Neuro part 1 Flashcards
trio of parkinsons
tremor - resting, pill rolling
rigidity - cog wheel
bradykinesia
tx parkinsons if motor symptoms are affecting QoL
levodopa
what drug classes are used in parkinsons if motor symptoms not affecting QoL/ mild symptoms
dopamine agonists
MOA-B
COMT inhibitors
examples of parkinson drugs:
dopamine agonists
ropinirole
pramipexole, apomorphine
bromocriptine, cabergoline
examples of parkinson drugs:
MOA-B
selegeline
rasagiline
examples of parkinson drugs:
COMT inhibitors
entacapone
tolcapone
examples of parkinson drugs:
Antimuscarinics
procyclidine
benzotropine
trihexyphenidyl
gold standard in parkinsons treatment
sinemet - levodopa + carbidopa
is levodopa useful in neuroleptic induced parkinsonism
no
2 important things to remember in prescription of levodopa
same time every day
needs to be continued e.g. if patient admitted to hospital
major side effect of dopamine agonists (3)
impulse control disorders
hallucinations
excessive daytime somnolence - shouldnt drive
when are antimuscarinics used in parkinsons treatment
drug induced, not idiopathic
tx sudden off states in levodopa using patients
amantadine
tx levodopa associated nausea
domperidone
which drugs are most likely to cause impulse control disorders, hallucinations and excessive daytime somnolence in parkinsons treatment
can occur with any dopaminergic therapy but most likely with dopamine agonists
- ropinirole
pramipexole, apomorphine
bromocriptine, cabergoline
parkinsonism syndrome:
- vertical gaze palsy (down gaze worse than up gaze)
- lack of tremor
- poor response to levodopa
progressive supranuclear palsy
parkinsonism syndrome:
- ataxia and cerebellar signs
- postural hypotension, erectile dysfunction, bladder disfunction
- poor response to levodopa
multisystem atrophy
parkinsonism syndrome:
- rigidity and weakness in one limb
- apraxia
- sensory disturbance
cortico-basilar degeneration
cognitive decline with visual hallucinations
fluctuating symptoms
onset of cognitive decline before onset of parkinson features
dementia with lewy bodies
drugs that cause drug induced parkinsons
anti-psychotics
amiodarone
metoclopramide
tx of tremor in drug induced parkinsons
procyclidine
inheritance of wilsons disease
AR
ix wilsons disease: serum cearuloplasmin total serum copper free serum copper 24 hour urinary copper excretion
main ix: reduced serum cearuloplasmin
reduced total serum copper
increased free serum copper
increased 24 hour urinary copper excretion
tx wilsons disease
penicillamine
1st line treatment of benign essential tremor
propranolol
inheritance of benign essential tremor
AD
2 causes of intention tremor
wilsons disease
cerebellar disease
drug causes of acute dystonia
typical antipsychotics - haloperidol, chlorpromazine
metoclopramide
suddenly stopping levodopa
fasciculations
absence of sensory symptoms
mixed upper and lower motor neuron symptoms
MND
primary symptom in MND is
muscle weakness
what type of dementia has MND been linked to
fronto-temporal
what muscles can be seen to waste in MND
tibialis anterior and small muscles of hands
which of the following are present in MND
- extraocular/eye involvement
- sensory loss
- sphincter dysfunction
- cerebellar signs
none
typical picture of ALS (MND)
mixed upper and lower MN
LMN in arms and UMN in legs
starts in hands
typical picture of progressive bulbar/psuedobulbar palsy
progressive bulbar muscle weakness with subsequent limb involvement - worst prognosis
MND that is purely lower motor neuron
progressive spinal muscle atrophy
MND that is purely upper motor neuron
primary lateral sclerosis
drug treatment in MND that prolongs life
riluzole
tx drooling in MND
anti-cholinergic
EMG of MND
reduced number of action potentials with increased amplitude
Lower motor neuron limb and bulbar weakness ED infertility gynaecomastia atrophic testes X linked
Kennedy’s disease
antibodies in myasthenia gravis
Anti-AchR / Anti-MuSK
against nicotinic receptors at NMJ
2 key features of myasthenia gravis
muscle weakness and fatigability
describe the pattern of myasthenia gravis throughout the day and with exercise
worse throughout the day and with exercise
improves after period of rest
common muscles involved in myasthenia gravis
extraocular - double vision
bulbar
describe sensation, muscle appearance tone and reflexes in myasthenia gravis
normal tone appearance and reflexes
normal sensation
tx myasthenia gravis
Pyrostigmine (LA anticholinesterase inhibitor)
tx myasthenia gravis relapse
prednisolone
tx myasthenia gravis crisis
IV Ig or plasmapheresis
drugs that can precipitate a myasthenia gravis crisis
beta blocker
what is affects in lambert eaton (LEMS)
pre-synaptic calcium channels in the PNS
2 causes of lambert eaton (LEMS)
paraneoplastic - small cell lung cancer, breast, ovarian
autoimmune - anti P/Q CGCC antibodies
primary symptom in lambert eaton (LEMS)
muscle weakness
describe the course of lambert eaton (LEMS) with exercise
improves with exercise
key symptoms in lambert eaton (LEMS)
muscle weakness that improves with exercise
limb symptoms –> gait disturbance
limb girdle weakness
autonomic involvement
reflexes in lambert eaton (LEMS)
hyporeflexia - improves with exercise
tx lambert eaton (LEMS)
prenisolone and/or azathioprine
is there tongue biting or incontinence in syncope
no
is there movement in syncope
either no movement or sometimes brief symmetrical clonic jerks in absence of tonic contraction
3 types of syncope
reflex
orthostatic
cardiac
reflex syncope: when the body overreacts to certain triggers
vasovagal
how many seizures do you need to have before diagnosis of epilepsy
2
typical age for febrile seizures
6m to 5 years
what is classed as febrile status epilepticus
> 30 mins
after what time should parents call an ambulance in a febrile seizure
if it lasts over 5 minutes - give them rectal diazepam or buccal midazolam to use in event
when do alcohol withdrawal seizures usually occur
36 hours after drinking
what drug can reduce the risk of alcohol withdrawal seizures
benzodiazepine
raised serum prolactin implies what kind of seizure
true epileptic
what is an aura
individualized and stereotypes symptoms that proceed the seizure by minutes
describe the tonic phase of tonic-clonic
falls to ground rigid and cyanosed stops breathing tongue biting and incontinence lasts about 1 minute
describe the clonic phase of tonic-clonic
asymmetrical convulsive jerks
eyes roll to back of head
breathing starts again
few minutes
seizure with brief lapses of awareness in which the patients stops what they are doing and stares blankly
absence seizure
Seizures that manifests as sudden loss of all muscle tone with maintenance of consciousness
atonic
seizure in first few months of life with Flexion of head, trunk, limbs → extension of arms (Salaam attack); last 1-2 secs, repeat up to 50 times
infantile spasm (west’s syndrome)
seizure in childhood with paraesthesia (e.g. unilateral face), usually on waking up/at night
benign rolandic epilepsy
Infrequent generalized seizures, often in morning or following sleep deprivation, Daytime absences and Sudden, shock like myoclonic seizure with usually good response to sodium valproate
juvenile myoclonic epilepsy
what investigation is done to rule out structural abnormality in epilepsy
MRI
investigation to classify epilepsy
EEG
when should antiepileptics be started
after 2nd seizure
or after 1 if neurological deficit, brain imaging shows structural abnormality, EEG shows unequivocal epileptic activity or the patient/family consider the risk of another seizure unacceptable
1st line focal seizure
carbamazepine
2nd line focal seizure
lamotrigine
levetiracetam
sodium valproate
1st line absence seizure
sodium valproate
ethosuximide
1st line atonic or tonic clonic seizure
sodium valproate
2nd line atonic or tonic clonic seizure
lamotrigine
carbamazepine
1st line myoclonic seizure
sodium valproate
2nd line myoclonic seizure
lamotrigine
clonazepam
antiepileptic of choice in pregnancy
lamotrigine
main side effects of valproate
teratogeniticity
weight gain
P450 inhibitor
major side effect of lamotrigine
steven johnson syndrome
carbamazepine is first line for what type of seizures
focal
main side effect of carbamazepine
agranulocytosis
what factors increase risk of SUDEP
poorly controlled epilepsy
smoking
alcohol
illicit drugs
how long can you not drive after 1st seizure
- car
- HGV
car : 6 months
HGV: 5 years
how long can you not drive with epilepsy
- car
- HGV
car - fit free for 12 months
HGV - off medication for 10 years and seizure free
what do P450 enzyme inducers do
reduce efficacy of certain drugs - contraceptive pill - suggest switch to IUS
examples of P450 enzyme inducers
carbamazepine
phenytoin
are anti-convulsants safe in breast feeding
yes mostly
what should be taken in pregnancy if taking phenytoin
vitamin K in last month to prevent clotting disorder in new born
dose of folic acid for pregnant women on antiepileptics
5mg before birth and during 1st trim
1st line tx status epilepticus in hospital
IV lorazepam
1st line tx status epilepticus in primary care
buccal midazolam or rectal diazepam
2nd line tx status epileptics
phenytoin, phenobarbital, levetiracetum
3rd line tx status epilepticus
GA
how often can lorazapam be repeated in status epilepticus
max 2 times (2-4mg)
give 10-20 mins after first dose
motor disturbance in MS
spastic weakness
MS: Lehermittes phenomenon
electrical shock down spine and arms/paraesthesia in limbs when head is bent forward/flexed
MS: uhtoffs phenomenon
worsening of symptoms with heat and exercise
s/s of MS
FATIGUE spastic weakness, brisk reflexes and +ve babinski sensory disturbance ataxia and tremor optic neuritis and RAPD incontinence
ix MS
MRI with contrast
what is seen on LP of MS
oligoclonal bands of IgG
MS treatment: spasticity
baclofen or gabapentin
MS treatment: sensory symptoms
amitriptyline or gabapentin
MS treatment: bladder dysfunction
bladder training, oxybutinin
MS treatment: fatigue (if all other causes ruled out)
amantadine
MS treatment: relapse
IV steroids - methylprednisolone (5 days)
plasma exchange
MS treatment: 1st line
B interferon
Capaxone (glitramer acetate)
tecfidera
MS treatment: 2nd line
Tysabri
fingolimod
MS treatment: 3rd line
Mitoxantrone
presentation: Vitamin B12 deficiency
dorsal column affected first - joint position and vibration
nerve involved: weakness of wrist flexion
ulnar
nerve involved: humeral shaft fracture
radial nerve
nerve involved: burning thigh pain
lateral cutaneous nerve of the thigh - meralgia paraesthetica
wrist drop
radial
foot drop
loss of sensation over dorsum of foot
common peroneal
nerve involved: weak plantar flexion
sensory loss over sole of foot
tibial nerve
antibodies in guillian barre
anti - GBM1 antibodies
common cause of GBS
campylobacter
presentation of GBS
ascending symmetrical muscle weakness starting in lower limbs and spreading
back/leg pain initially
LP of GBS
isolated rise in protein
nerve conduction in GBS
slowed conduction
tx GBS
IV IG
plasmapheresis
what is miller fisher syndrome
variant of GBS - ophthalmoplegia, areflexia and ataxia
eye muscles involved first
descending paralysis
anti-GQ1b antibodies
begins around puberty distal muscle wasting in legs mainly motor loss foot drop loss of reflexes
charcot-marie tooth disease (hereditary peripheral neuropathy)
inheritance of charcot marie tooth
AD
most common viral cause meningitis
enteroviruses - echovirus
if any doubt over bacterial meningitis and RFs for what should patient be started on
antibiotics + IV aciclovir
most common meningitis in 0-3 months
Group BS
causes of meningitis in 0-3 months
group BS
e coli
listeria
most common cause of meningitis in 6 - 60 year olds (< 40)
N meningitidis - most common
also strep pneumoniae
causes of meningitis in 3m - 6 years
n meningitidis
strep pneumonia
h influenzae
causes meningitis over 60
strep pneumoniae
n meningitidis
listeria
meningitis in immunocompromised
listeria
meningitis and skull fracture
pneumococcal
meningitis and surgery or open head wound
staph aureus
meningitis and CSF shunt
staph epidermidis
meningitis and severely immunocompromised e.g. HIV
cryptococcal (fungal)
most common complication of meningitis
sensorineural hearing loss
what is - Waterhouse-Friderichsen syndrome
adrenal insufficiency secondary to adrenal haemorrhage
ix for meningitis
LP
ix for meningitis if LP contraindicated
CT to investigate raised ICP
if there is:
whole blood PCR and culture
when is LP contraindicated
meningococcal septicaemia increased ICP immunosuppressed FND altered consciousness
bacterial meningitis CSF
low glucose
high protein
neutrophils - polymorphs
what can be done in GP if meningococcal disease suspected
IM benzylpenicillin
meningitis treatment: < 3 months
IV cefotaxime + amoxicillin or ampicillin
meningitis treatment: 3 months - 50 years
IV cefotaxime or ceftriazone
meningitis treatment: > 50 years
IV cefotaxime or ceftriaxone + amoxicillin or ampicillin
meningitis treatment: meningococcal
IV benzylpenicillin or cefotaxime or ceftriaxone
meningitis treatment: pneumococcal
IV cefotaxime or ceftriaxone
meningitis treatment: H influenzae
IV cefotaxime or ceftriaxone
meningitis treatment: listeria
IV amoxicillin or ampicillin + gentamicin
meningitis treatment: penicillin allergy
chloramphenicol
when should dexamethasone be given in meningitis treatment
just before or with first dose of abx
when is dexamethasone CI in meningitis treatment:
septic shock
meningococcal septicaemia
immunocompromised or following surgery
< 3 months old
what happens when viral infection confirmed
stop abx
supportive treatment
contact prophylaxis for meningitis
ciprofloxacin - single dose
if < 12 - rifampicin 4 doses
main cause of encephalitis
HSV 1
differentiate encephalitis from meningitis
encephalitis has psychiatric symptoms - psychosis, odd behaviour, speech and memory problems
MRI HSV encephalitis
bilateral focal temporal lobe enhancement
tx HSV encephalitis
IV aciclovir
ix for HSV encephalitis
LP
ix brain abscess
CT
tx brain abscess
IV metronidazole and ceftriaxone
dexamethason
urgent drainage
Tysabri is a risk factor for what neurological condition
progressive multifocal leukoencephalopathy in JCV positive patients
