Neuro stuff you forget

Question 1

Describe the visual field defect you get in ischaemic stroke

Answer 1

Contralateral homonymous hemianopia with macula sparing

The damage would be on same side but area of vision lost is flipped. It more points to PCA but can happen w/ MCA or ACA.

Question 2

Describe S/S of posterior inferior cerebellar artery stroke

Answer 2

Lateral medullary syndrome because the PICA supplies the lateral medulla. It presents with:
- Ipsilateral Horner’s, Cerebellar signs, loss of facial spinothalamic sensation (pain, temperature)
- Contralateral - loss of spinothalamic sensation (ipsilateral on face)

Question 3

What is presentation of upper brainstem and lower brainstem infarction

Answer 3

Upper - locked-in syndrome
Lower - pseudobulbar palsy

Question 4

Describe Weber’s syndrome

Answer 4

A midbrain stroke in branches of the posterior cerebral artery (PCA) that supply the midbrain. Presents with:
- Ipsilateral palsy of CN3 (dilated pupil - mydriasis, as loss of CN3 PSNS) and down/out
- Contralateral hemiparesis - decussation of UMNs occurs below the lesion (midbrain > pons > medulla where they decussate)

Question 5

When is endarterectomy indicated?

Answer 5

> 70% stenosed (ECST) or NASCET trial said >50%.

NB this is done via MRA/CTA after carotid doppler done.

Question 6

Describe acute Mx of ischaemic stroke and the windows

Answer 6

Emergency CT and other Ix.
- Aspirin 300mg after CT if cannot do thrombolysis. Given daily (In AF anticoagulants/warfarin should not be started until 14 days after stroke)

• Thrombolysis if can be given <4.5hrs of symptom onset but lots of CI (cannot be bleeding anywhere). Hold off aspirin and give 24hrs later
• Endovascular/mechanical thrombectomy, criteria are:
  - Large clots in large anterior vessels (widespread sx)
  - <6hrs of Sx onset (if <4.5 can do this + thrombolysis)
  - Pt reasonably functioning/not too frail

Question 7

Supportive care for stroke

Answer 7

Admit to stroke unit
Assess swallow to prevent aspiration pneumonia (NG PEG?)
Prevent DVT via IPCDs (not stockings or heparin - haemorrhage)
Cannot drive for 1m after stroke

Question 8

Describe stroke primary and secondary prevention

Answer 8

Primary - lifestyle: exercise, reduce alcohol/smoking weight loss, control conditions (DM, HTN, cholesterol)
Secondary:
- Dual antiplatelet therapy, usually aspirin 300mg for 2 weeks then switch to clopidogrel or aspirin + dipyridamole
- Statins for high cholesterol
- Control HTN 2 weeks later (not in acute phase), same with anticoagulants if CHADS-VASc AF indicates

Question 9

What is malignant MCA syndrome and how is it treated?

Answer 9

Space occupying cerebral oedema following MCA stroke causing rapid neurological deterioration.
Requires mannitol and surgical decompression

Question 10

What is definition of TIA? Mx?

Answer 10

Transient episode of neurological dysfunction caused by ischaemia without acute infarction

Same as stroke - aspirin 300mg. Control HTN long term

Question 11

Bamford classification criteria for total anterior circulation stroke (TACS)

Answer 11

All 3 of following:
- Unilateral weakness (face, arm and leg)
- Homonymous hemianopia (remember, contralateral with macular sparing)
- High cerebral dysfunction (e.g. dysphasia, visuospatial disorder

Question 12

Bamford classification criteria for partial anterior circulation stroke (PACS)

Answer 12

2/3 of following (opposed to all 3 for TACS)
- Unilateral weakness (face, arm and leg)
- Homonymous hemianopia (remember, contralateral with macular sparing)
- High cerebral dysfunction (e.g. dysphasia, visuospatial disorder

However, higher cerebral dysfunction alone is also classified as PACS

Question 13

Bamford classification criteria for posterior circulation stroke (POCS)

Answer 13

Effects cerebellum and brainstem, only need 1 of the following:
- CN palsy and a contralateral motor/sensory defect
- Bilateral motor/sensory deficit
- Conjugate eye movement disorder (e.g. horizontal gaze palsy)
- Cerebellar dysfunction (e.g. vertigo, nystagmus, ataxia)
- Isolate homonymous hemianopia

Question 14

Bamford classification criteria for lacunar syndrome (LAS)

Answer 14

A subcortical stroke only effecting a 1 small vessel hence no loss of higher cerebral function. One of following needs to be present:
- Pure sensory stroke
- Pure motor stroke
- Ataxic hemiparesis

Question 15

Describe what Cushing reflex is and the quadrad

Answer 15

Late sign indicating impending brain herniation. The quadrad is:
- HTN (increases to increase CPP = MAP - ICP)
- Bradycardia
- Irregular breathing
- Wide pulse pressure

Question 16

What is CPP equation and its significance?

Answer 16

Cerebral perfusion pressure = MAP - ICP

If ICP rises in stroke, CPP will fall. Body causes HTN to increase MAP to try to prevent this.

<60 CPP start getting LOC
<30 starts becoming fatal

Question 17

General Mx of haemorrhagic stroke (and correction of coagulation)

Answer 17

ABCDE
Priority is surgical drainage - clot evacuation/ligation of bleeding vessel
IV mannitol (osmotic causes water excretion at kidney)
Airway care - intubation/ventilation
Reverse anticoagulants:
- Warfarin corrected with Beriplex (prothrombin complex) + vit K to replace clotting factors.
- DOACs reversed with idarucizumab or andexanet alfa
- Heparin reversed with protamine

Question 18

How to tell apart chronic and acute haematoma on MRI (T2)

Answer 18

Acute - whiter than brain tissue as hyperdense (think T2 makes water white and blood is like water)
Chronic - darker than brain tissue

Question 19

Tx of SAH

Answer 19

Nimodipine

Question 20

Some of the neurosurgeons conservative Mx to rising ICP

Answer 20

Sit up in bed (gravity)
Good ventilation - high CO2 causes vasodilation, not good in haemorrhage
Keep patient cold (heat also causes vasodilation)
In severe cases, can sedate/paralyse pts to reduce metabolic demand

Question 21

Name Parkinson plus syndromes

Answer 21

Progressive supranuclear palsy - axial rigidity, signs of dementia (frontal disinhibition) and parkinson’s with faailure of downward gaze (gaze paresis)
MSA - prominent autonomic features (orthostatic hypotension, incontinence, difficulty regulating temperature)
Shy-Drager syndrome
Lewy body dementia - hallucinosis, flutating Level of conscious

More have symmetrical onset and poor response to L Dopa

Question 22

Parkinson’s drugs - name and describe MoA:
Peripheral dopa-decarboxylase inhibitor used w/ L-Dopa
Dopamine agonists
Monoamine oxidase B inhibitors
COMT inhibitor

Answer 22

Peripheral dopa-decarboxylase inhibitor = carbidopa, giving co-careldopa to prevent SE (nausea/hypotension)

Dopamine agonist = ropinirole/Pramimpexole. Remember have an O in suffix like dOpamine

MoABi - Selegilin/Rasagiline. End in ilin so Inhibit. Must not start SSRI due to risk of serotonin syndrome

COMT inhibitors = entacapone, prevent peripheral degradation of L-dopa. -pone kinda sounds like COMT

Question 23

Can you give metoclopramide, domperidone or anticholinergics to PD patients?

Answer 23

Metoclopramide no as dopamine antagonist that cross BBB
Domperidone yes, same MoA but cannot cross BBB
Do not give anticholingerics for drooling etc. as induce confusion in elderly

Question 24

What is kernig’s and Brudzinski’s signs?

Answer 24

Kernig’s = inability to allow full extension of the knee when the hip is flexed to 90 degrees
Brudzinski’s = forced flexion of the neck elicits a reflex flexion of the hips

Both signs of meningsm.

Question 25

When are you vaccinated against meningitis B, C and ACWY?

Answer 25

B - looks like an 8 so 8weeks and 16weeks
C - 12 weeks and 1 year
ACWY - 14years

Question 26

What is the defect seen in internuclear ophthalmoplegia?

Answer 26

Ipsilateral failure of adduction of the ipsilateral eye

It is due to lesion at medial longitudinal fasciculus in paramedian area of midbrain/pons, it interconnects CN 3, 4 6 so needed for conjugate eye movements.
Convergence maintained as Edinger-Westphal nucleus
Can be due to strokes or MS.

Question 27

Migraine headache prophylaxis

Answer 27

1st - topiramate / sodium valproate (teratogenic)
2nd - propranolol or atenolol (ci in asthma)
3rd - amitriptyline

Question 28

Cluster headache prophylaxis

Answer 28

Verapamil
Propranolol, valproate or prednisolone

Question 29

How long does tension, migraine and cluster headache typically last?

Answer 29

Tension - 30mins to 7 days
Migraine - 4 to 72hrs
Cluster - 15 to 180minutes

Question 30

Why do you need to be careful with AEDs and COCP?

Answer 30

AEDs are hepatic enzyme inducers so may reduce efficacy of OCP.

Question 31

What are 2 drug classes used in AD?

Answer 31

ACh inhibitors - Donepezil, Rivastigmine, galantamine. Give mild symptomatic benefit in mild/moderate.

Memantine (NMDA receptor antagonist) only used in moderate/severe AD.

Question 32

What is MMSE cut-offs for mild, moderate, severe AD?

Answer 32

Mild - 20-24
Moderate - 13-20
Severe - 0-12

Question 33

How do you distinguish between sensory ataxia and cerebellar ataxia?

Answer 33

Sensory ataxia gets worse when eyes closed/in dark, while cerebellar no change (bad in both)

This is because to maintain balance, we need 2/3 of proprioception, vestibular apparatus and vision. Only vestibular if in dark and sensory ataxia.

Question 34

Nerve roots of median and ulnar nerves and what they supply

Answer 34

Median - C6 to T1. Mainly does anterior compartment of forearm muscles. Also LLOAF (thenar). Sensation to palm.

Ulnar - C8 to T1. Mainly intrinsic muscles of hand apart from LLOAF and FCU and medial part of FDP.

Question 35

How do you distingusih between common peroneal nerve palsy and L5 radiculopathy

Answer 35

Peroneal nerve palsy generally causes an isolated foot drop, eversion also affected.

L5 radiculopathy is similar and inversion. Not complete paralysis, pain on straight leg raise and hip abductors more likely to be weak (L5 superior gluteal nerve)

Question 36

How do you treat essential tremor?

Answer 36

Propranolol or primidone

Question 37

How does Bell’s palsy present, Ix, DDx (from stroke), Tx.

Answer 37

Ipsilateral paralysis of facial muscles, hyperacusis, lost of taste in ant 1/3 of tongue, dry mouth (chorda tympani), decreased lacrimation.

Ix - clinical, but rule out Lyme disease.

Stroke has forehead sparing (Upper spares upper), Bell’s is lower so has no forehead sparing. Ramsay hunt syndrome

Most get better over 3 weeks. Steroids given within 72hrs of symptom onset and eye protection. Limited evidence of aciclovir but used if severe.

Question 38

What is Ramsay Hunt syndrome?

Answer 38

Reactivation of VZV in geniculate ganglion, a nerve bundle of the facial nerve. Causes similar Sx but with a vesicular rash.

Question 39

Describe normal pressure hydrocephalus MoA, Px, Ix, Mx

Answer 39

A reversible cause of dementia thought to be 2o to reduce CSF absorption at arachnoid vili. Can be secondary to injury, SAH, meningitis.

Classic triad = wee (incontinence), whacky (dementia), wobbly (gait abnormality similar to PD). Sx develop over a few months

CT shows hydrocephalus

Mx - ventriculoperitoneal shunting

Question 40

Describe idiopathic intracranial hypertension (pseudotumour cerebri) MoA, Px, Ix, Mx

Answer 40

Cause unknown

Sx of raised ICP in otherwise well obese women. These are pressure-like/throbbing headaches (worse in morning and on straining w/ vomiting), transient visual loss (<30s), neck and back pain, diplopia due to CN6 palsy. Papilloedema

Imaging, visual vield testing. Diagnosis via Dandy criteria.

Tx - low salt, weight reduction. Acetazolamide when indicated.

Question 41

What do you do with GCS of <13 or 8

Answer 41

Head injury and GCS <13 means CT scan within an hour

GCS of 8 = intubate (rhymes)