neuro/geris Flashcards
what are the likely causes of delirium
infection
hypo/hyper Na, K, Ca
metabolic
drug related
cerebral
constipation/retention
pain
what medications are associated with delirium
zopiclone
benzos
opiates
anticholinergic type drugs
parkinsons medications
what drugs can you give to a patient becoming agitated
benzodiazapines
haloperidol
what is the difference between hyper and hypo active delirium
hyper = agitation, restlessness, sometimes aggressiveness
hypo = motor retardation, apathy, slowing of speech, appear to be sedated
what are the common symptoms of a stroke in the carotid territory
weakness of face, leg, arm
amaurosis fugax
impaired languaged
what are the common symptoms of a stroke in the posterior circulation
dysarthria
dysphagia
diplopia
dizziness
ataxia
diplegia (stiffness, weakness on one side of the body)
what are the common symptoms of a stroke in the anterior circulation
contralateral weakness
contralateral sensory loss
dysarthria
dysphasia
homonymous hemianopia
higher cortical dysfunction
what 3 symptoms are needed to classify a total stroke
unilateral weakness and/or sensory deficit of face, arm and leg
homonymous hemianopia
higher cerebral dysfunction
what is a lacunar infarction
occlusion of deep penetrating arteries
affects small volume of subcortical white matter
what is the underlying process behind a lacunar infarction
arterial wall disorganisation
microatheroma
lipohyalinosis
how are the points allocated for best eye opening response in Glasgow coma scale
spontaneously
to speech
to pain
none
how are the points allocated for best verbal response in Glasgow coma scale
orientated in time/place/person
confused
inappropriate words
incomprehensible sounds
none
how are points allocated for best motor response in the Glasgow coma scale
obeys command
localises to pain
flexes to pain
extends to pain
none
what is the C6 myotome
elbow flexion
what is the C6 dermatome
thumb
what is the C6 reflex
biceps
what is the C7 myotome
elbow extension
what is the C7 dermatome
middle finger
what is the C7 reflex
triceps
what is the myotome for C8/T1
thumb extension and finger flexion
what is the dermatome for C8/T1
medial hand and forearm
what is the myotome for L5
dorsiflexion
what is the dermatome for L5
big toe, dorsum
what is the myotome for S1
plantar flexion
what is the dermatome for S1
small toe, side of foot, sole of foot
what is the reflex for S1
ankle jerk
what rate is CSF produced at
500ml/24 hours
what is the capacity of the ventricular system
20ml
what is the normal CSF pressure
5-15cm
what are the symptoms of raised ICP/hydrocephalus
headache
vomiting
visual disturbance
gait
unsteadiness
what are the signs of raised ICP/hydrocephalus
drowsiness
papilloedema
limitation of upward gaze
reduced visual acuity
what is the origin of the pyramidal tracts
cerebral cortex
what is the function of the pyramidal tracts
responsible for voluntary control of musculature of body and face
what do the pyramidal tracts split into
corticospinal and corticobulbar tracts
where does the corticospinal tract divide
caudal part of the medulla
what does the corticospinal tract divide into
anterior and lateral
what route does the lateral corticospinal tract take
decussates at medulla, terminates in ventral horn
what route does the anterior corticospinal tract take
remains ipsilateral, decussates/terminates in the cervical and upper thoracic segmental levels
what are the corticobulbar tracts composed of
upper motor neurones of the cranial nerves
what do the corticobulbar tracts control
muscles of the head, face and neck
where is the origin of the extrapyramidal tracts
brainstem
what is the function of the extrapyramidal tracts
responsible for involuntary and autonomic control
what are the 4 extrapyramidal tracts
vestibulospinal
reticulospinal
rubrospinal
tectospinal
which extrapyramidal tracts provide ipsilateral innervation
vestibulospinal
reticulospina;
which extrapyramidal tracts provide contralateral innervation
rubrospinal
tectospinal
what can cause optic neuritis
CIS
MS
Infection e.g. limes, HIV, syphillis
B12 defieincy
what are first line drugs for treating benign essential tremor
propanolol
primidone
what investigation can help differentiate between benign essential tremor and early Parkinson’s and why
DAT scan
binds to dopamine transporters on dopaminergic neurone which can identify nigrostriatal degeneration
what test is important in a myasthenia crisis
forced vital capacity
what causes friedreichs ataxia
atrophy of the dorsal root ganglia and thinning of the dorsal roots
how is papilitis differentiated from papilloedema of raised ICP
vision loss in papilitis
how can you differentiate a fixed dilated pupil caused by a squeeze on parasympathetic fibres of the 3rd nerve from a blind eye
test for an indirect pupillary reflex
what pattern of weakness is typically associated with myopathies
proximal
asymmetrical
when a nerve gets ‘squashed’, what is the general sequence of damage to the nerve in regards to motor and sensory demyelination and axonal loss
sensory demyelination, sensory axonal loss, motor demyelination, motor axonal loss
what causes a wrist drop
compression of the radial nerve at the spiral groove of the humerus
what are the 2 ways foot drop can occur
compression of the peroneal nerve at the neck of the fibular
L4/5 radiculopathy
2 commonest causes of generalised axonal neuropathy in the UK
diabetes
alcohol
what are the features of an ataxic gait
wide based
falls
can’t walk heel to toe
often worse in dark or when eyes closed
what is the dose of aspirin given for a stroke and how long is this continued for
300mg, continued for 2 weeks
gold standard imaging for a stroke
diffusion weighted MRI
what medication is given for secondary prevention of a stroke
75mg of clopidogrel
80mg of atorvastatin
what is ruptured in a subdural haemorrhage and what does it look like on CT
bridging veins
crescent shaped, not limited by cranial sutures
in what patients are subdural haemorrhages most often seen
elderly or alcoholics
what is ruptured in an extradural haemorrhage and what does it look like on cT
middle meningeal artery in temper-parietal region
biconvex shape, limited by cranial sutures
what is the typical history of an extradural haemorrhage
young person, head injury, ongoing headache, improvement in neurological status than rapid decline
what is the typical history of an extradural haemorrhage
young person, head injury, ongoing headache, improvement in neurological status than rapid decline
what do you get in a 6th cranial nerve palsy
internuclear opthalmoplegia
conjugate lateral gaze disorder
what is given to treat an MS relapse
500mg Methylprednisolone
what is Ramsay hunt syndrome
caused by varicella zoster virus, causes a unilateral lower motor neurone facial nerve palsy, painful and tender vesicular rash in ear
when do you typically see Lambert Eaton syndrome
in patients with small cell lung cancer
what is the pathophysiology behind Lambert eaton syndrome
immune system releases antibodies against voltage gaited calcium channels in small cell lung cancer cells, also target calcium channels in the pre-synaptic terminals of neuromuscular junction. less acetylcholine released, less muscle contraction
presentation of Lambert eaton syndrome
proximal muscle weakness - notably of legs and eyes
diplopia, ptosis and dysphagia
what is post-tetanic potentiation
patients with Lambert eaton syndrome have reduced tendon reflexes. reflexes become temporarily normal after a period of strong muscle contraction
treatment for Lambert eaton syndrome
amifampridine
what is Charcot Marie tooth
inherited disease - typically autosomal dominant affecting peripheral motor and sensory nerves - dysfunction in myelin or axons
classical features of Charcot Marie tooth disease
pes cavus - high foot arches
distal muscle wasting - ‘inverted champagne bottle legs’
loss of ankle dorsiflexion
what are other causes of peripheral neuropathy other than Charcot Marie tooth disease
A - alcohol
B - vitamin B12 deficiency
C - Cancer and Chronic Kidney Disease
D - Diabetes and Drugs (amiodarone, isoniazid, cisplatin)
E - Every vasculitis
what is the presentation of Guillain-Barre syndrome
symmetrical ascending weakness
reduced reflexes
peripheral loss of sensation or neuropathic pain
may progress to cranial nerves and cause facial weakness
what criteria can be used to diagnose Guillain Barre syndrome
brighton
what is neurofibromatosis
genetic condition causing benign nerve tumours
how is neurofibromatosis type 1 caused
mutations in NF1 gene on chromosome 17. codes for protein called neurofibromin which is a tumour suppressor gene
diagnosis for neurofibromatosis
2 out of the following CRABBING
- Cafe au lait spots > 5mm in children, 15mm in adults
- Relative with NF1
- Axillary or inguinal freckling
- Bony dysplasia like Bowing of a long bone or sphenoid wing dysplasia
- Iris hamartomas
- Neurofibromas
- Glioma of optic nerve
how is neurofibromatosis type 2 caused
found on chromosome 22. codes for protein called merlin which is a tumour suppressor gene particularly in Schwann cells
what is commonly associated with neurofibromatosis type 2
bilateral acoustic neuromas
what is tuberous sclerosis
genetic condition whose characteristic features are the production of hamartomas
what are the 2 mutations of tuberous sclerosis
TSC1 gene on chromosome 9 which codes for hamartin
TSC2 gene on chromosome 16 which codes for tuberin
skin signs seen in tuberous sclerosis
ash leaf spots
shagreen patches
angiofibromas
subungual fibromata
cafe au lait spots
poliosis
classical presentation for tuberous sclerosis
epilepsy and skin features
how to differentiate a presentation of foot drop in L5 radiculopathy and a common perineal palsy
in peroneal palsy eversion is affected whereas in radiculopathy there is weakness in ankle inversion
what is the nerve and muscle likely affected if a patient had a ‘claw hand’
radial nerve and hypothenar muscle
what is the first line treatment for trigeminal neuralgia
carbemazepine
typical effect on an ischaemic stroke in the anterior circulation
contralateral lower limb weakness
typical effect on an ischaemic stroke in the middle circulation
hemiparesis of lower contralateral face, speech impairment, contralateral weakness
typical effect of an ischamic stroke in the posterior circulation
acute vision loss, memory loss
typical presentation of progressive bulbar palsy
dysarthria, dysphagia, nasal regurgitation of fluids and choking - LMN lesions
factors that would indicate a pathogen in CSF sample is bacterial rather than viral
increased neutrophils, increased protein levels, decreased glucose, cloudy appearance
contraindications for performing a lumbar puncture
raised ICP, coagulopathy, focal neurology, infection at site of LP, decreased GCS
appearance of cells from temporal biopsy in giant cell arteritis
multinucleate giant cells
would would happen to someone who suddenly stopped taking prednisolone
adrenal crisis
acute treatment for cluster headache
100% O2
sumatriptan
prophylaxis for cluster headache
verapamil
most common infectious cause of encephalitis
herpes simplex virus type 1
diagnostic test for encephalitis
lumbar puncture with CSF viral PCR testing
what nerve palsy would cause a down and out appearance
occulomotor
what nerve palsy would cause an adducted eye
abducens
what areas are protected from chemotherapy
CNS and testes1
where is the lesion that causes gait ataxia
cerebellar vermis
preferred test for patient with suspected TIA
diffusion weighted MRI
Diagnostic test for Guillain barre
lumbar puncture
what would you see in lumbar puncture for Guillain barre
normal wcc, raised protein
what drugs can worsen myasthenia graves
beta blockers
what is Weber’s syndrome
ventral midbrain syndrome
ipsilateral CN III palsy and contralateral hemiparesis
what is Creutzfeldt-Jakob disease
rapidly progressing neurological condition caused by prion proteins
features of CJD
myoclonus
dementia
what is seen on EEG in CJD
Biphasic high amplitude sharp waves
what is seen on MRI in CJD
hyper intense signals in basal ganglia and thalamus
how do you differentiate between Parkinsons and multiple system atrophy
MSA will have unilateral symptoms and autonomic dysfunction e.g. postural hypotension, erectile dysfunction
what is a pituitary apoplexy
sudden enlargement of the pituitary - usually macroandenoma, secondary to haemorrhage or infarction
diagnostic investigation for pituitary apoplexy
MRI
what is given in pituitary apoplexy
IV hydrocortisone
preferred way to support nutrition in MND
peg
what can you get if you have had an injury at or above C6
autonomic dysreflexia
what can be the trigger for autonomic dysreflexia
urinary retention
faecal impaction
presentation of autonomic dysreflexia
extreme hypertension
flushing and sweating above lesion
agitation
what blood test can differentiate between a true seizure and a pseudoseizure
prolactin
when can you consider stopping anti-epileptic drugs
if seizure free > 2 years and weaned over 2-3 months
where is the lesion causing lateral medullary syndrome
posterior inferior cerebellar artery
symptoms of lateral medullary syndrome
cerebellar signs
ipsilateral facial numbness
Horner’s syndrome
contralateral sensor loss
what would you give pre-hospital in status epilepticus
PR diazepam
buccal midazolam
what is narcolepsy associated with
HLA-DR2
features of narcolepsy
typical onset - teenage years
hypersomnolence
cataplexy
sleep paralysis
vivid hallucinations when going to sleep/waking up
investigation for narcolepsy
multiple sleep latency EEG
management of narcolepsy
daytime stimulants - modafinil
night-time sodium oxybate
what would a CT show in herpes simplex encephalitis
temporal lobe changes
management for idiopathic intracranial hypertension
acetazolamide and advise weight loss
what do you give is clopidogrel is contraindicated/not tolerated
modified release dipyridamole
Cushings triad
hypertension
bradycardia
wide pulse pressure
investigation for acoustic neuroma
MRI of cerebellopontine angle
is bells palsy an upper or lower motor neurone lesion
lower
where would a lesion be if a patient were presenting as being ‘locked in’
basilar
how long does a cluster headache typically last
15 minutes to 2 hours
what do you get in Brown Sequard syndrome
ipsilateral weakness and loss of proprioception/vibration
contralateral loss of pain/temperature
what is Brown Sequard a result of
lateral hemisection of the spinal cord
where would the lesion be in an inferior homonymous quadrantanopia
superior optic radiations in parietal lobe
where would the lesion be in a superior homonymous quadrantanopia
inferior optic radiations in temporal lobe - Meyers loop
what does a painful 3rd nerve palsy indicate
posterior communicating artery aneurysm
triad of normal pressure hydrocephalus
dementia/bradyphrenia
urinary incontience
gait abnormality - similar to Parkinsons
what is likely to be seen on MRI in normal pressure hydrocephalus
ventriculomegaly without sulcal enlargement
what is cataplexy
sudden and transient loss of muscular tone caused by a strong emotion e.g. laughter
what would you give for chemotherapy induced nausea
ondansetron
what type of dementia is associated with MND
frontotemporal
what is Arnold-Chiari malformation
downward displacement/herniation of the cerebellar tonsils through the foramen magnum
features of Arnold-Chiari malformation
non-communicating hydrocephalus
headache
syringomyelia
how is carotid artery stenosis diagnosed
duplex ultrasound
what score measures disability or dependance on ADLs after a stroke
Barthel index
most common complication following meningitis
sensorineural hearing loss
what type of headache responds to indomethacin
paroxysmal hemicrania
what can cause subacute degeneration of the spine
replacing folate deficiency before replacing vitamin B12
when would you see an empty delta sign on venography
sagittal sinus thrombosis
what artery is affected in amaurosis fugax
retinal or ophthalmic
what nerve is damaged if you can’t abduct your thumb
median
what nerve is damaged if you can’t extend your wrist
radial
what nerve is damaged if you have weakness of ring/little fingers
ulnar
first line investigations for suspected acoustic neuroma
audiogram and gadolinium-enhanced MRI head
triad of lewy body dementia
REM sleep disorder, falls and hallucinations
deterrent from drinking alcohol treatment
disulfiram
what type of hallucination is most suggestive of delirium tremens
lillputian
what is Charcot neurological triad
symptoms associated with MS
dysarthria
nystagmus
intention tremor
criteria for diagnosing MS
mcdonald
scoring criteria for ALS
El escoria
1st line management in spinal cord compression
dexamethasone
1st line for generalised tonic-clonic seizures
males - sodium valproate
females - lamotrigine/levetericetam
1st line for focal seizures
lamotrigine or levetericetam
2nd line for focal seizures
carbamazepine
1st line for absence seizures
ethosuximide
2nd line for absence seizures
male - sodium valproate
females - lamotrigine or levetericetam
what anti epileptic medication may trigger absence seizures
carbamazepine
1st line for myoclonic seizures
males - sodium valproate
females - levetericetam
1st line for tonic/atonic seizures
males - sodium valproate
females - lamotrigine
common side effect of triptan use
tightening of chest/throat
what is syringomyelia
collection of CSF within spinal cord
what is the most common type of brain tumour
metastases
what types of cancer often metastasise to the brain
lung
bowel
breast
kidney
skin
most common primary brain tumour in adults
glioblastoma
prognosis of glioblastoma
poor around a year
imaging of a glioblastoma
solid tumours with central necrosis
rim that enhances with contrast
histology of glioblastoma
pleomorphic tumour cells border necrotic area
treatment/management of glioblastoma
surgery with chemo/radiotherapy
dexamethasone to treat oedema
what is the second most common primary brain tumour in adults
meningioma
what are meningiomas
typically benign
arise from arachnoid cap cells of the meninges and are next to dura
where are meningiomas typically located
falx cerebri
superior saggital sinus
convexity or skull base
what is seen on histology in a meningioma
spindle cells in concentric whorls and calcified psammoma bodies
what is seen on histology in a vestibular schwannoma
Antoni A or B patterns
Verocay bodies
what is the most common brain tumour in children
pilocytic astrocytoma
what is seen on histology in a pilocytic astrocytoma
Rosenthal fibres
(corkscrew eosinophilic bundle)
what is a medulloblastoma
aggressive paediatric brain tumour that arise from the infratentorial compartment and spreads through the CSF
seen on histology in medulloblastoma
small, blue cells
rosette pattern of cells with many mitotic figures
what is an ependymoma
commonly seen in the 4th ventricle
what is seen on histology in an ependymoma
perivascular pseudorosettes
what is an oligodendroma
benign slow growing tumour common in frontal lobes
what is seen on histology in an olgodendroma
calcifications with fried egg appearance
what is an haemangioblastoma
vascular tumour of cerebellum associated with VHL
what is seen on histology in a haemangioblastoma
foam cells and high vascularity
what is a craniopharyngioma
most common paediatric supratentorial tumour
solid/cystic tumour of seller region derived from remnants of Rathke’s pouch
how could a cranipharyngioma present
hormonal disturbance
symptoms of hydrocephalus
bitemporal hemianopia
1st line treatment for autoimmune encephalitis
corticosteroid e.g. pred
IvIg
2nd line treatment for autoimmune encephalitis
rituximab
plasma exchange
where is the lesion to cause Wernickes aphasia
superior temporal gyrus
what is an ergot and non-ergot derived dopamine agonist
ergot - bromocriptine
non-ergot - ropinerole
what has been damaged in syringomyelai
anterior white comissure due to compression of the spinothalamic tracts
what does riluzole do
prevents stimulation of glutamate receptors
MS investigation
MRI with contrast
