neuro Flashcards
1
Q
cauda equina big 3 presentation
acronym
causes
A
saddle paraesthesia
bilateral shooting pain down legs
bowel disturbance
Presentation = SPINE
Saddle anaesthesia
Pain / paralysis
Incontinence of bladder/ bowel
Numbness
Emergency
Compressive
- Tumours
- discs
Non compressive
- Inflammatory
- Infilitrive
- Granulomatosis
Vascular
- Spinal dural fistula
2
Q
C5 reflex
A
bicep (5 letters)
3
Q
c6 reflex
A
tricep (6 letters)
4
Q
c5 / c6 dermatome
A
c5 - thumb
5
Q
c5 myotome
A
elbow flex (think bicep - 5 letters)
6
Q
c6 myotome
A
elbow extension (think tricep - 6 letters)
7
Q
L5 dermatome
A
top of foot, big toe
8
Q
C6 dermatome
A
c6- middle finger
9
Q
L5 myotome
A
dorsiflexion (pathology = foot drop)
10
Q
S1 dermatome
A
bottom of foot, little foot
11
Q
S1 myotome
A
plantarflexion
12
Q
S1 reflex
A
ankle jerk
13
Q
is dissection of an artery ischaemic or haemorrhgaic stroke?
A
ischaemic
14
Q
risk factors of dissection –> stroke
A
younger patients
cyclists
hyperextending neck - painting roof, hair salon
15
Q
long-term BP aim after ischaemic stroke
A
130/80
16
Q
long-term lipids reduction (%) after ischaemic stroke
A
40%
17
Q
endartectomy indication
A
Tightening of over 50% (or90% stenosis?) of carotid artery seen in USS
within 6h of symptoms onset
18
Q
how long after stroke must thrombectomy be completed in
A
6h
can be alongside thombolysis
19
Q
thrombectomy vs endartectomy
A
endartectomy = surgery to open up vessel and remove clot and stitch back up
thrombectomy = catheter inserted up wrist/groin then clot sucked/ aspirated/ stented
20
Q
CAA (cerebral amyloid angiopathy)
A
Amyloid beta peptide is deposited in small-medium vessels - makes them fragile
21
Q
long-term BP aim after haemorrhagic stroke
A
140/90
22
Q
stroke medication
A
aspirin short term
then clopidogrel
consider dual therapy if high risk of stroke (but balance against risk of bleed)
23
Q
stroke medication if on AF
A
warfarin
24
Q
stroke investigations
A
Bloods
- Urea
- Sodium
- CRP/ESR
- LFTs
- WCC
- Lipid profile
- Clotting
ECG
- Looking for AF
USS carotid
Brain imaging - CT/MRI
- Within 1h
Consider echocardiogram
- For ischaemic
24 vs 72h tape
- Heart rhythm if normal ECG - looking for paroxysmal AF
25
what is small vessel disease SVD
Small vessels in brain narrowed and don't dilate properly
26
pattern of weakness neuropathy
distal>proximal
(mainly hands and feet affected)
27
pattern of weakness myelopathy
below level of lesion
28
pattern of weakness myopathy
proximal >distal
(proximal limbs affected , called limb-girdle position)
29
pattern of weakness NMJ disorder
fluctuating muscle fatigue
30
deep tendon reflexes neuropathy
severe reduction
early loss
31
deep tendon reflexes myopathy
mild reduction
late loss
32
deep tendon reflexes myelopathy
increased
33
deep tendon reflexes NMJ disorder
normal of mildly reduced
34
posterior stroke symptoms
Dysarthria
Dysphagia
Diplopia
Dizziness
Ataxia
Diplegia - both sides affectedq
35
total(/ partial) anterior circulation ischaemic stroke
ACA + MCA infarction
all of
- homononymous hemianopia
- unilateral weakness and or sensory loss of face/arm/leg
- higher cerebral dysfunction (dysphasia, visuospatial disorder)
partial is 2 of these
36
lacunar syndrome
Pure motor hemiparesis
Ataxic hemiparesis
‘Clumsy hand’ and dysarthria
Pure hemisensory
Mixed sensorimotor
No cortical features (dysphasia, apraxia, neglect, visual field loss)
lacunar strokes - Small deep penetrating arteries that supply midbrain
37
contralateral tongue bite indicates what (until proven otherwise)
epilepsy
38
antidepressants and blackouts?
lower seizure threshold
39
automatisms associated with what lobe seizure
temporal
40
single limb twitching
associated with contralateral tumour
41
what is typical of myoclonic jerks
what type of epilepsy is it
Morning
Worse with sleep deprivation/ go out / alcohol night before
Teenagers and young people
Form of generalised epilepsy
Consciousness maintained
Drop cereal
42
how long after no seizure event til drive
1y
43
dissociative seizure tx
investigations
driving
not with drugs! psychiatry (associated with trauma)
normal EEG (different to epilepsy)
3months without event
44
feel whole body shaking =
dissociative (aware still)
45
temporal lobe vs parietal lobe
which lobe is insight ?
PARIETAL
Spatial awareness
Judging distances and shapes
Drawing
Body and environment awareness
Sensory function (but not pain)
Angular gyrus - calculation, reading, writing, R-L orientation
TEMPORAL
Medial
- Limbic memory circuit
- Emotional circuits
Lateral
- Word and picture meaning store - lexicon
- understanding speech
insight - frontal
46
proximal myopathy
- symptoms/ description
- test
- cause
myopathy - proximal weakness worse
Slower walking, Struggling to walk up and down hill, needs regular rest
Having to leave earlier
Stairs are awkward so affect lectures and home life
Withdrawn socially as a result - embarrassed, not going out, people have made comments
Ask them to do a sort of one leg squat/ crouch - body weight on proximal leg muscles - lose balance/ won't try
Cause:
- High dose Corticosteroids
- Chemotherapy, radical radiotherapy
- Transplant patients
- Autoimmune disease
- Respiratory disease - emphysema, chronic bronchitis
47
why is myasthenic syndrome associated with partial ptosis (as the day goes on)
Smooth muscle 50% has no NMJ - so doesn't fatigue (so not total)
Skeletal muscle 50% does fatigue
Doesn’t affect eyesight
as day goes on due to the fatiguability
48
myasthenic syndrome eg's of symptoms and test
Struggles to keep up / attention throughout lecture, playing guitar, typing on keyboard. Needs rest at regular intervals walking, even on flat
Ask them to do something related to the story - eg write out a sentence (you're the control) or walk a distance or do a repeated movement.
49
myasthenic syndrome causes
myasthenic gravis, lambert-eaton syndrome
50
peripheral neuropathy
- most common cause
- signs or symptoms first
- large fibre
- small fibre
- examination
- tx
- DM
- signs (picked up in diabetic screening tests)
- Large
---Lost vibration sense, pain pin prick fine
---Pick up late
-Small
---Symptoms early
--- Burning pain at feet at night
--- Numb feet
--- Reduction in pin prick
(so examine with vibration and pin prick!)
- pain relief, treat underlying cause (DM, B12 def), prednisolone if inflammatory/vasculitic
51
gloves and stocking vs peripheral neuropathy in terms of symptoms
gloves and stocking is sensation loss to above knee (gloves and tights!) otherwise just peripheral neuropathy
52
carpal tunnel
- what nerve
- symptoms/signs
- treatment
- median nerve, wrist (mononeuropathy)
Worst in morning (fetal position at night)
Not sudden onset
Radiates up arm
Shaking out helps
numbness/ tingling in thumb, index
Struggling open jars, pincer grip
Median supplied thumb and that side of the hand front and back, but often the tingling isn’t localised clearly so may feel like whole land
often no signs
treatment
- Splint at night
- Surgery
53
ulnaropathy
axillary nerve mononeuropathy
lower limb
funny bone, elbow
Numbness over deltoid muscle
Weakness of shoulder abduction
So need to pin prick deltoid muscle before shoulder relocation
lower limb rare
54
spinal claudication syndrome symptoms
Lower limb radicular pain. Only comes on walking (not standing/sitting), maybe after X distance. Stops and starts with rest and continuing
+/- pins/needles/heaviness
Pain all down leg (not just calf with other claudication)
55
vertebral pain syndrome symptoms
pain (acheing, non-radiating)
restricted movement
spasm
56
myelopathy syndrome
- symptoms
- signs
- cause
Neck pain, lower back pain, NOT legs
Stiffer walking
Bilateral mainly
Clumsy hands, buttons hard, velcro shoes
Less precise, stiff / thick socks
“Legs don't do what i tell them to do”
Signs before symptoms
Babinksi
Hyperreflexia
Clonus
Hoffman
-- Upper limb babinski
-- Flick middle finger up
-- Thumb flicks in
Cross adductors reflexes
-- Feel for medial knee- adductor tendon (proud when knee adducted)
-- Tap on it while leg hung relaxed
-- Same leg goes in = normal. If both leg goes in = cross adductor reflexes
Pectoralis reflex
-- Arm reflexes from tapping anywhere on pectoralis
Treacle hands
Disc osteophyte core compression
57
cerebellar syndrome
Ataxia
Nystagmus
Ipsilateral
“Feel drunk”
58
anterior horn cell disorders
- eg cause
- symptoms
MND
Descending motor system
No radiating pain
No dermatomal sensory loss
Wasted muscle
Second nerve root affected in relatively short time period
59
parasellar syndrome symptoms
bitemporal hemianopia
hypopituitarism
60
glasgow coma scale
- go through each and how many points
- total points out of
BEOR (best eye opening response)
Spontaneously 4
to speech 3
to pain 2
None 1
BVR ( best verbal response)
orientated in time/place/person 5
Confused 4
inappropriate words 3
incomprehensible sounds 2
None 1
BMR (best motor response)
obeys commands 6
localises to pain 5
Withdraws from pain 4
flexes to pain 3
extends to pain (goes away from the pain stimulus) 2
None 1
15 max
61
mobility grades 1-7
Grade 1 - no problem
2
3 - limited by distance
4 - cant walk independently but can walk with aid
Subsections
5 - cant walk independently with aid but can walk with a person assisting
5a - one person aiding
5b - two people aiding
6- cant walk but can transfer
7 - bed bound, can't transfer, hoisted
62
CT vs MRI
- acute brain
- acute spine
Urgent/ acute brain = CT
- CT accessible 24/day, able to acquire within minutes
MRI - longer waiting time, need to complete checklist about metal so quicker. All kit eg ecg wires, tubes need to be MRI compatible - so this is faff
- Haemorrhage is easy to spot on CT - clear, white. Less so on MRI
urgent/ acute spine = MRI
- MRI gives good visualisation of spinal cord and nerve roots
- CT only good for trauma / fracture
63
CT
- units
- 1000 =
-100 =
0 =
+ 7 =
+25 =
+35 =
+70 =
+1000 =
Hounsfield
-1000 = air (black)
-100 = fat
0 = water (none in brain)
+7 = CSF
+25 = white matter
+35 = grey batter
+ 70 = blood
+1000 = bone (white)
64
what to look at on brain scan
Is there a mass
- Symmetry
- Is it intra axial or extra axial / intraparenchymal or extraparenchymal (inside or outside brain).
- If outside brain - subdural or extradural
Is there blood
- White
Is there hydrocephalus
- 3rd ventricle is no longer a slit (as it should be) and temporal horns now visible
Bone windows
65
causes of coma
Common
- Drugs
- Anoxia (post arrest)
- Mass lesions - Head injury, bleeds, SAH
- Infections (HSV can cause epilepsy)
- Infarctions- brainstem
- Epilepsy
- Metabolic (DKA, hypoG, hepatic encephalopathy, Uraemia )
Uncommon
- Tumours
- Venous occlusion
- Hypothermia
- Psychiatric - catatonic
66
Sudden onset headache with third cranial nerve palsy OR painful 3rd CN palsy = ??? until proven otherwise
SAH
eye down out and dilated
67
lumbar puncture
- when following headache
- when in regards to CT
- 12 h post for xanthochromia to form
- after CT to exclude raised ICP due to space occupying lesion- otherwise risk brainstem herniation
68
status epilepticus
- duration
- tx
Length
5min + generalised tonic clonic
10 min + focal
10-15 absence
(in practice, 30+ in definition)
consider non-epileptic seizure/ functional as these are longer than epileptic seizures
1) IV lorazepam / diazepam / clonazepam
2) Phenytoin (cardiac monitoring needed) / sodium valproate / levetiracetam
69
thunderclap headache
- differential
- signs that it is serious
SAH, migraine
suggestive of SAH if:
- positive kernig sign (meningism) - laid on back then hip flexed with knee at 90 deg
- seizure
- altered conciousness
- not had anything similar before
- old age
- strenuous exercise/ trauma at time of onset
- back of head (but migrane may be here too)
- no migranous aura
- PMH- coarctation of aorta, polycystic kidneys
70
SAH
- examintation findings
- investigations
- causes
Meningism
Neurological deficits
- Rarely: hemiplegic migraine
- More commonly: proprioception/ pronator drift -- can appear like weakness but actually power on examination is normal
Retinal haemorrhages / papilloedema
CT (See bleed and whether safe to LP)
LP (12 h after - xanthochromia)
vascular imaging - angiograms
- Looking for
--- Arterial filling, narrowing
--- Bulging = aneurysm
--- Where dye passes too quickly through into veins = AV malformation
Ruptured berry aneurysm
AV malformation
71
central spinal lesions effect where first and why
what are some central spinal lesions
Cervical fibres (arm) are medial Fibres to leg more lateral
So central spinal disorder will cause issue to arm before leg
(gracile (Arm) cunneate (leg ) medial and lateral in dorsal column and also in spinothalamic and pyramidal (motor) tracts))
Tumour - intrinsic
Syringomyelia
Whiplash
72
traumatic spinal cord disorder
- cause
- next step
whiplash, gunshot, stab, haematoma
MRI spine
73
degenerative disc disease in spinal cord disorder
- cause
- next step
cervical and lumbar spondylosis, spinal canal stenosis
MRI/ CT spine
74
inflammatory spinal cord disorder
- cause
- next step
MS, Transverse myelitis, NMO
Lumbar puncture, MRI spine, and brain with contrast
75
neoplastic spinal cord disorder
- cause
- next step
MRI with contrast
intrinsic spinal cord tumours
- ependymoma
Extrinsic spinal cord tumours
- meningioma, metastatic, lymphoma
76
infective spinal cord disorder
- cause
- next step
HIV, HTLV, abscess, empyema
MRI, ESR, BBV, FBC
77
vascular spinal cord disorder
- cause
- next step
anterior spinal cord artery occlusion, spinal dural fistula, vasculitis
AAA repair → accidentally clamp artery → spinal cord ischaemia
Owls eyes occlusions on axial imaging
MRI, Angiography, vasculitis screen
78
metabolic spinal cord disorder
- cause
- next step
Vit B12 deficiency → degeneration
B12 Folate MMA and fasting homocysteine levels (raised indicates B12 def at cellular level)
79
Granulomatous spinal cord disorder- cause
- next step
Sarcoidosis
serum ACE level, MRI, CXR
80
hereditary spinal cord disorder
- cause
- next step
Hereditary spastic paraplegia, Fredrich's ataxia
Genetic panel
81
what presentations are spinal cord emergencies and what needs to be done and why
Acute/Subacute onset
- Bladder- bowel weakness
- Saddle anaesthesia
- Leg weakness
- Constant Sensory deficit
- Significant pain (back)
Acute MRI
- Need to rule our cord compression
82
thrombolysis
- what
- how long post stroke
- indications
- contraindications
4.5h but earlier the better
IV alteplase
infarct , embolic
if any bleeding anywhere
Recent LP
Acute pancreatitis
Aneurysm
Pregnant
Low platelets
83
blue lips and blackout
indicates epilepsy due to not in syncope due to short blackout duration
84
unilateral vision loss differential diagnosis
1 Optic neuritis (Acute)
2 MS (acute)
3 Retinal disease (Acute)
- Retinal detachment
- Blurry vision
- Loss of visions from side / edges - curtain across - complete / greying
- Needs repairing - scleral buckle surgery/ virectomy
4 Trauma (acute)
- Outside of eye
- Retina /Optic nerve
5 Glaucoma (acute)
- Drainage of aqueous humour suddenly occluded - rapid rise in intraocular pressure
- vomitting, pain, red eye
6 Retinal artery occlusion (acute)
- Cotton wool spots
7 Anterior ischaemic neuropathy
- corticosteroid asap
- maybe + jaw claudication, scalp tenderness, facial pain
8 Vitreous hemorrhage
- Haemorrhage into vitreous humour - reduces light reaching retina
- See spots - floaters
- blurred vision
- Red tinge to vision
9 cataracts (chronic)
10 Neurosarcoidosis - (Sarcoidosis with chest and neural elements)
- Pain behind eye
- Colours seem less bright
- Difficulty reading
- associated with bells palsy (LMN)
- Investigate with Chest X Ray and serum ACE enzyme
probs more :(
85
optic neuritis
- causes
Clinically isolated syndrome, idiopathic
MS
B12 deficiency
Infection - Lymes, syphilis , HIV
86
optic neuritis
- symptoms
- signs
Pain in eye
Eye movement pain
Loss of vision
- Central vision blurred
- Reduced colour
RAPD (relative afferent pupil defect) = slower response when light is shone on affected side
RAPD on swinging light test - on affected side - BOTH pupils are dilated not constricted when light shone on
Dyschromatopsia - colour blind
87
optic neuritis
- treatment
MS-associated
- Spontaneously improves over 2-3 months (Steroids speeds it up)
- No differences in acuity long term
Not MS-associated
- IV corticosteroids, oral corticosteroids
88
MS presentation symptoms - areas
Sites of periventricular demyelination / sclerosis:
Optic nerves (optic neuritis)
- Pain in eye / on movement
- Vision loss
- Central vision blurred
- Reduced colour
Corpus callosum
Brainstem
- Diplopia
- Vertigo
- Facial numbness/weakness
- Dysarthria
- Dysphasia
- Nystagmus
- Brainstem or spinal tract plaque
- Clumsy / poor proprioception - ataxia
Spinal cord
- Weakness (motor)
- Often leg
- Spasticity (continual contraction) → stiffness/tightness
- Movement / function impaired eg speech slurred, gait
- Intention tremor
- numbness/ tingling (Sensory) / pain - Often limb
- Bladder dysfunction
- Sexual dysfunction
- Lhermitte’s sign (tingling down neck, spine)
uhtoffs - worse with heat
also worse with exercise
89
MS types
Benign
- Few relapses
- Little disability
Relapsing and remitting
- Most common
- Onset = days (sudden). Recovery (partial/fully) = weeks
Secondary progressive MS
- Follows on from relapsing and remitting, normally after 35 years - late stage MS
- Gradually worsening symptoms with fewer remissions
Primary progressive MS
- Gradually worsening disability without relapses or remission
- Typically presents later
- Associated with fewer inflammatory changes on MRI
90
MS diagnosis vs clinically isolated symptoms
MS requires 2 or more attacks of the CNS (seen on MRI)
91
MS pathophysiology
Autoimmune: T cell mediated
- T cells stimulate B cells to produce antibody to myelin
So multiple sites of CNS (not PNS ever) are demyelinated in white matter (axons)
Myelin can regenerate but less effectively (thinner and shorter myelin sheaths) and is very sensitive to high heat (Uhtoff’s)
- Sclerosis → slowed, blocked conduction → impaired movement and function
Healing periods = remission periods
Demyelination mostly at periventricular sites
- Optic nerves (optic neuritis)
- Corpus callosum
- Brainstem
- Spinal cord
92
GCS drop causes
Head injury
Hypoglycaemia
Stroke
Epilepsy
Overdose
93
ACA/MCA/PCA stroke presentations
ACA
- Lower limb
- Gait
- Incontinence
- Drowsiness
MCA
- Face droop
- Upper limb - weakness, numbness
- Hemianopia
- Expressive / receptive dysphasia (brocas, wernickes) -L
PCA
- Headache (rare in ischaemic stroke)
- Visual issues - peripheral vision, face recognition, colour naming, can’t interpret what they can see, cortical blindness
94
what must be done prior to thrombolysis
Blood sugars first (quick bedside test not lab bloods) - need to exclude hypoglycaemia
Esp if prev hypoglycemia, can look like deficit, neuro decline
