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Neurology > Neurological disease- Part 2 > Flashcards

Neurological disease- Part 2 Flashcards

1
Q

What 3 components in the brain keep the intracranial pressure stable?

A

Brain tissue, blood, CSF

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2
Q

Localised lesions that cause a raised intracranial pressure

A

Haemorrhage, abscess, tumour (HAT)

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3
Q

Generalised pathology that causes a raised intracranial pressure?

A

Oedema post trauma

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4
Q

Another name for localised lesions that raise intracranial pressure?

A

Space Occupying Lesions

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5
Q

What is an effect of intracranial space occupying lesions?

A

Causes an internal shift between intracranial spaces.

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6
Q

What is uncal herniation

A

Cerebellum moves inferiorly over edge of tentorium

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7
Q

What is coning

A

Cerebellum moves inferiorly into foramen magnum

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8
Q

Name the 6 different types of brain herniation

A

Cingulate, central, uncal, cerebellotonsilar(coning), upward (cerebellum up into cerebrum space), transcalvarial (out via skull fracture)

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9
Q

What is subfalcine herniation?

A

Midline shift

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10
Q

What can be a consequence of cingulate herniation

A

Crushed lateral ventricle

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11
Q

What can be a consequence of uncal herniation (tentorial herniation)

A

Aqueduct is narrowed

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12
Q

What are the symptoms and signs of pressure on brain?

A

Morning headaches and nausea (due to squeeze on cortex and brainstem) and papilloedema (squeeze on optic nerve)

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13
Q

Consequences as intracranial pressure contonues to increase?

A

pupillary dilation, falling GCS, brain stem death

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14
Q

Name the different types of primary brain tumours and their cell of origin

A

Glial cells- gliomas (glioblastoma, oligodendroglioma, ependymoma)

Embryonic neural cells- medulloblastoma

Arachnoidal cell- meningioma

Nerve sheath cell- schwannoma, neurofibroma

Pituitary gland- adenoma

Lymphoid cell- lymphoma

Capillary vessels- haemangioblastoma

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15
Q

Common metastastic malignancy sites to brain

A

Breast, lung, kidney, colon, melanoma

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16
Q

What is the difference in location of brain tumours in adults and children

A

Adults more likely to find the tumour above tentorium, in a child more likely below tentorium

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17
Q

Do glioma’s metastasie outside of the CNS?

A

no

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18
Q

What are 3 common types of Glioma

A

Astrocytoma ,glioblastoma (astrocytes)

Oligodendroglioma (oligodendrocytes)

Ependymoma (ependymal cells)

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19
Q

Describe an astrocytoma

A

On microsopy they look like normal astrocytes, it grows very slowly

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20
Q

Describe a glioblastoma

A

Under microsope- necrosis is seen and cells are large with multiple/ irregular nuclei, they grow quickly

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21
Q

Describe a medulloblastoma

A

Tumour of primitive neuroectoderm

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22
Q

Where would you find, who is most likely to be affect and what does a medulloblastoma look like under a microscope?

A

Posterior fossa, especially brainstem

Children

Sheets of small undifferentiated cells

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23
Q

Describe a meningioma

A

From arachnocytes, “benign”- don’t metastasis but can be locally aggressive and invade the skull, they are slow growing and often resectable

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24
Q

What does a mengioma look like under a microscope?

A

Bland cells forming small groups which resemble an arachnoid granulation, sometimes there is calcification called psammoma body formation

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25
Q

Describe where you find a 8th vestibulocochlear nerve schwannoma

A

at angle between pons and cerebellum

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26
Q

What is another name for a 8th vestibulocochlear nerve schwannoma

A

Acoustic neuroma

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27
Q

Symptom of an acoustic neuroma

A

Unilateral deafness, is a benign lesion but removal is difficult technically

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28
Q

Describe a pituitary adenoma

A

Benign tumour of pituitary in pituitary fossa, it often secretes a pituitary hormone, it grows superiorly and impinges on optic chiasma creating visual signs.

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29
Q

Describe a CNS lymphoma

A

Is a high grade neoplasm and is usually diffuse large B-cell lymphoma, it is often deep and acentral site in the brain making it difficult to biopsy

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30
Q

How would you treat a CNS lymphoma

A

Difficultly as you can’t biopsy as so deep and drugs can’t cross the blood brain barrier

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31
Q

Does a CNS lymphoma spread outside CNS

A

generally no

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32
Q

Describe a haemangioblastoma

A

Tumour of the blood vessels, is space occupying that may bleed and is most often found in the cerebellum

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33
Q

Define functional neurological disorders

A

Change in function rather than structure of a system, symptoms are not explained by a neurological disease

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34
Q

What is the diagnostic criteria for functional neurological symptom disorder?

A

A->/1 symptoms of altered voluntary motor or sensory function

B- Clinical findings show incompatibility between symptom anf recognised neurological or medical conditions

C-Symptom/ deficit is not better explained by another medical or mental disorder

D-Causes clinically significant distress or impairment in social, occupational or other important areas of functioning or warrant medical evaluation

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35
Q

Functional symptoms and signs of functional neurological dysorder

A

Hoover’s sign- Ask to push down with right heel- shows hip extension is weak but hen when asked to push heel down and flex the opposite hip hip extension is normal

Functional sensory- hemisensory disturbance

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36
Q

Investigations for functional neurological syndrome

A

MRI brain scan, negative video EEG, functional MRI

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37
Q

Management of functional neurological disorder

A

Explain what they do and don’t have, you believe them, explain that it is common and self-help is key to recovery, antidepressants, referral to psychiatry, physical rehabilitation, cognitive behavioural therapy

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38
Q

What is the average normal cerebral blood flow?

A

55-60mL/100g brain tissue per minute

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39
Q

What is the average cerebral blood flow to thegrey matter and white matter?

A

Grey matter- 75mL/100g/minute

White matter-
45ML/100g/minute

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40
Q

At what cerebral blood flow is it classed as ischaemia and at what level is there permanent damage causes?

A

Ischaemia at 20mL/100g/minute

Permanent damage at 10mL/100g/minute

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41
Q

What factor determines cerebral blood flow and how can you calculate this?

A

Cerebreal perfusion pressure, calculated

CPP=MAP-ICP

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42
Q

What factors regulate cerebral blood flow under physiological conditions?

A

CPP, concentration of arterial CO2, arterial PO2

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43
Q

Define cerebral autoregulation

A

The ability to maintain constant blood flow to the brain over a wide range of CPP (50-150mmHg)

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44
Q

What happens to the blood vessels if cerebral perfusion pressure is low or high?

A

CPP is low the cerebral arterioles dilate to allow adequate flow at the decreased pressure

CPP is high, the cerebral arterioles constrict

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45
Q

Under what pathological conditions can cerebral blood flow not be autoregulated?

A

If CPP exceeds 150mmHg (hypertensive crisis), exudation of the fluid from the vascular system with resultant vasogenic oedema, toxins such as CO2, first 4-5 days of head trauma

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46
Q

Define cerebral oedema

A

Is a state of increased brain volume as a result of an increase in water content, a prominent cause of subacute to chronic intracranial hypertension

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47
Q

Go over different types of oedema

A

On spreadsheet

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48
Q

What does the Monro-Kelly Doctrine state?

A

When a new intracranial mass is introduced a compensatory change in volume must occur through a reciprocal decrease in venous blood or CSF to keep total incracranial volume constant

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49
Q

Define compliance

A

Change in volume observed for a given change in pressure

dV/dP

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50
Q

Define elastance

A

Change in pressure observed for a given change in volume

dP/dV

Represents the accomodation to outward expansion of an intracranial mass

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51
Q

What is the homeostatic mechanism 8-15 mmHg?

A

When the venous system collapse and squeezes venous blood out throuhg jugular, emissary and scalp veins

CSF is displaced from ventricular system through the foramina of Luschka and Magendie into spinal subarachoid space

This is done in response to increased volume

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52
Q

Describe Lundberg A waves

A

Abrupt elevation in ICP for 5-20 minutes followed by a rapid fall in the pressure to resting levels, amplitude may reach as high as 50-100mmHg

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53
Q

Describe Lundberg B waves

A

Frequency of 0.5-2 waves per minute, are related to rhythmic variations in breathing

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54
Q

Describe Lundberg C waves

A

Rhymthic variations related to waves of systemic blood pressure have small amplitude

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55
Q

What is Cushing’s reflex and what is it characterised by?

A

Is a vasopressor response in response to increased ICP (>MAP), characterised by hypertension, irregular breathing and bradycardia

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56
Q

How would you manage increased ICP?

A

head and elevation, mannitol/ hypertonic saline, hyperventilation- decreased CBF, barbiturate coma (decrease cerebral metabolism, CBF), surgical decompression

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57
Q

What levels does the spinal cord extend?

A

C1-L2

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58
Q

Is weakness a sign of UMN or LMN lesion

A

Both

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59
Q

Is atrophy a sign of UMN or LMN lesion

A

LMN

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60
Q

Are decreased reflexes a sign of UMN or LMN lesion

A

LMN

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61
Q

Are increased reflexes a sign of UMN or LMN lesions?

A

UMN

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62
Q

Is increased tone a sign of UMN or LMN lesion

A

UMN

63
Q

Is decreased tone a sign of UMN or LMN lesion

A

LMN

64
Q

Is fasiculations a sign of UMN or LMN lesion

A

LMN

65
Q

Is babinski a sign of UMN or LMN lesion

A

UMN

66
Q

Spinal level myotome actions

A

On sheet

67
Q

Dermatomes

A

On sheet

68
Q

Define disc prolapse

A

An acute herniation of intervertebra disc causing compression of spina roots or spinal cord, can occur centrally causing- cervical/thoracic myelopathy/cauda equine syndrome or occur laterally causing radiculopathy

69
Q

Sympoms/signs/investigations for disc prolapse?

A

acute pain down arm/leg, numbness and weakness in distribution of nerve root involves, investigate with MRi

70
Q

Disc prolapse management?

A

rehabilitation, nerve root inject, lumbar/ cervical discetomy

71
Q

Whar are some of the causes of degenerative spinal diseases?

A

disc prolapse, ligamentum hypertrophy, osteophyte formation

72
Q

Define cervical spondylosis

A

Umberella term for degenerative change in cervical spine leading to spine and nerve root compression, patient presents with either myelopathy or radiculopathy

73
Q

cervical spondylosis management

A

surgery for progressive moderate to severe myelopathy otherwise conservation

74
Q

the 3 sub categories of spinal tumours

A

Extradural, intradural and intramedullary

75
Q

Examples of extradural tumours

A

Metastases, primary bone tumours

76
Q

Examples of intradural tumours

A

meningioma, neurofibroma, lipoma

77
Q

Examples of intramedullary

A

astrocytes, ependymoma, teratoma, haemangioblastoma

78
Q

Investigation for malignant cord compression and treatment

A

malignant cord compression considered if patient presenst with pain, weakness, sphincter disturbance

need MRI

Management involves surgical decompression and radiotherapy

79
Q

Name 3 types of spina linfections

A

osteomyelitis- infection within vertebral body

Discitis- infection of intervertebral disc

Epidural abscess- infection in the epidural space

80
Q

A patient presents with back pain, pyrexia and focal neurology, what is the dianosis and what investigation would you use?

A

urgent MRI and epidural abscess

81
Q

What are the risk factors for epidural abscess?

A

IV drug abuse, diabetes, chronic renal failure, alcoholism

82
Q

What organisms cause an epidural abscess?

A

staph aureus, streptococcus, e.coli

83
Q

How is an epidural abscess managed?

A

with urgent surgical decompression and long-term IV antibiotics

84
Q

What are the risk factors for osteomyelitis?

A

IV drug abuse, diabetes, chronic renal failure, alcoholism, AIDS

85
Q

How do you treat oteomyelitis?

A

with antibiotics

86
Q

What is the purpose of a cognitive assessment?

A

To raise the possibilty of cognitive impairments which may need further assessment/ onwards referral and may impact treatment/ consent

87
Q

What are you assessing in a cognitive assessment?

A

memory, language, processing speed, attention/ concentration, executive functioning, personality, insight, visual spatial,

88
Q

Names of methods used to assess?

A

Hodges, Addenbrooke’s Cognitive Examination-III, MOCA

89
Q

How do you treat congnitive problems

A

quantifying and monitoring change, pre and post surgery assessments, impact of medication on cognition, rehab potential, behavioural management, cognitive rehabilitation, support and education, advice on return to work/ education, advice on care requirements

90
Q

Hydrocephalus types

A

On spreadsheet

91
Q

Describe the process of production of CSF

A

CSf is produced by the choroid plexus within the brain through a metabolically active process whereby Na is pumped into the subarachnoid space and water follows from the blood vessels.

92
Q

How much CSF does the average adult brain produce in a day?

A

450-600cc’s of CSF every day

93
Q

At any given moment how much CSF is present in an average adult?

A

150cc’s of CSF, only 25cc’s is whith the brain ventricles

94
Q

Whch formen does the CSF travel through to get from the lateral ventricle to the 3rd ventricle?

A

Foramen monro

95
Q

Which foramen does the CSF travel through to pass from the 3rd ventricle to the 4th ventricle?

A

Cerebral aqueduct of Sylvius

96
Q

Which foramen does the CSF exit the 4th ventricle via?

A

Exits through either of two Foramina of Luschka (L=lateral) or the single foramen of Magendie (M=midline)

97
Q

After the CSF has left the 4th ventricle what path does it take

A

CSF flows through the subarachnoid space around brain and spinal cord, is eventually reabsorbed into the venous system through numerous arachnoid granulations along the dural venous sinuse`s

98
Q

When do arachnoid villi open?

A

Arachnoid granulations contain arachnoid villi open when the ICP is 3-5cm H2O greater than dural venous sinus pressure

99
Q

How is CSF reabsorbed

A

CSF is reabsorbed by the pressure gradient between the intracranial space (ICP) and the venous system

100
Q

Indications for performing a lumbar puncture

A

to obtain CSF for the diagnosis of:
meningitis, meningoencephalitis, subarachnoid haemorrhage, malignancy, idiopathic intracranial hypertension, other neurologic syndromes, infusions of drugs or contrast

101
Q

Contraindications for performing a lumbar puncture

A

unstable patient with cardio or resp instability, localised skin/ soft tissue infection over puncture site, evidence of unstable bleeding disorder, increased intracranial pressure, chiari malformations

102
Q

Size of spinal needle normally used in a lumbar puncture

A

22 gauge

  1. 5 <1yr
  2. 5 for 1yr to middle childhood
  3. 5 for older children and adolescents

use atraumatic needles, less spinal headaches

103
Q

What position should a patient lie in before getting a lumbar puncture?

A

Lateral Decubitus position:
maximally flex spine without compressing airway, keep alignment of feet, knees and hips, position head to left if right handed or vice versa

104
Q

Describe the steps of a lumbar puncture?

A

Apply topical anesthetic 30-45 mins prior to procedure at site L3-L4

Put patient in lateral decubitus position

Cleanse skin with povidone iodine (puncture site and radially out to 10cm, allow to dry)

Drape patient

Anesthetize with lidocaine if topical wasn’t used (by intradermally raising a wheal at needle insertion site)

Insert spinal needle with stylet with bevel up, aim towards umbilicus directing needle slightly cephalad

A pop of sudden decrease in resitance indicated that the ligamentum flavum and dura are punctured

Remove stylet and check for flow of spinal fluid

When CSF flows, attach a manometer to obtain opening pressure, attach the manometer with a 3 way stopcock, record column with highest level is achieved and respiratory variation is noted.

Collect 3 vials each 1ml of CSF

Check closing pressure with manometer

Reinsert stylet and remove needle in one quiick motion

Cleanse back and cover puncture site

105
Q

When conducting a lumbar puncture and you have got to the step of checking for spinal fluid flow, if there is no fluid what should you do?

A

Rotate needle 90degrees, and then reinsert the stylet and advance needle slowly checking frequently for CSF
If in a low flow situations, compression of the jugular vein can increase CSF pressure

106
Q

What are the 3 vials collected in a lumbar puncture of CSF used to check?

A

Tube 1- culture and gram stain

tube 2- glucose and protein

tube 3- cell count and differential and extra CSF

107
Q

How would you hold a child during this procedure?

A

Hold infant’s hands between flexed legs with one hand and flex head with other hand

108
Q

What is the paramedian (lateral) approach for lumbar puncture?

A

needle passes through eerector spinae muscles and ligamentum flavum

This is used for patients who have calcifications from repeated LPs or anatomical abnormalities

109
Q

Complications from a lumbar puncture

A

headache, apnea, back pain (can cause disc herniation), bleeding or fluid leak, infection, pain, haematoma, subarachnoid epidermal cyst, ocluar muscle palsy, nerve trauma, brainstem herniation

110
Q

How to improve a spinal headache caused from a lumbar puncture

A

make patient supine for at least 2hours, hydration, caffeiene, epidural blood patch

111
Q

How to prevent spinal headache from lumbar puncture

A

passing needle bevel parallel to longitudinal fibres of dura, replacing stylet before removing needle, using small diameter needles, using atraumatic needles

112
Q

if a patient feels an electric shock or dysesthesias when doing a lumbar puncture what do you do?

A

wihtdram needle immediately, if the pain or motor weakness continues start corticoseroids and schedule electromyogram/ nerve conduction velocity studies

113
Q

What do you do if a herniation occurs during a lumbar puncture?

A

it manifests as altered mental status followed by cranial nerve abnormalities and Cushing triad, is rapidly fatal.

immediately remove needel and raise head of bed 30-45o and use mannitol or 3% slaine, intubate and hyperventilate, emergency neurosurgical consult

114
Q

How does an epidermal inclusion cyst occur when completing a lumbar puncture

A

Due to use of stylet and occurs when a core of skin is driven into spinal or paraspinal space with hollow needle, you should not remove stylet until through the skin

115
Q

What should normal CSF results be?

A

appears clear and colourless, opening pressure is 6-16mm/H2O
Protein level-35mg%
glucose level-60mg%
WCC<5

116
Q

Define a coma

A

A state of unrousable psychological unresponsiveness in which the subject lies with eyes closed and show no psychologically undertandable response to external stimulus or inner need

117
Q

What are the 2 things consciousness depends on?

A

intact ascending reticular activatinf system (arousal) and a functional cerberal cortex (content of consciousness, awareness)

118
Q

Common causes of GCS

A

Toxic/ metabolic states (hypoxia/ hypercapnia/ sepsis /hypotension, drug intoxication, renal or liver failure, hypoglycaemia, ketoacidosis), seizures, damage to reticular activating system, causes of raised intracranial pressure (tumour, stroke, EDH, SDH, SAH, hydrocephalus)

119
Q

Define a persistent vegetative state

A

A state in which the brain stem recovers to a considerable extent but there is no evidence of recovery of cortical function

120
Q

What is “locked-in” syndrome

A

Patient has total paralysis below 3rd cranial nerve nuclei, so no horizontal eye movements

121
Q

If a patient is unconscious and has a depressed respiration what are common causes?

A

drug overdose, metabolic disturbance

122
Q

If a patient is unconscious and has a increased respiration what are common causes?

A

hypoxia, hypercapnia, acidosis

123
Q

If a patient is unconscious and has a fluctuating respiration what are common causes?

A

brainstem lesion

124
Q

Using the GCS what is considered a coma?

A

GCS = to 8

eye opening <2/=2
verbal response <2/=2
Motor response 4 or less

125
Q

Causes of a coma without focal or lateralising signs and without meningism?

A

anoxic/ ischaemic conditions, metabolic disturbances, intoxications, systemic infections, hyperthermia/ hypothermia, epilepsy

126
Q

Investigations for causes of a coma without focal or lateralising signs and without meningism?

A

toxicology, blood sugar and electrolytes, hepatic and renal function, blood gases, BP, CO poisoning

127
Q

Causes of a coma without focal or lateralising signs but signs of meningism?

A

subarrachnoid haemorrhage, meningitis, encephalitis

128
Q

Investigations for causes of a coma without focal or lateralising signs but signs of meningism?

A

CT head scan, LP (appearance, cell count, glucose level, capsular antigen tests)

129
Q

Causes of a coma with focal or lateralising signs and without meningism?

A

cerebral tumour, cerebral haemorrhage, cerberal infarction, cerebral abscess

130
Q

What does a subdural haematoma look like on CT

A

convex

131
Q

What does a extradural haematoma look like on a CT scan?

A

concave

132
Q

Parasympathetic function of the facial nerve?

A

lacrimation, salivation of submandibular and sublingual glands

133
Q

Parasympathetic function of the glossopharyngeal nerve?

A

parotid gland

134
Q

What is the location on the III and IV cn nuclei?

A

midbrain

135
Q

What is the location on the V, VI and VII cn nuclei?

A

pons

136
Q

What is the location on the VIII cn nuclei?

A

pontomedullary junction

137
Q

What is the location on the IX, X, XI cn nuclei?

A

medulla

138
Q

If someone presents with unusual combinations of cranial nerve sings what should be suspected?

A

chronic or malignant meningitis

139
Q

If someone present with pure motor signs what condition is expected?

A

myasthenia gravis

140
Q

Optic neuritis

A

on spreadsheet

141
Q

Causes of dilated pupils?

A

youth, dim lighting, anxiety, excitement, “mydriatic” eye drops, amphetamine, cocaine overdose, 3rd nerve palsy, brain death

142
Q

Causes of small pupils

A

old age, bright light, “miotic” eye drops, opiate overdose, horner’s syndrome

143
Q

Causes for painless, pupil spared isolated 3rd nerve palsy?

A

microvascular- diabetes, hypertension

144
Q

Causes for painful, pupil affected isolated 3rd nerve palsy

A

posterior communicating artery aneurysm, raised ICP

145
Q

Isolated 6th nerve palsy causes?

A

idiopathic, diabetes, meningitis, raised intracranial pressure

146
Q

Causes for nystagmus?

A

congenital, serious visual impairment, peripheral vestibular problem, central vestibular/ brainste disease, cerebellar disease, toxins (medication and alcohol)

147
Q

What is trigeminal neuralgia?

A

paroxysmal attacks of lanciating pain caused by a vascular loop- compression of 5th nerve in the posterior fossa

148
Q

How is trigeminal neuralgia treated?

A

with carbamazepine

149
Q

What is Bell’s palsy

A

unilateral facial weakness, lmn palsy, often have pain behind ear, eye closure is often affected, treated with steroids

150
Q

How can you tell the difference between UMN or LMN facial paralysis

A

In UMn both sides of the face will get wrinkles which asked to scruch their face- UMN would be a stroke or tumour

151
Q

What is vestibular neuronitis?

A

Has a sudden onset and has symptoms of disabling vertigo, vomiting

152
Q

Pseudobulbar palsy and bulbar palsy

A

on spreadsheet

153
Q

Is pseudobulbar palsy a UMN or LMN lesion

A

UMN

154
Q

Is bulbar palsy a UMN or LMN lesion

A

LMN

Neurology (7 decks)

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