:
spasticity: baclofen / botox
urinary: CISC, anti-Ach (oxybutynin)
neuropathic pain: gabapentin
depression: SSRIs, psychological therapies

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18
Q

classification multiple sclerosis

A 
progressive relapsing (pt declines w each relapse) 
secondary progressive (relapse / remission ends and pt suddenly  declines)
primary progressive (no relapse / remission) 
80% relapsing-remitting (relapses may or may not leave permanent deficits) 
clinically isolated syndrome (1st episode + signs consistent w MS on MRI)
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19
Q

2 main types of stroke + RFs for each

A

ischaemic: embolic / small or large vessel atherosclerosis
haemorrhagic: HTN, aneurysm / AVM rupture, trauma, altered haemostasis

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20
Q

acute management stroke

A

urgent CT head → exclude haemorrhage
ischaemic:
< 4.5hrs (hyperacute) → thrombolysis: IV alteplase
consider thrombectomy <6hrs for severe stroke
> 4.5hrs → aspirin 300mg (2nd line clopidogrel)
repeat CT after 24hrs to reconfirm no haemorrhage
haemorrhagic:
refer to neurosurgery for coiling of aneurysms / decompressive hemicraniectomy

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21
Q

ongoing management post-stroke

A

cons: MDT approach (incl. SALT swallow assessment)
RF modification: exercise, diet, smoking cessation

medical:
antiplatelet therapy: clopidogrel
if AF → warfarin (start after 2wks)
manage CV RFs: statin, anti-HTN, treat diabetes

surgical: endovascular stenting, carotid endarterectomy (stenosis > 70%)

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22
Q

management TIA

A

all pts seen within 7 days
if ABCD2 score (risk of stroke) > 3 → see within 24hrs
cons: RF modification
med: RF modification (treat HTN + diabetes)
statin + clopidogrel 75mg OD
warfarin if AF
surg: carotid endarterectomy: if stenosis > 70%

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23
Q

corticospinal tract function

A

descending tract
motor
pyramidal decussation in medulla

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24
Q

spinothalamic tract function

A

ascending tract
pain, temperature
decussates at level of innervation

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25
Q

dorsal columns function

A

ascending tract
light touch, proprioception, vibration
decussation in medulla

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26
Q

presentation anterior cord syndrome (Beck’s)

A

preservation of dorsal columns (light touch, proprioception, vibration)
loss of spinothalamic (temperature, pain) contralateral
UMN signs below lesion
LMN signs at level of lesion

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27
Q

presentation Brown-Sequard

A

hemisection of spinal cord
ipsilateral motor UMN signs below lesion / LMN at level of lesion
ipsilateral loss of light touch, proprioception, vibration
contralateral pain / temp loss (spinothalamic)

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28
Q

presentation central cord syndrome

A

central corticospinal damage → motor loss affecting arms > legs
spinothalamic + dorsal tract damage → loss of pain, temp, proprioception, light touch, vibration

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29
Q

cauda equina presentation

A 
back pain / sciatica 
areflexia (ankle jerk) 
flaccid LL weakness 
saddle anaesthesia 
bowel / bladder dysfunction
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30
Q

investigations for guillain barre

A

bloods: FBC, CRP / ESR, culture → infection
stool MC+S → infection
antiganglioside Ab
imaging to exclude other problems
lumbar puncture → raised CSF protein, normal WCC
spirometry → reduced FVC
nerve conduction studies → reduced velocity

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31
Q

typical Hx extradural haemorrhage

A 
head trauma (pterion) 
blackout on impact, lucid interval, deterioration
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32
Q

typical Hx subdural haemorrhage

A

fluctuating consciousness

alcoholics / elderly (brain atrophy pulls on venous sinuses)

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33
Q

source of bleed in extradural haemorrhage

A

middle meningeal artery (beneath pterion)

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34
Q

differentials for tremor

A

resting tremor: parkinsonism, benign essential tremor, drugs e.g. antipsychotics, beta-agonists
intention tremor: cerebellar syndrome
postural tremor:
thyrotoxicosis, caffeine, anxiety, same drugs as above

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35
Q

typical presentation lewy body dementia

A

visual hallucinations
fluctuating memory problems / cognitive impairment
parkinsonism

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36
Q

causes of unilateral ptosis

A

Horner’s (constricted pupil, partial ptosis)
oculomotor nerve palsy (dilated pupil, complete ptosis)
stroke
myaesthenia gravis
congenital e.g. simple congenital myogenic ptosis, myotonic dystrophy

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37
Q

causes of bilateral ptosis

A

myaesthenia gravis
guillain-barre syndrome
myotonic dystrophy

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38
Q

innervation of upper limb reflexes

A

biceps: C5/6
triceps: C7
supinator: C6

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39
Q

reflex grading

A 
0 = absent
1+ = present only w reinforcement 
2+ = normal 
3+ = hyperactive w/o clonus
4+ = hyperactive w clonus
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40
Q

MRC power scale

A

0 No contraction
1 Flicker or trace of contraction
2 Active movement, with gravity eliminated
3 Active movement against gravity
4 Active movement against gravity and resistance
5 Normal power

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41
Q

innervation of lower limb reflexes

A

patellar: L3-4
achilles: S1-2

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42
Q

lower limb + upper limb dermatomes

A

upper: C5, C6, C7, C8, T1
lower: L1, L2, L3, L4, L5, S1

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43
Q

myaesthenia gravis aetiology vs lambert eaton

A

MG: autoimmune neuromuscular disease w Ab against AchR (affects postsynaptic membrane of NMJ)

LEMS: autoimmune against VGCC (voltage-gated calcium channels)

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44
Q

investigations myaesthenia gravis

A

bloods: CK (exclude myopathy), AchR Ab, MuSK Ab, anti-VGCC Ab (Lambert-Eaton), TFTs
Tensilon test: trial short acting anticholinesterase → ↑ACh → transient symptom improvement
lung function testing → reduced FVC
CXR / CT thorax → exclude thymoma / lung Ca
nerve conduction testing → reduced muscle action potential with stimulation
EMG → ↓response to repetitive stimulation →↑single-fibre jitter

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45
Q

management acute myaesthenic crisis

A

ABCDE
IVIg / plasmaphoresis
prednisolone
monitor FVC → intubation / ventilation

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46
Q

management chronic myaesthenia gravis

A

anticholinesterases e.g. pyridostigmine (symptomatic only)
immunosuppression: prednisolone (2nd line: azathioprine, ciclosporin)
thymectomy

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47
Q

types of motor neurone disease

A

primary lateral sclerosis (UMN)
progressive muscular atrophy (LMN)
amyotrophic lateral sclerosis (UMN + LMN)
progressive bulbar palsy (LMN IX-XII)

48
Q

management motor neurone disease

A

supportive management
cons: MDT, palliation, psychosocial support, physiotherapy, OT, etc.
med: riluzole (prolongs life slightly but no improvement in function / QOL)
baclofen → spasticity
NIV → resp failure
anti-muscarinic e.g. atropine → salivation
dietician → diet modification, PEG / NG feeding → dysphagia, weight loss

49
Q

causes of unilateral facial nerve palsy

A 
UMN: stroke
LMN:
idiopathic: Bell's palsy 
Ramsay-Hunt syndrome (VZV → painful vesicles) 
infection e.g. otitis media 
parotid mass
cancer e.g. acoustic neuroma
50
Q

management facial nerve palsy

A

cons: ENT / neuro / ophthamology involvement
eyelid taping, lubricating eye drops, protective glasses
med: high dose prednisolone within 72hrs
surg: if corneal damage → lateral tarsorrhaphy (suturing of lateral parts of eyelids)
facial nerve decompression: middle fossa craniotomy via mastoid bone

51
Q

causes of horner’s syndrome

A

1st order: stroke, MS, syringomyelia, encephalitis
2nd order: pancoast syndrome, cervical rib
3rd order: carotid aneurysm / dissection, cavernous sinus thrombosis

52
Q

investigations for horner’s syndrome

A

cocaine drop test: failure of dilatation (normal: cocaine blocks NA reuptake at NMJ → pupil dilatation / Horner’s: lack of NA → no dilatation)
CXR → pancoast tumour
CT / MRI brain / spinal cord → stroke, inflammation, spinal cord lesions
carotid angio

53
Q

causes of bilateral facial nerve palsy

A 
sarcoidosis 
GBS
lyme disease
bilateral acoustic neuroma (neurofibromatosis type 2)
Bell's palsy
54
Q

presentation neurofibromatosis type 1

A 
cafe au lait spots (>5 >15mm / >5mm if pre-pubertal) 
Lisch nodules (iris) 
axillary (Crowe's sign) / inguinal freckling 
neurofibromas of skin
learning disability 
epilepsy
scoliosis
phaeochromocytoma
55
Q

presentation neurofibromatosis type 2

A

schwanommas / meningiomas / gliomas → hearing loss, tinnitus, balance problems, headache, facial pain / numbness

56
Q

causes of diplopia

A 
CN palsies (3,4,6)
SOL
multiple sclerosis
myaesthenia gravis
myotonic dystrophy
GBS 
BPPV
57
Q

causes of 3rd nerve palsy

A

medical: ischaemic / vascular (diabetes, HTN, vasculitis, MS)
surgical: compression (emergency → refer to neurosurg)
trauma, SOL, cavernous sinus thrombosis, posterior communicating artery aneurysm

58
Q

causes of 4th / 6th nerve palsy

A

trauma
SOL
ischaemic / vascular: HTN, diabetes, vasculitis
MS

59
Q

management acute myasthenic crisis

A

plasmaphoresis / IVIg
prednisolone
monitor FVC and consider intubation / ventilation

60
Q

definition clinically isolated syndrome (MS) + prognosis

A

isolated ep of MS Sx w consistent changes on MRI

60-80% progress to MS

61
Q

causes of hearing loss

A

conductive: wax, foreign body, otitis media, otosclerosis
sensorineural: age-related, ototoxic drugs e.g. gentamicin, Menieres, acoustic neuroma, infection (meningitis)

62
Q

visual pathway

A

optic nerve → optic chiasm → optic tract → parietal (upper) radiation / temporal (lower) radiation → occipital visual cortex

63
Q

lesion of optic nerve

A

ipsilateral monocular visual loss

64
Q

lesion of optic chiasm

A

bitemporal hemianopia

pituitary tumour, craniopharyngioma

65
Q

lesion of optic tract

A

contralateral homonymous hemianopia

66
Q

lesion of parietal optic radiation

A

contralateral inferior homonymous quadrantopia

67
Q

lesion of temporal optic radiation

A

contralateral superior homonymous quadrantopia

68
Q

lesion of occipital visual cortex

A

macula sparing contralateral homonymous hemianopia

69
Q

internuclear ophthalmoplegia: definition, features, differentials

A

lesion of medial longitudinal fasciculus (connects CNIII, IV, VI)
ipsilateral failure of adduction
contralateral horizontal nystagmus on abduction
MS, vascular disease

70
Q

causes of dysarthria

A 
motor speech impairment 
UMN (pseudobulbar): stroke, MS, MND
LMN (bulbar): myasthenia gravis, GBS, MND
cerebellar 
basal ganglia: Parkinson's (hypokinetic)
71
Q

receptive aphasia: definition, cause

A

lesion affecting Wernicke’s area (temporal)
fluent meaningless speech w neologisms, word substitutions
impaired comprehension

72
Q

expressive aphasia: definition, cause

A

lesion affecting Broca’s area (frontal)

incomprehensible speech, comprehension intact

73
Q

conductive aphasia: definition, cause

A

lesion affecting arcuate fasciculus (connect’s Broca’s + Wernicke’s areas)
comprehension intact, speech fluent, cannot repeat words / phrases

74
Q

global aphasia: definition, cause

A

affects Broca’s, Wernicke’s + arcuate fasciculus

severe expressive + receptive aphasia

75
Q

features Friedrich’s ataxia

A 
autosomal recessive
bilat cerebellar ataxia
mixed UMN + LMN signs (LL > UL) 
areflexia, wasting, spastic weakness
loss of vibration sense, proprioception, light touch (dorsal columns) 
kyphoscoliosis
pes cavus
high-arched palate 
assoc w HOCM, diabetes,
76
Q

features Charcot-Marie-Tooth

A

hereditary peripheral neuropathy (CMT1+2 autosomal dominant)
pes cavus, foot drop, hammer toes
stork-leg deformity / inverted champagne bottle leg (distal muscle wasting)
distal muscle weakness + atrophy
hyporeflexia

77
Q

causes of bilateral UMN lesion

A

MS
spinal cord lesion
MND
cerebral palsy

78
Q

causes of unilateral UMN lesion

A

stroke
SOL
MS

79
Q

causes of bilateral LMN lesion

A

symmetrical + distal = peripheral neuropathy: diabetes, alcohol, GBS, CMT

symmetrical + proximal = myopathy: myotonic dystrophy, myasethenia gravis, dermatomyositis / polymyositis

asymmetrical: mononeuritis multiplex (SLE, RA, vasculitis)

80
Q

causes of unilateral LMN lesion

A

anterior horn: polio
radiculopathy: disc herniation, OA
peripheral nerve lesion e.g. carpal tunnel, common peroneal nerve lesion
plexus lesion e.g. Erb’s / Klumpke’s palsy

81
Q

causes of mixed UMN + LMN signs

A

MND
vit B12 deficiency
Friedreich’s ataxia
infection e.g. west nile, diptheria

82
Q

presentation syringomyelia

A

cape-like loss of temp, neuropathic pain, paraesthesia
spastic weakness UL > LL
wasting of small muscles of hand
bowel / bladder dysfunction
preservation of dorsal columns until late

83
Q

causes of hydrocephalus

A

50% idiopathic

communicating:
↓absorption: meningitis, post-haemorrhagic
↑production: choroid plexus tumour (rare)

non-communicating (obstruction): tumours, SAH, intraventricular haemorrhage, congenital (e.g. aqueduct stenosis)

84
Q

management hydrocephalus

A

ABCDE
referral to neurosurgery
acute: external ventricular drain
long-term: ventriculoperitoneal shunt

85
Q

glasgow coma scale

A

eyes (4): normal, to sound, to pain, none
motor (5): normal, localises to pain, flex from pain, abnormal flexion (decorticate), abnormal extension (decerebrate), none
verbal (6): normal, confused, inappropriate words, incomprehensible sounds, none

86
Q

management guillain barre syndrome

A 
supportive management
IVIg / plasmapheresis 
monitor FVC: intubation / ventilation 
analgesia
physiotherapy (prevent flexion contractures) 
thromboprophylaxis
87
Q

causes of peripheral neuropathy

A

motor: CMT, GBS, lead poisoning
sensory: diabetes, alcohol, B12 / thiamine deficiency, leprosy
autonomic: diabetes, alcohol, amyloidosis

88
Q

mononeuritis multiplex

definition + causes

A

isolated damage to at least 2 separate nerve areas

vasculitis, Sjogrens, RA, sarcoidosis, SLE

89
Q

presentation wernicke’s encephalopathy vs korsakoff’s

A

wernicke’s:
ataxia
mental stage changes (confusion, altered consciousness)
eye signs: ophthalmoplegia, nystagmus

korsakoffs': 
agnosia 
anterograde amnesia 
aphasia 
apraxia 
confabulation 
deficit in executive functions
90
Q

presentation of ulnar nerve palsy

A

claw hand: flexion of 4th + 5th fingers (passive extension only)
wasting of hypothenar eminence + dorsal interossei
loss of sensation / paraesthesia 1.5 medial fingers (dorsal + palmar)

91
Q

ulnar paradox

A

injury to ulnar nerve proximal to elbow → reduced clawing

92
Q

causes of ulnar nerve palsy

A

more common at elbow than wrist
compression in cubital tunnel / guyon canal
trauma: elbow dislocation, supracondylar fractures, self-harm at wrist
degenerative arthritis

93
Q

what muscles does the median nerve innervate in the hand

A 
LOAF:
lateral 2 lumbricals
opponens pollicis
abducens pollicis
flexor pollicis brevis
94
Q

lacunar infarct definition + Bamford classification criteria

A

involves perforating arteries (branches of MCA)
1 of the following:
1. unilateral weakness (+- sensory deficit) of arm + face, arm + leg or all 3
2. pure sensory stroke
3. ataxic hemiparesis

95
Q

posterior circulation infarct definition + Bamford classification criteria

A 
involves vertebrobasilar arteries
1 of the following: 
1. cerebellar / brainstem syn
2. loss of consciousness
3. isolated homonymous hemianopia
96
Q

lateral medullary syndrome presentation + affects which arteries?

A 
posterior inferior cerebellar artery / vertebral artery infarct (AKA Wallenberg syn) 
ipsilateral facial numbness
contralateral limb sensory loss 
nystagmus + ataxia 
Horner's syndrome
97
Q

anterior vs middle cerebral artery infarcts

A

anterior: leg > arm, personality changes, loss of judgement / social behaviour
middle: arm > leg, aphasia (wernicke’s / broca’s)

98
Q

types of seizures

A

generalised (both hemispheres, loss of consciousness):
tonic / clonic / tonic-clonic / myoclonic / atonic / absence
partial / focal: simplex / complex (impaired consciouness)

99
Q

management status epilepticus (incl doses)

A

ABCDE (incl. oxygen)

  1. buccal midazolam (10mg) / IV lorazepam (2-4mg)
  2. IV lorazepam (repeat)
  3. IV phenytoin
  4. rapid induction of GA (at 30min)
100
Q

management epilepsy

A

cons: MDT, driving advice, medical bracelets
med: refer to neurologist for anti-epileptics
carbamazepine → focal seizures
sodium valproate → generalised seizures
lamotrigine if child-bearing age
surg: lobectomy / hemispherotomy (disconnection of hemispheres) - uncommon

101
Q

meningitis CSF findings

A

bacterial: turbid, neuts, ↓↓glucose, ↑↑protein
viral: clear / cloudy, lymphocytes, normal glucose, ↑protein
TB / fungal: clear / cloudy, lymphocytes, ↓glucose, ↑protein

102
Q

meningitis management (incl doses)

A

ABCDE
empirical IV ceftriaxone (2-4g) + IV dexamethasone (10mg)

if in community IM / IV benpen

103
Q

causes of meningitis

A

viral (most common): enterovirus, influenza, HSV

bacterial: neisseria meningitides, strep pneumo
fungal: crytococcus

104
Q

contraindications to lumbar puncture

A

raised ICP (coning)
sepsis
coagulopathy
cutaneous lesion: superficial infection, spina bifida

105
Q

investigations meningitis

A

bedside: lumbar puncture
bloods: FBC, CRP, U&Es, culture, glucose, clotting, meningococcal PCR, ABG
imaging: CT head (check for raised ICP)

106
Q

causes of encephalitis

A

viral: HSV (most common), arbovirus
bacterial: neisseria meningitides, syphilis, listeria
TB
parasitic
prion disease

107
Q

encephalitis diagnostic criteria

A

major: altered mental status > 24hrs w no other cause
minor: > 2 for possible / > 3 to confirm
fever, seizures, new focal neurology, CSF ↑WBC, abnormality on imaging / EEG

108
Q

management of raised ICP

A

ABCDE
head elevation 40degrees to aid CSF outflow
manage seizures
analgesia + sedatives
IV mannitol / hypertonic saline via central line (risk of rebound ↑ICP)
neurosurgery: surgical evacuation, ventricular drainage, burr hole / craniotomy to decompress

109
Q

axillary nerve injury
nerve roots
causes
motor + sensory deficits

A

C5-C6
shoulder dislocation
surgical neck of humerus fracture
iatrogenic (rotator cuff repair)

deltoid wasting + paralysis: reduced abduction
teres minor paralysis: reduced external rotation

loss of regimental patch (lower 1/2 of deltoid)

110
Q

presentation of Erb’s palsy

A

waiter’s tip: internally rotated shoulder, pronated forearm, flexed wrist
sensory loss over C5/C6
loss of biceps reflex / moro reflex

111
Q

causes of Erb’s palsy

A

over-flexion of the neck:
fall onto neck
traumatic vaginal delivery

112
Q

presentation of Klumpke’s palsy

A

claw hand
(wrist extension, MCP hypertension, DIP + PIP flexion)
supinated forearm
C8, T1 sensory loss (pinky finger + medial forearm)

113
Q

causes of Klumpke’s palsy

A

over-abduction of shoulder:
falling with arm gripping overhead
traumatic vaginal delivery

114
Q

complications of SAH

A 
rebleeding (30%)
vasospasm → ischaemia 
hydrocephalus
SIADH 
seizures
115
Q

presentation / associations myaesthenia gravis vs LEMS

A 
MG: muscle weakness w use
eye Sx: ptosis, diplopia, complex ophthalmoplegia
bulbar Sx: dysphagia, dysarthria 
resp involvement 
assoc w thymoma

LEMS: muscle weakness improves w use
autonomic Sx: dry mouth, constipation, hypotension, blurred vision
assoc w small cell lung carcinoma

NAM: med / surg / specialties (18 decks)

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