Neurological Presentations Flashcards
What can cause focal damage to cerebral hemispheres?
Vascular events
Tumours
Trauma
Localised inflammatory/infective lesions
What can cause generalised/multifocal cerebral dysfunction?
Degenerative disorders e.g. Alzheimer’s, dementia with Lewy bodies
Multiple infarcts
Demyelination
What are the normal functions of the frontal lobe?
Primary motor cortex at the precentral gyrus, controls motor function on opposite side of the body
UMN cell bodies are in primary motor cortex
Frontal eye field
Broca’s area - in dominant hemisphere only, expressive centre of speech
Prefrontal cortex - personality, emotional expression, initiative
Cortical micturition centre
What is the blood supply of the frontal lobe?
Anterior cerebral artery and middle cerebral artery
What are symptoms of lesions from the frontal lobe?
Contralateral weakness due to damage of precentral gyrus, UMN pattern
Gait apraxia - slow, shuffling, upright, wide-based
Due to damage in premotor and suppl. motor area
Conjugate eye deviation
Focal seizures
Expressive dysphasia - intelligence in tact, cannot find the right words
Personality, behavioural change
Anosmia
Primitive reflexes usually inhibited by prefrontal cortex, suppressed as baby grows
Incontinence
What are the functions of the parietal lobe?
Primary somatosensory cortex - postcentral gyrus, receives somatosensory from contralateral side
Language - arcuate fasciculus connects with Broca’s to Wernicke’s (in temporal) through parietal lobe
Numbers - dominant hemisphere
Integration of somatosensory, visual and auditory information, visual pathways
What is the blood supply of the parietal lobe?
Middle cerebral artery
What are symptoms of lesions from the parietal lobe?
Cortical contralateral sensory loss
Visual disturbances e.g. contralateral homonymous inferior quadrantanopia
What are syndromes of the dominant parietal lobe?
Wernicke’s dysphasia - impaired comprehension, gibberish, poor insight
Gerstmann’s - inability to differentiate right and left sides of the body
Cannot carry out a series of tasks
What are the functions of the temporal lobe?
Wernicke’s area - comprehensive of written and spoken language
Auditory and vestibular system
Limbic system
Visual pathway - lower part of optic radiations pass deep
What is the blood supply of the temporal lobe?
Posterior cerebral - medial part of the lobe
Middle cerebral - lateral part
What are symptoms from lesions of the temporal lobe?
Wernicke's receptive dysphasia Visual disturbances Memory impairment Emotional disturbances - aggression, rage, hypersexuality Cortical deafness
What are the different types of dysphasia?
Broca’s - expressive
Wernicke’s - receptive
Conduction - damage to arcuate fasciculus, non-sensical but patient aware
Global - lesions of both Broca’s and Wernicke’s; mostly stroke of left middle cerebral artery territory
Nominal - inability to name objects
What is the function of the occipital lobe?
Perception of vision
Recognition of what is visualised
What are symptoms of occipital lobe defects?
Contralateral homonymous hemianopic field defect
Cortical blindness - retention of pupillary reflexes
Visual agnosia - impairment of perception or identification
Visual illusions
What are the most common causes of transient loss of consciousness?
Syncope
Seizures
Hypoglycaemia Narcolepsy/cataplexy Hyperventilation Vertebrobasilar ischaemia Vertebrobasilar migraine Psychogenic or non-epileptic attacks
What would you ask about in a history for loss of consciousness?
Before - triggers? prodromes - visual, auditory, palpitations? change of colour?
During - Duration? convulsions? continence? tongue biting?
After - time for recovery
What are the 5P’s and 5C’s of loss of consciousness
Precipitant Prodrome Palpitations Position Post event
Colour Convulsions Continence Cardiac hx FH of sudden cardiac death
What investigations would you request for a patient who has come in with loss of consciousness?
FBC, U&E, Blood glucose BP - lying and standing EEG ECG - 24hr Imaging with MRI Carotid sinus massage Table tilt test
What 3 things characterise syncope?
Loss of consciousness
Transient - recover by themselves
Global cerebral hypoperfusion
What are your differentials for LOC?
NEURO: RICP, epilepsy, Parkinson’s, Lewy Body dementia
CARDIAC: arrhythmias, HOCM, aortic stenosis
METABOLIC: diabetic autonomic failure, uraemia, hypoglycaemia
DRUGS: diuretics, antihypertensive
OTHER: hyperventilation induced, carotid hypersensitivity
What are the central causes for vertigo?
vertebrobasilar ischaemia posterior circulation stroke Acoustic neuroma MS Alcohol
What are the peripheral causes for vertigo?
Viral labyrinthitis Vestibular neuronitis BPPV Meniere's Ototoxic drugs
What are some bedside examinations you’d want to do in a patient presenting with vertigo? Describe the results in terms of where the lesion is
Rombergs
- proprioception or vestibular system issue
- they fall towards the side of the lesion
- normal if cerebellar cause
Uttunberg
- march on spot with eyes shut
- rotate towards the side of a labyrinthine lesion
Head impulse
- patient fixes eyes and examiner moves head
- catch up saccade will occur when head rotated to side of lesion if peripheral lesion
Skew deviation
- cover eyes and if central lesion then vertical correction will occur when eye uncovered
Dix-hallpike - BPPV
What is ataxia?
Describe an ataxic gait
Disorder of co-ordination, balance and speech
Wide based, appear drunk, can’t stand with feet together
Where can a lesion be to cause ataxia?
What type of ataxia would you get at these locations?
Cerebellar vermis = gait ataxia
Cerebellar hemisphere = peripheral ataxia (finger-nose test)
Can also be due to poor proprioception:
- peripheral sensory neuropathy
- DCML
What can cause a bilateral ataxia? What would you seen on examination of ataxia was bilateral?
- Alcohol (cerebellar degeneration)
- B1 and B12 deficiency
- MS
- CJD and other intracranial infections
- Drugs
Patient veers from side to side
What can cause a unilateral ataxia? What would you seen on examination of ataxia was bilateral?
- Cerebellar or brainstem stroke
- SOL
Patients veers to the side of the lesion
What is friedreich’s ataxia? What pattern of inheritance does it show?
Genetic progressive neurodegenerative movement disorder
Unsteady posture, frequent falling, progressive difficulty in walking
Autosomal recessive
Kyphoscoliosis
Absent ankle jerks but extensor plantars
Optic atrophy
Associated with HCOM and diabetes
What is ataxic telangiectasia and what are the signs, symptoms and associated diseases?
AR inherited combined immunodeficiency disorder:
- cerebellar ataxia
- telangiectasia (including ocular)
- recurrent chest infections
Associated with lymphoma and leukaemia
What is athetosis? What can cause it?
Slow involuntary writhing movements affecting the extremities
Asphyxia, neonatal jaundice, Huntington’s and cerebrovascular disease
What is dystonia?
Sustained muscle contraction frequently causing twisting movements or abnormal postures because of con-contraction of antagonistic muscles
How is dystonia managed?
Focal - botulinum injections
Generalised - L Dopa if <40, Anticholinergics, tetrabenazine, deep brain stimulation
What is chorea?
Continuous, irregular, jerky movements occurring at random locations
What can cause chorea?
Hereditary - Huntington’s, benign hereditary, Wilson’s
Infection - syndenham’s , HIV, meningitis/encephalitis
Vascular - infarct, polycythaemia
Metabolic - glucose, hyperthyroid, hypocalcaemia
Immune - SLE, anti-phospholipid, pregnancy
Drugs - Dopamine antagonist, oral contraceptive, amphetamines and cocaine
What is spasmodic torticollis?
Shortened sternocleidomastoid means the head is tilted and chin tilted the opposite way
What is myoclonus?
Sudden shock like muscle jerks that are frequently repetitive
What are tics?
Rapid repetitive stereotyped movements
Can be voluntarily suppressed - lead to internal tension
Triggered by stress or boredom
What are the types of tics?
Motor - eye blinking, head jerk, nose twitch, shoulder shrug, facial grimace
Vocal - throat clear, grunting, coughing, sniffing
Other - vulgar words, repeating words, vulgar gestures
What is a tremor? What are the types and what could cause them?
Rhythmical oscillatory movement of body part
Resting: Parkinson’s
Postural: anxiety, alcohol, thyroid, essential, Wilsons
Action: cerebellar disease
What is an essential tremor? Describe the tremor seen in this disorder
Autosomal dominant postural tremor
- Symmetrical
- affects UL (+/- head)
- Low amplitude
- High frequency
- Not present in sleep
- Improve with alcohol
How are essential tremors managed?
Propranolol and Primidone
What would you investigate when determining the cause for a tremor?
Neurological exam Type of tremor Medication history Thyroid function LFT Copper levels Imaging
What is characteristic of polyneuropathies?
Motor and/or sensory disorder of multiple peripheral or cranial nerves
Symmetrical
Widespread
Worse distally
What would be a typical history of someone with a sensory peripheral neuropathy?
- glove and stocking distribution of paraesthesia
- problem with small objects like buttons
- burning their fingers
What would be a typical history of someone with a motor peripheral neuropathy?
- becoming clumsy handed
- falling more
- wasting hand muscles
- high stepping gait
What are the autonomic signs of polyneuropathy?
Postural hypo
Reduced sweating
Ejaculatory failure
Horner’s
Constipation Nocturnal diarrhoea Urine retention Erectile dysfunction Holmes-adie pupil
What can cause primarily sensory polyneuropathy?
Diabetes Uraemia (renal failure) Alcohol Reduced B1 Reduced B12/folate Leprosy
What can cause primarily motor polyneuropathy?
- Guillain-Barre
- Chronic inflammatory demyelinating polyradiculoneuropathy
- Charcot-marie tooth
- Lead poisoning
- Diptheria
What causes mixed polyneuropathy i.e. sensory and motor?
Hypothyroid/glycaemia
Malignancy - paraneoplastic (SCLC), polycythaemia vera
Autoimmune: polyarteritis nodosa, RA, sjogrens, sarcoid
Infection - lyme, HIV
Drugs: isoniazid, phenyotin, metronidazole
What are your differentials for motor weakness?
V: stroke I: GBC, sepsis, encephalopathy T: cord injury, RICP A: MS, myasthenia, poly/dermatomyositis, cushings, thyroid dysfunction, SLE, Duchenne M: hypoglycaemia, hypokalaemia, hypercalcaemia I: N: MSCC, hypercalcaemia D: statins, alcohol, steroids
What is the neurological disturbance in fibular neuropathy?
Lateral leg and dorsal foot sensation loss
Foot drop
What causes meralgia paraesthetica? In whom and how does it present?
Compression of the lateral femoral cutaneous nerve anywhere along its course (L2/L3 and around ASIS)
RF: obesity, pregnancy, tense ascites
- Tingling/burning in upper antero-lateral thigh
- Worse on standing
Which body parts are most affected by diabetic sensory neuropathy?
Feet > hands
How would a polyneuropathy as a result of B1 deficiency present?
Feet > Hands
Burning and shooting pains
Reduced reflexes
Muscle weakness
What is the sensory disturbance in B6 excess/deficiency?
PATCHY sensory loss of extremities
What is the sensory disturbance in B12 deficiency?
Transient and MIGRATORY
Loss of proprioception and vibration
What drugs can cause sensory disturbance?
Chemotherapy agents Antiretrovirals Phenytoin Metronidazole and nitrofurantoin Isoniazid
What is the sensory disturbance in migraine with aura?
Acute spreading loss
Typically from hand up ipsilateral arm to face and tongue
Last <1hr
What primary care investigations would you want to do for someone presenting with a polyneuropathy?
HBA1C TFTs LFTs (alcohol abuse) Vitamin levels CRP, WCC (infection?)
Which side of the brain are the speech centres found?
Dominant hemisphere
Left (most of the time even if left handed people)
What is neuropathic pain?
How does it present?
Pain due to a dysfunctional nervous system
Shooting, electrical burning pain
Can be continuous or intermittent
Spontaneous
What are some causes of neuropathic pain?
Peripheral:
- diabetes, alcohol, herpes, radiculopathy, tumour infiltration, trigeminal neuralgia
Central:
- MS, post-stroke, chemotherapy
How is neuropathic pain managed?
- amitriptyline, duloxetine, gabapentin, pregabalin
- switch drugs don’t add
Flare: tramadol Localised area (e.g. herpes): capsaicin cream
What are the CI’s and ADR’s associated with neuropathic pain meds?
Amitriptyline
- CI in arrhythmia, heart block, post MI
- ADR - Anticholinergic syndrome, drowsiness, long QT
Duloxetine ADR - GI upset, drowsy, dry mouth
Gabapentin
- Caution in diabetes
- ADR - dizzy, drowsy, unsteady
Pregablin ADR - headache, dizzy, drowsy
What is first line management for trigeminal neuralgia?
Carbamazepine
Where can lesions be to affect bladder control?
What conditions would typically affect bladder control at each of these levels?
CENTRAL:
- Stroke, MS, head injury, dementia, parkinsons
SUPRASACRAL (often about T12)
- spinal cord injury, MS, spina bifida, cervical spondylosis
SACRAL (S2,3,4) and PERIPHERAL
- spinal cord injury, spina bifida, cauda equina, peripheral neuropathy eg diabetes
Describe the bladder and sphincter dysfunction in someone with a lesion above T12
overactive/spastic bladder so that bladder volume is low and there are involuntary contractions
- the sphincter control is uncoordinated with bladder contraction
- patient gets urge incontinence
Describe the bladder and sphincter dysfunction in someone with a lesion at S2,3,4 or peripheral
- flaccid and underactive bladder so that bladder volume is high
- underactive sphincter control
- patients get urinary retention
Describe a hemiplegic gait and state what would cause it
Knee is extended and the foot dropped
Circumduct the leg to compensate
Cause: contralateral brain lesion
Describe a diplegic/ paraplegic gait and state would would cause it
Legs adducted giving a scissoring movement
Circumduct legs to compensate
Cause: bilateral brain lesion (CP), spinal cord lesion, MND
Describe a neuropathic gait (due to peripheral neuropathy)
High steppage and then slam the foot down in order to sense when it’s on the floor
Describe a myopathic gait and state what would cause it
Waddling - laterally flex torso away and circumduct the leg
Cause: polymyalgia rheumatica, muscular dystrophy
Describe an antalgic gait
Shortened stance phase on affected leg
Describe a frontal gait and state what would cause it
Wide based and a normal arm swing are what differentiate it from Parkinonism gait as everything else is the same i.e. shuffling, hesitation to start, en bloc turning
Cause: frontal lobe pathology
What are causes of proximal weakness?
CONGENITAL MIND
Normal sensation
Congenital - mitochondrial Metabolic - Cushing's, thyroid Inflammatory - dermato/polymyositis, inclusion body myositis Neuromuscular - MG, LE Dystrophies - Becker's
What are causes of bilateral UMN signs?
Pyramidal weakness - 3Ms
MS
MND (normal sensation)
Myelopathy
Others
What are causes of unilateral UMN signs?
Pyramidal weakness
Intracranial - CVA, SOL, MS
Brainstem - MS
Spinal cord - particular sensory level, trauma, SOL, abscess
What are causes of bilateral LMN signs?
Distal weakness
If abnormal sensation distally Sensorimotor polyneuropathy - VIT DIM Vasculitis - SLE, RA, PAN Infection - herpes, HIV, syphilis Toxins - alcohol, TB, drugs Diabetes Inherited - Charcot Marie Metabolic - B12 def, B1
Normal sensation -
Distal motor neuropathy
GBS
Lead poisoning
Myotonic dystrophy
Progressive muscular atrophy
What are causes of unilateral LMN signs?
Weakness depends on lesion
Radiculopathy
Plexopathy - Erbs, Klumpke’s, thoracic outlet syndrome
Nerve palsy - median (idiopathic, pregnancy), ulnar (compression at elbow, fractures), radial (elbow, humeral shaft fracture, saturday night palsy), axillary (shoulder dislocation), common peroneal (plaster cast compression, trauma, diabetes, leprosy)
What are causes of both UMN and LMN signs?
MND
Dual pathology - e.g. cervical myelopathy, and polyneuropathy
Cervical radiculomyopathy
What are causes of absent ankle (and knee) jerks, and extensor plantars?
Subacute combined degeneration of the cord
Freidrich’s ataxia
MND
What are causes of cerebellar disease?
MS Alcohol Vascular Inherited - ataxia telangiectasia SOL
What are causes of optic atrophy?
MS, ischaemia, temporal arteritis, compression
What are causes of unilateral facial nerve LMN signs?
Bell's palsy Ramsay Hunt Brainstem - SOL, stroke TB Nerve infiltration
What are causes of bilateral facial nerve LMN signs?
Bilateral Bell's Sarcoid Autoimmune - MG GBS Amyloidosis
What are causes of a bulbar palsy?
MND
Brainstem/infarct, SOL
MG
GBS
What are the causes of pseudobulbar palsy?
MND brainstem infarct MS internal capsule infarct Neurodegenerative disorders
What can cause CN3-6 lesion?
Cavernous sinus thrombosis
What can cause a homonymous hemianopia?
Stroke, cerebral SOL
What can cause a bitemporal hemianopia?
pituitary tumour
aneurysm
What can cause tunnel vision?
glaucoma
retinitis pigmentosa
What causes a central scotoma?
MS temporal arteritis compression glaucoma DM methanol
What can cause a homonymous quadrantopia?
pits
pariteral - inferior
temporal - superior
What can cause monocular vision?
central retinal artery occlusion
vitreous haemorrhage
trauma
papilloedema
What can cause chorea?
huntington’s, drugs, stroke HIV
What can cause hemiballism?
stroke, sol, trauma, hiv
What can cause athetosis?
Asyphxia
neonatal jaundice
thalamic stroke
What can cause dystonia?
Primary dystonia Brain trauma Wilson's PD Huntington's encephalitis stroke SOL
What can cause myoclonus?
epilepsy metabolic psychological toxins/drugs SOL PD MS CJD
