Neuro Flashcards
Signs of MCA stroke
CL facial weakness (forehead sparing) Hemiparesis Hemisensory loss Hemineglect Receptive/expressive dysphasia Quadrantanopia /homonymous hemianopia
Signs of ACA stroke
Motor cortex:
contralateral Lower limb weakness (hemiparesis/hemiplegia)
Pelvic floor weakness
Sensory cortex:
Contralateral leg/pernieum loss
Urinary incontinence
Frontal lobe: Disinhibition syndrome
Olfactory: Anosmia
Signs of PCA stroke
Occipital lobe:
cerebellar syndrome
brainstem
CL homonymous hemianopia +macular sparing.
Posterior inferior cerebellar artery infarct: Lateral medullary syndrome:
- Vertigo
-Ipsilateral ataxia, Horners, hemifacial sensory loss
-dysarthria/hoarsness
dysphagia
nystagmus
-CL pain/temp sensory loss.
Investigations of Stroke
ECG -arrythmias
Echo - Thrombi, endocarditis, shunts
Bloods: FBC - U+Es: renal impairment Lipids glucose ESR
Carotid Doppler +/- angio
CTH - detect haemorrhage
>6h.
MRI brain. - more sensitive.
Management Ischaemic stroke
ABCDE
NBM until SALT
Monitor Glucose
BP <185/110
neuro Obs.
<4.5h from onset.
CT Head rule out bleed.
MEDICAL: IV thrombolysis (alteplase /r-tpa)
hold aspirin for 24h.
thrombectomy if occlusion of proximal anterior circulation.
>4.5h from onset. CT head exclude ICH Aspirin 300mg, clop 75mg. Heparin if high risk of emboli recurrence/stroke progression. (metallic valves) SALT r/v->?NG tube. Thromboprophylaxis.
SURGICAL: if mass effect - <48h. HEMICRANIECTOMY
Stroke unit:
Specialist nursing, physio
Early mobilisation
DVT prophylaxis.
secondary prevention
rehab.
Primary prevention of stroke
Control HTN Lipids DM Smoking cardiac disease Lifelong anticoagulation if AF carotid endartectomy if symptomatic 70% stenosis. exercise
Secondary prevention of stroke
RF control
-start statin after 48h
Aspirin/clopi 300mg 2weeks after a stroke,
then 75mg clopi,
DOAC if cardioembolic/AF.
Rehab: MENDS
MDT - physio, salt, dietician, ot, spns, neurologist, family.
Eating - screen swallowing -?NG/PEG with specialist,
screen malnutrition (MUST)
Neuro rehab - physio, speech therapy, botulinum if spasticity.
DVT prophylaxis.
Sores.
OT
- impairment
disability
handicap
Lacunar stroke
Small infarcts around basal ganglia, internal capsule
thalamus, pons.
Pure motor: internal capsule.
CL Hemiparesis/hemiplegia face/arm/leg.
Dysarthria/dysphagia
Pure sensory: thalamus
CL numbness.
Dysarthria/clumsy hand pons.
Ataxic hemiparesis internal capsule.
-weakness/clumsiness ipsilateral side. LEg >arm
Mixed sensorimotor(internal capsule) -hemiparesis/plegia+ sensory impairment
Causes of stroke
Ischaemia (80%) - atheroma (large e.g.MCA/small - lacunar), embolism (cardiac - AF, Endocarditis, MI, cardioversion, prosthetic valves)
Atherothromboembolism - carotids.
Haemorrhage - BP, Trauma, aneurysm, anticoagulation, thrombolysis
Sepsis- watershed stroke carotid dissection vasculitis cerebral vasospasm - SAH Venous sinus thrombosis APS, thrombophilia
Risk factors for stroke
HTN Smoking DM lipids fh PVD Prev hx black, asian PCV OCP
Millard gubler syndrome
Pontine infarct 6th/7th CN nuclei + corticospinal tracts - DIPLOPIA -LMN facial palsy/loss of corneal reflex. -CL hemiplegia.
Locked in syndrome
Ventral pons infartion - Basilar artery.
Central pontine myelinolysis - rapid correction of Hyponatremia
Aware and cognitively intact -> completely paralysed other than eye muscles.
Differentials of stroke
Head injury +/- haemorrhage Hyper/Hypoglycaemia SOL Hemiplegic migraine Todds palsy (post ictal) Infections (encephalitis, abscess, toxo, HIV, HTLV) Drugs (opiates)
TIA definition
Sudden onset focal neurology lasting <24h due to temporary occlusion of part of cerebral circulation.
Stroke definition
rapid onset, focal neurological deficit due to a vascular lesion lasting >24h
Signs TIA causes
Carotid bruits
BP raised
heart murmur
Af
Causes of TIA
Atherothromboembolism from carotids
cardioembolism - AF, post MI, valve.
Hyperviscosity - PCV, SCD, myeloma.
Differential of TIA
Vascular - CVA, migraine, GCA
Epilepsy
hyperventilation
Hypoglycaemia
Ix TIA
Aim to find cause and define vascular risk: Bloods: FBC, U+E, ESR, GLucose, Lipid CXR, ECG Echo Carotid doppler +/- angio Consider MRI/CT
MX TIA
speed of intervention prevents strokes.
avoid driving 1mo.
- Antiplatelet/anticoagulate
- Aspirin/Clopi 300mg for 2w then 75mg. Add Dipyridamole to aspirin.
Warfarin/rivaroxaban if cardiac emboli - Cardiac RF control
- BP, LIPIDS, DM, smoking.
exercise
- diet, salt,
3. Assess risk with ABCD2 score Age >60 BP>140/90 Unilateral weakness 2 Speech disturbance wo weakness 1 other sx 0 Duration of symptoms >1h 2 10m-1h 1 <10m 0 Hx DM 1
> /= 4 -> TIA clinic in 24h
< 4 -> in 1 week.
Carotid endartectomy
if >70% stenosis + symptoms.
within 2 weeks.
SDH Definition.
Bleeding from bridging veins between cortex and sinuses. Haematoma between dura and arachnoid. Minor trauma. deceleration injuries.
SDH RFs
Elderly (brain atrophy)
Falls (epileptics, alcoholics)
Anticoagulation
SDH symptoms
Headache Fluctuating GCS Sleepiness Gradual physical/mental slowing Unsteadiness
SDH Signs
Raised ICP (can -> tentorial herniation) Localising signs late
Imaging (CT/MRI) SDH
Crescentic haematoma one hemisphere
Clot goes white -> grey with time
Mid line shift
Mx SDH
- Irrigation/Evacuation via burr hole craniostomy
2.Craniotomy
Address causes of trauma
if old, supportive
-Monitor GCS
Rescan if deteriroation
only consider surgery if neuro dysfunction
Extradural haemorrhage
Temporal/parietal bone fracture -> laceration of middle meningeal artery/vein.
Blood between bone and dura
Suspect if after head injury, GCS falls, is slow to improve/ lucid interval.
Presentation of EDH
Deterioaration of GCS after injury that caused LOC,
initial improvement of GCS
Lucid interval hs/days
Raised ICP
- HEadache
- vomiting
- confusion –> coma
- Fits
- ipsilateral 3rd nerve palsy (Blown pupil)
- hemiparesis with upgoing plantars and increaed reflexes
Brainstem compression
-Deep irregualr breathing
Cushing response (raised bpm decreased HR) late
death by cardiorespiratory arrest.
Ix EDH
CT - lens shaped haematoma
skull fracture.
Mx EDH
Neuroprotective ventilation (o2>100m co2 35-40)
IV mannitol - central line 1g/kg.
craniectomy for clot evacuation and vessel ligation
Haemorrhagic stroke mx
IV mannitol
sit up - encourage hyperventilate
Surgical -> coiling (aneurysms), craniotomy, ventricular drainage.
Dural venous sinus thrombosis causes
pregnancy ocp head injury dehydration cancer thrombophilia
DUral venous sinus thrombosis ix
CT MR venography
LP -> increased pressure, RBCs, xanthochromia
Dural venus sinus thrombosis mx
LMWH-> warfarin
Fibrinolytics - streptokinase
thrombophilia screen
Meningitis Ix
Start Abx immediatly
Isolate in sideroom
Bloods
FBC, U+E, CRP, LFt, meningococcal PCR, clotting, glucose, blood cultures,
throat swab
Viral meningitis - neutrophilia -> lymphocytosis
Bac - neutrophila
CT head (if focal neurology, seizures, papilloedema, LOC)
LP - MCS, glucose, virology/pcr, lactate.
LP results
Bacterial = Raised opening pressure, TUrbid appearance, LOW glucose, High protein, high neutrophils.
Viral: Normal opening pressure, CLear, normal glucose, Raised protein.normal, raised WCC, lymphocytes.
TB: raised opening pressure, fibrin web appearance, low glucoe, raised protein, Lymphocytes.
Fungal - basophils/eosinophils
meningitis Mx:
ABC 15L O2
IVI fluids
Abx - IV cefotaxime 2mg QDS, IV aciclovir 10mg/kg..
Dexamethasone 0.15mg/kg IV QDS - if raised proteins, WCC on CSF
Replace electrolytes.
Anticonvulsants - IV lorazepam 4mg pRN.
Contraindications to LP
Thrombocytopenia Lateness Pressure (raised ICP) Unstable (CVS,resp) Coagulation disorder Infection at LP site Neurology - focal signs.
Causes of encephalitis
Viruses HSV1/2 CMV EBV VZV Arboviruses HIV
Non viral - bacterial meningitis
TB
malaria
Lyme disease
Ix encephalitis
Bloods: cultures, viral PCR, malaria film,
if neurology. do ct.
Contrast CT - focal bilateral temporal involvment - HSV
LP - Csf protein, lymphocytes, PCR
EEg- diffuse abnormalities
Mx encephalitis
Aciclovir 10mg/kg/8h IVI over 1h for 14 days.
supportive
phenytoin if siezures
Parkinsons Ix
Dopaminergic agent trial with LEVODOPA.
Serum caerloplasmin - decreased - WILSONS
24h urine cu - increased WILSONS
MRI /dat scan
Head injury initial assessment
Head injury
A?intubation, immobilise C spine
B100% o2, RR
C- IV access, BP, HR
D- GCS, pupils
Tx seizures Lorazepam 2-4mgivi Phenytoin 18mg/kg then 100mg 6-8h.
E -expose look for other obvious injuries.
2 -Lacerations -skull/facial deformity -csf from nose/ears -battles sign, racoon eyes -blood behind TM -c spine tenderness/deformity Head to toe examination Log roll
Hx - how and when
GCS and vitals immediately
Headache, fits, vomiting, amnesia. ETOH
Head injury Ix
Ix:Ecg, Bloods: FBC, U+E, glucose, clotting, EtOH, ABG , CT head + cspine if - Break (open/depressed/base of skull) Amnesia >30 mins retrograde - Neuro deficit/seizure GCS<13 @any time/<15 2h after inury Sickness LOC - or any amnesia + Dangerous mechanism/>65/coagulopathy.
head injury mx
Rx;
Neurosurgiery opinion if ICP, CT evidence bleed / significant skull #
Admit if - abnormal imaging, difficult to assess: EtoH/post ictal, not returned to GCS post imaging, CNS - vomiting, severe headache.
Reverse anticoagulation - PCC.
Neuro Obs every 30mins
Discharge advice
- stay for 48h
- give advice card - return on confusion, weakness, visual/hearing problems, v painful headache, vomiting, fits.
Status epilepticus mx
Airway
Breathing: 100% o2
C: HR, BP, CRT, bloods - glucose, FBC, U+E, LFT, CRP, blood cultures, calcium, procalcitonin, AED levels, tox screen, EtoH, GAS - lactate - glucose - if low start 100ml 20% glucose. THiamine if etoh.
IV access 2 large bore cannulae in ACFs -> start IV lorazepam 4mg 2mins
D- GCS, Pupils, Glucose
E - examine for injuries.
Start IV lorazepam 4mg over 2 mins/Diazepam IV /PR 10mg, Buccal midazolam 10mg
Repeat
Call senior help
Then Phenytoin 18mg/kg IVI - + cardiac monitor
Then call anaesthetist - propofol etc. Rapid induction sequence.
Cerebral abscess Pre disposing factors
Infection - ear, sinus, dental, periodontal SKull # Congenital heart disease Endocarditis Bronchiectasis Immunosuppression
Organisms causing cerebral abscess
Frontal sinus/teeth: strep milleri, Oropharyngeal: anaerobes.
Ear: bacteroides, other anaerobes.
Signs of cerebral anaerobes
Seizures Fever localising signs ICP infection elsewhere
Ix of cerebral abscess
CT/MRI - ring enhancing lesion
WCC/ESR
Mx Cerebral abscess
Neurosurgical referral
abx: ceftriaxone
treat raised ICP
Epilepsy definition
Recurrent tendency to spontaneous intermittent abnormal electrical activity in part of the brain, manifesting as seizures.
Causes of epilepsy
2/3 idiopathic
Congenital: NF Tuberous sclerosis TORCH Perinatal anoxia
Acquired:: Vascular (CVA) Cortical scarring - trauma, infection SOL SLE, PAN, MS, sarcoid
Non epileptic provoked seizures
Withdrawal: etoh, opiates, benzos
Metabolic: glucose, Na, Ca, Urea, Nh3
ICP: trauma, bleed, cortical venous thrombosis,
Infection: meningitis, encephalitis, cystercosis, HIV
Eclampsia
Pseudoseizures.
Simple partial seizures
Focal, motor, sensory, autonomic, psychic symptoms
Complex partial
Aura
Autonomic -skin colour, temp, palpitations
Awareness lost - motor arrest/motionless stare
Automatisms: Lip smacking, fumbling, chewing, swallowing
Amnesia
Usually from temporal lobe.
Absence seizures
Abrupt onset/offset
Short <10s
Eyes - gaze/blank stare
Normal -intelligence, examination, brain scan
Clonus/automatisms possible
EEG: 3Hz spike and wave
stimulated by hyperventiliation and phonics
Tonic clonic seizures
LOC Tonic - stiff limbs clonic -jerking Cyanosis -incontinence, tongue biting (lateral). Post ictal confusion/ drowsiness.
Myoclonic
sudden limb, face, trunk jerk.
West syndorme
Clusters of head nodding and arm jerks
EEG -hypsarrythmia
Investigations of Epilepsy
Bloods:: FBC, U+E, Procalcitonin, glucose
AED levels, urine toxicology
ECG
EEG- support dx.
MRI - if developed as adult, focal onset, continue despire 1st line tx.
Drug therapy for epilepsy
Tonic clonic: Valproate, Lamotrigine
Absences: Valproate, ethosuximide, lamotrigine.
Tonic/atonic/myoclonic: Valproate, Levetiracetam
Focal/2nd gen: Lamotrigine, CBZ
Women/pregnancy
Avoid valproate. take lamotrigine/cbz
5mg Folic acid daily
CBZ/Phenytoin inducers -> reduce OCP effectiveness.
Side effects of AEDs
Inducers: CBZ, phenytoin, barbs
Inhibitors: valproate
Lamotrigine: Skin rash/ SJS wi 8wks Rash -> fever, LFTs, DIC (hypersensitivity) Diplopia/blurred vision Levels affected by inducers/inhibitors. nystagmus, ataxia
Valproate: Appetite increase/wt gain Liver failure - monitor over first 6m Pancreatitis - reversible hair loss oedema ataxia teratogenicity, tremor, thrombocytopaenia encephalopathy - ammonia
Carbemazepine: Leukopenia skin reactions diplopia, blurred vision SIADH - hyponatremia ataxia
Phenytoin - gingival hypertrophy Hirsutism Cerebealler - ataxia, nystagmus, dysarthria Peripheral neuropathy Diplopia Tremor
idiopathic intracranial Hypertension
Obese Females
- ICP, headache, papillodema
- blurred vision, 6th nerve palsy, enlarged blind spot
Cause - idiopathic, venous sinus thrombosis, drugs.
Mx: Wt loss, acetazolamide, furosemide, predinsolone, Lumbar peritoneal shunt (if vision deterioates/drugs dont work.).
permanent vision loss 10%
Prognosis self limiting. usually.
Types of cerebral oedema
- Vasogenic (increased cap permeability) trauma, tumour, ischamia, infarction
- Cytogenic - hypoxia
- Interstitial - obstructive hydrocephalus, hyponatremia.
Causes of Raised ICP
Haemorrhage Tumours infection (meningitis, encephalitis, abscess) hydrocephalus status cerebral oedema
acute mx raised ICP
ABC Treat seizures/Hypertension Elevate bed to 40 deg Neuroprotective ventilation (pao2 > 130 , co2 <4.5 good sedation/NM blockade
Mannitol/hypertonic saline -> 1g/kg 20% at 5ml/kg.
Herniation syndromes
Tonsilar (coning)
- posterior fossa pressure -> cerebellar tonsils -> foramen Magnum
- Brainstem/medulla cardioresp centres compression
- CN6 palsy, upgoing plantars, irregular breathing - apnoea.
Transtentorial/uncal
- lateral supratentorial mass - compress ipsilateral inferomedial temporal lobe (uncus) against free margin of tentorium cerebellii
- IPsilateral CN3 palsy (mydriasis then down and out)
- Ipsilateral corticospinal tract -> CL hemiparesis
- compression -> cl CStracts-> ipsilateral hemiparesis .
Subfalcine
- frontal mass
- cingulate gyrus (medial frontal lobe) -> under falx cerebri
- compression of ACA -> stroke
- > CL motor/sensory loss legs >arms
- abulia
Causes of cord compression
Trauma Infection (epidural abscess Tb) cancer - breast, thyroid, lung, kidney, prostate Disc prolapse Haematoma Intrinsic cord tumour Myeloma AVM
Mx cord compression
- call neurosurgery
- Malignancy : dexamethasone IV
abscess - abx
Progressive supranuclear palsy features
Vertical gaze palsy symmetrical Parkinsonian features Pseudobulbar palsy - speech and swallowing problems. axial rigidity postural instability - falls. Tufted astrocytes Coiled bodies.
Parkinsons tx
Dopamine agonists (bromocriptine, ropinirole): - younger older: L DOpa + carbidopa. entacapone - peripheral COMT inhibitor
Tolcapone
Resegiline MAOBi
Multiple system atrophy
Shy drager syndrome Alpha synucleinopathy Rigidity > tremor Cerebellar ataxia Postural hypotension Papp Lantos bodies. (oligodendrocyte inclusions of a synuclei
Corticobulbar degeneration
Unilateral Parkinsonism prominent rigidity Aphasia Dysarthria Apraxia Alien limbs (cortical sernsory loss) astrocyte tau plaques balloons neruones.
Lewy body dementia
Early dementia
Visual hallucinations
Fluctuating cognition
Parkinsons symptoms
vascular parkinsons
Sudden onset
Parkinsons symptoms - legs, pyramidal signs
gait problems
Alzheimers definition
chronic neurodegenerative disease with insidious onset and progressive slow decline in memory loss and behavioural changes
Features of alzheimers
Amnesia Aphasia Apraxia Agnosia Poor abstract thinking
Essential tremor features
Gradual onset No associated symptoms Symmetrical worse when lifting up 50% fhx
PD tremor = asymmetrical, worse at rest.
Ix Essential tremor
Hx, Ex, Bloods: anaemia, hyperthyroid.
Mx essential tremor
- Propranolol
- Primidone (if asthmatic)
- Reduce caffeine intake.
3rd Nerve Palsy
features
causes
Investigations
Ptosis
Eye movement
Down and out
blown pupil (surgical)
Acute causes
- rapidly expanding intracranial aneurysm
- vasa nervorum occlusion - elderly + HTN (pupil sparing)
- internal carotid artery dissection (Rare)
Ix: CT angiogram/MRA- rule out rapidly expanding aneurysm
Catheter angiography
Left homonymous hemianopia
Right sided hemisphere lesion
may also have left arm weakness
Somatosensory neglect.
inform the DVLA
Language problems
Left sided brain lesion
BPPV features
Dizziness when turning over. Nausea. short duration. room spinning around. Posterior semicircular canal.
most no cause.
can be caused by head injury.
Rare -> Persistent postural perceptual dizziness.
Ix: Hallpike test.
Tx: Epley maneovre
cawthorne cooksey exercises.
watch and wat
PEG tube
considered in pts who need long term feeding, unable to eat and drink, high risk of aspiration.
Pts who do not recover sufficiently with nG tube.
PD Features
Age 50-85
20% no tremor at presentation.
Asymmetry -> affects other side in 3 years.
Pain, depression, sleep disturbance can present early.
50% pts depression
Sleep fragmentation, acting out dreams.
Dx with examination.
-Bradykinesia (slowness and progressve decrement of movements)
-rigidity
-gait/postural abnormalities.
Dyskinesia - caused by antipsychotics/levodopa
-writhing excess movements
PD mx
MDT approach
- Start with levodopa
- COMT inhibitor entacapone (if wearing off)
- Apomorphine
Dopamine agonists
Pramipexole - can cause behavioural problems - gambling, hypersexuality, compulsions.
LDOPA SEs
Peak dose dyskinesia - jerky movements 30mins after dose. Wearing off (sx returning before next dose) Restless leg syndrome (pain in legs, urge to move them)_
Skull fracture
Drunk man hits head -Boggy swelling
Skull XR - Fracture
-Arrange urgent CT
liaise with seniors - discuss with radiology and anaesthetics - may need intubation/ventilation to keep still for scan.
Can restrain him to prevent self harm or risk of physical injury, or injury to others.
Trauma Mx
A-Eapproach. w cervical spine.
2 large bore cannulae (14G) , FBC , U+E, clotting, glucose and cross match.
IV fluid
Monitor - BP, sats, RR
ECG
Lateral Cervical spine, CXR, pelvic XR
NGT, Urinary catheter, further imaging considered
Consider Intubation and ventilation if breathing difficulty.
GCS
Eyes
4: Opens spontaneously
3: Opens to voice
2: opens to pain
1: doesnt open
Voice
5: responds orientated.
4: confused
3: words
2: sounds
1: no response to pain
Motor
6: obeys commands
5: localises pain
4: normal flexion (withdraws from pain)
3: abnormal flexion
2: : extends to pain
1: no response
post seizure Ix
Collateral hx Examine pt fully ECG Cardiac monitor and pulse oximetry FBC, U+E, glucose, Calcium blood gases
Seizures - Cerebral mets suspicion
Get CT head
Portable CXR
Liaise with anaesthetiest to intubate and ventilate if not still.
Cerebral mets mx
Liase with oncology/radiotherapist Administer IV dexamethasone, start oral steroids. Anti convulsants Restaging- CT/FDG PET Analgesia
Myaesthenia gravis definition
Autoimmune.
Achr antibodies and depletion of ach receptors.
-> muscle weakness.
fatiguability
More common in F <30 and Males >50.
Most often affects extraocular, bulbar, face and neck muscles, and proximal limbs.
Normal reflexes
4 causes of anterior mediastinal mass
Thymic mass/thymoma
Thyroid mass
Teratoma
Terrible lymphoma/cancerous lymph nodes.
MG Ix
Ice pack test - place over affected eyelid -> temporary resolution.
EMG (confirmatory) - instability of NM system. nerve stimulation -> decrement.
Positive ACHr antibodies. 90%
Check TFTs, get CK incase of muscular problems.
CXR: Thymomas
Myaesthic crisis
Resp muscle weaknes, cant clear bronchial secretions, bronchospasm -> resp failure.
Consider NGT.
Precipitants: chest sepsis, emotion, exercise, pregnaancy, hypokalaemia, drugs (opiates, antibiotics (tetracycline), and b blockers) , penicillamine.
MG treatment
Admit if SOBOE/swallowing.
- Corticosteroids (titrate upwards)
- Azathioprine
- Pyridostigmine (acetylcholinesterase inhibitor)
- Thymic mass - thymectomy.
Crisis
- IVIG 1g/kg over 3days
- Plasmapheresis
Complications of MG
Hyperthyroidism
Acetylcholinesterase inhibitors - > mimic crisis
thymoma 15%
GCA symptoms
constant Headache - temporal. Scalp tenderness Jaw claudication Vision loss Tired Nausea
Signs
- temporal tenderness
- palpable thickened temporal artery
- visual loss (ifso urgent opthalmology)
IX GCA
ESR, CRP (more sensitive) Low Hb/Plt Visual examination. Vascular USS of temporal arteries CT PET Temporal artery biopsy - does not exclude - skip lesions. (do multiple biopsies)
mx GCA
Visual symptoms -
IVmethyprednisolone (0.5-1.0g for 3 days)
Oral pred 60mg.
no visual: Start high dose oral 40-60mg pred immediately until acute phase markers resolve Low dose steroids for 12 - 18 months. GIve bisphosphonates. .
Complications of GCA
Polymyalgia rheumatica
complete remission 2 years
blindness
optic neuropathy
CSF ranges
wcc: 0-5cells/uL RBC: 0- 10/mm3 Protein: 0.15-0.45g/L Glucose 2.8-4.2mmol/L Opening pressure 10-20mmH20
Isolated raised CSF protein
traumatic tap.
Multiple sclerosis symptoms
2 attacks separated in time. F>M, Monosymptomatic presentation - optic neuritis (painful vision loss) demyelination -Limb numbness, tingling or weakness -double vision -ataxia -worse with heat -fatigue -vertigo -depression -impotence -constipation -facial pain -dysarthria -urinary incontinence -memory less.
- INO - lesion in MLF in brainstem
Symptoms can worsen with heat, exercise.
Lhermittes sign - limb tingling with neck flexion
MS Ix
Bloods: FBC, U+E, LFT, TFT
MRI brain/cord/orbit (optic neuritis) - sensitive for plaque detection. multiple focal white mater lesions. doesnt correlate w sx.
Abs - AQP4 -
LP - oligoclonal IgG bands
Mx MS
Baclofen - spasticity Beta interferon - reduce relapse frequency Methylprednsiolone - shortens relapses. Natalizumab - highly active,RRMS Dimethylfumerate
56 yo Slow progressing weakness of proximal and distal muscles. + dysphagia
Inclusion body Myositis
Proximal muscle weakness, ptosis, dysphagia. smoker.
Lambert eaton myaesthenic syndrome
Limb weakness, bulbar weakness, dysphagia, dysarthria.
MND
Mixed upper and lower motor neurone signs
MND -resp muscles -speaking, drooling -wasting tongue -brisk reflexes -asymmetrical muscle wasting no sensory signs foot drop
Mx MND
Explain risk of aspiration pneumonia NBM until SALT review monitor weight closely. Riluzole - slows progression.
Ix MND
EMG
NCS
Bloods to exclude ddx.
scans.
36M Weakness hands and legs 3 days. Legs -> arms. tingling fingers and toes 3 days ago. Cant hold onto things. Episode of diarrhoea 10 days ago.
Guillan barre - rapidly ascending paralysis following bacterial/viral infection. 10% sensory sx. C jejuni, covid, vaccine, infections. Can involve resp muscles.
- can cause back pain - inflammation on nerve roots.
- can cause autonomic dysfunction - palpitations
- can cause facial weakness.
Mx Guillan barre
Ix: Bloods
MRI
LP - high CSF protein , can be normal in first few days) No cells.
EMG/Nerve conduction - demyelinating acute neuropathy. /axonal . Confirms DX.
Monitor forced Vital capacity.
monitor swallowing.
Plasma exchange
ITU if reduced VC
IVIG over 5 days.
complications:
common peroneal palsy - foot drop. Wt loss -> vulnerable to compression.
Headache on wakening
visual disturbance
Headache precipitated by coughing, straining, exertion.
worse on standing up
Raised ICP
black spots both eyes, last a few seconds. provoked by posture change.
Transient visual obscurations due to raised ICP
ICP fields
enlarged blind spots
Peripheral visual field constrictions
advanced -> loss central vision and acuity.
Female
fat
tetracycline dor acne
Raised ICP
Raised RBC but neg xanthochromia - traumatic tap.
Idiopathic intracranial hypertension
thunderclap headache
SAH,
hypotension
nasal triptan
verapamil (need to titrate)
steroids
Cluster headaches.
SAH causes
Berry aneurysm rupture (70-80%) - at anteriror and posterior communicating arteries, and MCA.
20% bilateral
AVM
hypertension
rare: trauma, anticoagulants, tumours, vasculopathy. spinal vascular malformations, infection.
SAH ix
CT (90% accurate in 24h - after drops)
LP - if normal cT /no CI, xanthrocromia. from 12h - 2w.
Mx SAH
cerebral Angiogram for clipping/coiling of aneurysm.
drainage of hydrocephalus.
Juvenile myoclonic epilepsy
Tonic clonic seizures
Myoclonic jerks
absences
childhood-> adulthood.
tx: valproate
levetiracetam
(cbz ->makes myoclonus worse)
Lennox gastaut epilepsy
Progressive epilepsy
intellectual dysfunction
atonic, absence, tonic.
temporary weakness following seizure
Todds paresis
Left incongruous homonymous hemianopia
Lesion in right optic tract
Left inferior homonymous quadranopia
right Parietal lesion
Left superior homonymous quadranopia
Right temporal lesion
left congruous homonymous hemianopia
lesion in right optic radiation/occipital cortex
left Macula sparing homonymous hemianopia
lesion in right occipital cortex
Hoovers sign.
test if normal leg is pushing down into couch as tries to lift other leg.
Organic vs non organic leg weakness.
Syringomyelia
fluid filled cavities in spinal cord.
can damage anterior horn cells-> LMN signs.
Neck and arms (cape like) loss of temp sensation.
accidental burns
SPastic weakness UL
Upgoing plantars.
np pain
bowel/bladder dysfucntion.
Rare -> horners.
(preservation of light touch, vibration, proprioception)
Ix Syringomyelia
Full spine MRI
brain MRI - exclude CHiari malformation
Tx syringomyelia
treat cause
shunt
Neuroleptic malignant syndrome treatment
Dantrolene
Lorazepam
Migraine mx
- oral triptan + NSAID + paracetamol
age 12-17 : nasal triptan
- Metoclopramide, prochlorperazine, non oral nSAID, triptan
- Prevention: if >2 attacks per month.
Topiramate/propranolol.
acupuncture.
acoustic neuroma (vestibular schwannoma)
Vertigo
sensoneruinal Hearing loss
tinnitus
absent corneal reflex
-CNVII, - facial palsy
IX: MRI cerebellopontine angle.
Mx: refferral ENT
surgery, radiotherapy, observation.
Degenerative cervical myelopathy
Progresive. Pain neck, UL/LL loss motor function Numbness Urinary/fecal incontinence Hoffmans sign - flick hand
Ix , MXDCM
MRI cervical spine
Cervical decompressive surgery
CI to thrombolysis
Abslute -Prev ICH -Seizure -neoplasm -SAH -stroke/brain injury last 3m -LP last 7 days -GI bleed last 3 w Active bleeding Preg Oes Varices HTN>185/120
Relative INR>1.7 current anticoagulation Haemorhagic diathesis active diabetic haemorrhagic retinopathy intracardiac thrombus major surgery /trauam last 2 weeks.
Ipsilateral ataxia nystagmus dysphagia facial numbness cn palsy CL hemisensorry loss
Lateral medullary syndrome
t2dm numb leg and arm
Lacunar infarct
Charcot marie tooth
PMP22 gene demylinating puberty - muscle wasting, pes cavus, clawed toes foot drop, leg weakness
complicatios of thrombolysis
angioedema
haemorrhagic transformation
pons bleed
pinpoint pupils
Acute confusional state (delirium) mx
elderly:
Haloperidol 0.5mg/olanzapine
If Parkinsons: Lorazepam.
