Neuro longs Flashcards
MS
-dx
-clinical features
-mx
-pregnancy
-ddx
DX:
Dissemination in time and space of episodes and lesions.
RRMS, PPMS, SPMS, benign MS, NMO (Aquaporin 4 ab), MOG (myelin oligodendrocyte glucoprotein ab)
MRI: T2 hyperintense.
Evoked potentials: visual, somatosensory, brainstem.
LP: oligoclonal bands, IgG
CLINICAL FEATURES:
-optic neuritis
-INO
-myelopathy
-lhermitte’s and uhthoff’s
-exercise induced
-trigeminal neuralgia
-painful spasms
-cerebellar
-UMN
MX:
Bladder
- Spasticity (baclofen)
- Urgency (amitriptyline)
Tic douleroux (carbamazepine)
Facial spasm (physio)
Intention tremor (propranolol, clonazepam)
DMTs: beta interferon, copolymer 1, natalizumab (progressive multifocal leucoencephalopathy, JC virus), IVIG, alemtuzumab (T/B cell depletion, ITP, thyroid dx, rare infections) / rituximab / ocrelizumab, mitoxantrone.
Oral: fingolimod, teriflunomide (TB, HTN, alopecia, diarrhoea), dimethyl fumarate
Autologous SCT.
Acute: steroids.
Pregnancy: copaxone / natalizumab, discontinue disease modifying therapy, teriflunomide X grade, caution GnRH protocol for IVF (increased MS).
DDX:
-NMOSD and MOG ab
-Inflammatory dx (SLE, sjogren, PAN)
-infectious (HIV, HTLV1, PML, syphilis, lyme)
-granulomatous (sarcoid, GPA)
-myelin (adrenoleukodystrophy, metachromatic leucodystrophy)
-other (SCA, vit B12 def, vascular dx, CADASIL).
Spinal cord injury complications
Respiratory
Cardiovascular
- Orthostatic hypotension
- Autonomic dysreflexia
Bladder
Bowel
Spasticity
Pain syndromes
- nociceptive pain
- neuropathic pain
- pain treatment
Pressure ulcers
Osteoporosis and bone fractures
Myasthenia Gravis.
HISTORY.
-eye: diplopia, ptosis
-bulbar: dysphagia, dysarthria, fatigue
-neck: dropped head
-limb girdle: proximal muscle weakness, fatigueability
-anaesthesia
-thymectomy
-drugs interfering with NMJ
-autoimmune dx (SLE, RA)
EXAMINATION.
-muscle fatigue (ptosis, extraocular muscles, bulbar, facial, dysarthria, prox muscles)
-thymectomy scar
-reflexes preserved
INVESTIGATIONS.
-ice pack test (ptosis)
-AChR-ab, anti-MUSK (muscle-specific kinase), LRP4 (low density lipoprotein receptor-related protein 4)
-EMG: decrementation
-thymoma Ix: CXR, thoracic CT or MRI.
-autoimmune screen (ANA, RF, Anti-dsDNA, TFT)
-PFTs
DDx.
-ocular muscle dystrophy
-lambert eaton syndrome
TREATMENT.
-pyridostigmine (acetylcholinesterase inhibitor)
-increase potassium (supplement, pot sparing diuretics)
-avoid meds interfering with NMJ transmission (streptomycin, gentamicin, quinidine, procainamide, beta blockers).
-vaccination (avoid live)
-myasthenic crisis: triggers, treatment, ICU for NIV and PLEX.
-excessive anticholinesterase tx (cholinergic crisis). Cease meds and monitor muscle strength.
Disease suppressing.
-steroids (worse 7-10/7)
-immunosuppression: azathioprine, ciclosporin, mycophenolate.
-thymectomy
-IVIG, rituximab
-PLEX (myasthenic crisis, periop or peripartum).
Lambert Eaton Syndrome
-associations
-ab
-EMG
-weakness pattern
ASSOCIATIONS.
Paraneoplastic or autoimmune (SCLC).
AB: VGCC ab increase ACh.
EMG: increment with increased frequency of stimulation.
WEAKNESS PATTERN:
Proximal muscle weakness, improves with use.
Ocular/ bulbar last.
Parkinsons
DDx: MSA, PSP, CBS, lewy body dementia, drug-induced, vascular, huntingtons, spinocerebellar ataxia, wilsons,
Motor:
Rest tremor
Bradykinesia with decrement
Rigidity “lead pipe” velocity independent
Gait: freezing, failure to initiate
Non-motor:
-autonomic dysfunction
-sleep disorder
-sensory symptoms
-neuropsychiatric symptoms
Determinants of QoL: depression, dressing, apathy, pain, fatigue.
Mx: levodopa, dopamine agonists (apomorphine, pramipexole, ropinirole, rotigotine patch), monoamine oxidase inhibitors (MOA, selegile, rasagiline), amantadine, anticholinergics
C/o impulse control disorders = gambling, hypersexual, binge eating, shopping
C/o punding = repetitive behaviours.
Red flags:
-symmetric
-early falls
-dysphagia or dysarthria
-urinary incontinence
-early dementia
-no tremor
MSA-C
MSA-P
MSA-P: erectile dysfunction, urinary incontinence, postural hypotension, early instability, pyramidal/cerebellar signs, poor levodopa response, rapid progression, minimal tremor.
Hot cross bun sign (pons)
-MSA
-spinocerebellar atrophy
-parkinsonism with vasculitis
-creutzfeldt-Jakob disease
PSP
early falls
supranuclear down gaze palsy
postural instability
frontal dementia
PSP-P
asymmetric
tremor
levodopa response
better prognosis
MRI: hummingbird
corticobasal syndrome = corticobasal degeneration
asymmetric rigid jerking arm (alien limb)
apraxia
frontal lobe dementia
limb pain / cortical sensory loss
supranuclear gaze palsy
myoclonus
oculomotor apraxia (saccade delay)
lewy body dementia
cognitive decline fluctuating
visual hallucinations
parkinsonism
RBD sleep
drug induced parkinsonism
neuroleptics
antiemetics
lithium
CADASIL
cerebral
autosomal
dominant
arteriopathy with subcortical
infarcts and leukoencephalopathy
Epilepsy
Pregnancy: lamotrigine better.
Bad = multiple, phenobarbitone, valproate.
Driving: seizure.
-private: GP / specialist ax -> factors that reduce crash risk NO 1 year.
-commercial: specialist ax -> factors that reduce crash risk NO 10 years.
-conditional license
Driving: epilepsy treated for the first time.
-6/12 post seizure.
Peripheral nerve disease
-acute
-subacute
-chronic
Acute: GBS, vasculitis, prophyria, infectious (lyme), toxic/drug
Subacute: toxic, nutritional, malignancy, paraneoplastic, metabolic
Chronic: inherited
Course:
-monophasic
-relapsing/remitting:
. CIDP
. Hereditary neuropathy with liability to pressure palsy, porphyria
Mononeuritis multiplex:
-diabetes
-vasculitis
-leprosy
-sarcoidosis
-demyelinating neuropathy
-hereditary liability to pressure palsies
-neurofibromatosis
-entrapment/compressive neuropathy
motor neurons
-MND
-poliomyelitis
-lead
-MMNCB
-botulism
-drugs (vincristine, dapsone, amiodarone)
sensory neurones
-rare
-diabetes, b12, b6 excess
-hereditary
-HIV
-amyloid, sarcoid
-sjogren
-paraneoplastic
Hereditary neuropathy with liability to pressure palsies (HNLPP)
focal pressure palsy after minor trauma
entrapment neuropathy
demyelinating peripheral neuropathy
autosomal dominant
Stiff person syndrome
GAD antibodies
Assoc. w T1DM, pernicious anaemia, thyroid, coeliac, vitiligo.
Stiff
Spasms
C/o autonomic failure (temp, bowel, bladder).
Tx: benzo, gabapentin, baclofen, pregabalin.
