Neuro (things I forget) Flashcards
What is the most common cause of brain metastases?
Lung tumours
What are the clinical features of degenerative cervical myelopathy?
- Pain
- Loss of motor function = weakness/stiffness/impaired gait/etc.
- Loss of sensory function = numbness
- Loss of autonomic function = incontinence
- Hoffman’s sign = reflex test - gently flick one finger on patient’s hand –> reflex twitching of other fingers on same hand
What are the clinical features of adhesive capsulitis?
- ‘Frozen shoulder’ - stiffness/pain in shoulder
- External rotation affected more
- Freezing phase –> adhesive phase –> recovery phase
What is L’hermitte’s sign?
Seen in patients with MS - electric shock sensations after flexion of neck
What is Uhthoff’s phenomenon?
Seen in patients with MS - temporary worsening of symptoms due to heat sensitivity e.g. getting into bath
What diagnostic criteria is used for multiple sclerosis?
McDonald’s Criteria
What are the investigations for MS?
Diagnosis requires demonstration of lesions disseminated in time and space
- MRI = periventricular plaques/high signal T2 lesions
CSF = oligoclonal bands
What is the management for MS?
Acute relapse = high dose steroids e.g. oral/IV methylprednisolone
Reducing risk of relapse = natalizumab/ocrelizumab/fingolimod/beta-interferon/glatiramer acetate
What is the most common complication of meningitis?
Sensorineural hearing loss
What is the management for migraines?
Acute attack = sumatriptan and NSAID/paracetamol
Prophylaxis = topiramate/propranolol (preferred in women of child-bearing age)
What is the commonest cause of sporadic encephalitis?
Herpes simplex encephalitis
What are the investigations and management for encephalitis?
- CSF = lymphocytosis/elevated protein/PCR (for HSV/VZV/enteroviruses)
- MRI = medial temporal and inferior frontal changes
- IV aciclovir
What are the clinical features of temporal lobe seizures?
- Aura
- Hallucinations/flashbacks/deja vu
- Anxiety
- Automatisms
What are the clinical features of frontal lobe seizures?
Jacksonion march motor disturbances
What is the main distinguishing feature between seizures and syncope?
Seizure - confusion after recovery
Syncope - rapid recovery
What are the clinical features of Parkinson’s?
- Bradykinesia/tremor/rigidity
- Difficulty initiating movement
- Postural instability
- Unilateral symptoms
- Pill rolling tremor
What is a complication of cabergoline?
Dopamine agonist used in Parkinson’s - may cause interstitial lung disease/pulmonary complications
What are the clinical features of progresssive supranuclear palsy?
A.k.a ‘Parkinson Plus syndrome’
- Postural instability
- Impairment of vertical gaze
- Parkinsonism
- Cognitive impairment
What are the clinical features of essential tremors?
- Postural tremor - worse if arms outstretched
- Improved by alcohol and rest
- Most common cause of head tremor (titubation)
What is the management for essential tremor?
Propranolol
What is autonomic dysreflexia and what are the clinical features?
Occurs in patients who have had a spinal cord injury at/above T6
Commonly triggered by faecal impaction/bladder distension
- Severe HTN
- Bradycardia
- Pounding headache
- Flushing/sweating above level of lesion
- Cool/pale skin below level of lesion
- Agitation
Describe the difference between Broca’s and Wernicke’s aphasia?
Broca’s:
- Frontal lobe
- Difficulty speaking fluently e.g. limited words at a time/halting/effortful
- Able to understand speech and read
Wernicke’s:
- Superior temporal gyrus (responsible for language comprehension)
- Speech is fluent but makes little sense and/or includes nonsense
- Person doesn’t realise they’re speaking nonsense
Global:
- Affects both areas
- Can only produce a few recognisable words
- Understand very little/no spoken language
What are the clinical features of Bell’s palsy and what is the management?
- Lower motor neuron facial nerve palsy - forehead affected
- Post-auricular pain
- Altered taste
- Dry eyes
- Hyperacusis
- Oral prednisolone
What is the first line management and common side effect for Parkinson’s?
Levodopa - synthetic dopamine
- ‘Wearing-off phenomenon’ = experiencing symptoms towards end of dose and prior to next dose
What are the clinical features of Guillain-Barre syndrome?
- History of gastroenteritis
- Progressive symmetrical ascending weakness of limbs
- Reduced/absent reflexes
- Mild sensory symptoms
What is used to measure disability/dependence in activities of daily living in stroke patients?
Barthel Index:
- Feeding
- Bathing
- Grooming
- Dressing
- Bowel control
- Bladder control
- Toilet use
- Transfers (bed to chair/chair to bed)
- Mobility on level surfaces
- Stairs
Which part of the brain is commonly affected in Alzheimer’s?
Widespread cerebral atrophy mainly involving the cortex and hippocampus
What will a LP show in patients with Alzheimer’s?
- Beta amyloid plaques
- Tau protein neurofibrillary tangles
What is the first line management for Alzheimer’s?
Acetylcholinesterase inhibitors e.g. donepezil/rivastigmine/galantamine
What is the first line management for myasthenia gravis?
Long acting acetylcholinesterase inhibitors e.g. pyridostigmine/neostigmine
What is the management for myasthenia crisis?
IV immunoglobulins and plasmapheresis
What is the typical presentation of idiopathic intracranial hypertension and what is the management?
Obese, young female with headaches and blurred vision - acetazolamide (carbonic anhydrase inhibitor)
What is status epilepticus?
- Single seizure lasting >5 minutes
OR - 2 seizures within a 5 minute period without the patient returning to normal between them
What is the management for status epilepticus?
- ABC
- Benzodiazepines = IV lorazepam (community setting = PR diazepam/buccal midazolam)
- Can give IV lorazepam twice
- Second line = levetiracetam/phenytoin/sodium valproate
What is the classic presentation of spinal stenosis?
- Back pain with associated leg/buttock pain
- Relieved with flexion and worsened with extension
What are the clinical features of a basal skull fracture?
- Haemotympanum (accumulation of blood within middle ear)
- Panda eyes
- CSF leakage from ear/nose
- Battle’s sign (bruising over the mastoid process)
What management is contraindicated in basal skull fractures?
Insertion of NG tube - risk of CNS entry through cribriform plate
Describe the epidemiology of MND
- Amyotrophic lateral sclerosis is most common followed by progressive bulbar palsy
- Typical patient = man in 60s
What is the management for MND?
- ALS = riluzole
- Respiratory care (non-invasive ventilation - BIPAP)
- PEG nutrition
What are the clinical features of normal pressure hydrocephalus?
Hakim’s triad:
- Difficulty walking
- Poor bladder control
- Cognitive impairment
What is the investigation for normal pressure hydrocephalus?
MRI = ventriculomegaly without sulcal enlargement
What is Meniere’s disease and what is the management?
Balance disorder caused by excess fluid in labyrinth
- Acute attacks = buccal/IM prochlorperazine
- Prophylaxis = betahistine and vestibular rehabilitation exercises
Describe neurofibromatosis type 2
Autosomal dominant condition characterised by development of vestibular schwannomas - hearing loss/tinnitus/balance problems
What cranial nerves are affected by vestibular schwannomas (acoustic neuromas) and what do they cause?
- CN V = absent corneal reflex
- CN VII = unilateral facial numbness
- CN VIII = vertigo and unilateral hearing loss
Describe stroke - posterior inferior cerebellar artery
a.k.a Wallenberg/lateral medullary syndrome
- Ipsilateral loss of temperature sensation and facial pain
- Contralateral limb/torso pain and temperature loss
- Ataxia
- Nystagmus
- Ipsilateral Horner’s
Describe stroke - anterior inferior cerebellar artery
a.k.a lateral pontine syndrome
- Ipsilateral facial paralysis
- Ipsilateral deafness
- Ipsilateral loss of temperature sensation and facial pain
- Contralateral limb/torso pain and temperature loss
- Ataxia
- Nystagmus
Describe stroke - anterior cerebral artery
- Contralateral hemiparesis and sensory loss
- Lower extremities worse
- Incontinence
- Personality changes
Describe stroke - middle cerebral artery
- Contralateral hemiparesis and sensory loss
- Upper extremities worse
- Contralateral homonymous hemianopia
- Aphasia
Describe stroke - posterior communicating artery
- Contralateral homonymous hemianopia with macular sparing
- Visual agnosia
Describe stroke - Weber’s syndrome (branches of posterior cerebral artery that supply midbrain)
- Ipsilateral CN III palsy
- Contralateral weakness
Describe stroke - retinal/ophthalmic artery
Amaurosis fugax
Describe stroke - basilar artery
Locked-in syndrome
Describe stroke - lacunar
- Associated with HTN
- Basal ganglia/thalamus/internal capsule
-Isolated hemiparesis/hemisensory loss/hemiparesis with limb ataxia
What is needed after a patient has a TIA?
Specialist referral within 24 hours for diffusion weighted MRI - show area of ischaemia but not infarction
What eye symptoms would you see in each cranial nerve palsy?
Oculomotor (CN III) = eye deviates down and out/ptosis/dilated pupil
Trochlear (CN IV) = impaired downward gaze/vertical diplopia/eye deviates upwards and outwards
Abducens (CN VI) = impaired abduction/horizontal diplopia
Where do homonymous quadrantanopias affect?
Inferior - parietal
Superior - temporal
What side effects may be associated with antiparkinsonian medications?
Dopamine receptor agonists e.g. ropinirole/cabergoline = risk of inhibition disorders
What are the types of multiple system atrophy and what are the features?
MSA-P (predominant parkinsonian features) and MSA-C (predominant cerebellar features)
- Parkinsonism
- Autonomic disturbance e.g. ED/postural hypotension/atonic bladder
- Cerebellar signs
What is a pontine haemorrhage and what are the clinical features?
Life-threatening condition that occurs as a complication secondary to chronic HTN
- Reduced GCS score
- Quadriplegia
- Miosis
- Absent horizontal eye movements
What do the ulnar/median/radial nerve supply sensation to?
Ulnar = medial 1 1/2 fingers
Median = palmar aspect of thumb and lateral 2 1/2 fingers (and fingertips)
Radial = dorsal aspect of thumb and lateral 2 1/2 fingers
What will a radial nerve palsy cause?
‘Saturday night palsy’ - wrist drop
What is the common peroneal nerve also known as and what will a lesion cause?
Common fibular nerve - weakness of foot dorsiflexion and foot eversion
If a patient suffers from foot drop and weak dorsiflexion, it may indicate there is spinal nerve root
compression of which nerve?
L5
How can you differentiate between a seizure and a pseudoseizure?
Prolactin
What is the Cushing reflex?
A physiological nervous system response to increased ICP
- Bradycardia
- Irregular breathing
- Wide pulse pressure
How might raised ICP be investigated?
Headache worsened by valsalva manoeuvres e.g. blowing into empty syringe/coughing/lying down –> CT head
What is venous sinus thrombosis?
Thrombotic obstruction of cerebral veins and/or dural sinuses - thrombus reduces venous drainage and increases ICP –> headache, diplopia, nausea and seizures
What is a common differential diagnosis for TIA?
Hypoglycaemia –> focal neurological symptoms (bilateral symptoms)
What is Bell’s palsy and what is the management?
Acute, unilateral, idiopathic paralysis of facial nerve
Oral prednisolone within 72 hours (and eye care e.g. lubricating eye drops)
What vessel is affected in extradural haematomas and what is the classic presentation?
Ruptured middle meningeal artery (temporal region)
- Features of raised ICP
- Initial brief loss of consciousness
- Lucid interval
- Second deterioration
What vessel is affected in subdural haematomas and what is the classic presentation?
Ruptured bridging veins between cortex and venous sinuses (frontal or parietal lobes)
- Slower onset of symptoms
- Fluctuating consciousness/confusion
What investigation can be done afterwards to confirm a subarachnoid haemorrhage and what will it show?
Lumbar puncture 12 hours after onset of symptoms
- Breakdown products of RBCs e.g. bilirubin (xanthochromia)
- Normal or raised opening pressure
What is a common complication of subarachnoid haemorrhage?
SIADH –> hyponatraemia
What haemorrhage is a common cause of neonatal deterioration?
Intraventricular haemorrhage
What is Ramsay-Hunt syndrome and what are the clinical features?
Reactivation of VZV in geniculate ganglion
- Tinnitus
- Vertigo
- Facial paralysis
- Loss of taste
- Dry eyes
What 6 things are checked to confirm brain death?
- Pupillary reflex
- Corneal reflex
- Oculo-vestibular reflex
- Cough reflex
- Response to supra-orbital pressure
- No spontaneous respiratory effort
What is chiari malformation?
Herniation of cerebellar tonsils through foramen magnum - causes symptoms by compressing the brainstem
What is chiari malformation associated with and what are the features?
Sryingomelia - dilation of CSF space within spinal cord due to disturbed CSF flow at foramen magnum
- Loss of sensation of pain, temperature and non-discriminative touch
What nerve is common affected by humeral shaft fractures and what does it cause?
Radial nerve - wrist drop
What nerves are responsible for the biceps reflex?
C5-C6
What are the features of trigeminal neuralgia and how does it differ from a common differential?
Sharp, unilateral, electric shock-like facial pain triggered by chewing or touching affected area on face - continuous throbbing, aching pain
Similar to temporal arteritis but this would have temporal artery tenderness
What is the management for trigeminal neuralgia?
First line = carbamazepine
What is the management for alcohol withdrawal?
Benzodiazepines e.g. chlordiazepoxide
BUT
give lorazepam in liver cirrhosis as it isn’t metabolised through liver-dependent oxidative pathways
What is subacute degeneration of the spinal cord and what are the clinical features?
Caused by vitamin B12 deficiency which affects the lateral corticospinal tracts, dorsal column and spinocerebelllar tracts
- Signs of peripheral neuropathy
- Loss of proprioception, vibration and fine touch in legs
- Spastic weakness in legs
- Abnormal gait
- Positive Romberg’s test
- Absent ankle jerks/extensor plantars
Describe the GCS
Eye response = /4
Verbal response = /5
Motor response = /6
Overall = /15
Describe the GCS - eye response
4 = spontaneous
3 = to speech
2 = to pain
1 = none
Describe the GCS - verbal response
5 = orientated
4 = confused
3 = words
2 = sounds
1 = none
Describe the GCS - motor response
6 = obeys commands
5 = localises to pain
4 = withdraws from pain
3 = flexion to pain
2 = extension to pain
1 = none
What is a common compliation of subarachnoid haemorrhages and what is the management?
Rebleeding of intracranial aneurysm –> aneurysm coiling
What is Stevens-Johnson syndrome and what are the clinical features?
Skin/mucosa reaction to some medications e.g. lamotrigine/penicillin/NSAIDs
- Maculopapular rash with vesicles or blisters
- Systemic involvement
What is diffuse axonal injury anwhat is the best investigation?
Occurs when the head is rapidly accelerated or decelerated
- Multiple haemorrhages
- Diffuse axonal damage in white matter
- MRI
What is an ataxic gait?
- Wide-based gait
- Inability to coordinator lower limbs to walk in heel-to-toe fashion
What is pituitary apoplexy and what are the clinical features?
Sudden enlargement of pituitary tumour secondary to haemorrhage or infarction
- Sudden onset headache
- Vomiting
- Neck stiffness
- Visual field defects
- Features of pituitary insufficiency e.g. hypotension
What is Lambert-eaton syndrome associated with?
Small cell lung cancer
What are the clinical features of Horner’s syndrome?
Unilateral:
- Anhidrosis
- Miosis
- Ptosis
- Enophthalmos
What is mydriasis?
Opposite of miosis - dilated pupil
What is the most common genetic mutation associated with Charcot-Marie-Tooth disease and what are the clinical features?
PMP22 dupplication
- Foot drop
- High arched feet
- Distal muscle weakness/atrophy
- Hyporeflexia
Describe myotonic dystrophy
- Typical onset 20-30
- Affects skeletal, cardiac and smooth muscle
- Autosomal dominant trinucleotide repeat disorder
- Myotonic facies
- Frontal balding
- Bilateral ptosis
- Cataracts
- Dysarthria
Describe Friedreich’s ataxia
- Typical onset 10-15
- Autosomal recessive trinucleotide repeat disorder
- Absent ankle jerks/extensor plantars
- Cerebellar ataxia
- Optic atrophy
- Spinocerebellar tract degeneration
Describe benign paroxysmal positional vertigo
- Vertigo triggered by change in head position
- Investigation = Dix-Hallpike manoeuvre
- Management = Epley manoeuvre (Brandt-Daroff exercises at home)
Describe thoracic outlet syndrome
- Nerves/blood vessels in thoracic outlet (space between collarbone and 1st rib) are compressed
- Pain/numbness/tingling/weakness in arm
- Adson’s test = radial pulse diminishes with head rotation and deep breathing
