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Final year Medicine > Neuro > Flashcards

Neuro Flashcards

1
Q

Signs of MCA stroke

A 
CL facial weakness (forehead sparing)
Hemiparesis
Hemisensory loss
Hemineglect
Receptive/expressive dysphasia
Quadrantanopia /homonymous hemianopia
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2
Q

Signs of ACA stroke

A

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

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3
Q

Signs of PCA stroke

A

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.

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4
Q

Investigations of Stroke

A

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.

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5
Q

Management Ischaemic stroke

A

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.

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6
Q

Primary prevention of stroke

A 
Control HTN
Lipids
DM
Smoking
cardiac disease
Lifelong anticoagulation if AF
carotid endartectomy if symptomatic 70% stenosis.
exercise
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7
Q

Secondary prevention of stroke

A

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

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8
Q

Lacunar stroke

A

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
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9
Q

Causes of stroke

A

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
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10
Q

Risk factors for stroke

A 
HTN
Smoking
DM
lipids
fh
PVD
Prev hx
black, asian
PCV
OCP
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11
Q

Millard gubler syndrome

A 
Pontine infarct
6th/7th CN nuclei + corticospinal tracts
- DIPLOPIA
-LMN facial palsy/loss of corneal reflex.
-CL hemiplegia.
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12
Q

Locked in syndrome

A

Ventral pons infartion - Basilar artery.
Central pontine myelinolysis - rapid correction of Hyponatremia

Aware and cognitively intact -> completely paralysed other than eye muscles.

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13
Q

Differentials of stroke

A 
Head injury +/- haemorrhage
Hyper/Hypoglycaemia
SOL
Hemiplegic migraine
Todds palsy (post ictal)
Infections (encephalitis, abscess, toxo, HIV, HTLV)
Drugs (opiates)
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14
Q

TIA definition

A

Sudden onset focal neurology lasting <24h due to temporary occlusion of part of cerebral circulation.

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15
Q

Stroke definition

A

rapid onset, focal neurological deficit due to a vascular lesion lasting >24h

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16
Q

Signs TIA causes

A

Carotid bruits
BP raised
heart murmur
Af

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17
Q

Causes of TIA

A

Atherothromboembolism from carotids
cardioembolism - AF, post MI, valve.
Hyperviscosity - PCV, SCD, myeloma.

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18
Q

Differential of TIA

A

Vascular - CVA, migraine, GCA
Epilepsy
hyperventilation
Hypoglycaemia

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19
Q

Ix TIA

A 
Aim to find cause and define vascular risk:
Bloods: FBC, U+E, ESR, GLucose, Lipid
CXR,
ECG
Echo
Carotid doppler +/- angio
Consider MRI/CT
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20
Q

MX TIA

A

speed of intervention prevents strokes.
avoid driving 1mo.

  1. Antiplatelet/anticoagulate
    - Aspirin/Clopi 300mg for 2w then 75mg. Add Dipyridamole to aspirin.
    Warfarin/rivaroxaban if cardiac emboli
  2. 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.

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21
Q

SDH Definition.

A

Bleeding from bridging veins between cortex and sinuses. Haematoma between dura and arachnoid. Minor trauma. deceleration injuries.

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22
Q

SDH RFs

A

Elderly (brain atrophy)
Falls (epileptics, alcoholics)
Anticoagulation

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23
Q

SDH symptoms

A 
Headache
Fluctuating GCS
Sleepiness
Gradual physical/mental slowing
Unsteadiness
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24
Q

SDH Signs

A 
Raised ICP (can -> tentorial herniation)
Localising signs late
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25
Q

Imaging (CT/MRI) SDH

A

Crescentic haematoma one hemisphere
Clot goes white -> grey with time
Mid line shift

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26
Q

Mx SDH

A
  1. 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

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27
Q

Extradural haemorrhage

A

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.

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28
Q

Presentation of EDH

A

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.

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29
Q

Ix EDH

A

CT - lens shaped haematoma

skull fracture.

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30
Q

Mx EDH

A

Neuroprotective ventilation (o2>100m co2 35-40)
IV mannitol - central line 1g/kg.
craniectomy for clot evacuation and vessel ligation

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31
Q

Haemorrhagic stroke mx

A

IV mannitol
sit up - encourage hyperventilate
Surgical -> coiling (aneurysms), craniotomy, ventricular drainage.

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32
Q

Dural venous sinus thrombosis causes

A 
pregnancy
ocp
head injury
dehydration
cancer
thrombophilia
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33
Q

DUral venous sinus thrombosis ix

A

CT MR venography

LP -> increased pressure, RBCs, xanthochromia

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34
Q

Dural venus sinus thrombosis mx

A

LMWH-> warfarin
Fibrinolytics - streptokinase
thrombophilia screen

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35
Q

Meningitis Ix

A

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.

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36
Q

LP results

A

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

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37
Q

meningitis Mx:

A

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.

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38
Q

Contraindications to LP

A 
Thrombocytopenia
Lateness 
Pressure (raised ICP)
Unstable (CVS,resp)
Coagulation disorder
Infection at LP site
Neurology - focal signs.
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39
Q

Causes of encephalitis

A 
Viruses
HSV1/2
CMV EBV VZV
Arboviruses
HIV

Non viral - bacterial meningitis
TB
malaria
Lyme disease

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40
Q

Ix encephalitis

A

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

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41
Q

Mx encephalitis

A

Aciclovir 10mg/kg/8h IVI over 1h for 14 days.
supportive
phenytoin if siezures

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42
Q

Parkinsons Ix

A

Dopaminergic agent trial with LEVODOPA.

Serum caerloplasmin - decreased - WILSONS
24h urine cu - increased WILSONS

MRI /dat scan

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43
Q

Head injury initial assessment

A

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

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44
Q

Head injury Ix

A 
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.
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45
Q

head injury mx

A

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.
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46
Q

Status epilepticus mx

A

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.

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47
Q

Cerebral abscess Pre disposing factors

A 
Infection - ear, sinus, dental, periodontal
SKull #
Congenital heart disease
Endocarditis
Bronchiectasis
Immunosuppression
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48
Q

Organisms causing cerebral abscess

A

Frontal sinus/teeth: strep milleri, Oropharyngeal: anaerobes.
Ear: bacteroides, other anaerobes.

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49
Q

Signs of cerebral anaerobes

A 
Seizures
Fever
localising signs
ICP
infection elsewhere
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50
Q

Ix of cerebral abscess

A

CT/MRI - ring enhancing lesion

WCC/ESR

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51
Q

Mx Cerebral abscess

A

Neurosurgical referral
abx: ceftriaxone
treat raised ICP

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52
Q

Epilepsy definition

A

Recurrent tendency to spontaneous intermittent abnormal electrical activity in part of the brain, manifesting as seizures.

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53
Q

Causes of epilepsy

A

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.

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54
Q

Simple partial seizures

A

Focal, motor, sensory, autonomic, psychic symptoms

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55
Q

Complex partial

A

Aura
Autonomic -skin colour, temp, palpitations
Awareness lost - motor arrest/motionless stare
Automatisms: Lip smacking, fumbling, chewing, swallowing
Amnesia

Usually from temporal lobe.

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56
Q

Absence seizures

A

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

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57
Q

Tonic clonic seizures

A 
LOC
Tonic - stiff limbs
clonic -jerking
Cyanosis -incontinence, tongue biting (lateral). 
Post ictal confusion/ drowsiness.
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58
Q

Myoclonic

A

sudden limb, face, trunk jerk.

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59
Q

West syndorme

A

Clusters of head nodding and arm jerks

EEG -hypsarrythmia

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60
Q

Investigations of Epilepsy

A

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.

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61
Q

Drug therapy for epilepsy

A

Tonic clonic: Valproate, Lamotrigine
Absences: Valproate, ethosuximide, lamotrigine.
Tonic/atonic/myoclonic: Valproate, Levetiracetam
Focal/2nd gen: Lamotrigine, CBZ

62
Q

Women/pregnancy

A

Avoid valproate. take lamotrigine/cbz
5mg Folic acid daily
CBZ/Phenytoin inducers -> reduce OCP effectiveness.

63
Q

Side effects of AEDs

A

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
64
Q

idiopathic intracranial Hypertension

A

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.

65
Q

Types of cerebral oedema

A
  1. Vasogenic (increased cap permeability) trauma, tumour, ischamia, infarction
  2. Cytogenic - hypoxia
  3. Interstitial - obstructive hydrocephalus, hyponatremia.
66
Q

Causes of Raised ICP

A 
Haemorrhage
Tumours
infection (meningitis, encephalitis, abscess)
hydrocephalus
status
cerebral oedema
67
Q

acute mx raised ICP

A 
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.

68
Q

Herniation syndromes

A

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
69
Q

Causes of cord compression

A 
Trauma
Infection (epidural abscess Tb)
cancer - breast, thyroid, lung, kidney, prostate
Disc prolapse
Haematoma
Intrinsic cord tumour
Myeloma
AVM
70
Q

Mx cord compression

A
  1. call neurosurgery
  2. Malignancy : dexamethasone IV
    abscess - abx
71
Q

Progressive supranuclear palsy features

A 
Vertical gaze palsy
symmetrical Parkinsonian features
Pseudobulbar palsy - speech and swallowing problems.
axial rigidity
postural instability - falls. 
Tufted astrocytes
Coiled bodies.
72
Q

Parkinsons tx

A 
Dopamine agonists (bromocriptine, ropinirole):  - younger
older: L DOpa + carbidopa. 
entacapone - peripheral COMT inhibitor

Tolcapone
Resegiline MAOBi

73
Q

Multiple system atrophy

A 
Shy drager syndrome
Alpha synucleinopathy
Rigidity > tremor
Cerebellar ataxia
Postural hypotension
Papp Lantos bodies. (oligodendrocyte inclusions of a synuclei
74
Q

Corticobulbar degeneration

A 
Unilateral Parkinsonism
prominent rigidity
Aphasia
Dysarthria
Apraxia
Alien limbs (cortical sernsory loss)
astrocyte tau plaques
balloons neruones.
75
Q

Lewy body dementia

A

Early dementia
Visual hallucinations
Fluctuating cognition
Parkinsons symptoms

76
Q

vascular parkinsons

A

Sudden onset
Parkinsons symptoms - legs, pyramidal signs
gait problems

77
Q

Alzheimers definition

A

chronic neurodegenerative disease with insidious onset and progressive slow decline in memory loss and behavioural changes

78
Q

Features of alzheimers

A 
Amnesia
Aphasia
Apraxia
Agnosia
Poor abstract thinking
79
Q

Essential tremor features

A 
Gradual onset
No associated symptoms
Symmetrical
worse when lifting up
50% fhx

PD tremor = asymmetrical, worse at rest.

80
Q

Ix Essential tremor

A

Hx, Ex, Bloods: anaemia, hyperthyroid.

81
Q

Mx essential tremor

A
  1. Propranolol
  2. Primidone (if asthmatic)
  3. Reduce caffeine intake.
82
Q

3rd Nerve Palsy
features
causes
Investigations

A

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

83
Q

Left homonymous hemianopia

A

Right sided hemisphere lesion
may also have left arm weakness
Somatosensory neglect.
inform the DVLA

84
Q

Language problems

A

Left sided brain lesion

85
Q

BPPV features

A

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

86
Q

PEG tube

A

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.

87
Q

PD Features

A

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

88
Q

PD mx

A

MDT approach

  1. Start with levodopa
    • COMT inhibitor entacapone (if wearing off)
  3. Apomorphine
89
Q

Dopamine agonists

A

Pramipexole - can cause behavioural problems - gambling, hypersexuality, compulsions.

90
Q

LDOPA SEs

A 
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)_
91
Q

Skull fracture

A

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.

92
Q

Trauma Mx

A

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.

93
Q

GCS

A

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

94
Q

post seizure Ix

A 
Collateral hx
Examine pt fully
ECG
Cardiac monitor and pulse oximetry
FBC, U+E, glucose, Calcium
blood gases
95
Q

Seizures - Cerebral mets suspicion

A

Get CT head
Portable CXR
Liaise with anaesthetiest to intubate and ventilate if not still.

96
Q

Cerebral mets mx

A 
Liase with oncology/radiotherapist
Administer IV dexamethasone, start oral steroids.
Anti convulsants
Restaging- CT/FDG PET
Analgesia
97
Q

Myaesthenia gravis definition

A

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

98
Q

4 causes of anterior mediastinal mass

A

Thymic mass/thymoma
Thyroid mass
Teratoma
Terrible lymphoma/cancerous lymph nodes.

99
Q

MG Ix

A

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

100
Q

Myaesthic crisis

A

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.

101
Q

MG treatment

A

Admit if SOBOE/swallowing.

  1. Corticosteroids (titrate upwards)
  2. Azathioprine
  3. Pyridostigmine (acetylcholinesterase inhibitor)
  4. Thymic mass - thymectomy.

Crisis

  1. IVIG 1g/kg over 3days
  2. Plasmapheresis
102
Q

Complications of MG

A

Hyperthyroidism
Acetylcholinesterase inhibitors - > mimic crisis
thymoma 15%

103
Q

GCA symptoms

A 
constant Headache - temporal. 
Scalp tenderness
Jaw claudication
Vision loss
Tired
Nausea

Signs

  • temporal tenderness
  • palpable thickened temporal artery
  • visual loss (ifso urgent opthalmology)
104
Q

IX GCA

A 
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)
105
Q

mx GCA

A

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. .
106
Q

Complications of GCA

A

Polymyalgia rheumatica
complete remission 2 years
blindness
optic neuropathy

107
Q

CSF ranges

A 
wcc: 0-5cells/uL
RBC: 0- 10/mm3
Protein: 0.15-0.45g/L
Glucose 2.8-4.2mmol/L
Opening pressure 10-20mmH20
108
Q

Isolated raised CSF protein

A

traumatic tap.

109
Q

Multiple sclerosis symptoms

A 
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

110
Q

MS Ix

A

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

111
Q

Mx MS

A 
Baclofen - spasticity
Beta interferon - reduce relapse frequency
Methylprednsiolone - shortens relapses. 
Natalizumab - highly active,RRMS
Dimethylfumerate
112
Q

56 yo Slow progressing weakness of proximal and distal muscles. + dysphagia

A

Inclusion body Myositis

113
Q

Proximal muscle weakness, ptosis, dysphagia. smoker.

A

Lambert eaton myaesthenic syndrome

114
Q

Limb weakness, bulbar weakness, dysphagia, dysarthria.

A

MND

115
Q

Mixed upper and lower motor neurone signs

A 
MND
-resp muscles
-speaking,
drooling
-wasting tongue
-brisk reflexes
-asymmetrical muscle wasting
no sensory signs
foot drop
116
Q

Mx MND

A 
Explain risk of aspiration pneumonia
NBM until SALT review
monitor weight
 closely.
Riluzole - slows progression.
117
Q

Ix MND

A

EMG
NCS
Bloods to exclude ddx.
scans.

118
Q 
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.
A 
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.
119
Q

Mx Guillan barre

A

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.

120
Q

Headache on wakening
visual disturbance
Headache precipitated by coughing, straining, exertion.
worse on standing up

A

Raised ICP

121
Q

black spots both eyes, last a few seconds. provoked by posture change.

A

Transient visual obscurations due to raised ICP

122
Q

ICP fields

A

enlarged blind spots
Peripheral visual field constrictions
advanced -> loss central vision and acuity.

123
Q

Female
fat
tetracycline dor acne

Raised ICP
Raised RBC but neg xanthochromia - traumatic tap.

A

Idiopathic intracranial hypertension

124
Q

thunderclap headache

A

SAH,

hypotension

125
Q

nasal triptan
verapamil (need to titrate)
steroids

A

Cluster headaches.

126
Q

SAH causes

A

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.

127
Q

SAH ix

A

CT (90% accurate in 24h - after drops)

LP - if normal cT /no CI, xanthrocromia. from 12h - 2w.

128
Q

Mx SAH

A

cerebral Angiogram for clipping/coiling of aneurysm.

drainage of hydrocephalus.

129
Q

Juvenile myoclonic epilepsy

A

Tonic clonic seizures
Myoclonic jerks
absences
childhood-> adulthood.

tx: valproate
levetiracetam
(cbz ->makes myoclonus worse)

130
Q

Lennox gastaut epilepsy

A

Progressive epilepsy
intellectual dysfunction
atonic, absence, tonic.

131
Q

temporary weakness following seizure

A

Todds paresis

132
Q

Left incongruous homonymous hemianopia

A

Lesion in right optic tract

133
Q

Left inferior homonymous quadranopia

A

right Parietal lesion

134
Q

Left superior homonymous quadranopia

A

Right temporal lesion

135
Q

left congruous homonymous hemianopia

A

lesion in right optic radiation/occipital cortex

136
Q

left Macula sparing homonymous hemianopia

A

lesion in right occipital cortex

137
Q

Hoovers sign.

A

test if normal leg is pushing down into couch as tries to lift other leg.

Organic vs non organic leg weakness.

138
Q

Syringomyelia

A

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)

139
Q

Ix Syringomyelia

A

Full spine MRI

brain MRI - exclude CHiari malformation

140
Q

Tx syringomyelia

A

treat cause

shunt

141
Q

Neuroleptic malignant syndrome treatment

A

Dantrolene

Lorazepam

142
Q

Migraine mx

A
  1. oral triptan + NSAID + paracetamol

age 12-17 : nasal triptan

  1. Metoclopramide, prochlorperazine, non oral nSAID, triptan
  2. Prevention: if >2 attacks per month.
    Topiramate/propranolol.
    acupuncture.
143
Q

acoustic neuroma (vestibular schwannoma)

A

Vertigo
sensoneruinal Hearing loss
tinnitus
absent corneal reflex

-CNVII, - facial palsy

IX: MRI cerebellopontine angle.

Mx: refferral ENT
surgery, radiotherapy, observation.

144
Q

Degenerative cervical myelopathy

A 
Progresive. 
Pain neck, UL/LL
loss motor function
Numbness
Urinary/fecal incontinence
Hoffmans sign - flick hand
145
Q

Ix , MXDCM

A

MRI cervical spine

Cervical decompressive surgery

146
Q

CI to thrombolysis

A 
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.
147
Q 
Ipsilateral ataxia
nystagmus
dysphagia
facial numbness
cn palsy 
CL hemisensorry loss
A

Lateral medullary syndrome

148
Q

t2dm numb leg and arm

A

Lacunar infarct

149
Q

Charcot marie tooth

A 
PMP22 gene
demylinating 
puberty - muscle wasting, pes cavus, clawed toes
foot drop,
leg weakness
150
Q

complicatios of thrombolysis

A

angioedema

haemorrhagic transformation

151
Q

pons bleed

A

pinpoint pupils

152
Q

Acute confusional state (delirium) mx

A

elderly:
Haloperidol 0.5mg/olanzapine
If Parkinsons: Lorazepam.

Final year Medicine (18 decks)

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