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3rd year medicine > Neuro guidelines > Flashcards

Neuro guidelines Flashcards

1
Q

investigations following first seizure

A

EEG and brain MRI

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2
Q

investigation to determine true from pseudoseizure

A

raised serum prolactin for a couple hours

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3
Q

when do you NORMALLY start AEDs?

A

After second seizurE

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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

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5
Q

driving ban after 1st seizure

A

6 months

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6
Q

how long do you need to be seizure free for to drive if you have epilepsy

A

12 months

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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)

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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

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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

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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

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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

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12
Q

Mx for drug induced parkinsonism

A

procyclidine

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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)

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14
Q

Acute relapse of MS Mx

A

IV methylprednisolone for 5d, shortens flares

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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

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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

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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
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18
Q

when are anticholinesterses CI in alzheimers

A

DONEPEZIL is CI bradycardia. not the others

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19
Q

name 3 anticholinesterases for AD

A

galantaine

rivastigmine (can be given as patch if not able to swallow)

donepezil

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20
Q

what is 1st and 2nd line in AD

A

1st = anticholinesterases 2nd = memantine

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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

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22
Q

Lewy body dementia Tx

A

same as AD

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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

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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

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25
Q

Immediate Mx of haemorhagic stroke

A

control BP to 100-120 with labetolol and consult neurosurgery

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26
Q

Ongoing Mx of ischaemic stroke

A

After 2w, stop aspirin and give clopidogrel lifelong 75mg

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27
Q

What is clopidogrel is CI, what do you give for long term secondary preventions

A

aspirin + dipyridamole

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28
Q

DVT prophylaxis of stroke in hospital

A

intermitten pneumatic calf devices

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29
Q

when do you do a carotid endarterectomy after a stroke

A

if stenosis >50%

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30
Q

when do you start a statin after a stroke

A

if cholesterol >3.5

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31
Q

ABCD2 score

A

for TIA age >60 BP 140>90 clinical features = speech 1p, unilateral weakness 2p duration (10-59m, 60+m) = 1 and 2 points diabetes

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32
Q

immediate management of TIA

A

300mg aspirin

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33
Q

when do you NOT give 300mg aspirin in a TIA and what do you do in those cases

A

anti coagulated/bleeding disorder –> admit for head CT already on low dose aspirin –> just continue at same dose until TIA appointment

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34
Q

when do you arrange TIA appointment

A

crescendo TIA = discuss admission now TIA in last 7d = assessment within 24 hours TIA >7d ago = assessment within 7d

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35
Q

drug for life in TIA?

A

Yes, clopidogrel 75mg as in stroke

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36
Q

first line sedative in delerium

A

0.5mg haloperidol CI in PD so use lorazepam instead

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37
Q

investigation for meningitis

A

Serum PCR and blood culture LP unless CI (meningococcal septicaemia or raised ICP)

turbid CSF

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38
Q

think its meningitis and you’re a GP?

A

Give IM benzylpenicillin as long as it doesn’t delay transfer to hospital

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39
Q

empirical Abx for menignitis in hospital depending on age

A

<3m = cefotaxime + amoxicillin 3m-50y = ceftriaxone/cefotaxime >50y = ceftriaxone/cefotaxime + amoxicillin

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40
Q

IV antibiotic for specific meningitis bug: - meningiococcal - pneumococcal/hamophilus - listeria –what else do you give to everyone

A
  • M = benzylpenicillin + cefotaxime - P/H = cefotaxime - L = amoxicillin + gentamicin You give dexamethasone alongside first dose of antibiotic to everyone to reduce neuro complication rate
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41
Q

how do you confirm a SAH has occurred

A

1st do CT head if negative, check CSF for xanthchromia (yellow CSF) at least 12 hours later

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42
Q

management for SAH when waiting for surgery

A

strict bed rest, stool softness, no straining, BP control

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43
Q

medical management for SAH after surgery

A

21 days nimodipine (CCB) to prevent vasospasm

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44
Q

presentation and Mx of vasospasm post SAH

A

presents 4-9d after surgery for SAH with focal deficits +/- reduced cognitive function triple H therapy - hypervolaemia, induced hypertension, haemodilution

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45
Q

1st line Ix for Lyme disease

A

ELISA for antibodies against burrelia burgdorferi can diagnose clinically if symptoms present and bull eye erythema migrans present

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46
Q

Mx of Lyme: - early - disseminated

A

early = doxycycline disseminated = ceftriaxone beware of Jarisch-Herxheimer reaction

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47
Q

Encephalitis best Ix two other Ixs

A

Best = MRI shows hyperdensitiy in temporal lobe EEG shows lateralised periodic discharges at 2Hz CSF shows lymphocytosis and elevated protein

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48
Q

Mx of encephalitis

A

IV aciclovir as most common cause is HSV1

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49
Q

trigeminal neuralgia

presentation

Mx when do you refer

A

any stimulation of nerve (sensation of face) elicits excruciating pain

carbamazepine

refer if <50yo or fails to respond to above

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50
Q

Bells palsy Mx time cutoff for Tx

A

1mg/kg 10d prednisolone eye care give within 72 hours for best effect

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51
Q

myasthenia gravis presentation

Best Ix

other Ix needed

A

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

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52
Q

Mx for Myaesthenia gravis - flare

A

flare = prednisolone

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53
Q

Mx for Myaesthenia gravis - ongoing - how do you monitor respiratory function

A

ongoing = antcholinesterase inhibitor long acting:

  • pyridostigmine first line

immunosuppression may be used: pred initially

thymectomy

Monitor with FVC

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54
Q

Mx for Myaesthenia gravis - crisis

A

plasmapheresis and IV immunoglobulin

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55
Q

Guillain barre syndrome: - LP - nerve conduction studies - antibody

A
  • LP shows isolated protein rise (normal WCC)
  • nerve conduction studies (slow response due to demyelination)
  • anti-GM1
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56
Q

GBS Mx

A

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

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57
Q

MND Ix

A

Normal nerve conduction study EMG shows few APs with normal amplitude + fibrillation

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58
Q

Mx for MND

A

riluzole and BiPAP at night

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59
Q

acute Mx of migraine 1st and 2nd line

A

1st = NSAID + oral triptan + paracetamol ——-> if <17yrs old use nasal triptan instead 2nd = non-ral metoclopromide/prochlorperazine (beware of dystonic reaction)

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60
Q

cutoff for migraine prophylaxis frequency

A

2+ per month

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61
Q

migraine prophylaxis Mx 1st and 2nd line adjunct?

A

1 = propranolol (or topiramate if not woman of childbearing age) 2 = acupuncture —> can also use riboflavin as adjunct

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62
Q

cluster headache acute Mx

A

100% oxygen and subcut triptan

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63
Q

prophylaxis cluster headache

A

verapamil

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64
Q

tension headache acute Mx

A

NSAID, paracetamol

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65
Q

Tension headache propylaxis

A

acupuncture (NOT amitriptyline which is often used)

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66
Q

When do you do a head CT within 1 hour after a head injury

A

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

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67
Q

when do you do a head CT within 8 hours after a head injury

A

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)

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68
Q

lumbar puncture anatomy

A

iliac crests

L3/4 , L4/5

termination of spinal cord:

adult: L1
baby: L3

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69
Q

lumbar puncture analysis

A
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70
Q

21

photophobic

pyrexial

headache

protein raised

glucose low

white cell raised

pressure: raised

diagnosis

A

bacterial meningitis

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71
Q

37

worst headache ever

lumbar puncture:

protein normal

glucose normal

WCC normal

opening pressure normal

appearance:

xanthochromia - yellow CSF

diagnosis?

A

subarachnoid haemorrhage

  • can get xanthochromia - yellow CSF
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72
Q

GBS presentation

A

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

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73
Q

causes of bilateral facial nerve palsy

A

sarcoidosis

guillain-Barre syndrome

lyme disease

bilateral acoustic neuromas (as in neurofibromatosis type 2)

Bell’s palsy (mostly unilateral)

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74
Q

cause of unilateral facial nerve palsy

A

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

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75
Q

interpretation of pupillary findings in head injuries

A
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76
Q

diagnosis

most likely affected people

A

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

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77
Q

diagnosis

A

subarachnoid haemorrhage

blood seen within CSF spaces

most likely berry aneurysm rupture in circle of willis

thunderclap headache

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78
Q

diagnosis

A

intracerebral haemorrhage

surrounding low density due to oedema

history of intractable HTN

sudden onset severe posterior headache

dysphasia (difficulty speaking) and vomiting

right hemiparesis

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79
Q

diagnosis

A

cerebral metastesis

multiple ‘ring-enhancing lesions’ due to cerebral mets

known hx of lung cancer

increasing headaches and clumsiness

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80
Q

diagnosis

A

glioma

large enhancing mass invades corpus callosum and crosses midline

headaches

visual field defect

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81
Q

diagnosis

A

meningioma

large enhancing mass

makes broad contact with meningeal surface

headaches - worse in morning

loss of balance

increasingly irritable

increased tone on right

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82
Q

diagnosis

A

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

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83
Q

diagnosis

A

skull mets

multiple destructive (lytic) bone lesions of skull due to bone mets

known hx of breast cancer

headaches and palpable lumps on scalp

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84
Q

diagnosis

A

acute infarct

string sign - dense middle cerebral artery due to thrombus

acute onset right hemiparesis

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85
Q

diagnosis

A

old infarct -MCA territory

goes low density (dark) when infarcted area dies

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86
Q

diagnosis

A

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

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87
Q

management of head injury

A

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

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88
Q

common side effect after lumbar puncture

A

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

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89
Q

syncope classification

A

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

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90
Q

investigations for syncope

A

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

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91
Q

diabetic neuropathy Mx

A

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

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92
Q

what is cervical spondylosis

A

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)
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93
Q

Mx for cervical spondylosis

A

NSAIDs

corticosteroid injections

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94
Q

most common complication of meningitis

A

sensorineural hearing loss

infective: sepsis, intracerebral abscess
pressure: brain herniation, hydrocephalus

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95
Q

cerebral abscess presentation

A

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
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96
Q

cerebral abscess Ix and Mx

A

medical emergency

Ix: CT

Mx: CT-guided aspiration through hole in skull

aspiration MC&S

empirical abx/ antifungals

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97
Q

symptoms of raised intracranial pressure

A
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98
Q

benign (idiopathic) intracranial hypertension

links?

A

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

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99
Q

chronic benign intracranial hypertension

Ix and Mx

A

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

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100
Q

what is motor neurone disease

presentation

A

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
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101
Q

types of motor neurone disease

A

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

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102
Q

what is bulbar palsy

A

paralysis of muscles of swallowing and speech

–> dysphagia + dysphasia

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103
Q

Mx for ALS type MND

A

riluzole

for treatment of ALS MND

for slowing progression

no cure

quinine for muscle cramps

baclofen for stiffness, spasticity, increased tone

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104
Q

measuring resp function after diagnosis of MND

A

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
Q

neurofibromatosis types and chromosome mutations

A

both inherited autosomal dominant

two types:

  • NF1 (von Recklinghausen’s syndrome):

chromosome 17 mutation

  • NF2:

chromosome 22 mutation

106
Q

neurofibromatosis features

A

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
Q

differences between neurofibromatosis and tuberous sclerosis

A

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
Q

multiple sclerosis

tingling in hands which comes on when flexes neck

sign?

A

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
Q

multiple sclerosis features

A

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
Q

is Bells palsy U/LMN

do you get forehead sparing

A

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
Q

Mx of Bells palsy

A

prednisolone 1mg/kg for 10 days within 72hrs of onset (not after)

can give artificial tears and eye lubricants

112
Q

weakness to left hand

wasting of hypothenar eminence

weakness of finger abduction

weakness of thumb adduction

which nerve affected

113
Q

which nerve is damaged in claw hand

A

ulner nerve

claw hand: hyperextension of metacarpophalangeal joints and flexion at distal and proximal interphalangeal joints of 4th and 5th digits

114
Q

what signs do you get with ulner damage at wrist

A

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
Q

damage to ulner nerve at elbow features

A

same as damage at wrist +

  • ulner paradox (clawing is more severe in distal lesions therefore at elbow less severe)

radial deviation of wrist

116
Q

what makes an essential tremor worse

A

essential tremor worse on outstretched hand

often strong Fhx

117
Q

first line mx for essential tremor

what else makes it better

A

first line Mx: propanolol

other: alcohol makes it better

118
Q

what is the frequency of a pill rolling tremor

119
Q

how long can a cluster headache last

A

btwn 15mins to 2hrs

120
Q

what are timings of migraines

121
Q

features of migraine

A

one sided headache

patient lying still

potential photophobia / phonophobia

vomiting

122
Q

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

A

trigeminal neuralgia

patient would not be clutchin pain as so sensitive

123
Q

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

A

cluster headache

124
Q

mx of cluster headache

A

acute:

  • 100% O2
  • s/c triptan
    prophylaxis: verapamil (CCB)
125
Q

mx of ischaemic stroke

A

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
Q

Mx of ischaemic stroke >6hrs onset

A

if >6hrs onset cant do thrombolysis or thrombectomy

aspirin 300mg orally or rectally ASAP if haemorrhagic stroke excluded

127
Q

secondary prevention of stroke

A

after 14days

clopidogrel 75mg

if clopidogrel CI then aspirin + dipridamole

if cholesterol >3.5 = statin (atorvastatin 20-80mg)

target systolic BP< 130

128
Q

how long can you not drive for after a stroke

129
Q

when to do a carotid artery endartectomy after stroke

A

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
Q

ptosis + dilated pupil + eye deviated ‘down and out’

what nerve palsy

A

third nerve palsy (occulomotor)

131
Q

ptosis + constricted pupil

diagnosis

A

Horner’s

constricted pupil: miosis

132
Q

what is webers syndrome

A

ipsilateral third nerve palsy (occulomotor) with contralateral hemiplegia - caused by midbrain strokes

133
Q

Mx for trigeminal neuralgia

A

first line: carbamazepine 100mg DB

134
Q

features of parkinsonism

A

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
Q

weight loss + tremor

pulse: 102

diagnosis

A

thyrotoxicosis

tachycardia

fine tremor when hands outstretched

weight loss

136
Q

COPD + flap when arms both outstretched

diagnosis

A

CO2 retention

137
Q

which seizures can you display automatism (unaware of what youre doing/ unresponsiveness) and emptional disturbance

A

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
Q

loses consciousness immediately

falls to ground

stiffens and straightens limbs alternatively

during seizure bites tongue

type of seizure

A

tonic clonic

139
Q

young boy

occasional periods where he stares blankly in class

diagnosis

A

absence seizure

140
Q

next most important step in mx for bells palsy after prescribing prednisolone

A

prescribe artificial tears and advise eye taping at night

141
Q

wide based gait + loss of heel to toe walking

most likely location of patients lesion

A

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
Q

shuffling gait

diagnsois

A

parkinsons

hesitant motion, short, small steps and reduced arm swinging

143
Q

what is wrong in a high stepping gait

A

neuropathic gait

occurs when patient loses function of ankle dorsiflexor muscles

to prevent toes from dragging, patients lift feet higher during swing phase

144
Q

problem in trendelenburg gait

A

when hip abductors are too weak to stabilise leg in swing phase

waddling appearance

145
Q

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

A

multiple sclerosis

visual loss likely 2ndry to optic neuritis

Mx: referral to neurology

146
Q

stiffness and pain in left shoulder started 1 month ago

similar episode that self resolved

global restriction of shoulder movement particularly external rotation

diagnosis

A

adhesive capsulitis (frozen shoulder)

restriction of shoulder movements

  • especially external rotation

Mx: early physiotherapy

147
Q

features of degenerative cervical myelopathy

A

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
Q

degenerative cervical myelopathy Ix and Mx

A

Ix: MRI - gold standard

Mx: urgent referral to spinal surgery - decompressive surgery

149
Q

LOC + rapid recovery + short post-ictal period

diagnosis

150
Q

todd’s paresis

A

weakness after LOC –> seizure

can affect one part of body or the whole body

typically resolves within 48hrs

151
Q

6months - 5yrs old

early during viral infection

temp rises rapidly

seizure bried and generalised tonic/tonic-clonic

diagnosis

A

febrile convulsion

152
Q

what is the peak time incidence of alcohol withdrawal seizure

A

36hrs following cessation of alcohol

153
Q

epileptic seizure Ix and mx

A

Ix:

after 1st seizure: EEG + MRI

Mx:

following 2nd epileptic seizure

generalised seizures: sodium valproate

partial seizures: carbamazepine

154
Q

what do you have to think about in Mx of epilepsy

A

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
Q

second line med for generalised/ partial seizures

side effect

A

lamotrigine

side effect: stevens-Johnsons syndrome

156
Q

side effect of carbamazepine

A

used as first line for partial seizures

main side effect: leucopenia + agranulocytosis

157
Q

main side effect of sodium volproate

A

teratogenic

158
Q

acute management of seizures

A

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
Q

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?

A

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
Q

parkinsons disease mx

A

clinical diagnosis

Mx:

  • motor symptoms affecting QOL: levodopa
  • not affecting QOL: dopamine agonist, levodopa, or monoamine oxidase B inhibitor (MAO-B)
161
Q

which conditions can you get from not taking parkinsons meds properly

A

acute akinesia or neuroleptic malignant syndrome

162
Q

which antiparkinson drug has the highest chance of inhibition disorders

A

dopamine agonist therapy

163
Q

what can happen if you stop levodopa acutely

mx to stop this

A

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
Q

DVLA guidence on provoked seizure by head injury for bus driver

A

must inform DVLA and await guidence before driving again

165
Q

syncope DVLA guidelines

A

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
Q

facial and contralateral body loss of pain sensation

nystagmus

ataxia

diagnosis?

which artery affected

A

lateral medullary syndrome

most often due to a posterior inferior cerebellar artery (PICA) stroke

on same side as facial symptoms

affects brain stem

167
Q

facial and contralateral body loss of pain sensation

nystamus

ataxia

same sided facial weakness

loss of hearing

which artery stroke?

A

anterior inferior cerebellar artery infarct

168
Q

locked in syndrome

which artery infarct

A

basilar artery infarct

locked in: patient unable to move or communicate but is fully conscious

169
Q

contralateral hemiparesis and sensory loss

lower extremity >upper

which artery infarct

A

anterior cerebral artery

170
Q

contralateral hemiparesis and sensory loss

upper extremity > lower

contralateral homonymous hemianopia

aphasia

infarct which artery

A

middle cerebral artery

171
Q

contralateral homonymous hemianopia with macular sparing

visual agnosia

infarct which artery

A

posterior cerebral artery

homonymous hemianopia (with macula sparing) = occipital lesion

172
Q

visual field defect for pituitary gland tumour

A

pituitary tumour = bitemporal hemianopia, upper quadrant defect

lower quadrant = superior chiasmal compression (craniopharyngioma)

173
Q

visual field defect in open angle glaucoma in right eye

A

unilateral peripheral visual field loss

174
Q

extensive stroke with right sided hemiplegia

what side would the homonymous hemianopia be on

which side is the lesion

A

right side

homonymous hemianopia on same side as paresis

lesion is contralateral (left side)

175
Q

homonymous quadrantanopias

A

PITS

parietal: inferior
temporal: superior

to find out lesion in either parietal or temporal

176
Q

incongrous defects and congruous defects

A

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
Q

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

A

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
Q

bilateral acoustic neuroma is seen in which type of neurofibromatosis

A

neurofibromatosis 2

179
Q

investigation of choice for vestibular schwannoma (acoustic neuroma)

A

MRI of cerebellopontine angle

180
Q

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

A

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
Q

most common primary brain tumour

A

glioblastoma multiforme

poor prognosis

on imaging: solid tumour with central necrosis and rim that enhances with contrast

182
Q

which cancer is most likely to cause brain mets

A

lung cancer

also

breast

bowel

skin (melanoma)

kidney

183
Q

diagnosis

A

glioblastoma multiforme

peripherally enhancing lesion

necrosis inside

184
Q

diagnosis

A

meningioma

well circumscribed

dural tail where tumor connects to dura

185
Q

recent parkinsonism diagnosis + associated autonomic disturbance (atonic bladder, postural hypotension, erectile dysfunction)

A

multisystem atrophy

with recent parkinsons diagnosis

idiopathic parkinsons disease can also cause autonomic instability but usually very late development

186
Q

chronic HTN

unconsciousness

reduced GCS

quadraplegia

miosis (constriction)

absent horizontal eye movements

A

pontine haemorrhage

complication 2ndry to chronic HTN

187
Q

TACI vs PACI

A

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
Q

what does this show

A

homonymous hemianopia (of right side)

189
Q

what visual defect?

A

homonymous hemianopia with macular sparing

from posterior infarcts

190
Q

visual defect?

A

bitemporal hemianopia

upper quadrant defect = pituitary adenoma

lower quadrant defect = craniopharyngioma

191
Q

lacunar infarcts (LACI)

A

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
Q

posterior circulation infarcts (POCI)

A

presents with 1 of the following

cerebellar or brainstem syndrome

loss of consciousness

isolated homonymous hemianopia

193
Q

amyotrophic lateral sclerosis

A

associated with mixed UMN and LMN signs (usually no sensory deficits)

194
Q

Charcot-Marie-Tooth syndrome

A

hereditary

sensory and motor peripheral neuropathy

LMN signs in all limbs

reduced sensation (more pronounced distally)

195
Q

fasciculations

which disease

A

motor neuron disease

196
Q

mixed UMN and LMN signs

no sensory deficit

which type of motor neurone disease

A

amyotrophic lateral sclerosis

197
Q

Ix for motor neurone disease

A

clinical diagnosis

normal motor conduction in conduction studies - exlcudes neuropathy

MRI to exclusee cervical cord compression and myelopathy

198
Q

neck stiffness

photophobia

fever

altered mental state

diagnosis

A

encephalitis

altered mental status = encephalitis

cerebral function intact = meningitis

199
Q

what should you prescribe for all cases of suspected encephalitis

A

acyclovir IV

  • to cover herpes simplex virus (HSV) -1 infection
200
Q

uses of carbamazepine

A

epilepsy - particularly partial seizures (1st line Mx)

trigeminal neuralgia

bipolar disorder

ineffective in absence seizures

201
Q

CT head scan

hypodense collection around convexity of brain not limited to suture lines

A

chronic subdural haematoma

hypotense: darker = chronic
hyperdense: lighter = acute

not limited to sutures = subdural

limited to sutures = extradural

202
Q

Ix and Mx for acute subdural haematoma

A

Ix: CT

Mx:

  • monitoring of intracranial pressure
  • decompressive craniectomy
203
Q

Ix and Mx of chronic subdural haematoma

A

Ix: CT (hypodense)

Mx:

  • if incidental or no symptoms: conservative
  • if confused + neurological deficit = surgical decompression with Burr holes
204
Q

neuroleptic malignant syndrome bloods

A

raised CK

leukocytosis

raised CK due to rhabdomyolysis

can lead to kidney damage therefore can have hyperkalaemia and hypocalcaemia

206
Q

typical features of neuroleptic malignant syndrome

A

tetrad

fever

muscle rigidity

autonomic instability: hypertension, tachycardia, tachypnoea

altered mental state

207
Q

Mx of neuroleptic malignant syndrome

A

stop antipsychotic

IV fluids to stop renal failure

208
Q

differences between serotonin syndrome and neuroleptic malignant syndrome

209
Q

GCS scoring

A

if testing motor response to pain (in supraorbital region)

arm must be brought above clavicle for localising otherwise will be scored as flexing

210
Q

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

A

phenytoin

gingival hyperplasia (overgrowth of gum)

lymphadenopathy

peripheral neuropathy

dyskinesia

monitoring:

  • trough levels immediately before dose if:

adjustment

suspected toxicity

non-adherence

211
Q

DVLA dementia

A

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
Q

most common complication following meningitis

A

sensorineural hearing loss

  • hearing tests routinely performed to assess for this
213
Q

diagnosis of Meningitis

A

if partially treated with abx

negative CSF culture

glucose, protein and wcc unchanged

214
Q

what should a patient presenting to GP within 7 days of clinically suspected TIA get

A

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
Q

most important next step for patient presenting with TIA that has a bleeding disorder or is taking anticoagulant

A

needs immediate admission for imaging to exclude haemorrhage

216
Q

reflexes nerve roots

217
Q

when is Bells palsy more common

218
Q

isolated hemisensory loss

A

lacunar infarct

219
Q

homonymous hemianopia with macular sparing

A

posterior cerebral artery infarct

221
Q

degenerative cervical myelopathy features

A

loss of fine motor function in both upper limbs

delay in diagnosis

222
Q

multiple sclerosis features

A

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
Q

Mx degenerative cervical myelopathy

A

decompressive surgery

224
Q

headache triggered by cough, valsalva (breathing out against closed mouth and nose), sneeze or exercise

A

raised ICP until proven otherwise

LP contraindicated

225
Q

ascending weakness following an infection

diagnosis

A

Guillain-Barre syndrome

progressive ascending weakness to akk four limbs

back/ leg pain

after gastroenteritis infection - caused by campylobacter jejuni

226
Q

Guillain-Barre syndrome Ix

A

lumbar puncture - rise in protein with normal white blood cell count

nerve conduction studies may be performed

227
Q

trigeminal neuralgia red flags suggesting serious underlying cause

A

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
Q

brain abscess mx

A

IV 3rd gen cephalosporin (ceftriaxone) + metronidazole

229
Q

cranial nerves

230
Q

main side effect of levodopa

A

dyskinesia

231
Q

what side effect can you get from stopping levodopa abruptly

A

acute dystonia

use patch if patient cant take orally

232
Q

what should levodopa be taken with

A

levodopa + carbidopa or benserazide (stops peripheral conversion of levodopa to dopamine)

233
Q

man stares into space

non responsive

then repeatedly smacks his lips and appears to be chewing

lasts for around 1 min

A

focal impaired awareness seizure

  • not aware of surroundings whilst having seizure
  • include automatims (lip smacking, picking at clothes, fumbling)
  • wandering
234
Q

focal aware seizure

A

fully awake, alert, able to recall events during seizure

some are frozen

usually last 1-2 mins

235
Q

absence seizure

A

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

237
Q

wernicke’s aphasia - which part of brain affected

A

temporal lobe lesion

  • results in word substitution and neologisms (new words)

speech still fluent

238
Q

expressive (Broca’s aphasia) - which part of brain affected

A

frontal lobe

  • speech non-fluent, laboured, halting
240
Q

when can you consider stopping antiepileptics

A

can be considered if seizure free for >2yrs

AED stopped over 2-3 months

241
Q

aniscoria worse in bright light

left pupil smaller than right

which anatomical location most likely damaged

A

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
Q

topiramate contraindication use for prophylaxis of migraine

A

teratogenic

243
Q

parkinsons mx

A

L-dopa + carbidopa/ benserazide

if cant eat: dopamine agnoists

apomorphine injection

rotigotine patch - works after 12hrs

244
Q

temporal lobe petechial haemorrhages

aphasia

fever

headache

confusion

A

herpes simplex encephalitis (HSV-1)

most likely affects temporal lobe

therefore aphasia

fever, headache, psychiatric symptoms, seizures, vomiting

Mx: IV acyclovir

245
Q

vet

cervical lymphadenopathy

malaise

for two weeks

negative EBV serology

A

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
Q

tests for glandular fever

A

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

248
Q

definitive ix for degenerative cervical myelopathy

A

MRI cervical spine

250
Q

vision worse going down stairs

251
Q

cause of blown pupil from head trauma

A

extrdural haemorrhage

transtentorial herniation - ipsilateral dilated pupil - affects occulomotor nerve

252
Q

what type of ventilation can be used to help raised ICP

A

hyperventilation –> reduced CO2 –> vasoconstriction of cerebral arteries –> reduced ICP

253
Q

wernicke’s aphasia lesion location

A

fluent speech but abnormal comprehesion

-

location: superior temporal gyrus

254
Q

brocas (expressive) aphasia

A

non-fluent speech, laboured, halting

normal comprehension

location: inferior frontal gyrus
- supplied by left MCA

255
Q

in status epilepticus what do you need to rule out before thinking of other causes

A

rule out hypoxia and hypoglycaemia

  • do capillary blood glucose

O2

256
Q

obese young female with headaches and blurred vision

+ papilloedema

A

idiopathic intracranial HTN (BP can be normal)

257
Q

laughter –> fall/ collapse

258
Q

common trigger for cluster headaches

A

acohol

also noctural sleep

more common in men and smokers

259
Q

urinary incontinence

gait ataxia

dementia

A

normal pressure hydrocephalus

wet, wobbly and whacky

3rd year medicine (31 decks)

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