Neuro guidelines Flashcards
1
Q
investigations following first seizure
A
EEG and brain MRI
2
Q
investigation to determine true from pseudoseizure
A
raised serum prolactin for a couple hours
3
Q
when do you NORMALLY start AEDs?
A
After second seizurE
4
Q
what would make you start AEDs after a first seizure
A
EEG shows unequivocal epileptiform activity There is a structural abnormality on brain MRI There is a persisting neurological deficit Family or family considers risk of second seizure unacceptable
5
Q
driving ban after 1st seizure
A
6 months
6
Q
how long do you need to be seizure free for to drive if you have epilepsy
A
12 months
7
Q
1st line epilepsy meds: - generalised - absence - partial - pregnancy
A
generalised = valproate absence = valproate or ethosuximide partial = carbamazepine pregnancy = lamotrigine (usually 2nd line as well)
8
Q
status epilepticus and timing
A
0m = O2 and ABCDE 5m = buccal midaz or IV loraz 10m = IV lorazepam 15m = escalate + phenytoin 45m = intubate
9
Q
Parkinson’s investigations
A
clinical diagnosis Use DaT scan (SPECT) and MRI brian to exclude P+ syndromes and to ensure diagnosis if unsure
10
Q
1st line for PD and SE
A
if motor Sx = levodopa and carbidopa/benserazide if no motor Sx predominate = can chose from any SE = dyskinesia
11
Q
2nd line PD and SE
A
non-ergot derived dopamine agonists (bromocriptine, cabergoline, pergolide, ropinorole) SE = impulse, hallucinations MAO-Bi = seleginine. SE = ? COMTi = entacapone. SE = orange urine and diarrhoea
12
Q
Mx for drug induced parkinsonism
A
procyclidine
13
Q
investigations that help MS diagnosis
A
contrast brain MRI shows dawson fingers and periventricular plaques. McDonald criteria. CSF shows oligoclonal bands (doesn’t NEED to be present for diagnosis)
14
Q
Acute relapse of MS Mx
A
IV methylprednisolone for 5d, shortens flares
15
Q
1st line DMARD for MS and criteria to get it
A
beta interferon need 2 relapses in past 2 years and also be able to walk 10-100m unaided
16
Q
2nd line drugs for MS - glatiramer - natalizumab - fingolimod
A
glatiramer = immune decoy natalizumab = alpha4beta1 inhibitor preventing leucocyte transmission through the BBB fingolimod = sphingosine receptor modulator preventing lymphocytes leaving the lymph nodes
17
Q
Symptom treatment for MS: - fatigue - spasticity - bladder dysfunction - ossciloscopia
A
- fatigue = amantadine + CBT - spasticity = baclofen + gabapentin - bladder dysfunction –> residual volume = self catherisation –> no residual volume = anticholinergics - ossciloscopia = gabapentin
18
Q
when are anticholinesterses CI in alzheimers
A
DONEPEZIL is CI bradycardia. not the others
19
Q
name 3 anticholinesterases for AD
A
galantaine
rivastigmine (can be given as patch if not able to swallow)
donepezil
20
Q
what is 1st and 2nd line in AD
A
1st = anticholinesterases 2nd = memantine
21
Q
How do you treat Frontotemporal Dementia
A
You cant really. acetylcholinesterases/memantine don’t work because those systems aren’t affected the same way as AD and LBD
22
Q
Lewy body dementia Tx
A
same as AD
23
Q
ROSIER score
A
rule out of stroke in the emergency room any score of >0 means stroke is likely +1 = speech problem, face/arm/leg weakness, vision problem -1 = TLOC, seizure, syncope
24
Q
Immediate Mx of ischaemic stroke
A
Always = 300mg aspirin for 2 weeks within 4.5 hours = thrombolyse within 6 hours (or 24 if have done scan and ischaemic bit is still small) if MCA/ACA proximal = thrombectomy ALONGSIDE thrombolysis
25
Immediate Mx of haemorhagic stroke
control BP to 100-120 with labetolol and consult neurosurgery
26
Ongoing Mx of ischaemic stroke
After 2w, stop aspirin and give clopidogrel lifelong 75mg
27
What is clopidogrel is CI, what do you give for long term secondary preventions
aspirin + dipyridamole
28
DVT prophylaxis of stroke in hospital
intermitten pneumatic calf devices
29
when do you do a carotid endarterectomy after a stroke
if stenosis \>50%
30
when do you start a statin after a stroke
if cholesterol \>3.5
31
ABCD2 score
for TIA age \>60 BP 140\>90 clinical features = speech 1p, unilateral weakness 2p duration (10-59m, 60+m) = 1 and 2 points diabetes
32
immediate management of TIA
300mg aspirin
33
when do you NOT give 300mg aspirin in a TIA and what do you do in those cases
anti coagulated/bleeding disorder --\> admit for head CT already on low dose aspirin --\> just continue at same dose until TIA appointment
34
when do you arrange TIA appointment
crescendo TIA = discuss admission now TIA in last 7d = assessment within 24 hours TIA \>7d ago = assessment within 7d
35
drug for life in TIA?
Yes, clopidogrel 75mg as in stroke
36
first line sedative in delerium
0.5mg haloperidol CI in PD so use lorazepam instead
37
investigation for meningitis
Serum PCR and blood culture LP unless CI (meningococcal septicaemia or raised ICP)
turbid CSF
38
think its meningitis and you're a GP?
Give IM benzylpenicillin as long as it doesn't delay transfer to hospital
39
empirical Abx for menignitis in hospital depending on age
\<3m = cefotaxime + amoxicillin 3m-50y = ceftriaxone/cefotaxime \>50y = ceftriaxone/cefotaxime + amoxicillin
40
IV antibiotic for specific meningitis bug: - meningiococcal - pneumococcal/hamophilus - listeria --what else do you give to everyone
- M = benzylpenicillin + cefotaxime - P/H = cefotaxime - L = amoxicillin + gentamicin You give dexamethasone alongside first dose of antibiotic to everyone to reduce neuro complication rate
41
how do you confirm a SAH has occurred
1st do CT head if negative, check CSF for xanthchromia (yellow CSF) at least 12 hours later
42
management for SAH when waiting for surgery
strict bed rest, stool softness, no straining, BP control
43
medical management for SAH after surgery
21 days nimodipine (CCB) to prevent vasospasm
44
presentation and Mx of vasospasm post SAH
presents 4-9d after surgery for SAH with focal deficits +/- reduced cognitive function triple H therapy - hypervolaemia, induced hypertension, haemodilution
45
1st line Ix for Lyme disease
ELISA for antibodies against burrelia burgdorferi can diagnose clinically if symptoms present and bull eye erythema migrans present
46
Mx of Lyme: - early - disseminated
early = doxycycline disseminated = ceftriaxone beware of Jarisch-Herxheimer reaction
47
Encephalitis best Ix two other Ixs
Best = MRI shows hyperdensitiy in temporal lobe EEG shows lateralised periodic discharges at 2Hz CSF shows lymphocytosis and elevated protein
48
Mx of encephalitis
IV aciclovir as most common cause is HSV1
49
trigeminal neuralgia
presentation
Mx when do you refer
any stimulation of nerve (sensation of face) elicits excruciating pain
carbamazepine
refer if \<50yo or fails to respond to above
50
Bells palsy Mx time cutoff for Tx
1mg/kg 10d prednisolone eye care give within 72 hours for best effect
51
myasthenia gravis presentation
Best Ix
other Ix needed
autoimmune antibodies to acetylcholine receptors --\> insufficient functioning
symptoms worse when fatigued, better in morning after rest
presentation:
- ptosis (**drooping** of eye)
diplopia (**double vision**)
face muscle weakness
dysphagia (**difficulty swallowing**)
weak arms, legs or neck
shortness of breath and occasionally serious breathing difficulties
- muscle weakness (peripherally in later stages)
**Best = single fibre EMG** (trace decreases in amplitude with receptive stimulation)
others = CT chest to **exclude thymoma**
antibodies to acetylcholine receptors 85-95% patients
Tensilon test (IV edrophinium) NOT used anymore
52
Mx for Myaesthenia gravis - flare
flare = prednisolone
53
Mx for Myaesthenia gravis - ongoing - how do you monitor respiratory function
ongoing = antcholinesterase inhibitor long acting:
- pyridostigmine first line
immunosuppression may be used: pred initially
thymectomy
Monitor with FVC
54
Mx for Myaesthenia gravis - crisis
plasmapheresis and IV immunoglobulin
55
Guillain barre syndrome: - LP - nerve conduction studies - antibody
- LP shows isolated protein rise (normal WCC)
- nerve conduction studies (slow response due to demyelination)
- anti-GM1
56
GBS Mx
IVIG
plasma exchange (plasmapheresis) – an alternative to IVIG where a machine is used to filter your blood to remove the harmful substances that are attacking your nerves
57
MND Ix
Normal nerve conduction study EMG shows few APs with normal amplitude + fibrillation
58
Mx for MND
riluzole and BiPAP at night
59
acute Mx of migraine 1st and 2nd line
1st = NSAID + oral triptan + paracetamol -------\> if \<17yrs old use nasal triptan instead 2nd = non-ral metoclopromide/prochlorperazine (beware of dystonic reaction)
60
cutoff for migraine prophylaxis frequency
2+ per month
61
migraine prophylaxis Mx 1st and 2nd line adjunct?
1 = propranolol (or topiramate if not woman of childbearing age) 2 = acupuncture ---\> can also use riboflavin as adjunct
62
cluster headache acute Mx
100% oxygen and subcut triptan
63
prophylaxis cluster headache
verapamil
64
tension headache acute Mx
NSAID, paracetamol
65
Tension headache propylaxis
acupuncture (NOT amitriptyline which is often used)
66
When do you do a head CT within 1 hour after a head injury
GCS \<15 2 hours after injury GCS \<13 on clerking focal neurological deficit post-traumatic seizure 2+ episodes of vomiting open or depressed skull fracture
67
when do you do a head CT within 8 hours after a head injury
Need to have some loss of consciousness and: - be over 65 - be on warfarin or have bleeding disorder - have 30mins amnesia before event - dangerous mechanism of injury (struck by vehicle, ejected from vehicle, fall \>1m/5 stairs)
68
lumbar puncture anatomy
iliac crests
L3/4 , L4/5
termination of spinal cord:
adult: L1
baby: L3
69
lumbar puncture analysis
70
21
photophobic
pyrexial
headache
protein raised
glucose low
white cell raised
pressure: raised
diagnosis
bacterial meningitis
71
37
worst headache ever
lumbar puncture:
protein normal
glucose normal
WCC normal
opening pressure normal
appearance:
xanthochromia - yellow CSF
diagnosis?
subarachnoid haemorrhage
- can get xanthochromia - yellow CSF
72
GBS presentation
**muscle weakness**
**ascending weakness** lower extremities first but proximal muscles earlier than distal ones
**reflexes reduced**/absent
**numbness/tingling**
back/leg pain
immune response causing **demyelination of peripheral nerves**
often triggered by infection (**Campylobacter jejuni**) - hx of gastroenteritis
can be treated
73
causes of bilateral facial nerve palsy
sarcoidosis
guillain-Barre syndrome
lyme disease
bilateral acoustic neuromas (as in neurofibromatosis type 2)
Bell's palsy (mostly unilateral)
74
cause of unilateral facial nerve palsy
bilateral causes can also be unilateral
lower motor neuron:
**Bells palsy**
**Ramsay-Hunt syndrome** (due to herpes zoster- rash in ear)
acoustic neuroma
parotid tumours
HIV
multiple sclerosis (may also be UMN palsy)
diabetes mellitus
Upper motor neuron: (**forehead sparing)**
**stroke**
75
interpretation of pupillary findings in head injuries
76
diagnosis
most likely affected people
chronic subdural haemorrhage
chronic as darker (infarct of cells)
patients on anticoagulation
alcoholics
old people
patients with bleeding disorders
with fall
slower onset of symptoms than extradural
can be chronic or acute
77
diagnosis
subarachnoid haemorrhage
blood seen within CSF spaces
most likely berry aneurysm rupture in circle of willis
thunderclap headache
78
diagnosis
intracerebral haemorrhage
surrounding low density due to oedema
history of intractable HTN
sudden onset severe posterior headache
dysphasia (difficulty speaking) and vomiting
right hemiparesis
79
diagnosis
cerebral metastesis
multiple 'ring-enhancing lesions' due to cerebral mets
known hx of lung cancer
increasing headaches and clumsiness
80
diagnosis
glioma
large enhancing mass invades corpus callosum and crosses midline
headaches
visual field defect
81
diagnosis
meningioma
large enhancing mass
makes broad contact with meningeal surface
headaches - worse in morning
loss of balance
increasingly irritable
increased tone on right
82
diagnosis
scalp haematoma
swelling of scalp soft tissues
if you see scalp haematoma, check for underlying skull fracture and intracranial haemorrhage
direct blunt trauma to right side of head
scalp swelling and bleeding
83
diagnosis
skull mets
multiple destructive (lytic) bone lesions of skull due to bone mets
known hx of breast cancer
headaches and palpable lumps on scalp
84
diagnosis
acute infarct
string sign - dense middle cerebral artery due to thrombus
acute onset right hemiparesis
85
diagnosis
old infarct -MCA territory
goes low density (dark) when infarcted area dies
86
diagnosis
extradural haemorrhage with contracoup injury
lens shaped collection of blood: extradural haemorrhage
usually from damage to middle meningeal artery
runs behind pterion (weakest part of skull)
post traumatic intracranial haemorrhage at site of impact = coup injury
can have contracoup injury on opposite side of brain to site of impact - caused by acceleration-deceleration forces at time of injury
fall fron height with direct trauma to left side of head
87
management of head injury
whilst waiting for surgery may need IV mannitol/furosemide if rising ICP
surgery
diffuse cerebral oedema may require decompressive craniotomy
depressed skull fracture: if open require surgical reduction and debridement
ICP monitoring appropriate: GCS 3-8 and normal CT
ICP monitoring mandatory: GCS 3-8 and abnormal CT
hyponatraemia most likely due to syndrome of inappropriate ADH secretion
minimum cerebral perfusion pressure in adults: 70mmHg
minimum cerebral perfusion pressure in children: 40-70mmHg
88
common side effect after lumbar puncture
post lumbar puncture headache
24-48hrs following LP
may last several days
worsens in upright position
improves with recumbent position
more common in young females and with low BMI
Mx:
- if pain continues \>72hrs: blood patch, epidural saline, intravenous caffeine
to prevent subdural haematoma
89
syncope classification
reflex syncope (most common):
- vasovagal (fainting): emotion, pain, stress
situational: cough, micturition, gastrointestinal
carotid sinus syncope
orthostatic syncope:
- primary autonomic failure: parkinsons, lewy body dementia
- secondary autonomic failure: diabetic neuropathy
drug induced: diuretics, alcohol, vasodilators
volume depletion: haemorrhagic, diarrhoea
cardiac syncope:
- arrhythmias
structural: valvular, MI
PE
90
investigations for syncope
cardio exam
postural BP:
- symptomatic fall in systolic BP\>20 or diastolic BP\>10
- or decrease in systolic BP\<90
considered diagnostic
ECG
carotid sinus massage
tilt table test
24h ECG
91
diabetic neuropathy Mx
sensory loss
first line Mx: amitriptyline, duloxetine, gabapentin or pregabalin
if one doesnt work try one of the others
tramadol : rescue therapy for exaccerbations of neuropathic pain
92
what is cervical spondylosis
extremely common
age-related wear and tear affecting the spinal disks in your neck - osteoarthritis of neck
neck pain
referred pain may mimic headache
complications:
- radiculopathy (pinched nerve)
- myelopathy (injury to spinal cord due to compression)
93
Mx for cervical spondylosis
NSAIDs
corticosteroid injections
94
most common complication of meningitis
sensorineural hearing loss
infective: sepsis, intracerebral abscess
pressure: brain herniation, hydrocephalus
95
cerebral abscess presentation
high temp
Increased ICP symptoms:
- headache in single section of head
- seizures
- nause and vomiting
- stiff neck
- changes in vision
- changes in mental state
- problems with nerve function
96
cerebral abscess Ix and Mx
medical emergency
Ix: CT
Mx: CT-guided aspiration through hole in skull
aspiration MC&S
empirical abx/ antifungals
97
symptoms of raised intracranial pressure
98
benign (idiopathic) intracranial hypertension
links?
overweight - more common in overweight women in 20s/30s
endocrine problems
meds: abx, steroids, COCP
lack of red blood cells (iron deficiency anaemia) or too many RBCs (polycythaemia)
CKD
lupus
99
chronic benign intracranial hypertension
Ix and Mx
Ix: CT
lumbar puncture
Mx:
- lose weight
- stop meds causing symptoms
take off contraceptive
diuretics
oral pred to relieve headaches and reduce risk of vision loss
regular lumpar punctures to remove excess fluid from spine
100
what is motor neurone disease
presentation
affects motor neurones --\> muscle weakness
risk factor: frontotemporal dementia
presentation:
- muscle weakness - decreased dexterity, falls trips
- dysphagia, dysphasia, tongue fasciculations (bulbar presentation)
- muscle weakness, wasting, twitching
- breathing problems- SOB
- fatigue, excessive daytime sleepiness
- may include behavioural changes, emotional lability, frontotemporal dementia
101
types of motor neurone disease
**amyotrophic lateral sclerosis (ALS)**: most common
- both upper and lower motor neurones affected
- limb muscle weakness and wasting
- stiffness
- over-active reflexes
- speech and swalllowing signs later affected
progressive bulbar palsy (PBP)
- speech and swallowing
- when ALS begins in muscles of speech and swallowing it is PBP (muscles of speech and swallowing as nerves that control these are in the bulb)
- limb muscles may later be affected
progressive musclar atrophy
- much slower progression and longer survival
lower motor neurones affected
if it moves to upper limbs = ALS
primary lateral sclerosis
upper motor neurones
very rare
102
what is bulbar palsy
paralysis of muscles of swallowing and speech
--\> dysphagia + dysphasia
103
Mx for ALS type MND
riluzole
for treatment of ALS MND
for slowing progression
no cure
quinine for muscle cramps
baclofen for stiffness, spasticity, increased tone
104
measuring resp function after diagnosis of MND
O2 sats
forced vital capacity
and/or sniff nasal inspiratory pressure and/or maximal inspiratory pressure
if severe bulbar impairment or cognitive impairment that affects resp:
- O2 sats
- dont need to do other tests
repeat tests every 2-3 months
105
neurofibromatosis types and chromosome mutations
both inherited autosomal dominant
two types:
- NF1 (von Recklinghausen's syndrome):
chromosome 17 mutation
- NF2:
chromosome 22 mutation
106
neurofibromatosis features
NF1:
- cafe-au-lait spots (\>=6, 15mm in diameter)
- axillary/groin freckles
- peripheral neurofibromas
- iris hamatomas (Lisch nodules) in \>90%
- scoliosis
- pheochromocytomas
NF2
- bilateral vestibular schwannomas (acoustic neuroma) (deafness, vertigo)
- multiple intracranial schwannomas
mengiomas and ependymomas
107
differences between neurofibromatosis and tuberous sclerosis
Neurofibromatosis:
- cafe-au-lait spots (can be in tuberous sclerosis but more common in neurofibromatosis)
- axillary/ groin freckles
- pheochromocytomas
- iris hamartomas (Lisch nodules)
- NF2: acoustic neuromas
tuberous sclerosis:
- ash leaf spots
- adenoma sebaceum
- shagreen patches
- subungal fibromata
- epilepsy
- retinal hamartomas
108
multiple sclerosis
tingling in hands which comes on when flexes neck
sign?
Lhermitte's sign = indicates disease near dorsal column nuclei of cervical cord
also seen in subacute combined degeneration of cord and in cervical stenosis
109
multiple sclerosis features
clinical diagnosis
\>= 2 relapses plus either:
- clinical evidence of two or more lesions
- or one lesion + reasonable historical evidence of previous relapse
visual:
- optic neuritis: common presenting feature
Uhthoff's phenomenon: worseing of vision following rise in body temp
sensory:
- pins and needles
- numbness
- trigeminal neuralgia
- Lhermittes syndrome: paraesthesiae in limbs on neck flexion
motor: spastic weakness: most commonly in legs
cerebellar:
- ataxia: in acute relapse
- tremor
110
is Bells palsy U/LMN
do you get forehead sparing
its lower motor neurone
the entire side of the patients face is affected (no forehead sparing)
reduced reflexes
still have facial sensation
hypersensitivity to sound
111
Mx of Bells palsy
prednisolone 1mg/kg for 10 days within 72hrs of onset (not after)
can give artificial tears and eye lubricants
112
weakness to left hand
wasting of hypothenar eminence
weakness of finger abduction
weakness of thumb adduction
which nerve affected
113
which nerve is damaged in claw hand
ulner nerve
claw hand: hyperextension of metacarpophalangeal joints and flexion at distal and proximal interphalangeal joints of 4th and 5th digits
114
what signs do you get with ulner damage at wrist
claw hand
wasting and paralysis of intrinsic hand muscles (except lateral two - big two)
wasting and paralysis of hypothenar muscles
sensory loss to medial 1 1/2 fingers
115
damage to ulner nerve at elbow features
same as damage at wrist +
- ulner paradox (clawing is more severe in distal lesions therefore at elbow less severe)
radial deviation of wrist
116
what makes an essential tremor worse
essential tremor worse on outstretched hand
often strong Fhx
117
first line mx for essential tremor
what else makes it better
first line Mx: propanolol
other: alcohol makes it better
118
what is the frequency of a pill rolling tremor
4-6Hz
119
how long can a cluster headache last
btwn 15mins to 2hrs
120
what are timings of migraines
4-72hrs
121
features of migraine
one sided headache
patient lying still
potential photophobia / phonophobia
vomiting
122
2second -3min severe unilateral pain on head/face
evoked by light touch (e.g. wind, washing, shaving, talking) can cause sharp shooting pain (electric-shock like)
particularly susceptable areas: nasolabial fold, chin
diagnosis
trigeminal neuralgia
patient would not be clutchin pain as so sensitive
123
headaches in bursts lasting several weeks
usually once a year
each episode lasting 15mins -2hrs
intense sharp, stabbing pain around one eye
restless and agitated
redness, watering and lid swelling of same eye
diagnosis
cluster headache
124
mx of cluster headache
acute:
- 100% O2
- s/c triptan
prophylaxis: verapamil (CCB)
125
mx of ischaemic stroke
if \<4.5 of onset and excluded haemorrhagic via imaging: thrombolysis - alteplase
acute ischaemic stroke + confirmed occlusion of **proximal anterior circulation** (by CTA or MRA) =
**thrombectomy (within 6hrs onset**) + **thrombolysis (if within 4.5hrs** onset)
ishaemic stroke btwn **6-24hrs onset** + confirmed occlusion of **proximal anterior circulation + confirmed potential to salvage brain tissue** =
thrombectectomy
126
Mx of ischaemic stroke \>6hrs onset
if \>6hrs onset cant do thrombolysis or thrombectomy
aspirin 300mg orally or rectally ASAP if haemorrhagic stroke excluded
127
secondary prevention of stroke
after 14days
**clopidogrel 75mg**
if clopidogrel CI then aspirin + dipridamole
if **cholesterol \>3.5 = statin** (atorvastatin 20-80mg)
target systolic BP\< 130
128
how long can you not drive for after a stroke
4 weeks
129
when to do a carotid artery endartectomy after stroke
recommended if patient had stroke or TIA in carotid territory and not severely disabled
if carotid stenosis \>70% (ECST criteria)
or \>50% (NASCET criteria)
130
ptosis + dilated pupil + eye deviated 'down and out'
what nerve palsy
third nerve palsy (occulomotor)
131
ptosis + constricted pupil
diagnosis
Horner's
constricted pupil: miosis
132
what is webers syndrome
ipsilateral third nerve palsy (occulomotor) with contralateral hemiplegia - caused by midbrain strokes
133
Mx for trigeminal neuralgia
first line: carbamazepine 100mg DB
134
features of parkinsonism
resting pill rolling tremor - 4-6Hz
bradykinesia
rigidity
flexed posture
short shuffling steps
micrographia (writing gets smaller as writing)
mask like face (emotionless)
depression and dementia are common
may be hx of anti-psychotic use
135
weight loss + tremor
pulse: 102
diagnosis
thyrotoxicosis
tachycardia
fine tremor when hands outstretched
weight loss
136
COPD + flap when arms both outstretched
diagnosis
CO2 retention
137
which seizures can you display automatism (unaware of what youre doing/ unresponsiveness) and emptional disturbance
focal seizure with impaired awareness (also called complex focal seizure)
emotional disturbance
automatism
followed by post-ictal tiredness
absence seizures dont involve gross motor movement
focal aware seizures and absence seizures involve rapid recovery without spleepiness
138
loses consciousness immediately
falls to ground
stiffens and straightens limbs alternatively
during seizure bites tongue
type of seizure
tonic clonic
139
young boy
occasional periods where he stares blankly in class
diagnosis
absence seizure
140
next most important step in mx for bells palsy after prescribing prednisolone
prescribe artificial tears and advise eye taping at night
141
wide based gait + loss of heel to toe walking
most likely location of patients lesion
cerebellum
wide-based gait with loss of heel to toe walking is called an ataxic gait
cerebellar vermis = gait ataxia
cerebellar hemisphere = peripheral (finger-nose ataxia)
142
shuffling gait
diagnsois
parkinsons
hesitant motion, short, small steps and reduced arm swinging
143
what is wrong in a high stepping gait
neuropathic gait
occurs when patient loses function of ankle dorsiflexor muscles
to prevent toes from dragging, patients lift feet higher during swing phase
144
problem in trendelenburg gait
when hip abductors are too weak to stabilise leg in swing phase
waddling appearance
145
32yr F
3day hx altered sensation in left foot and right forearm
episode of visual blurring in right eye a few months ago which resolved after a few days
brisk reflexes
diagnosis
multiple sclerosis
visual loss likely 2ndry to optic neuritis
Mx: referral to neurology
146
stiffness and pain in left shoulder started 1 month ago
similar episode that self resolved
global restriction of shoulder movement particularly external rotation
diagnosis
**adhesive capsulitis (frozen shoulder)**
restriction of shoulder movements
- especially **external rotation**
Mx: early **physiotherapy**
147
features of degenerative cervical myelopathy
pain (neck, upper, lower limbs)
loss of motor function (loss of digital dexterity)
loss of sensory function - numbness
loss of autonomic function (urinary/ foecal incontinence)
Hoffman's sign: reflex test for cervical myelopathy (gently flicking one finger:
+ve result = reflex twitching of other fingers
148
degenerative cervical myelopathy Ix and Mx
Ix: **MRI** - gold standard
Mx: urgent referral to spinal surgery - decompressive surgery
149
LOC + rapid recovery + short post-ictal period
diagnosis
syncope
150
todd's paresis
weakness after LOC --\> seizure
can affect one part of body or the whole body
typically resolves within 48hrs
151
6months - 5yrs old
early during viral infection
temp rises rapidly
seizure bried and generalised tonic/tonic-clonic
diagnosis
febrile convulsion
152
what is the peak time incidence of alcohol withdrawal seizure
36hrs following cessation of alcohol
153
epileptic seizure Ix and mx
Ix:
after 1st seizure: EEG + MRI
Mx:
following 2nd epileptic seizure
generalised seizures: sodium valproate
partial seizures: carbamazepine
154
what do you have to think about in Mx of epilepsy
patients who drive:
- cant drive for 6months following seizure
- with established epilepsy must be fit free for 12 months before driving
patients taking other meds:
- can affect warfarin
women wanting to get pregnant:
- antiepileptics are teratogenic (esp sodium valproate)
- fine to breast feed
women taking contraception:
- can have effects on eachother
155
second line med for generalised/ partial seizures
side effect
lamotrigine
side effect: stevens-Johnsons syndrome
156
side effect of carbamazepine
used as first line for partial seizures
main side effect: leucopenia + agranulocytosis
157
main side effect of sodium volproate
teratogenic
158
acute management of seizures
if dont terminate after 5-10mins
rescue medication: Benzodiazepines (diazepam) rectally/ intranasally/under tongue
if they continue to fit after this = status epilepticus
medical emergency
further benzos, infusions of antiepileptics or use of general aneasthesia after 45mins
159
78yr
feels too young to be slowing down and using zimmer frame
fine tremor in one hand
6months
trouble picking up a pen
next step?
parkinsons disease
slowing down: bradykinesia
zimmer suggests balance problems
unilateral tremor
reduced fine motor control
diagnosed and mx initiated by elderly care doctor - urgent referral
160
parkinsons disease mx
clinical diagnosis
Mx:
- motor symptoms affecting QOL: levodopa
- not affecting QOL: dopamine agonist, levodopa, or monoamine oxidase B inhibitor (MAO-B)
161
which conditions can you get from not taking parkinsons meds properly
acute akinesia or neuroleptic malignant syndrome
162
which antiparkinson drug has the highest chance of inhibition disorders
dopamine agonist therapy
163
what can happen if you stop levodopa acutely
mx to stop this
levodopa should not be stopped acutely if patient is admitted
rescue medication to prevent acute dystonia: give dopamine agonist patch if levodopa cannot be taken orally
164
DVLA guidence on provoked seizure by head injury for bus driver
must inform DVLA and await guidence before driving again
165
syncope DVLA guidelines
simple faint: no restriction
single episode: explained and treated: 4 wks off
single episode unexplained: 6 months off
two or more episodes: 12 months off
166
facial and contralateral body loss of pain sensation
nystagmus
ataxia
diagnosis?
which artery affected
lateral medullary syndrome
most often due to a posterior inferior cerebellar artery (PICA) stroke
on same side as facial symptoms
affects brain stem
167
facial and contralateral body loss of pain sensation
nystamus
ataxia
same sided facial weakness
loss of hearing
which artery stroke?
anterior inferior cerebellar artery infarct
168
locked in syndrome
which artery infarct
basilar artery infarct
locked in: patient unable to move or communicate but is fully conscious
169
contralateral hemiparesis and sensory loss
lower extremity \>upper
which artery infarct
anterior cerebral artery
170
contralateral hemiparesis and sensory loss
upper extremity \> lower
contralateral homonymous hemianopia
aphasia
infarct which artery
middle cerebral artery
171
contralateral homonymous hemianopia with macular sparing
visual agnosia
infarct which artery
posterior cerebral artery
homonymous hemianopia (with macula sparing) = occipital lesion
172
visual field defect for pituitary gland tumour
**pituitary tumour = bitemporal hemianopia, upper quadrant defect**
lower quadrant = superior chiasmal compression (craniopharyngioma)
173
visual field defect in open angle glaucoma in right eye
unilateral peripheral visual field loss
174
extensive stroke with right sided hemiplegia
what side would the homonymous hemianopia be on
which side is the lesion
right side
homonymous hemianopia on same side as paresis
lesion is contralateral (left side)
175
homonymous quadrantanopias
PITS
parietal: inferior
temporal: superior
to find out lesion in either parietal or temporal
176
incongrous defects and congruous defects
incongruous defects (incomplete/ asymmetric visual field loss):
optic tract lesion
congrous defect (complete or symmetrical visual field loss):
optic radiation lesion or occipital cortex
177
vertigo + hearing loss (right ear) + tinnitus (right ear) + absent corneal reflex
hearing loss getting progressively worse over last 9 months
webers test lateralizes to left ear
diagnosis
acoustic neuroma
vestibular schwannoma includes a combination of **vertigo, hearing loss, (unilateral) tinnitus and an absent corneal reflex**
absent corneal reflex (lack of eyelid movement after touching eye with cotton wool)
178
bilateral acoustic neuroma is seen in which type of neurofibromatosis
neurofibromatosis 2
179
investigation of choice for vestibular schwannoma (acoustic neuroma)
MRI of cerebellopontine angle
180
27yr
severe morning headache associated with nausea
MRI: large tumour arising from falx cerebri and pushing on brain
well defined border btwn tumour and brain parenchyma
diagnosis
meningioma
typically benign tumours
develop from dura mater of meninges
- dont invade brain substance so cause symptoms by compression and are well defined
usually in falx cerebri, superior saggital sinus, convexity or skull base
181
most common primary brain tumour
glioblastoma multiforme
poor prognosis
on imaging: solid tumour with central necrosis and rim that enhances with contrast
182
which cancer is most likely to cause brain mets
lung cancer
also
breast
bowel
skin (melanoma)
kidney
183
diagnosis
glioblastoma multiforme
peripherally enhancing lesion
necrosis inside
184
diagnosis
meningioma
well circumscribed
dural tail where tumor connects to dura
185
recent parkinsonism diagnosis + associated autonomic disturbance (atonic bladder, postural hypotension, erectile dysfunction)
multisystem atrophy
with recent parkinsons diagnosis
idiopathic parkinsons disease can also cause autonomic instability but usually very late development
186
**chronic HTN**
unconsciousness
**reduced GCS**
**quadraplegia**
**miosis** (constriction)
absent horizontal eye movements
pontine haemorrhage
complication 2ndry to chronic HTN
187
TACI vs PACI
total anterior circulation infarcts (TACI)
- middle and anterior arteries
- unilateral hemiparesis and/or hemisensory loss of face, arm and leg
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphasia
partial anterior circulation infarcts (PACI)
- smaller arteries of anterior circulation
- 2 of above are present
188
what does this show
homonymous hemianopia (of right side)
189
what visual defect?
homonymous hemianopia with macular sparing
from posterior infarcts
190
visual defect?
bitemporal hemianopia
upper quadrant defect = pituitary adenoma
lower quadrant defect = craniopharyngioma
191
lacunar infarcts (LACI)
presents with 1 of the following
- unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three
- pure sensory stroke
- ataxic hemiparesis
192
posterior circulation infarcts (POCI)
presents with 1 of the following
cerebellar or brainstem syndrome
loss of consciousness
isolated homonymous hemianopia
193
amyotrophic lateral sclerosis
associated with mixed UMN and LMN signs (usually no sensory deficits)
194
Charcot-Marie-Tooth syndrome
hereditary
sensory and motor peripheral neuropathy
LMN signs in all limbs
reduced sensation (more pronounced distally)
195
fasciculations
which disease
motor neuron disease
196
mixed UMN and LMN signs
no sensory deficit
which type of motor neurone disease
amyotrophic lateral sclerosis
197
Ix for motor neurone disease
clinical diagnosis
normal motor conduction in conduction studies - exlcudes neuropathy
MRI to exclusee cervical cord compression and myelopathy
198
neck stiffness
photophobia
fever
altered mental state
diagnosis
encephalitis
altered mental status = encephalitis
cerebral function intact = meningitis
199
what should you prescribe for all cases of suspected encephalitis
acyclovir IV
- to cover herpes simplex virus (HSV) -1 infection
200
uses of carbamazepine
epilepsy - particularly partial seizures (1st line Mx)
trigeminal neuralgia
bipolar disorder
ineffective in absence seizures
201
CT head scan
hypodense collection around convexity of brain not limited to suture lines
chronic subdural haematoma
hypotense: darker = chronic
hyperdense: lighter = acute
not limited to sutures = subdural
limited to sutures = extradural
202
Ix and Mx for acute subdural haematoma
Ix: CT
Mx:
- monitoring of intracranial pressure
- decompressive craniectomy
203
Ix and Mx of chronic subdural haematoma
Ix: **CT (hypodense)**
Mx:
- if incidental or no symptoms: conservative
- if confused + neurological deficit = surgical decompression with **Burr holes**
204
neuroleptic malignant syndrome bloods
raised CK
leukocytosis
raised CK due to rhabdomyolysis
can lead to kidney damage therefore can have hyperkalaemia and hypocalcaemia
205
206
typical features of neuroleptic malignant syndrome
tetrad
fever
muscle rigidity
autonomic instability: hypertension, tachycardia, tachypnoea
altered mental state
207
Mx of neuroleptic malignant syndrome
stop antipsychotic
IV fluids to stop renal failure
208
differences between serotonin syndrome and neuroleptic malignant syndrome
209
GCS scoring
if testing motor response to pain (in supraorbital region)
arm must be brought above clavicle for localising otherwise will be scored as flexing
210
epilepsy review
medication change
reduced sensation in glove and stocking distribution
reduced ankle reflex
lymphadenopathy in cervical and inguinal region
bleeding around gums
which is most likely anti-epileptic
phenytoin
gingival hyperplasia (overgrowth of gum)
lymphadenopathy
peripheral neuropathy
dyskinesia
monitoring:
- trough levels immediately before dose if:
adjustment
suspected toxicity
non-adherence
211
DVLA dementia
legally obliged to tell DVLA if diagnosed with dementia
if patient is unable to do this such as not having mental capacity, doctor needs to tell DVLA asap
212
most common complication following meningitis
sensorineural hearing loss
- hearing tests routinely performed to assess for this
213
diagnosis of Meningitis
if partially treated with abx
negative CSF culture
glucose, protein and wcc unchanged
214
what should a patient presenting to GP within 7 days of clinically suspected TIA get
TIA: focal neurological deficit lasting \<24hrs (ischaemia without infarct)
300mg aspirin immediately
referral for specialist review within 24hrs
if already taking low-dose aspirin continue current dose until reviewed by specialist
215
most important next step for patient presenting with TIA that has a bleeding disorder or is taking anticoagulant
needs immediate admission for imaging to exclude haemorrhage
216
reflexes nerve roots
217
when is Bells palsy more common
pregnancy
218
isolated hemisensory loss
lacunar infarct
219
homonymous hemianopia with macular sparing
posterior cerebral artery infarct
220
221
degenerative cervical myelopathy features
loss of fine motor function in both upper limbs
delay in diagnosis
222
multiple sclerosis features
affects both sensory and motor
motor mostly UMN
dissociated sensory loss that is numbness at different unlinked sites
more common in women
usually presents before 45yrs
223
Mx degenerative cervical myelopathy
decompressive surgery
224
headache triggered by cough, valsalva (breathing out against closed mouth and nose), sneeze or exercise
raised ICP until proven otherwise
LP contraindicated
225
ascending weakness following an infection
diagnosis
Guillain-Barre syndrome
progressive ascending weakness to akk four limbs
back/ leg pain
after gastroenteritis infection - caused by campylobacter jejuni
226
Guillain-Barre syndrome Ix
lumbar puncture - rise in protein with normal white blood cell count
nerve conduction studies may be performed
227
trigeminal neuralgia red flags suggesting serious underlying cause
sensory changes
hearing loss
hx of skin or oral lesions
pain only in opthalmic division
optic neuritis
FHx of multiple sclerosis
age onset \<40yrs
Mx: urgent referral for specialist assessment if red flags
228
brain abscess mx
IV 3rd gen cephalosporin (ceftriaxone) + metronidazole
229
cranial nerves
230
main side effect of levodopa
dyskinesia
231
what side effect can you get from stopping levodopa abruptly
acute dystonia
use patch if patient cant take orally
232
what should levodopa be taken with
levodopa + carbidopa or benserazide (stops peripheral conversion of levodopa to dopamine)
233
man stares into space
non responsive
then repeatedly smacks his lips and appears to be chewing
lasts for around 1 min
focal impaired awareness seizure
- not aware of surroundings whilst having seizure
- include automatims (lip smacking, picking at clothes, fumbling)
- wandering
234
focal aware seizure
fully awake, alert, able to recall events during seizure
some are frozen
usually last 1-2 mins
235
absence seizure
children
staring into space, blank look
generalise seizure
usually a change in muscle tone and movement:
Blinking over and over that may look like fluttering of the eyelids
Smacking the lips or chewing movements
Rubbing fingers together or making other hand motions
236
237
wernicke's aphasia - which part of brain affected
temporal lobe lesion
- results in word substitution and neologisms (new words)
speech still fluent
238
expressive (Broca's aphasia) - which part of brain affected
frontal lobe
- speech non-fluent, laboured, halting
239
240
when can you consider stopping antiepileptics
can be considered if seizure free for \>2yrs
AED stopped over 2-3 months
241
aniscoria worse in bright light
left pupil smaller than right
which anatomical location most likely damaged
aniscoria = pupil of one eye differs in size from other
in bright light implies problem with dilated pupil (as should constrict in bright light)
right ciliary ganglion - decreased parasympathetic innervation of her right eye
242
topiramate contraindication use for prophylaxis of migraine
teratogenic
243
parkinsons mx
L-dopa + carbidopa/ benserazide
if cant eat: dopamine agnoists
apomorphine injection
rotigotine patch - works after 12hrs
244
temporal lobe petechial haemorrhages
aphasia
fever
headache
confusion
herpes simplex encephalitis (HSV-1)
most likely affects temporal lobe
therefore aphasia
fever, headache, psychiatric symptoms, seizures, vomiting
Mx: IV acyclovir
245
vet
cervical lymphadenopathy
malaise
for two weeks
negative EBV serology
acute toxoplasmosis
in immunocopetent patient can mimic EBV infection- low grade fever, generalised lymphadenopathy, prominant cervical lymph nodes, malaise
usually carried by cats
should be suspected in negative EBV serology
pregnancy testing and counselling is paramount due to risk of congenital toxoplasmosis
in immunocompromised patients can cause anaemia, seizures, chorioretinitis
EBV = glandular fever
246
tests for glandular fever
monospot test
serology testing:
- VCA IgM - positive in currently infected patients
- VCA IgG - appears in acute phase of infection and persists for life
EBNA IgG - seen 2-4months after infection - persists for life
247
248
definitive ix for degenerative cervical myelopathy
MRI cervical spine
249
250
vision worse going down stairs
251
cause of blown pupil from head trauma
extrdural haemorrhage
transtentorial herniation - ipsilateral dilated pupil - affects occulomotor nerve
252
what type of ventilation can be used to help raised ICP
hyperventilation --\> reduced CO2 --\> vasoconstriction of cerebral arteries --\> reduced ICP
253
wernicke's aphasia lesion location
fluent speech but abnormal comprehesion
-
location: superior temporal gyrus
254
brocas (expressive) aphasia
non-fluent speech, laboured, halting
normal comprehension
location: inferior frontal gyrus
- supplied by left MCA
255
in status epilepticus what do you need to rule out before thinking of other causes
rule out hypoxia and hypoglycaemia
- do capillary blood glucose
O2
256
obese young female with headaches and blurred vision
+ papilloedema
idiopathic intracranial HTN (BP can be normal)
257
laughter --\> fall/ collapse
cataplexy
258
common trigger for cluster headaches
acohol
also noctural sleep
more common in men and smokers
259
urinary incontinence
gait ataxia
dementia
normal pressure hydrocephalus
wet, wobbly and whacky
