Neurological Flashcards
What would a patient with an oculomotor nerve palsy look like?
Unilateral complete ptosis
Eye down and out
Fixed dilated pupil in both direct and consensual light reflex (note opposite eye would dilate as consensual reflex still present)
If partial nerve palsy it would spare pupillary and lid parasympathetic nerves
Causes of optic nerve lesion
- optic/retrobulbar optic neuritis
Optic nerve compression eg pit tumour/aneurysm
Toxic/ischaemic/hereditary optic neuropathy
Vit B12 def
Trauma
infection
papilloedema
Causes of oculomotor nerve lesion
Aneurysm of posterior communicating artery
Internal carotid aneurysm
Microvascular infarction eg diabetes (spares pupil)
Midbrain infarction
Demyelination brainstem- MS
Myasthenia, orbital mass, inflammation
Causes of UMN facial palsy (spares forehead)
Stroke with hemiparesis on contralateral side Intracranial tumour MS Syphilis HIV
Causes of LMN facial palsy
Bells palsy Ramsey hunt syndrome Infection- lyme disease, TB otitis media skull # CPA tumours diabetes sarcoidosis Stroke- brainstem lesion demyelination-MS
Where is the damage in internuclear opthalmoplegia?
Damage to medial longitudinal fasciulus in brainstem and causes:
- disconjugate horizontal movements
- incomplete adduction of ipsilateral eye
- coarse jerky nystagmus of opposite abducting eye
Which nerves are affected in cavernous sinus syndrome and what are the symptoms?
Ipsilateral III, IV, VI, V1
Painful opthalmoplegia with fixed dilated pupil
Orbital congestion, chemosis, periorbital oedema
Proptosis
Sensory loss over V1 and possible horners
What causes cavernous sinus syndrome?
- tumours- nasopharyngeal/menigiomas
- pit apoplexy
- vascular- aneurysms of carotid, carotid sinus AV fistula, aseptic thrombosis
- infections
- granulomatous disease
What nerves are affected in Jugular foramen syndrome and what are the symptoms?
IX, X, XI Dysphagia, dysphonia Sensory loss of posterior 1/3 tongue, soft palate, larynx Sternocleidomasteoid/trapezius atrophy Absent gag reflex Headache/hydrocephalus/raised ICP
What nerves are affected in CPA syndrome? what are symptoms?
V, VII, VIII (less commonly VI, IV, X)
Facial sensory loss LMN facial weakness without hyperacusis Sensorineural hearing loss and tinnitus Nystagmus and gaze palsies If grows and puts pressure on cerebellum- ataxia
Which syndrome causes an ipsilateral 3rd nerve palsy and contralateral hemiparesis?
Weber’s syndrome
What are the differential diagnoses of stroke?
SOL: tumour, abscess, parasities Viral encephalitis Neuroinflammatory Metabolic Migraine Epilepsy- Todds paresis following a focal seizure Neuropsychiatric
What investigations would you do in a possible stroke?
Bloods: FBC, glucose, clotting, ESR, TFTs, ANA ECG- AF CT brain SALT review CXR- aspiration fasting glucose and lipids Thrombophilia screen MRI brain 24hr tape Carotid doppler
What is the acute management of stroke?
Confirm ischaemia
- Thrombolysis within 4.5hrs if no contraindications
- 300mg aspirin continued for 2 weeks
- If in AF wait 2 weeks until starting anti-coag
- Keep glucose 4-11mmol/L
- monitor BP- anti-hypertensives only given in hypertensive emergency eg encephalopthy, nephropathy, CCF
Who would be referred for hemicraniotomy?
Refer within 24hrs onset
Age <60yrs
Clinical deficits suggesting a MCA infarc with NIHSS score>15
Decrease in level of conciousness
Signs on CT of infarct of at least 50% MCA territory +/- additional territory of ant/post cerebral artery
Name some contraindications to thrombolysis?
Seizure at onset of stroke Symptoms suggestign SAH stroke/serious head injury in last 3 months Major surgery or trauma in last 2 weeks Previous intracranial haemorrhage Intracranial neoplasm AV malformation or aneurysm GI/urinary tract haemorrhage in last 3 weeks LP in preceeding week Current INR>1.7 Acute pericarditis Glucose <2.7 Preganancy
What are the acute and chronic complications of stroke?
Acute: raised ICP, haemorrhagic transformation, aspiration pneumonia
Chronic: pneumonia, contractures, DVT, pressure sores, UTI, constipation, depression, seizures, thalamic pain syndrome
What would you use in the secondary prevention of stroke?
Clopidogrel 75mg OD (if TIA on aspirin and dypyridamole)
Anticoagulation if in AF ( wait 2 weeks after stroke, start immediately if TIA)
Statin- aim to reduce non-HDL by 40%
Treat hypertension
LIfestyle- smoking, alcohol, exercise, diet
What score is used in strokes?
NIHSS (National institute for health stroke score)- used to assess severity of stroke and is scored out of 42.
Uses level of conciousness, gaze, visual field deficit, motor and sensory deficit, dysarthria, ataxia etc
WHat new interventional treatment for strokes is becoming available?
Mechanical thrombectomy- intra-arterial clot retrival via cannulation of femoral artery.
Used for people with proximal vessel occlusion.
NNT for 1 person to acheive functional independance is 2.6. Ideally done within 5hrs
How would you investigate and manage a patient with possible SAH?
- CT head- 95% accurate if done within 48hrs
- LP 12hrs later- xanthochromia
- Arterial imaging- CT/MR angiography
- supportive care- stabilise BP, ventilation, avoid hyperglycamia and hyperthermia
- stop anti-coagulation
- Commence nimodipine- reduce risk of vasospasm
- Liaise with neurosurgery- ? clipping/endovascular coiling
What are the clinical features of MS?
OPtic neuritis: pain behind eye on movement, reduction in visual acuity, colour desaturation, RAPD. Visual acuity reaches nadir at 2 weeks
Diplopia: VIth nerve palsy or INO
Spinal cord syndrome: sensory disturbance, paraparesis, bowel/urinary dysfunction
Weakness and spasticity =0 later
Cerebellar signs- unsual at presenations
Dysarthria, dysphagia, pain, trigeminal neuralgia
Lhermittes sign: electric shock on flexion of neck
Uhtoffs phenomonen: worsening symptoms with rise in body temp
What investigations would you request for a patient with possible MS?
ESR, ANA, ANCA, dsDNA, ENA, anti-phospholipid
MRI: classical peri-ventricular white matter lesions and involvement of corpus callosum. Other sites are juxtacortical white matter, brainstem, cerebellum, spinal cord
Visual and auditory evoked potentials
CSF- mild raised WCC, unmatched oligoclonal bands
What criteria can be used to diagnose MS without 2 episodes occuring?
Revised McDonald criteria using MRI evidence of active and previous lesion or further MRII showing new lesion 30 days apart
What is the management of MS?
Acute relapses- steroid therapy
Symptomatic mx: physio, OT, SALT, antispasmodics- baclofen, IM botox, catheter, oxybutanin, laxatives
Disease modifying therapy: 1st line- relapsing and remitting - Beta interferon - glatiramer acetate - dimethyl fumarate - alemtuzumab
2nd line
- natalixumab- several cases of PML causing death so limited to severe active disease
- Fingolimod- 1st oral therapy, prevents lymphocyte movement across blood brain barrier
- mitoxantrone
MS mimics/differentials?
Vasculitis: SLE, Sjorgrens, sarcoid, neuromyelitis optics
Vascular: TIA/stroke recurrent, CADISIL, Fabrys disease, antiphospholipis
Mitochondrial disease MELAS
Infection: lyme disese, HIV, encephalitis, syphilis, PML
Metabolic: B12 def
Leucodystrophies
What is the criteria for diagnosis of neuromyelitis optica/Devics disease?
Requires bilateral optic neuritis, myelitis and 2 of the following 3 criteria:
- Spinal cord lesion involving 3 or more spinal levels
- Initially normal MRI brain
- Aquaporin 4 positive serum antibody
Treat with IVIg and plasma exchange in acute setting and steroids and immunosuppression long term
Do you know any rating scales for disability in MS?
The expanded disability status scale (EDSS) most widely used and ranged from normal 0 to 10 (death due to MS), 5= ambulatory without aid or rest for 200m.
What are the causes of parkinsonism?
Idiopathic parkinsons disease Drug induced: neuroleptics, antiemetics, valproate Parkinsons plus syndromes: PSP, MSA, Corticobasal degeneration Dementia with Lewy bodies Toxins: MPTP, manganese, carbon monoxide Wilsons disease Normal pressure hydrocephalus Post traumatic Post encephalitic Vascular parkinsonism
Which signs point away from diagnosis of IPD?
Symmetry
Tardive dyskinesia (drug induced)
Early falls (PSNP)
Early autonomic disturbance (MSA)
Early dementia and visual hallucinations (LBD)
unilateral apraxia, alien limb, myoclonus, dystonic posturing (CBD)
What are the causes of chorea?
Huntingdons disease Wilsons disease Sydenhams chorea Drug induced: anticonvulsants, OCP Pregnancy Polycythaemia rubra vera Cerebral infarction Prion disease Other inherited neurological disorder: spinocerebellar ataxias, neuroacanthocytosis
What causes a cerebellar disorder?
Demyelination Vascular- infarction/haemorrhage Space occupying lesion Alcoholic degeneration Drugs esp carbamazipine, phenytoin, barbiturates Metabolic: B12, copper, vit E def Hypothyroidism Coeliac disease Genetic: spinocerebellar ataxias, Friedriechs ataxia, Ataxia telangiectasia, Von-hippel-lindau MSA with cerebellar features
What do you know about the genetics of spinocerebellar ataxias?
SCAs heterogenous group of AD genetic conditions causing degenerative cerebellar syndrome.
Mutations are trinucelotide CTG or CAG repeats, demonstrate antcipation.
What do you know about Miller-Fisher syndrome?
Autoimmune, usually post infective disorder
Opthalmoplegia, ataxia, loss of lower limb reflexes assoc with anti=GQ1b antibodies
What is subacute combined degeneration of the cord?
Symmetrical dysaesthesia, loss of posterior column sensory modalities and spastic quadra/paraparesis due to B12 def (usually seen in patients with pernicious anaemia)
What is the definition of spasticity and how is it different from other types of hypertonia??
Spasticity increased tone due to upper motor lesion which is velocity dependent (resistance increases with rate the muscle is stretched)- clasp knife. In contrast extrapyramidal syndromes the rigidity is constant throughout and not velocity dependent
How are spinal tumours classified according to their anatomical location?
Intradural tumours- intramedullary or extramedullary
- ependymomas- include astrocytomas, glioblastomas, haemangioblastomas, glial tumours, mets, cavernomas
Extradural tumours- mets
Do you know any of the features of HTLV-1 infection?
Tropical spastic paraparesis
T cell leukaemia/lymphoma
Peripheral sensorimotor neuropathy
Low grade myositis
Other features: arthritis, sicca syndrome, uveitus, alveolitis
What do you know about stiff person syndrome?
Rare auto-immune or even rarer paraneoplastic syndrome driven by anti-GAD antibodies. Rigidity of axial and sometimes lower limb muscles- can be mistaken for spastic paraparesis.
Treat with immunosuppression, plasma exchange
What is a bulbar palsy and what are the causes?
LMN lesion of lower cranial nerves
characterised by nasal speech, nasal regurgitation, tongue wasting & fasciculations, dysphagia and drooling
Causes: MG, MND, neuropathy, myopathy
What is pseudobulbar palsy and what are the causes?
UMN lesion affecting supply to tongue and oropharynx
characterised by spastic hoarse voice, slow tongue movements, assoc brisk facial reflexes, dysphagia and drooling
Causes: MS, brainstem stroke, MND
