Neuro - Preading Flashcards
What areas / questions are covered in a neurological systems review?
- Headaches
- Fits / falls / LOC
- Memory problems
- Balance / coordination problems
- Vision problems
- Photophobia & neck stiffness
- Hearing difficulties
- Speech problem
- Swalling problem
- Weakness
- Numbness / tingling / paresthesia
- Incontinence or erecticle dysfunction
What are some features of Cluster headaches?
Features:
- Pattern - high frequency over a period of weeks –> then months of symptom free (i.e. clustering)
- occur at night (characteristically)
- Duration - 15 mins - 3 hours
- Better or worse? - unable to stay still during
- Other symptoms?
- Eye involvement (unilateral autonomic dysfunction); red eye, eye watering, nasal congestion
What are some features of migraine headaches?
Features:
- Pattern - spread out over the year
- Duration - hours to days
- Better or worse?
- lying down in dark room
- multiple triggers
- Other symptoms:
- Aura symptoms
- Nausea / vomiting
- Photophobia
- Phonophobia
What condition is most associated with “Sudden onset, excruciating headache”?
Subarachnoid haemorrhage
What condition is best associated with “Facial tenderness and rhinorrhoea”?
Sinusitus
What condition is best associated with “Pain around eye, blurred vision with halos around lights”?
Acute glaucoma
What condition is best associated with “20 minute unilateral, debilitating episodes of retro-orbital pain with red eye and eye watering”?
Cluster headaches
What condition is best associated with “headache triggered by changes in position or exertion. Changes in vision with leaning forward”?
Increased intracranial pressure
List as many headache ‘Red-Flags’ as you can. (10 total)
- Sudden-onset headache reaching max intensity < 5 mins (subarachnoid haemorrhage)
- Headache with fever (meningitis)
- New onset neurological deficit
- New onset cognitive dysfunction
- Change in personality
- Impaired level of consciousness
- Recent head trauma (< 3 months)
- Headache triggered by cough, valsalva, sneeze, exercise or change in posture (↑ ICP)
- Headache + jaw claudication and scalp tenderness (GCA)
- Headache + halos around lights or headaches that get worse in the dark (acute narrow-angle glaucoma)
What TLOC condition is best associated with “Chest pain, brteathlessness and collapse on exertion”?
Aortioc stenosis
What TLOC condition is best associated with “palpitations or chest pain beforehand, family history of sudden exaplained death”?
Arrhythmia / cardiogenic syncope
What TLOC condition is best associated with “triggered by; fear, pain, micturition or prolonged standing. Preceded by pallor, nausea or sweating. No confusion afterwards”?
Vasovagal syncope
What TLOC condition is best associated with “Collapse on shaving or turning the head”?
Carotid sinus hypersensitivity
What TLOC condition is best associated with “triggered by vigorous exercise in a young person”?
Hypertrophic cardiomyopathy (HOCM) / cardiogenic syncope
What TLOC condition is best associated with “Being told off by teachers for seemingly daydreaming”?
Absence seizures
What TLOC condition is best associated with “Pale and sweaty beforeheand, jerking of limbs, eyes rolled back, short duration of episode, no confusion afterwards”?
Vasovagal syncope
What TLOC condition is best associated with “Twitching and jerking in the morning”?
Early morning myoclonus
- Often presents as feature of ‘juvenile myoclonic epilepsy’
- More likely to occur if; sleep deprived or alcohol excess
- Can present with infrequenct GTCS (generalised tonic-clonic seizures)
What TLOC condition is best associated with “Crying out, falling to floor, period of stiffness followed by rhythmic jerking that gradually decreases in amplitude and frequency, period of confusion for 30 mins afterwards”?
Generalised tonic-clonic seizures
What TLOC condition is best associated with “Violent shaking, head moving side to side, arching back, episodes of stillness before starting again. Forced eye closure”?
Psychogenic non-epileptic seizure (PNES)
also called non-epileptic attack disorder (NEAD)
Seizures can be ‘provoked’ or ‘unprovoked’, give some examples of things that can provoke seizures.
- Alcohol - withdrawal / excess
- Cocaine
- MDMA (ecstacy)
- Amphetamines
- Opiods e.g. tramadol
A tool to distinguish between syncope and seizure is to asses the presyncopal symptoms, this can be remembered as PPP - what does this stand for?
Vasovagal syncope features:
-
Position
- Should only happen when upright
-
Provocation
- pain, dehydration, emotional shock
-
Prodrome
- light headeded, dizziness, blurred vision, ears ringing
Absence of these = consider cardiogenic syncope + cardiac opinion
What is the difference between pyramidal and extra-pyramidal tracts?
Both pyramidal + extrapyramidal are descending motor tracts
-
Pyramidal tracts:
- Path = carry motor fibres from cortex –> brainstem + spinal cord
- Role = voluntary control of muscles
-
Extra-pyramidal tracts:
- Path = carry fibres from brainstem –> spinal cord
- Role = involuntary / automatic control of muscles e.g. tone, balance, posture, locomotion
On which sides of the body will a brainstem lesion show 1) limb signs 2) cranial nerve signs?
Brainstem lesion:
- Limb signs = contralateral
- Cranial nerve signs = ipsilateral
What is the name of the condition which involves damage to one hemi-section of the spinal cord?
Brown-Séquard syndrome
- Cause: dmg to one half of the spinal cord
- Features:
- Ipsilateral spastic paralysis below level of lesion + flaccid paralysis at level of lesion (as LMN is affected at level of lesion)
- Ipsilateral loss of vibration + proprioception (dorsal column)
- Contralateral loss of pain + temperature (spinothalamic)
Draw the visual pathway.
Describe this image + where is the lesion?
Homonymous hemianopia
Lesion = occopital cortex or optic radiation
Describe this image + where is the lesion?
Bi-temporal Hemianopia
Lesion = otpic chiasm
What is a lumbar puncture (LP) test useful for?
- Assessing pressure of CSF
- Presence of infection / inflammation e.g. meningitis / encephalitis
A 35 year old male with polycystic kidney disease is brought to the emergency department by his wife. He woke up this morning with a sudden and severe headache.
What is the most appropriate next step?
- Lumbar puncture after 12 hours
- X-ray head
- CT head
- Ultrasound of the kidneys
CT Head
-
Sudden onset, excrutiating headache + PCKD = subarachnoid haemorrhage
- PCKD - causes ↑ BP –> can cause cerebral aneurysm, which can rupture causing a subarachnoid haemorrhage
- Sometimes, blood from a subarachnoid haemorrhage won’t show on CT –> in this case do a LP after 12 hrs (RBCs will have broken down and products e.g. bilirubin will leak into CSF)
- Xanthochromia = yellow discoloration indicating the presence of bilirubin in CSF
A 25 year old male student is brought in by his friends who are worried about him. The patient had a sore throat that cleared up a few days ago, and now has headache, fever, and neck stiffness. Examination reveals him to be alert with no focal neurology or papilledema.
Which investigation is most useful for establishing a diagnosis?
- Blood cultures
- CT head
- MRI brain
- Lumbar puncture
Lumbar puncture
- Headache + neck stiffness + fever = meningitis
- MUST check there are no signs of ↑ ICP e.g.
- papilledema
- focal neurological deficit
- reduced GCS
- LP in a patient with ↑ ICP –> can cause herniation of brain into the spinal canal (coning) which can be fatal
A 65 year old male is being reviewed on the stroke ward after returning from radiology. Imaging reveals an ischemic stroke involving the left temporal lobe.
What visual field defect would most likely be found upon examination?
- Bitemporal hemianopia
- Right superior quadrantanopia
- Right inferior quadrantanopia
- Left superior quadrantanopia
- Right homonymous hemianopia
Right superior quadrantanopia
- This is because optic radiations split into 2 pathways based on whether they refer to the superior retina or inferior retina:
- superior retina (inferior visual field) = optic radiation in parietal lobe
- inferior retina (superior visual field) = optic radiations in temporal lobe
- Thus left temporal lobe lesion –> right sided, superior visual field defect i.e. right super quadrantanopia
How would you describe motor neuron disease (MND)?
What are the types and features of MND?
MND = condition affecting the nerves controlling movement, unknown cause, rarely presents before 40yrs and can present in a variety of patterns
Amyotrophic lateral sclerosis i.e. ALS (50%):
- Arms = LMN signs
- Legs = UMN signs
- Familial cases = gene on chromosome 21 for superoxide dismutase
Primary lateral sclerosis:
- UMN signs only
Progressive muscular atrophy:
- LMN signs only
- Affects distal muscles before proximal
- carries best prognosis
Progressive bulbar palsy:
- palsy of the following:
- tongue
- muscles of chewing/swallowing
- facial muscles (due to loss of function of brainstem motor nuclei)
- carries worst prognosis
