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Neuro Shorts Flashcards

1
Q

What are the Key Findings on Cerebellar Examination ?

A

DANISH

  • Dysmetria, Dysdiadokinesis
  • Ataxic Broad based gait
  • Nystagmus (Toward side of lesion)
  • Intention tremor
  • Staccato Speech, Saccades
  • Hypotonia (Rebound)
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2
Q

Differential Diagnosis of Cerebellar lesions

A

V - Vascular - Ischaemic or Hemorrhagic
I - Inflammatory (Demyelinating) - Multiple Sclerosis
N - Neoplastic SOL - Meningiomas, Primary CNS tumours, Metastatic disease (Cerebellarpontine angle)
D - Degenerative - Multiple system atrophy
C - Congenital (Inherited) - Fredrichs Ataxia and Spinocerebellar Ataxia
A - Autoimmune - Paraneoplastic - AntiYo and AntiHu
T - Trauma or Toxins - Drugs - ETOH, Lithium, Phenytoin

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3
Q

Friedrichs Ataxia: Clinical signs

A

Combination

  • Bilateral Cerebellar
  • Dorsal column loss - Pes Cavus
  • UMN Pyramidal weakness
  • Absent AJ + KJ

Associations: High arched Palate, Kyphoscoliosis
Other conditions: HOCM, DM, Sensorineural deafness

Ddx - MS

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4
Q

Friedrichs Ataxia: Ix and Mx

A

Ix - Clinical diagnosis, Genetic Testing (GAA trinucleotide repeat - AR), MRI Spine and Brain imaging
Mx - Supportive MDT

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5
Q

Parkinsonism - findings on clinical examination

A

Gait - Shuffling gait, freezing episodes, short stride, Stooped posture, Decreased arm Swing
UL - Resting tremor, Cogwheel rigidity, bradykinesia, Dysdiadokinesis, Dysmetria
Face - Glabellar tap, EOM, Nystagmus, Mask like faces, decreased blink rate, Hypophonia
Micrographia
Blood pressure - Postural hypotension

Complete examination with Formal MMSE

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6
Q

Parkinsonism: Ddx

A

Idiopathic Parkinson’s disease
Parkinsons plus syndromes
- Progressive supra nuclear palsy (Gaze palsy)
- Multiple system atrophy (Cerebellar signs, Autonomic dysfunction)
-Corticobasal degeneration
-Lewy body Dementia (early Dementia)
Drug induced Parkinsonism: Atypical Antipsychotics (Haloperidol) or Metoclopramide

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7
Q

Parkinsonism: Ix

A

Primarily a clinical diagnosis
Review any causative medications
Imaging - MRI - help diagnose some of the Parkinson’s plus syndromes (Hot Cross bun sign of MSA, Hummingbird sign of PSP)
Can also do functional neuroimaging - SPECT NM scan

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8
Q

Monocular Visual loss

  • Localise the lesion
  • Causes
A

Prechiasmal - At the level of the orbit, Retina or Optic Nerve
Causes;
-Orbital conditions: Acute angle closure Glaucoma
-Retina: Retinal detachment or CRAO (Vascular)
-Optic nerve (Optic Neuritis) -
- Vascular - DM, Vasculitis (GCA)
- Inflammatory (Demyelinating) - MS, NMO
- Infectious - Syphilis, Measles or mumps, EBV/CMV, HIV
- Drugs - Ethambutol

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9
Q

INO - What is it? Most common causes

A

internuclear Ophthalmoplegia
Inability for affected eye to ADDUCT
ABDUCTING eye nystagmus

Causes -MLF (Connects CN 6 and 3) 
Vascular - Ischaemia 
Inflammatory/demyelinating - MS 
Neoplastic - SOL 
Trauma 
Infectious - Syphilis
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10
Q

Homonymous hemianopia

  • Localise the lesion
  • Causes
A 
Post Chiasmal 
Cause 
-Vascular: Ischaemic or Hemorrhagic strokes
-Inflammatory/Demyelinating: MS 
-Neoplastic: SOL (Meningioma, Metastatic Disease) 
-D
-Infectious: Abscess or Encephalitis 
-C
-A
-Trauma
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11
Q

Bitemporal hemianopia

  • Localise the lesion
  • Causes
A

At the Level of the Optic Chiasm

  • Compressive lesions
  • Pituitary adenoma
  • SOL - meningiomas, Metastatic disease
  • Vascular - compression by aneurysm
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12
Q

CN3 - Oculomotor nerve palsy - Manifestations

A

Ptosis
+/- Pupil involvement - Dilated, non reactive pupil
Divergent Strabismus at rest (Down and Out)
Impairment in most EOM - except LR (Lateral movement)
Horizontal Diplopia

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13
Q

CN3 - Oculomotor nerve palsy - Causes

A

Can localise to the Cavernous sinus or brainstem
Vascular
- Compression from Aneurysm (Pupil involvement) - PCOM aneurysm, Carotid in the cavernous sinus
-Ischameia or haemorrhage involving brainstem
-Microvascular ischameia of Nerve - Metabolic factors - DM, HTN
-Vasculitis
Inflammatory - Demyelination (MS) - Brainstem
Neoplastic - SOL cavernous sinus, Pituitary masses
Trauma

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14
Q

CN4 - Trochlear - Manifestations

A

Vertical Diplopia
Head tilt
Affected eye sitting higher in primary gaze

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15
Q

CN4 - Trochlear - Causes

A

Localise to brainstem or Cavernous sinus

  • Vascular - Ischameia, Aneurysm compression
  • Inflammatory/Demyelinating lesions - MS
  • Neoplastic compression
  • Trauma
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16
Q

CN6 - Abducens - Manifestations

A

Failure of LATERAL RECTUS only

-Convergent strabismus in primary gaze

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17
Q

CN6 - Abducens - Causes

A

Localise to Brainstem or Cavernous sinus

  • Vascular - ischaemia, Aneurysm compression, Microvascular (DM, HTN)
  • Inflammatory or demyelinating
  • Neoplastic compression
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18
Q

Causes of Bilateral Ptosis

A

MG
Ocular Myopathy
Congenital Muscular Dystrophy
Syphilis

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19
Q

Causes of a Complex opthalmoplegia (7)

A
  1. Myasthenia Gravis
  2. Graves Opthalmopathy
  3. Miller fisher (Variant of GBS)
  4. MS
  5. PSP
  6. Wernickes Encephalopathy
  7. Brain stem lesions - affecting multiple nuclei - Ischaemia, Demyelination, Neoplastic
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20
Q

What is Horners Syndrome

A

Damage to the sympathetic pathway that supplies the head

-Results in Ptosis, Anhidrosis and Miosis

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21
Q

Causes of Horners Syndrome

A

Central (Brainstem or Spinal cord)

  1. Vascular - Ischaemia, Haemorrhage
  2. Demyelination -MS
  3. Neoplastic compression
  4. Trauma

Peripheral

  1. Apical lung tumor
  2. Cardiothoracic or neck surgery
  3. Aneurysms or Dissections
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22
Q

What additional features to look for with CN7 Palsy

A

CN6 opthalmoplegia (Cerebellar pontine angle or BS)
CN5, CN8 or cerebellar signs (Cerebellar pontine angle)
CN8 and vesicles (Ramsay hunt syndrome)
Pyramidal signs - reflexes - BS
Parotid tenderness

23
Q

CN7 Palsy - Causes

A

Idiopathic - most commonly viral induced
Ramsay hunt syndrome - Herpes Zoster
Parotid: Tumors, Radiation or prior surgery
BS Lesions: Infarction, Demyelination, Neoplastic compression
Cerebellarpontine angle lesions

24
Q

What Clinical features on examination for Cerebellar pontine angle masses?

A
  1. Cerebellar features

2. CN5, 7, 8 (Sometimes CN6)

25
Main Causes of Cerebellar pontine angle lesions ?
1. Acoustic neuroma 2. Other SOL - Meningiomas, Metastatic disease 3. Nasopharyngeal Ca
26
Peripherial Neuropathy: Causes
``` DANG THERAPIST D - Diabetes A - Alchohol N - Nutritional Deficiencies - Vitamin B12 G - GBS or CIDP ``` ``` T - Toxins - Drugs - Lithium, Phenytoin, Chemotherapeutics (Vinka Alkaloids), Heavy metals (Lead) He - Hereditary - CMT R - A - Amyloid P - Porphyria I - Infectious - HIV, Syphilis, EBV S - Systemic - Uraemia from CKD, Hypothyroidism T - Tumor - Paraneoplastic syndromes ```
27
Motor Peripherial Neuropathy causes
Lead Poisoning CIDP CMT Porphyria
28
CMT: Clinical features
``` Hereditary sensory motor polyneuropathy LL > UL, Motor > Sensory Distal wasting and weakness Pes Cavus and Hammer toes Bilateral foot Drop Decreased/Absent Reflexes Dorsal column sensory loss + Ataxic gait + Rhomberg positive ```
29
What are the main causes of Spastic Paraparesis?
UMN --> Spinal Cord Most likely (Bilateral Brain pathology) V - Vascular: Spinal artery occlusion (ST Loss) I - Inflammatory/Demyelinating: Multiple Sclerosis (DC loss, Cerebellar), NMO (Neuromyelitis Optica) N - Neoplastic - SC compression from tumour (Spinal Level) D - Degenerative - Cervical Myelopathy (Degenerative disc disease) - DC Signs, MND (mixed UMN and LMN signs) I - Infectious - Syphilis, TB, Epidural abscesses C - Congenital/Hereditary - Hereditary spastic Paraparesis, Fredrichs Ataxia (Cerebellar + DC Signs) A - Transverse Myelitis - SLE, Vasculitis (PAN) T - Trauma to Spinal cord (Spinal Level), Compression from Syringiomyelia E - Endocrine/Metabolic - B12 Deficiency (Subacute combined degeneration of the cord) - PN and DC signs
30
What are the main differentials for Mixed UMN and LMN findings
1. MND 2. Syringiomyelia - LMN in upper limbs, UMN in lower limbs, ST loss in cape like distribution 3. Cervical myelopathy - LMN at level of lesion, UMN below level of lesion + DC loss
31
Proximal Weakness - Differential Diagnosis
NMJ - MG, LEMS Muscle -Inherited muscular dystrophies - Beckers and Duchenne's, Limb girdle muscle dystrophy, Facioscapulohumeral -Inherited Myopathies 1. Autoimmune: Dermatomyositis, Polymyositis 2. Endocrinopathies: Hypothyroidism, Cushings disease 3. Drug induced: Steroids, Statin use 4. Other metabolic Causes: Hypokalaemic periodic paralysis
32
Distal weakness: Differentials
1. Any Motor peripheral neuropathy - CMT, CIDP 2. MND 3. Inherited myopathies: Myotonic dystrophy 4. Acquired Myopathies: IBM
33
Clinical Features of Beckers MD and DMD?
``` Beckers - Less Severe Waddling gait or wheelchair bound Proximal weakness (+Neck flexors) Face preserved Decreased/Absent reflexes ``` Associations: Kyphoscoliosis (Respiratory failure), Cardiomyopathy, Pul HTN
34
Clinical features of Myotonic dystrophy
Myopathic facies - loss of facial expression, Frontal balding, Bilateral ptosis, Triangular Facies - Wasting of SCM and Temporalis) Palatal weakness - Nasal speech Neck flexion weakness ``` Distal weakness (UL > LL) Wasting of the small muscles of the hands Percussion or Grip myotonia Reduced tendon reflexes Bilateral Foot Drop ``` Associations - Arrhythmia - PPM - Cardiomyopathy, MVP - Intellectual impairment - Diabetes mellitus (U/A) - Cataracts
35
Investigations of Myotonic Dystrophy
``` EMG to confirm myopathic process - Increased insertional activity and Fibrillations Confirm diagnosis - Muscle Biopsy (MRI) Genetic Testing to confirm Assess for Complications; - TTE - CM, ECG - Arrhythmia - Hba1c% ```
36
Management of Myotonic Dystrophy
``` MDT approach Genetic counselling - AD 50% of offspring + Anticipation Ankle/foot orthoses PT Annual ECHO Noctural BiPAP Speech therapy Management of DM Cataract surgery ```
37
Wasting of the Small muscles of the Hand: DDX
Global disuse atrophy - RA Anterior horn cells - MND SC - Cervical Myelopathy C8-T1 Nerve root lesion - Pan-coast syndrome from Apical Lung tutor Lower brachial Plexopathy Peripheral nerve - CMT (Global), Mononeuropathy (Median or ulnar nerve) Muscle - IBM, Myotonic dystrophy
38
How to differentiate CPN lesion and L4/5 Lesion
CPN - PED - Eversion and Dorsiflexion L4/5 - Add Inversion Sciatic - PED and TIP
39
DDX for a Foot Drop
1. Muscular causes - IBM, Myotonic dystrophy 2. Anterior horn cell - MND 3. L4/5 Lesion - Degenerative disc disease 4. Lumbar Plexopathy 5. Sciatic Nerve injury - THR, Trauma, Tumour compression (Sarcoma, Neurofibroma) 6. CPN injury - Direct compression (Plasters, prolonged immobility), Trauma (Fibula head fracture, post TKR), Tumor compression (Neurofibroma, Sarcoma), Mononeuritis multiplex (DM, Autoimmune conditions (SLE, RA) or vasculitis
40
Manifestations of a Radial Nerve Palsy
C5-C8 Wrist Drop - Weakness of wrist extension and Finger Extension Decreased Brachioradialis Sensation - anatomical snuff box
41
Radial nerve Palsy - Causes
At Wrist or spiral groove in the humerus 1. Compression 2. Trauma - Fracture 3. Mononeuritis Multiplex
42
Manifestations of a Median Nerve Palsy
C6-T1 Thenar wasting LOAF - Lumbricals, Opponens pollicis brevis, Abductor pollicus brevis and Flexor pollicis brevis -Weak thumb opposition and flexion Sensation - Palmar thumb and Digits 1 and 2
43
Median nerve Palsy - Causes
At Wrist --> Carpal tunnel 1. Arthropathy - RA 2. Obesity 3. Acromegaly 4. Pregnancy 5. Trauma
44
Manifestations of a Ulnar Nerve Palsy
C8 - T1 Ulnar claw hand Inability to flex digits 4 and 5, Weak Abduction and adduction of fingers Sensation - Palmar surface of digits 4 and 5 Hypothenar wasting
45
Ulnar nerve Palsy - Causes
At Elbow or wrist 1. Compression 2. Trauma - Fracture 3. Ganglion
46
Expressive Aphasia - Localise, other features
BED - Brocas area, expressive dysphasia STRIFE - Localised to the inferior frontal lobe FRONTAL lobe - higher centres - Interpreting a proverb (Too many cooks spoil the broth), Primitive reflexes, R Hemiparesis (UMN signs)
47
Receptive Aphasia - Localise, other features
STRIFE - Superior temporal gyrus - Receptive - Wernickes Aphasia TEMPORAL LOBE -Memory - STM (Recall 3 items), LTM (When did WW2 finish - 1945, When was the twin towers attack) -Also look for R hemiparesis and VF defect
48
HIGHER Centres - Parietal lobe - what signs to look out for
DOMINANT - Gerstmann syndrome - Acalculia - Agraphia - L R disorientation - Finger Agnosia NON DOMINANT - Spatial neglect - clock drawing - Dressing apraxia
49
MND: Clinical features
UL + LL - Mixed UMN and LMN findings, Hypertonia, Brisk reflexes, Fasiculations, Weakness (Proximal --> Distal) Bulbar involvement - Bulbar or Pseudobulbar palsy - Fasiculations, Wasting, Nasal speech, Palatal weakness
50
MND: Ddx
mixed UMN and LMN pathology - Cervical Myelopathy - Syringiomyelia - Dual pathology
51
MND: Ix
MND: primarily a clinical diagnosis MRI-Spine - Exclude other pathology - SOL (Tumours), Abscesses, Degenerative changes, Demyelination NCS (Rule out a neuropathy) and EMG (Demonstrate Fibrillations) Genetic testing
52
MND: Management
Supportive management Respiratory Support - NIV Riluzole - PO medications - extend life expectancy 3-6 month Other supportive measures: Secretions support - Chest PT, Bromhexine, Acapella MDT Approach - PT/OT Dietician And alternative feeding options - PEG/NGT
53
Chorea: Causes (And some features)
Huntingtons - Rigidity, Bradykinesia, Chorea, Intellectual impairment, Motor Impersistance Wilsons Disease - Cerebellar signs, KF rings, CLD Thyrotoxicosis PD - excess L.Dopa Therapy Sydnhems Chorea - Rheumatic Fever CTD - SLE
54
Classical Findings on NCS and EMG
NCS - Neuropathic process - Can demonstrate nerve affected, Sensory/Motor, Axonal (Decreased Amplitudes) or Demyelinating process (Increased Latency) (Change the ddx), NMJ - Decrement with repetitive stimulation EMG - Neuropathic Process - Denervation - Myopathic process - Increased insertional activity and fibrillations - NMJ - Increased Jitter

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