Neuro last min stuff Flashcards
Treatment of Absence seizures?
1st - Valproate or Ethosuximide
2nd - topiramate or levetiracetam
Treatment of Atonic/Tonic-Clonic seizures?
1st - Valproate
Levetiracetam
Lamotrigine
Topiramate
Treatment of Myoclonic seizures?
1st - Valproate, Levetiracetam or Clonazepam
2nd - Lamotrigine, topiramate
Treatment for focal seizures?
1st - carbamazepine
2nd - Lamotrigine, valproate, topiramate
Parkinson’s treatment:
- gold standard?
- dopamine agonists?
- COMT inhibitors?
- MOAI?
- Why is apomorphine used?
Sinemet (levodopa + carbidopa)
D anon - Pramipexole, apomorphine, roprinirole
COMT - Entacapone
MOAI - Selegeline, rasageline
Apomorphine - sudden ‘off’ states
5 parkinson plus syndromes?
Progressive supra nuclear palsy:
- vertical gaze palsy, speech and swallowing problems
Multi-system atrophy:
- Autonomic dysfunction, cerebellar dysfunction
- MRI - hot cross bun sign due to pontine & cerebellar atrophy
Corticobasal degeneration:
- One limb is prominent, apraxia, alien-limb phenomenon
LBD:
- cognitive decline, hallucinations
Vascular parkinsonsim:
- predominantly lower limbs with gait disturbance, pyramidal signs and cognitive dysfunction
Wilson’s disease presentation?
Young, parkinsonism, behavioural change & cognitive decline, hepatic and renal failure, keyser-fleischer rings in eyes
Treatment of dystonia:
- general?
- Focal?
- acute?
general - Baclofen
focal - botulinum toxin
acute - procyclidine
How to differentiate MND from myasthenia graves and MS/neuropathy?
myasthenia - it doesn’t affect eyes
MS/neuropathy - no sensory involvement
4 types of MND and features?
ALS: most common
- UMN in legs, LMN in arms
PLS:
- UMN only - loss of benz cells in motor cortex
Spinal muscular atrophy:
- purely LMN - loss of anterior horn cells
Progressive bulbar palsy:
- LMN - Affects CN IX, X and XII first - drooling, dysphagia, aspiration
What is pseudo bulbar palsy?
What is it seen in?
UMN lesions affecting CNIX, X and XII
Can be seen as part of PLS, parkinson’s etc
(if mix or UMN and LMN then likely bulbar onset ALS)
Myasthenia Gravis:
- Rx?
- Crisis treatment?
Rx - pyridostigmine
Crisis - IV Ig or plasmapheresis
Neurophysiology for:
- myasthenia gravis?
- lambert eaton?
MG - single fibre jitter, low amplitude potentials, decreased twitches with repeated stimulation
LEMS - low frequency AP’s, increase in twitch amplitude with exercise, increase in fasciculation with exercise
Rx for lambert eaton?
3,4 - diaminopyradine
If acute: IV Ig
What is botulism?
Infection with clostridium botulinum
Toxin blocks Each presyaptic terminals
Present with flaccid paralysis - afebrile
Rx: anti-toxin
Stokes adams attack?
Pre-attack?
Attack?
Recovery?
Transient arrhythmia causing by reduced cardiac output and loss of consciousness - multiple times per day in any posture
pre: palpitations
attack: fall with LOC, pallor, slow/absent pulse
post: within seconds, flushing
Diagnosis of epilepsy?
Largely clinical
CT/MRI to rule out structural abnormality
Investigations for MS?
MRI - plaques of demyelination
LP - oligoclonal bands of IgG
Evoked potentials - delayed
MS symptom management:
- spasticity?
- Sensory? (numbness, tingling, pain)
- Bladder dysfunction?
- Fatigue?
spas - Baclofen, physio, OT
sens - amitriptyline, gabapentin, TENS, acupuncture
Bladder dysfunction - bladder training, oxybutynin
Fatigue - hyperbaric oxygen, modafinil
Relapse management in MS?
IV Methylprednisolone
Plasma exchange
Disease modifying drugs in MS:
- 1st line?
- 2nd line?
3rd line?
1st: Tecfedira, B interferon, Capaxone
2nd - Tysabari, Fingolimod
3rd - Mitoxantrone
Tecfedira/Tysbari SE?
reactivation of JC virus causing progressive multifocal leukoencephalopathy
5 causes of mono neuritis multiplex?
Diabetes Rheumatoid Carcinomatosis Vasculitis (Wegners, PAN) Infection (HIV, leprosy)
Difference between polyneuropathy and mononeuritis multiplex?
Polyneuropathy - symmetrical and widespread, usually glove & stocking, weakness, autonomic/cranial nerves can be affected too
Mono multi - 2 mononeuroopathies in distinct locations at same time
11 Causes of polyneuropathy?
metabolic, nutritional, vascular, infectious, drugs, malignancy
Diabetes Hypothyroidism Renal failure B12 deficiency Vasculitis (weighers, PAN) Rheumatoid Infection (HIV, Lyme, syphilis) Alcohol Isoniazid Chemo Paraneoplastic syndrome
Nerve conduction of neuropathy?
reduced response at peripheral and distal locations
Ix for guillian barre?
nerve conduction: slowed
LP: increased protein with normal WCC
Management of guillian barre?
IV Ig
Plasmapheresis
+/- ventilatory support
Inheritance of charcot marie tooth?
Presentation?
Nerve conduction?
Management?
AD
Around puberty
Progressive muscle weakness - inverted champagne bottle - foot drop/high stepping gait
May be sensory loss and loss of reflexes
Nerve: temporal dispersion with stimuli arriving at different times - if severe complete conduction block
Rx: physio
3 most common viral causes of meningitis?
Echo virus - most common
Enterovirus: coxsackie
Herpes simplex
More insidious onset
Who gets cryptococcal meningitis?
HIV/immunosuppression (think hookers)
Most common bacterial meningitis if:
- immunocompromised?
- Skull fracture?
- Surgery/open head wound?
- CSF shunt?
Pneumo, Meningo, listeria, TB, Gm -ve rods (+cryptococcal)
Pneumococcal, HiB, B-haemolytic GAS
Staph aureus/epidermidis, aerobic Gm -ve rods
Staph epidermidis/aureus, Gm -ve rods, proprionibacterium acnes
Kernig’s sign?
pain and resistance on passive extension of knee with flexed hip –> meningitis
Prophylaxis of meningitis?
Single dose Ciprofloxacin
OR
4 doses Rifampicin
How to differentiate meningitis from encephalitis?
Quick onset psychosis, odd behaviour, speech and memory problems
May be with/without meningism (neck stiffness, headache, photophobia)
Causes of encephalitis?
Herpes simplex
Varicella zoster
CMV/HIV
Bilateral temporal lobe enhancement?
HSV encephalitis
Management of viral meningitis?
Encephalitis?
meningitis - supportive
encephalitis - IV aciclovir
Presentation of brain abscess?
Raised ICP: headache, drowsiness
Focal neurological signs
Fever
Preceding skull fracture, endocarditis, sinusitis, dental abscess etc
Who gets progressive multifocal leukoencephalopathy? Cause? Presentation? Imaging/LP? Rx?
immunocompromised, MS drugs tysibari/tecfedira
Reactivation of JC virus
Demyelination symptoms, similar to MS
LP - JC DNA
imaging - multifocal enhancing lesions
No effective treatment
Acute relief of migraine?
Prophylaxis?
Paracetamol + NSAID or Triptan
Prophylaxis of >3 attacks per month:
1st - propanolol
2nd - amitriptyline/topiramate/gabapentin/valproate
Management of tension headache?
paracetamol/NSAID
discourage chronic use of analgesia
Relaxation therapy
Management of acute tension headache?
Prophylaxis?
1st - high flow oxygen
2nd - sc triptan
Prophylaxis - Verapamil
(topiramate 2nd)
Difference between paroxysmal hemicrania and cluster headache?
Both assoc w autonomic features
CH comes in clusters were will get most days for 1-3 months, PH doesn’t
Paroxysmal shorter (5-30 mins) cluster longer (30 mins-3 hours)
PH shows definitive response to Indomethacin
(if PH present for >3 months with attacks of greater intensity then hemicrania continua)
SUNCT?
attacks last seconds-10 mins
Numerous per day (up to 50-60)
Lamotrigine/Gabapentin
Treatment for Bells Palsy?
Prednisolone for 5 days if present within 72 hours
4 features of narcolepsy?
Treatment?
daytime somnolence cataplexy hypnagogic hallucinations sleep paralysis (also assoc w REM sleep disorders)
Modafinil - reduces daytime somnolence
Sodium oxybate - reduces cataplexy
Watershed stroke?
caused by sudden drop in BP - hypoperfusion to watershed zones
TACS?
PACS?
3 of:
- unilateral weakness +/- sensory loss
- homonymous hemianopia
- higher cerebral dysfunction e.g. dysphasia
PACS if 2 present - blockage of middle OR ant cerebral
POCS?
One of the following:
- isolated homonymous hemianopia
- cerebellar/brainstem syndromes, decreased consciousness (ataxia, facial weakness, nystagmus, diplopia)
- Confusion/mood changes
LACS?
- Purely sensory loss
- Ataxic hemiparesis
- Unilateral weakness +/- sensory symptoms in face, arms or legs
Presentation of intracranial venous thrombosis?
- saggital
- transverse
- cavernous sinus
saggital: headache, vomiting, seizure, reduced vision, papilloedema
transverse: headache +/- mastoid pain, seizures, focal signs, papilloedema
Cavernous sinus: CN III IV, V1, VI, sympathetic palsy, ophthalmoplegia, swollen conjunctiva/eyelids, proptosis, photophobia, raised ICP - commonly from spread of facial infection
How to acutely manage raised ICP?
- elevate head to 30-40 degrees
- mannitol
- hypertonic saline
- intubate and hyperventilate (reduce pCO2 so cerebral vasoconstriction so lower ICP)
Symptoms of hernia:
- subfalcine?
- Uncal?
- Tonsillar?
- lower limb weakness
- Ipsilateral CN III palsy
- ataxia, CNVI palsy, babinski sign, potentially life threatening due to brainstem compression
Management of restless leg syndrome?
Ropinirole (dopaminergic agent)
OR clonazepam
Neurotransmitter change in Huntington’s?
low GABA
low ACh
High Dopamine
Contraindications of forceps/ventouse?
mal-presentation i.e. breech
Absolute cephalopelvic disproportion