Neuro core conditions Flashcards

1
Q

What is a TIA?

A

An acute loss of cerebral or ocular function
symptoms last less than 24 hours
caused by an inadequate cerebral or ocular blood supply due to ischaemia or embolism

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2
Q

How long do the symptoms of a TIA usually last?

A

minutes

may last a few hours

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3
Q

What are the 2 main types of ischaemic stroke?

A

Thrombotic ischaemic stroke

embolic stroke

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4
Q

What is a thrombotic ischaemic stroke?

A

blood clot spontaneously forms in the brain

common complication of atherosclerosis

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5
Q

What is an embolic stroke?

A

part of the fatty material from an atherosclerotic plaque or a clot in larger artery or the heart breaks off and travels to the brain

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6
Q

What are embolic strokes common complications of?

A

AF

Atherosclerosis of the carotid arteries

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7
Q

What % of strokes are ischaemic?

A

85

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8
Q

What are the 2 types of hemorrhagic stroke?

A

Intracerebral and subarachnoid

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9
Q

What is a intracerebral haemorrhagic stroke and what causes them?

A

Bleeding from a blood vessel within in the brain

High blood pressure

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10
Q

What is a subarachnoid haemorrhagic stroke?

A

bleeding from a blood vessel between the surface of the brain and the arachnoid tissue

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11
Q

What are the risk factors for strokes?5

A
high BP
age 
DM 
smoking 
alcohol
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12
Q

What are the FAST symptoms and signs of a stroke? And how do you elicit them?

A

FACIAL WEAKNESS
- ask person to smile or show their teeth
will be facial asymmetry

ARM WEAKNESS
Lift arm to 90 or 45 (if lying)
will fall or drift down

SPEECH PROBLEMS
slurred
struggles to find the name of commonplace objects

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13
Q

What are the features of a sudden onset focal neurological deficit (found in strokes)? 8

A

usually unilateral

facial weakness

unilateral weakness and sensory loss of upper and/or lower limb

speech problems

visual defects

disorders of perception

disorders of balance

coordination disorders

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14
Q

What investigations do you do in suspected stroke?

A

CT scan

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15
Q

How do you calculate the risk of stroke following a TIA?

A

ABCD2 score:
A- age >60 -1 point

B- BP 140/90 -1 point

C- clinical features:

  • unilateral weakness- 2 point
  • speech disturbances without weakness- 1 point

D-duration of symptoms

  • =/>60mins - 2points
  • 10-59 mins - 1 point

D- Diabetes - 1 point

People are at high risk of a stroke if they have a score of 4 or more
AF
more than 1 TIA a week
TIA whilst on anticoagulants

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16
Q

How do you manage people at high risk of a stroke post TIA?

A

refer within 24 hours

Give statin- e.g. simvastatin

If they aren’t currently on any blood thinners immediately give clopidogrel or aspirin

DON’T start anti-platelet treatment until haemorrhagic stroke has been ruled out

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17
Q

How do you manage a haemorrhagic stroke?

A

Control bleeding

anticonvulsants to control bleeding e.g. diazepam

antihypertensives- to stem the growth of the haematoma

osmotic diuretics- to decrease intracranial pressure in the subarachnoid space

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18
Q

What is the management for secondary prevention of strokes?

A

Manage: AF, diabetes, hypertension
Antiplatelet drug
statin

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19
Q

What are the neurological complications of strokes? 9

A
Neurological problems:
balance 
movement 
tone 
sensation 

Disturbances of spatial awareness- neglect
Visual agnosia- disturbance of perception
aphasia, dysarthria, apraxia of speech

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20
Q

Where is pain felt as a complication of stroke?

A

Pain:
Neuropathic
shoulder pain and subluxation
MSK pain

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21
Q

What are the mental health complications of stroke?6

A
Depression 
anxiety 
emotionalism 
disturbed social interaction 
attention and concentration problems 
memory problems
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22
Q

What are the causes of a subarachnoid haemorrhage? (SAH)

A

aneurysmal rupture

traumatic brain injury- most common

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23
Q

What causes a spontaneous SAH? 5

A

Bleeding from a berry aneurysm - 85%

Non-aneurysmal peri-mesencephalic haemorrhage-10%

vascular abnormalities- 5%:
arteriovenous malformation
vasculitis
abnormal blood vessels associated with a tumour

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24
Q

What is the mean age for SAH?

A

50

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25
Is SAH more common in F or M
F
26
Which ethnic group is SAH more common in?
Afro-Caribbean
27
What are the risk factors for a spontaneous SAH? 8
``` 1-HTN 2-smoking 3-cocaine 4-excess alcohol 5-Family history - get at younger age and more likely to have larger and multiple ones 6- autosomal dominant adult polycystic disease 7-Ehler's Danlos syndrome type IV 8- Neurofibromatosis type 1 ```
28
What are the features of a SAH headache? 3
Sudden explosive headache - thunder clap May lasts seconds or even fraction of a second Typically pulsates towards occiput
29
What are the other symptoms of SAH? 4
seizure confusional state Vomiting Neck stiffness and other signs of meningism- usually around 6 hours post onset of SAH
30
What are the warning symptoms of an SAH and what are they due to? 10
Sentinel bleeds= small leaks or expansion of the aneurysm May be up to 3 weeks prior to SAH ``` Symptoms: Headache like an SAH but usually resolves itself dizziness orbital pain diplopia visual loss sensory or motor disturbances seizures ptosis bruits dysphasia ```
31
What may be seen on fundoscopy in a patient with SAH? 2
Intraocular haemorrhages: - 15% - especially if they've got depressed level of consciousness - occurs due to raised pressure Isolated pupillary dilation with loss of light reflex -may indicate brain herniation due to rising ICP
32
What is the main focal neurological sign that may be present in SAH? And what does it suggest?
suggest stroke and bleeding from posterior communicating artery 1- complete or partial palsy of the oculomotor nerve
33
What causes the associated cardiac arrhythmias in SAH?
Marked rise in BP due to a sympathetic response and surges of adrenaline
34
What does SAH in a person with known seizures suggest?
Arteriovenous malformation
35
What do new-onset seizures and SAH suggest?
Berry Aneurysm
36
What should be done immediately in patients that present with severe sudden headache?
CT scan | CT scan without contrast is the first line
37
Once acute SAH has been confirmed what further investigation should follow?
Angiography | either cerebral angiography or CT angiography
38
When do you do a lumbar puncture in suspected SAH?
If the CT scan is negative but the history is suggestive
39
How long after the onset of SAH do you do a lumbar puncture?
12 hours | To allow time for red blood cells in the CSF to undergo sufficient lysis for oxyhaemoglobin and bilirubin to have formed
40
What investigation do you carry out on the CSF in SAH?
spectrophotometry | to detect small amounts of xanthochromia= yellow discolouration of spinal fluid
41
What ECG changes occur in SAH? Why should caution be taken?
CT prolongation, Q waves, dysrhythmias and ST elevation | May be interpreted incorrectly as an MI --> thrombolysis being given = DISASTROUS in SAH
42
what are the surgical options to occlude an aneurysm in SAH?
Endovascular obliteration by means of platinum spirals- preferred -through femoral catheterisation it obliterates the artery by causing a blood clot to form Direct neurosurgical approach-clipping
43
How do you manage delayed cerebral ischaemia due to vasospams in SAH?
Oral nimodipine (Ca channel blocker) and maintaining circulatory volume
44
Hydrocephalus can be a side effect of SAH in the first hours or days, how do you treat this?
Lumbar puncture or ventricular drainage
45
Hypertension as a response to SAH is a common complication, how do you manage this?
Nitroprusside- a potent vasodilator and labetolol (b-blocker) Need BP to be low enough to prevent re-bleeding whilst high enough to maintain cerebral perfusion
46
What preventative measures can be taken to stop re-bleeding?
Clipping or coiling aneurysm | Antifibrinolytic drugs
47
What are the complications of an SAH?
``` 1- overall death rate= 50% 2- cardiac arrest 3- cerebral ischaemia 4- hydrocephalus 5-can develop epilepsy 6- re-bleeding 7-intra-parenchymal haematomas ```
48
What are the differential diagnoses for SAH? 8
Other causes of stroke Meningitis-rarely features thunderclap headache ``` For the headache: Primary sexual headache cerebral venous sinus thrombosis Cervical artery dissection Carotid artery dissection hypertensive emergency Pituitary apoplexy= infarction or haemorrhage of the pituitary gland ```
49
How does peripheral neuropathy happen?
Axonal degeneration- nerves becomes electrically inert within a week Demyelination
50
What are the health conditions that causes peripheral neuropathy?
``` 1-DM 2- surgery 3-shingles 4-alcohol 5-low vit B12 6-hypothyroidism 7-CKD 8-chronic liver disease 9-vasculitis 10- MGUS (monoclonal gammopathy of undetermined significance = presence of abnormal protein in the blood) 11- myeloma 12-lymphoma 13- Charcot-Marie-Tooth disease 14- lead, arsenic or mercury 15- Guilain Barre syndrome 16- Amyloidosis 17 rheumatoid 18- lupus 19-sjorgen's syndrome ```
51
What medications can cause peripheral neuropathy?
``` chemotherapy Metronidazole or nitrofurantoin if taken for months Phenytoin (epilepsy) amiodarone thalidomide ```
52
What factors increase your risks of developing peripheral neuropathy if you have DM? 3
Smoke alcohol >40
53
What are the signs and symptoms of peripheral neuropathy? 6
``` Paraesthesia burning pain numbness loss of vibration and position sense muscle wasting ataxia due to loss of sense of posture ```
54
Where is usually first affected in peripheral neuropathy?
feet
55
How do you relieve neuropathic pain? 7
``` Amitryptyline Duolextine Pregabalin Gabapentin Capsaicin cream Lidocain plaster Tramadol- when other treatments haven't worked ```
56
How do you treat hyperhydrosis?
Botulin injection
57
What are the complications of peripheral neuropathy?
Foot ulcers --> sepsis and and gangrene May affect nerves controlling autonomic functions of the heart and circulatory system= cardiovascular neuropathy - may need treatment for hypotension: fludrocortisone or midodrine - or in rare cases a pacemaker
58
what is an epileptic seizure?
A transient occurs of signs/ symptoms due to abnormal electrical activity in the brain
59
When can you declare seziure epilepsy?
Once they've had at least 2 unprovoked seizures occurring more than 24 hours apart
60
Who gets provoked seizures that are not of primary cerebral origin?
``` People exposed to trainsient noxious stimulus People with: alcohol or drug withdrawal Fever hypoxia hypoglycaemia ```
61
What is status epilepticus?
A continuous seizure of 30mins or longer or recurrent seizures without regaining consciousness lasting 30mins or longer
62
What causes epilepsy?8
2/3rds do not have anatomically identifiable cause 1/3rd have symptomatic epilepsy= epilepsy due to underlying disease or condition: - most common cause of epilepsy in older people - cerebrovascular disease - cerebral tumour - post traumatic epilepsy - foetal hypoxia or trauma - cortical or vascular malformation - cerebral abscess or tuberculoma - surgery to brain
63
When does epilepsy most commonly start?
Children | or over 60s
64
What are the risk factors for epilepsy? 11
``` 1-learning disabilities 2-childhood epilepsy syndromes- genetic 3-tuberous sclerosis- genetic 4-neurofibromatosis- genetic 5- FH 6- Previous febrile seizures in childhood 7- Previous intracranial infections 8- Brain trauma or surgery 10- cerebrovascular disease 11-cerebral tumours ```
65
What are examples of seizure triggers?
walking sleep deprivation flashing lights
66
What are auras?
simple partial seizures with no loss of consciousness
67
What are the symptoms of temporal lobe auras?
Unexpected tastes and smells paraesthesia rising abdominal sensation
68
What happens in tonic seizures?
impairment of consciousness stiffening Trunk may be either straight or flexed at waist
69
What happens in clonic seizures?
Impairment of consciousness | jerking
70
What happens in Tonic-clonic seziures?
Impairment of consciousness | stiffening and jerking
71
What happens in absence seizures? And when do they begin? And how long do they last?
Begin in childhood sharp onset and offset with no residual symptoms child stares for a few seconds eyelids may twitch small jerking movements of the fingers may occur- usually not noticed Last 5-10 seconds, and less than 30 seconds
72
What happens in myoclonic seizures?
Brief shock like contraction of the limbs without apparent impairment of consciousness
73
What happens in focal motor seizures?
Jerking movement typically beginning at the face or one hand spreading to involve limbs
74
What happens in focal sensory seizures?
Typically involves the temporal lobe | may causes sensory, autonomic, emotional, cognitive or other changes
75
what happens in the post-ictal period (residual symtpoms) after a seizure?
``` Drowsiness amnesia Injury- biting the tongue aching limbs headaches Focal neurological deficit that slowly recovers ```
76
What are the differential diagnoses in epilepsy?
syncope cardiac arrhythmias Panic attacks with hyperventilation Non-epileptic attack disorders- F>M, provoked by stressful situations Children- night terrors, breath holding attacks
77
How do you treat people having a tonic-clonic seizure for more than 5 mins or who have more than 3 seizures?
Buccal midazolam Rectal diazepam- if buccal midazolam isn't available IV lorazepam if IV access already establishes
78
What are the long-term management options for epilepsy?
``` Carbamazepine phenytoin primidone sodium valoprate may increase risk of osteoperosis--> give vit D supplements ```
79
what are the viral causes of meningitis? 3
Enteroviruses: Coxsackie A &B Echovirus Herpes simples 2 (genital herpes complication) Usually self limiting
80
What are the fungal causes of meningitis? 2
LIFE THREATENING, but rare cryptococcus- most common tuberculos meningitis
81
What are the bacterial causes of meningitis is in children >3months and adults? 3
``` Neisseria meningitides (--> meningococcal disease) Strep pmeumoniae H. influenzae type b ```
82
What are the bacterial causes of meningitis in neonates (<1month)?4
Streptococcus agalactiae E.coli S.pneumoniae Listeria monocytogenes
83
What are the autoimmune causes of meningitis?2
SLE | Behcet's syndrome
84
What are the risk factors for meningitis?7
``` Young age winter season >65 immuno-compromised organ dysfunction smoking overcrowded housing ```
85
What are the non-specific symptoms of meningitis? (common signs are often missing in infants) 9
``` fever vomiting/ nausea lethargy irritabillity/ unsettled ill appearance refusing food/drink headache muscle ache/ joint pain respiratory symptoms ```
86
What are the specific symptoms of meningitis? 14
``` Non-blanching rash stiff neck cap refill time >2secs unusual skin colour shock and hypotension leg pain back rigidity bulging fontanelle photophobia paresis seziures Focal neurological deficit Kernig's sign brudzinksi's sign ```
87
What is Kernig's sign?
Person is unable to fully extend at knee when hip is flexed
88
What is Brudzinksi's sign?
Person's hips and knees flex when neck is flexed
89
What are the features of the rash?
Scanty petechial rash- purple or red non-blanching macules <2mm Pupuric (haemorrhagic) rash- spots >2mm. May be absent in early phase of illness, may intially be blanching or macular
90
What are the indications that meningococcal disease is likely to develop, in children? 4
The petechiae start to spread The rash become pupuric There are signs of bacterial meningitis There are signs of meningococcal septicaemia
91
What investigations do you do in meningitis?
Lumbar puncture
92
How do you manage a patient with meningitis?
If they have a rash: single dose of parenteral benzylpenicillin asap- ideally IV but can do IM Antibiotics + corticosteroids Benzylpenicillin if allergic: cefotaxime or chloramphenicol Give prophylaxis of close contacts
93
What are the complications of meningitis? 8
``` death neurological damage hearing loss seizures motor deficit cognitive impairment hydrocephalus visual disturbances ```
94
What is a common migraine?
Migraine without aura
95
What are classic migraines?
Migraines with aura
96
What is contraindicated in migraines with aura?
the contraceptive pill
97
What are the risk factors for migraines? 7
``` FH stress depression anxiety menstruation menopause head or neck trauma ```
98
What are the common internal triggers for migraines? 4
Menstrual cycle altered sleep pattern stress relaxation after stress- weekend migraine
99
What are the external triggers for migraines?
Specific foods- only suspect as trigger if migraine occurs within 6 hours of eating it strenuous exercise- for those not used to it (however regular exercise helps migraines) strong smells bright light dehydration missed meals jet lag
100
Are migraines more common in M or F?
F
101
When is the mean onset of migraines for F?
18
102
When is the mean onset of migraines for M?
14
103
What are the diagnostic criteria for migraine without aura?
Recurrent episodes of headaches lasting between 4-72hours associated with either nausea/ vomiting or photophobia and phonophobia or both usually unilateral Pulsating in character aggravated by routine physical activity
104
What are the diagnostic criteria for migraine with aura?
Symptoms of a migraine are preceded by the onset of an aura of visual or sensory symptoms or dysphasia Visual symptoms- zig-zag or flickering lights, spots, lines or loss of vision Sensory symptoms- pins and needles or numbness
105
What are episodic migraines?
headache which occurs on <15 days/ month | chronic = >15
106
When do menstrually related migraines occur?
2 days before and 3 days after the start of menstruation
107
What are the acute treatment options for migraines?
Oral combination therapy of oral triptan and an NSAID or paracetamol consider an antiemetic- metoclopermaide, domperidone or prochloerperazine
108
What oral triptans can be used?
sumatriptan | zolmitriptan, naratriptan, rizatriptan, eletriptan, almotriptan and frovatriptan
109
What are the prevantative treatment options for migraines?
topiramate or propanolol first line | If after 2 months these aren't working then offer 10 sessions of acupuncture over 5-8weeks
110
What are the risks with topiramate?
can impair effectiveness of oral contraceptives | can cause foetal malformations
111
Who can't take propanolol?4
``` People with asthma COPD PVD or uncontrolled heart failure ```
112
What are the complications of migraines? 6
Medication overuse status migrainosus- migraine .72hours increased risk of ischaemic stoke migraine with aura might increase risk of haemorrhagic stroke depression, bipolar, anxiety and panic disorder are all associated with migraine migraine triggered seizure
113
What classifies as an infrequent tension headache?
At least 10 episodes of TTH | On less than 1 day/month
114
What classifies as a frequent episode of tension headaches?
At least 10 episodea On 1 day or more each month On less than 15 days per month for at least 3 months
115
What classifies as a chronic tension headache?
Occurs on 15 days or more per month lasts for more than 3 month at a time or for more than 180 days in a year
116
Are tension headaches more common in F or M?
F
117
How long do tension headaches last?
30 mins to 7 days
118
To be diagnosed as a tension headache they have to have two of what criteria? 5And have both of what features?
``` Bilateral pressing or tightening (non-puslating) mild to moderate intensity not aggravated by exercise Radiate to or arise from the neck ``` Not associated with nausea or vomiting Photophobia or phonophobia may be present, but NOT both
119
How do you manage an acute tension headache?
Paracetamol aspirin (not for under 16s) NSAIDs
120
Who gets preventative treatment of tension headaches?
People requiring analgesia 2 or more days each week
121
What are the preventative options for a tension headache?
``` Acupuncture Amitryptiline (or if not tolerated nortriptyline) ```
122
How long are people on the upper does of amitryptilne for in tension headaches?
2 months | Then decrease dose by 10mg to 25mg each week
123
What causes Parkinson's disease?
Loss of dopamine containing cells in the substantia nigra
124
What is Parkinsonism?
Umbrella term for clinical syndrome involving bradykinesia plus at least one of: tremor rigidity postural insatbility
125
What are the causes of Parkinsonism? 6
``` Parkinson's disease= most common drug incuded cerebrovascular disease Lewy body dementia multiple system atrophy progressive supranuclear palsy ```
126
What are the risk factors for Parkinson's? 2
Age | FH
127
Is it more common in M or F?
M
128
What are the motor symptoms of Parkinson's? 6
``` Bradykinesia Hypokinesia = poverty of movement stiffness or rigidity resting tremor postural instabillity Frezing gait ```
129
How does bradykinesia in Parkinson's present?
slowness in initiation of voluntary movements | with progressive reduction in speed and amplitude of repetitive actions such as finger or foot tapping
130
How does hypokinesia in Parkinson's present?
Reduced facial expression, arm swing or blinlinh difficulty with fine movements- buttons, opening jars, small cramped handwriting= micrographia
131
What are the two types of rigidity in Parkinson's?
Lead pipe- constant resistance when a limb is passively flexed in the presence of increased tone without tremor Cogwheel rigidity regular intermittent relaxation of tension when a limb is passively flexed in the presence of tremor and increased tone
132
What are the features of the resting tremor in Parkinson's?
Usually improves with moving, mental concentration and during sleep May affect thumb and index finger= pill rolling wrist, leg, lips, chin or jaw absent in 30% of people at disease onset
133
Are the features of parkinson's unilateral or bilateral?
Early disease they are usually unilateral, become bilateral as the disease progresses
134
What are the non-motor symptoms of parkinson's? 7
``` depression anxiety fatigue reduced sense of smell cognitive impairment sleep disturbance constipation ```
135
What are the differential diagnoses of parkinson's disease? 7
``` drug induced Parkinsonism cerebrovascular disease Non-Parkinson's dementia progressive supranuclear palsy multiple system atrophy corticobasal degeneration Wilson's disease ```
136
What are the medication options for managing motor symptoms in Parkinson's? 6
Levodopa COMT inhibitors- entacapone Dopamine agonists- pramipexole, ropinirole Amantadine Anticholinergic drugs MAO-B inhibitors- selegiline or rasagiline
137
Where does deep brain stimulation stimulate in Parkinson's treatment? And who gets it?
``` subthalamic nucleus People with motor symptoms who are: Fit enough Levodopa responsive have no co-morbid health problems ```
138
What anti-emitcs can't you use in Parkinson's and which one can you use?
NOT: metoclopramide or prochlorperazine Low dose domperidone is ok
139
What causes fluctuations in motor symptoms in Parkinson's? 2
End to end dose failing | On-off phenomenon
140
What are the mental health complications of parkinson's? 7
``` depression anxiety apathy dementia cognitive impairment impusle control disorders psychosis ```
141
What are the autonomic complications of parkinson's? 8
``` constipation postural hypotension dysphagia weight loss excessive salivation hyperhidrosis bladder problems sexual problems ```
142
What are the most common type of proximal myopathies?
Muscular dystrophies e.g. Duchene
143
What are the inherited causes of peripheral myopathies? 2
Myopathies- e.g. Duchene, Becker's Inherited biochemical defects e.g myochondrial myopathy or lipid storage disease
144
What are the aquired causes of myopathies? 4
Immunologically mediated- SLE, RA Non-inflammatory myopathies- Hyper/hypothyroidism. DM, Cushing's Toxic and cachetic myopathies- alochol, protein malnutrition, statins, steroids Infection-HIV, cosackie
145
What are the signs and symptoms of myopathies? 5
weakness myalgia- may occur in inflammatory myopathy fluctuating muscle power- suggests metaboluc myopathy Malaise/ fatigue Atrophy of muscles with reduced reflexes - occurs late with myopathies (early with neuropathies
146
What are the features of weakness associated with myopathy? 5
Predominately affects proximal muscle groups- limb girdle and shoulders --> decreased foteal movements in utero floppy infant neonatally reduced muscle strength and power symmetrical proximal muscle weaknes with paraesthesia
147
What are the complications of peripheral myopathies? 4
respiratory failure aspiration pneumonia Joint contractures chest and spinal deformities
148
What is MS?
an autoimmune condition characterised by repeated episodes of inflammation of nervous tissue in the brain and spinal cord --> loss of myelin sheath --> slows or blocks signals
149
What are the causes of MS?
Genetic | Environmental
150
Is MS more common in M or F?
F
151
When is the peak incidence for MS?
40-50
152
What are the eye signs and symptoms of MS? 3
Optic neuritis- painful reduction of vision in 1 eye symmetrical jerking nystagmus --> double vision Lateral rectus weakness
153
What are the other (aside from eye) symptoms of MS?) 8
``` Bell's Palsy Deafness and feeling unsteady progressive loss of memory and language skills no-specific pain loss of sensation in legs ascending to the trunk incontinence impotence loss of thermoregulation ```
154
What will a MRI show in MS?
Periventricular lesions and discrete white matter abnormalities
155
What can electrophysiology detect in MS?
demyelination
156
What will be found in CSF in MS?
Rise in total protein | Increase in immunoglobulin concentration with presence of oligoclonal cases
157
What do you give for symptom exacerbations in MS?
Steroids | usually methylprednisolone for 5 days
158
What are the medication options to stop remitting and relapsing in MS> 7
``` Azathioprine Interferon-beta Glatiramer- designed to mimic the main protein in myelin Dimethyl fumarate teriflunomide aletuzumab ```