Neurological Flashcards
The spinal cord and cauda equina may be compressed by lesions that are…
Extradural (80%), intrdural/extramedullary (15%) and intramedullary
What motor neuron signs are expected in a degenerative cervical canal stenosis?
Lower motor neuron signs in the upper limbs and spastic paraparesis (UMN) in the lower limbs
What investigation should you order if spinal cord compression is likely?
MRI
What are the principles of treatment of degenerative canal stenosis?
- Conservative if mild or non-progressive
- Surgical treatment if moderate, severe or progressive: removal of compressing lesion (posterior approach = laminectomy, anterior approach = discectomy or vertebrectomy)
Compression in which 2 regions particularly cause sphincter disturbance?
Conus medullaris and cauda equina
What symptoms occur first in sphincter disturbance?
Difficulty initiating urine is usually the first symptom, followed by urinary retention or incontinence
What are the common causes of malignant spinal cord compression?
Lung, breast, prostate, kidney, lymphoma, myeloma
What are the principles of treatment of malignant spinal cord compression?
Commence dexamethasone
Options include:
- Palliation/symptom control only
- Radiotherapy
- Surgery
In what population and what region are spinal abscesses most common?
IVDU; thoraco-lumbar region
What are the FAST signs of stroke?
- Facial weakness
- Arm weakness
- Speech difficulty
- “Time to act fast” = 000
Main causes of intracerebral haemorrhage (2)
- Deep hypertensive location
2. Lobar (amyloid, AVM, tumour)
What area do you aim to rescue in the treatment of an acute stroke?
Penumbra
What is the CHADS2?
Scoring system for AF and stroke risk:
- 1 point for HF, HTN, >75yo, DM
- 2 points for previous stroke or TIA
If score is >1, oral anticoagulant is recommended
What are some secondary prevention strategies following stroke?
- BP and cholesterol medication
- Antiplatelet therapy
- Carotid endarterectomy if carotid artery stenosis (or stenting if
What are the features of a generalised tonic clonic seizure?
- Tonic phase: arms down, eyes open, cry
- Clonic phase
- Apnoea
- Last 1-5 minutes
- Minor injury common (tongue biting)
- After going confusion
What are the features of an absence seizure?
- Alteration of consciousness: stay upright, no warning
- Facial twitch
- Last 2-10 seconds
- Present in children or teenagers
What are the features of a myoclonic seizure?
- Sudden, involuntary muscle twitch
- Action-related
- Appear as a prodrome to GTCS
What are the features of a focal seizure?
- No alteration of consciousness
- Usually brief
- Features depend on location: eg/ temporal = deja-vu
What are the features of a focal dyscognitive seizure?
- Localised region
- Affects consciousness
- Similar to absence but longer, less distinct offset, automatisms, less frequent and preceding simple seizure
What are the subsyndromes of genetic generalised epilepsies?
- Childhood absence epilepsy
- Juvenile myoclonic epilepsy
- Juvenile absence epilepsy
- Epilepsy with tonic-clonic seizures alone
What are the features of childhood absence epilepsy (petit mal)?
- Onset in 4-8 yo (up to 12yo)
- Seizure types: absence seizures, GTCS
What are the features of juvenile absence epilepsy?
- Onset in adolescence
- Seizure types: GTCS, absence seizures (infrequent, absence status)
What are the features of juvenile myoclonic epilepsy?
- Onset in 12-18yo
- Seizure types: myoclonus, GTCS, absences in 30%
- Photosensitive
- Sleep-wake cycle
- May evolve from CAE
What are the features of a psychogenic pseudoseizure?
- Fluctuating intensity
- Very long
- Eyes closed
- Non-anatomical tremor
- Reactive
- Consciousness retained
What investigations are required in epilepsy?
- EEG
- MRI brain
What lifestyle issues should you warn a patient about with epilepsy?
- Swim only with someone who is aware
- Avoid heights
- Consider safety at work
- Triggers: alcohol, sleep
- Driving: 6-12 months seizure free
What are the features of MND?
- Disorder of upper and lower motor neurons
- Peak age of onset 55-70yo
- Muscle wasting including the tongue, generalised weakness
- Fasciculations
- Reflexes preserved until late, may have upgoing plantar reflex
- NO SENSORY LOSS
- Cranial nerves (except bulbar) spared
What clinical features should make you suspect myasthenia gravis?
- History of fatiguability
- Early involvement of extraocular muscles and lid opening muscles
- Dysarthria
- No muscle wasting
- Weakness increasing with repetitive exercise
- Reflexes and sensation unaffected
What tests are diagnostic for myasthenia gravis?
- Tensilon test
- Blood test for Autoantibodies-ACh receptor
- CT chest: thymoma
- EMG studies: repetitive stimulation, single fibre, post-exercise
What is the most common cause of focal mononeuropathy?
Compression
What is the most common cause of mononeuritis multiplex?
Almost always ischaemic
What investigations are required in a suspected myopathy?
- Needle EMG
- CK
- Family history and genetic testing
- Muscle biopsy
What would be seen on muscle biopsy in muscular dystrophy?
- Varying muscle fibre size
- Regenerating and degenerating fibres
- Increased fibrosis
What would be seen on muscle biopsy in polymyositis?
- Inflammatory cell infiltrate
- Degenerating and regenerating muscle cells
What are the cardinal features of Parkinson’s disease?
- Tremor
- Bradykinesia
- Rigidity
- Postural instability
What is dyskinesia?
Reversible levodopa-induced motor complication
- Abnormal involuntary movements
- Treat by adjusting levodopa dosing
What is dystonia?
Involuntary muscle contraction and involving abnormal movements and postures
- Can be an undertreated PD motor symptom or a complication of levodopa treatment
What are the levodopa-related motor complications?
- Wearing off
- On-off syndrome
- Failure to turn “on”
- Acute akinesia
What are the non-motor features of PD?
- Orthostatic hypotension
- Urine frequency
- Constipation
- Depression
What is the pain of a migraine like?
- Few hours to 3 days
- Recurrent, episodic
- Moderate to severe, building over minutes
- Unilateral
- Pulsating
- Aggravated by exercise
- With one r both of N+V, photo- or phonophobia
- Preceded by aura
What are the UMN signs?
- Spastic paralysis
- Increased reflexes
- Increased tone
- Babinski sign
What are the LMN signs?
- Flaccid paralysis
- Decreased reflexes
- Decreased tone
- Fasciculations
What are the 4 types of neuroepithelial tumours (gliomas)?
- Astrocytoma (most common)
- Ependymoma
- Oligodendroglioma
- Medulloblastoma
In what age group do gliomas most commonly present?
6th-8th decade
What are the symptoms of an intracranial mass?
- Symptoms of raised ICP: headache, N+V, drowsiness and eventual coma, papilloedema
- Seizures
- Focal neurological deficits
What are the typical features of headache in raised ICP?
- Gradually progressive
- Wore on waking, improves during the day
- Nausea and vomiting
- Drowsiness (if critical)
Principles of treatment of malignant astrocytoma?
- Commence steroids
- Resection of as much as possible
- Adjuvant chemo/radiotherapy
What are common sources of metastases to the brain?
Lung, brest, melanoma, kidney, GIT, unknown (15%)
Principles of treatment of brain metastases?
- Commence steroids
- Surgery to remove metastasis if solitary and have a reasonable life expectancy, or to confirm diagnosis
- Whole brain or stereotactic radiotherapy
What is the common feature of meningiomas on biopsy?
Whorls
Principles of treatment of meningioma?
- Total surgical excision and obliteration of the dural attachment
- Radiosurgery or radiotherapy if small, recurrent or malignant
What are the features of a tension-type headache?
- Mild to moderate
- Band-like, bilateral, pressing
- Not associated with exercise, nausea and photo/phonophobia
What are the features of a chronic daily headache?
- Most days, most of the day
- Can be chronic migraine or chronic tension-type headache
What are the features of a subarachnoid haemorrhage?
- Thunderclap onset
- May have neurological symptoms/signs: weakness/sensory loss and impairment of consciousness
- Associated photo/phonophobia, nausea
- May be unilateral
What are the causes of a thunderclap headache?
- Sexual headache
- Exertional headache
- Vasospastic headache
- Primary thunderclap headache
- SAH
What are the headaches not to miss?
- SAH
- Meningitis/encephalitis
- Subdural haematoma
- Space occupying lesion
- GCA
- Glaucoma
If the CT is normal, but SAH is suspected from the history, what should be performed?
Lumbar puncture
What are the management priorities in SAH?
- Monitor and treat the symptoms and complications: pain, N+V, raised ICP and hydrocephalus
- Prevent re-bleeding (normotension, CTA or surgical clipping)
What are the signs of transtentorial herniation?
- Unilateral dilated pupil (third nerve palsy)
- Contralateral hemiparesis (midbrain)
- HTN and bradycardia (Cushing response)
- Respiratory failure
How do you treat raised ICP?
- Elevate the head to encourage venous return
- Diuresis
- Hyperventilate and avoid hypoventilation
- Sedate/paralyse
- Remove mass
- Drain hydrocephalus
What is Uhthoff’s phenomenon?
Worsening of symptoms with heat in MS
What are the causes of transverse myelitis?
- MS
- Infectious/parainfectious inflammation
- Other autoimmune disorders: vasculitis, systemic autoimmune diseases
- No specific aetiology
What is required for MS diagnosis?
- Dissemination in space in the CNS
- Dissemination in time
How do you manage a relapse?
3-5 days of IV methylprednisolone, 1g/day
What are the first tier drugs for treatment of MS?
- Interferon B
- Glatiramer acetate
- Teriflunomide
What is a common automatism in complex partial seizures?
Lip smacking
