neuro SBAs Flashcards
Immediate Rx in meningococcal septicaemia (fever, headache, non-blanching rash, neck stiffness)
Immediate IV ceftriaxone or cefotaxime
then lumbar puncture if no signs of raised ICP
Wernicke’s encephalopathy (acute/subacute delirium) causes
Vit B12 deficiency
Thiamine deficiency
Secondary to alcohol
Wernicke’s encephalopathy clinical triad
- encephalopathy
- ocular dysfunction (nystagmus)
- ataxia
±apathy, disorientation, disturbed memory. Treat urgently with thiamine or it may progress to Korsakoff’s psychosis.
Expressive dysphasia affects
Broca’s area
cortical area i.e. not internal capsule
Receptive dysphasia affects
Wernicke’s area
Anti-ganglioside antibodies present in…
Guillain-Barre syndrome
miller-fisher variant
Miller-Fisher variant of GBS (rare) clinical triad
Opthalmoplegia
Ataxia
Arreflexia
Three weeks following an illness which caused crampy abdominal pains, vomiting and diarrhoea a 26 year old presented with progressive bilateral leg weakness. Knee jerks and ankle jerks were both reduced on examination. What is the diagnosis?
Guillain-Barre syndrome (a demyelinating polyneuropathy)
Most have prior influenza-like illness or gastroenteritis.
Beware of resp muscle weakness
AST and ALT may be elevated LP = high CSF protein with normal cell count (known as albuminocytological dissociation)
Pick’s disease is also known as
Frontotemporal lobe dementia
Down’s syndrome is associated with which type of dementia
Alzheimer’s
Brown-Sequard syndrome definition
Hemi-section of the cord. Results in ipsilateral paralysis of limbs, loss of light touch and vibration sensation, contralateral loss in pain and temperature below the point of the lesion (spinothalamic tracts cross at level of cord). C3,4,5 (phrenic nerve) innervates diaphragm so lesions below this will preserve it.
Signs of increased ICP
Papilloedema
N+V
Meningism (e.g. nuchal rigidity)
Painless, unilateral visual loss of short duration described as a ‘black curtain descending’ is called…
Amaurosis fugax
Acute eye pain with blurred vision “see haloes around things”. Older patients
What is the likely diagnosis
Closed/acute angle glaucoma
Extradural haemorrhage
Fractural temporal/parietal bone damaging middle meningeal artery and occurs post-severe trauma. Lucid interval before presentations. Lens shaped
50 year old complains of slowly worsening weakness in his L leg. Started gradually 3 months ago, now making him limp. Examination reveals increased tone, brisk reflexes and weakness in L leg. What is the likely diagnosis?
Recognise these as UMN signs.
R sided brain tumour
It is slowly progressive, so a slowly growing brain tumour is likely (strokes start suddenly)
Examination of the lower limbs reveals wasting of the muscles of the left calf with arreflexia on that side. What is the likely diagnosis?
LMN problems unilaterally so the problem is pressure on a nerve below the cauda equina or damage to the spine/nerve roots.
A patient complains of a tremor when he smokes cigarettes. What is the likely cause if the tremor gets worse when he puts the cigarette into his mouth. What is the likely cause?
This is typical of the ataxia with cerebellar disease, with the past pointing getting worse as you approach the target (either nose, or in this case the mouth)
A 15 month old toddler developed a maculo-papular rash 10 days after receiving the MMR vaccine, followed by a swelling at the angle of the left jaw. His mother phoned the surgery in a state of panic one morning because he is confused, having convulsions and has a high temperature. What is the likely diagnosis?
Encephalitis - altered state of consciousness, fever, headache, seizures ± focal neurology. Rx: IV acyclovir as most are caused by HSV.
(Vesicular patterns are seen in VZV, HSV and enteroviruses; EBV is maculopapular after ampicillin; Lyme disease has erythema migrans; TB has erythema nodosum)
A 35 year old woman has suddenly developed facial palsy. 6 months before this, she had an episode of blurred vision + unsteadiness. On examination, she has mild ataxia and an afferent pupillary defect.
MS is a demyelinating CNS condition which is characterised by 2 or more episodes of neurological dysfunction which are separated in both time and space. This person has had blurred vision and now 6 months later has developed facial palsy. RAPD is present.
A 70 year old man has suddenly developed facial weakness, which was preceded by 2 days of severe left ear pain, vertigo + deafness. On examination, he has red vesicles in his ear canal and on the hard palate. What is the likely diagnosis?
Ramsay Hunt syndrome = reactivation of VZV with CNVII palsy.
There is ear pain and erythematous vesicular rash in ear canal + hard palate. CN8 palsy = vertigo and hearing loss. Rx: acyclovir.
A 45 year old man who is had a SAH 2 months ago was prescribed an anti-convulsant to reduce the risk of seizure and continued to take it. He has now become increasingly confused, lethargic + ataxic. O/E nystagmus, an intention tremor, past-pointing. What is the likely diagnosis?
Phenytoin toxicity - unpredictable pharmacokinetic behaviour with narrow therapeutic range.
Symptoms: nystagmus, confusion, headache, ataxia and vertigo. Chronic use: gum hyperplasia.
A 45 year old type 1 diabetic patient presents with a history of feeling light headed. On examination, he is noted to have a blood pressure of 150/90 lying + 125/70 on standing. What is the likely diagnosis?
This patient has postural hypotension from diabetic autonomic neuropathy. Other symptoms: resting tachycardia, impaired HR variation, erectile dysfunction, decreased libido, dyspareunia, constipation, sweating dysfunction, urinary LUTS symptoms. Rx: fludrocortisone
A 73 year old male presents with difficulty ascending stairs. O/E: weakness of knee flexion, more on the left with some wasting of quadriceps and diminished knee reflexes. He has T2DM. What is the likely diagnosis?
Diabetic amyotrophy, more common in T2DM, is an uncommon peripheral diabetic neuropathic complaint.
It presents with severe muscle weakness and pain with proximal thigh muscle atrophy. The weak knee flexion and quadriceps wasting is typical. Reduced reflexes = peripheral neuropathy.
A 62 year old male diabetic presents with a sudden onset of double vision. He has ptosis and a deviation of the right eye down and right. The pupils are equal in size and are reactive to light. What is the likely diagnosis?
A complete (or surgical) CN3 palsy = compete ptosis, a dilated pupil, eye down and out. Causes: PCA aneurysm.
A partial (medical) pupil-sparing CN3 palsy = partial ptosis without pupillary signs. Causes: infarction of the nerve i.e. mononeuritis multiplex due to DM or vasculitis like GCA.
parasympathetic nerve compressed in surgical complete so pupil dilates
Testing loss of consciousness
24 ECG/holter monitor
Treatment for unconscious diabetic man with capillary blood glucose of 1.5mmol/L
IV dextrose
Hydrocephalus (enlargement of cerebral ventricular system) leads to abnormal accumulation of CSF in the ventricles. The two types are…
Obstructive - impaired outflow of CSF from ventricles e.g. lesions of 3rd ventricle or posterior fossa, cerebral aqueduct stenosis
Non-obstructive - impaired reabsorption into subarachnoid villi e.g. in tumours, meningitis, NPH
Obstructive hydrocephalus (impaired CSF outflow) signs and symptoms
Acute impaired GCS Diplopia CN6 palsy (increased ICP signs) Papilloedema Neonates have enlarged head circumference
Normal pressure hydrocephalus is an example of non-obstructive hydrocephalus. There is idiopathic chronic ventricular enlargement. Signs and symptoms include
Chronic cognitive decline Falls Urinary incontinence Gait apraxia (shuffling) Hyper-reflexia
Stroke anterior circulation lesions
Anterior cerebral - lower limbs, confusion
Middle cerebral - facial weakness, hemiparesis, hemisensory loss, dysphasia
Stroke small vessel (lacunar) lesions
Internal capsule/pons - pure sensory or motor deficit
Thalamus - LOC, hemisensory loss
Basal ganglia - hemichorea, parkinsonism
Stroke multiple lacunar infarct lesions presents with
Vascular dementia
Urinary incontinence
Gait apraxia
Stroke posterior circulation lesions
Posterior cerebral - hemianopia
AICA - vertigo, ipsilateral ataxia, deafness and facial weakness
PICA - lateral medullary syndrome
Basilar artery - CN pathology, LOC
Treatment to lower ICP
IV osmotic diuretic (mannitol)
Hyperventilation
Subdural haemorrhage location
Between dura and arachnoid membranes
Timeframe of subdural haemorrhage
Acute, subacute and chronic
Acute - within 72hr
Subacute - 3-20days
Chronic - after 3 weeks
A 60 year old woman treated with total thyroidectomy for thyroid carcinoma now presents with visual changes. O/E: bitemporal hemianopia. CT of the head shows a cystic lesion compressing the optic tracts.
This lesion is a…
Craniopharyngioma
Cerebral atrophy
Extracellular B-amyloid plaque deposits
Tau neurofibrillary tangles
Low cortical ACh
Pathophysiology of which condition?
Alzheimer’s dementia
Alzheimer’s dementia signs and symptoms
5 As
Amnesia Anomia Apraxia Agnosia Aphasia
(±depression and paranoid delusions)
Lewy body dementia
a-synuclein
Fluctuating onset with cognitive and motor symptoms.
Classical triad (2+ needed for DDx) consists of
Confusion/consciousness changes
Visual hallucinations
New onset Parkinsonism
±repeated falls, syncope
Parkinson’s disease (degeneration of DA neurones in substantia nigra) classical triad
Bradykinesia
Tremor
Rigidity (increased tone, cogwheel)
±postural instability
Parkinson’s disease
6M’s signs/symptoms
Monotonous speech Micrographia HypoMimesis (expressionless) March a petit pas Misery = depression Memory loss = dementia
Motor neurone disease type:
Mixed UMN and LMN disease
Amyotrophic lateral sclerosis (ALS)
also called Lou Gehrig’s disease
Motor neurone disease type:
LMN disease only
Progressive muscular atrophy variant
Motor neurone disease type:
UMN disease only
Primary lateral sclerosis variant
Motor neurone disease type:
Cranial nerve palsy that presents with dysthria and dysphagia, wasted fasiculating tongue (LMN) and brisk jaw jerk (UMN)
Progressive bulbar palsy variant
Types of multiple sclerosis (demyelinating CNS inflammatory disease. Type IV hypersensitivity)
Primary progressive
Relapsing-remitting
Progressive-relapsing
Marburg variant
Multiple sclerosis:
Uhthofff’s phenomenon
Transient increased symptoms by increased body temperature
Multiple sclerosis:
Lhermitte’s phenomenon
Electric shock-like sensation in arms and legs triggered by neck flexion
Motor neurone disease signs and symptoms
Mixed UMN and LMN signs usually.
Deterioration of motor neurones. No sensory involvement.
Bilateral progressive worsening muscle weakness, difficulty swallowing and speaking, brisk lower limb reflexes.
Myasthenia gravis definition
Autoimmune disease affecting NMJs. Anti-AChR (post-synaptic) antibodies lead to fluctuating muscle weakness and fatigue.
Associated with other AI diseases e.g. pernicious anaemia and thmomas.
Ocular symptoms of myasthenia gravis
Ptosis (bilateral drooping eyelids)
Diplopia
Facial weakness
Worse towards end of day
Migraine Rx
Acute: 5HT-1 antagonists (sumitriptan), NSAIDs, paracetamol, codeine, anti-emetics (metoclopramide)
Prophylactic: b-blocker (propranolol), second line (amitriptyline)
A 70 year old man with pain in the jaw after chewing food. He has also noticed pains in his shoulder + pelvic areas over the past 3-4 weeks, plus an episode of transient visual loss in the right eye. What is the likely diagnosis?
Temporal arteritis
A 40 year old teacher presented with a 24 hour history of occipital headache, which became worse in the evenings after work. She mentions work is stressful. O/E: apyrexial, looks ill + anxious with a pulse rate of 120/min. What is the likely diagnosis?
Tension headache
These are generalised (usually frontal or occipital) - band around front of the head. Pain is dull. Lasts a few hours and usually in times of stress, exertion, or lack of sleep.
Rx: NSAIDs
A 30 year old nurse presented with frontal headache after an acute viral illness. The pain was constant, affecting R side of head only. O/E: marked tenderness on R side of her face, over the maxillary area. What is the likely diagnosis?
Sinusitis
Epilepsy (status epilepticus) Rx
Resuscitate, protect airways, breathing + circ
Check glucose and thiamine levels (correct if needed)
PR diazepam/IV lorazepam
± IV phenytoin
± IV phenobarbitone
Treat the cause (correct electrolytes)
Bell’s palsy (ipsilateral facial muscle weakness) usually occurs after
upper resp tract infection
Guillain Barre syndrome is usually idiopathic (40%). However other causes include
Post-infection (1–3wks): bacterial e.g. campylobacter, viruses e.g. HIV, VZV, CMV
Malignancy (lymphoma, Hodgkins)
Post-vaccination
GBS lumbar puncture shows
High protein
Normal cell count
Normal glucose
Brain MRI or CT may show symmetrical atrophy of the striatum (particularly the caudate nuclei) and butterfly dilation of the lateral ventricles. What condition would this suggest?
Huntington’s disease
Genetic analysis is diagnostic if >39 CAG repeats in HD gene.
Which conidition is associated with frontotemporal lobar dementia (FTLD) from proganulin mutations?
Motor neurone disease
What are hamartomas on iris called (these are present in neurofibromas type 1)
Lisch nodules
How many cafe-au-lait spots and what size should they be for Type 1 NF diagnosis?
> 5 cafe-au-lait spots
5mm (pre-pubertal individuals)
15mm (post-pubertal individuals)
Buphthalmos (ox eye) is a congenital cause of
Glaucoma
this will present with watering and cloudy cornea
Anterior uveitis is the inflammation of the iris and ciliary body. Presentations include pain due to ciliary spasm and inflammation (esp on accommodation), photophobia, red eyes, blurred vision and lacrimination. On examination what are the findings?
Ciliary flush
Low visual acuity
Hypopyon (protein exudate and inflammatory cells)
Small irregular pupil (posterior synechiae adhesions)
Slit lamp: keratic precipitates (deposits of leucocytes)
Fundoscopy: finds the cause
Other complications e.g. intraocular pressure, cataract
Posterior uveitis is chorioretinal inflammation and may present with…
Floaters (debris/inflammatory cells in vitreous)
Decreased vision
Cluster headaches have an acute onset and are unilateral behind the eye. They last around 20-30mins and can be severe. Occur in clusters. Associated symptoms may/may not be present and they include
Swollen eyelid and forehead
Nasal congestion
Horner’s syndrome
Trigeminal neuralgia = shooting pain in CN5 distribution, usually V2 (maxillary).
It is mostly unilateral pain and is provoked by washing, shaving and chewing. Risk factors include:
60-80yrs of age
Multiple sclerosis
Female
Hypertension
Rx: carbamazepine ±phenytoin, gabapentin
Horner’s syndrome is characterised by
Unilateral miosis
Ptosis
Anhidrosis
(n.b. all are on the same side)
Horner’s syndrome is caused by
Brainstem/cervical spinal cord: tumour (glioma), infarction, syringomyelia/bulbia
T1 root: brachial plexus lesion, NF
Cervical sympathetic chain: Pancoast tumour
Internal carotid artery: dissection, occlusion
Migraine, cluster headaches
In Horner’s syndrome, central lesions affect sweating in head, arms and upper trunk. Neck lesions only affect facial sweating. Lesions distal to superior cervical ganglion do not affect sweating. What investigations are useful to determine level of lesion?
Testing with adrenaline helps indicate lesion levels because it should lead to pupil dilation
±USS/MRI of carotid artery
Rx: treat the cause
A 55yr old man presents with Hx of recurrent spontaneous attacks of vertigo, hearing loss and tinnitus. These last up to 2hr and are sometimes associated with vomiting. What is the likely diagnosis?
Meniere’s disease
Characterised by recurrent bouts of vertigo, associated with otological symptoms of deafness, tinnitus and aural fullness. Vertigo is usually disabling and vomiting is present. Deafness is sensorineural.
A 65yr old woman presents with vertigo, vomiting and dysphagia. O/E: L sided Horner’s syndrome and R sided loss of pain and temperature in the body. What is the likely diagnosis?
Lateral medullary syndrome i.e. PICA lesion
ipsilateral deficits - face pain + temp, Horner’s, cerebellar signs
contralateral deficits - body pain + temp
A 50yr old man presents with vertigo when rolling over quickly in bed, getting out of bed and bending over. Hearing is normal. What is the likely diagnosis?
Benign paroxysmal positional vertigo
Characterised by short episodes of vertigo triggered by head movements. Free-floating particles in endolymph of semicircular canal cause contiuing stimulation of auditory canal for several seconds after movement of the head has stopped.
What manoeuvre is used to confirm the diagnosis of BPPV?
Hallpike’s manoeuvre
Pt sits upright with head facing examiner. Examiner grasps patient’s head and rapidly move patient from sitting to lying position. +ve test provokes vertigo and rotatory nystagmus, that disappears after ~30s.
What manoeuvre is used to treat BPPV?
Epley maoeuvre
Orientate the head in various positions to displace the particles from the posterior canal
A 65yr old woman complains of constant aching pain around her R eye radiating to the forehead. There is reduced vision in the eye, which is red and congested with a dilated pupil. What is the likely diagnosis?
Acute closed angle glaucoma
Mostly affects long-sighted elderly. Caused by blockage of drainage of aqueous humour from anterior chamber via canal of Schlemm.
How is diagnosis of acute closed angle glaucoma made?
Measuring intraocular pressure during an acute attack
A 45yr old woman complains of pain behind the R ear and her mouth is sagging on the R hand side. What is the likely diagnosis?
Bell’s palsy
Muscles on one half of the face are affected. There may also be loss of taste on anterior 2/3s of tongue. EMG can be a good predictor of outcome.
A 65yr old woman presented with attacks of sudden weakness of the legs causing her to fall to the ground. There is no LOC or confusion afterwards. She has not had any attacks for several months now. What is the likely cause?
Drop attacks
No LOC, unclear causes and they usually resolve spontaneously.
A 34yr old woman falls to the ground after hearing some bad news. What is the likely cause?
Vasovagal syncope
Reflex bradycardia and peripheral vasodilation occurs in response to pain, emotion or prolonged standing. Symptoms of nausea and closing in of visual fields before collapse. Recovery is rapid when supine (after ~2min).
In multiple sclerosis, how does heat affect symptoms?
Heat worsens symptoms in MS
