Neurology 1 Flashcards
Name an example of a 5-HT3 antagonist
Adverse effects (2)
Ondansetron
Prolonged QT
Constipation
Absence seizure
Typical age range
Gender
Provoked by (2)
3-10yo
F>M
Stress, hyperventilation
Absence seizure
EEG:
Bilateral, symmetrical spikes and wave pattern
What is a positive Babinski?
Suggestive of upper motor neuron disease
Dorsiflexion of big toe and fanning out of the others
Lesions that can cause both absent ankle jerks and extensor plantars (Babinski) (6)
Upper and lower motor neuron disease
Subacute combined degeneration of the cord
Motor neuron disease
Friedreich’s ataxia
Synringomelia
Tabparesis (syphillis)
Conus medullaris lesion
What is Friedreich’s ataxia?
AD/AR
Age
Features other than ataxia (2)
Later features (3)
AR mitochondrial disease, trinucleotide repeat
Usually causing ataxia, HOCM and DM
Upper and lower motor neuron, absent ankle jerks, extensor plantar, optic atrophy
10-15yo
Later - heart failure, loss of vision and hearing
Receptive aphasia
Broca/Wernicke?
Where you lack comprehension, but can speak well, but none of what you’re saying makes sense because you can’t comprehend. i.e word salad
Wernicke’s aphasia
Expressive aphasia
Broca/Wernicke?
When you understand what people are saying but struggle to get the words out, speech is non fluent, repetitive and laboured.
Broca’s aphasia
What is conduction aphasia?
Usually secondary to a stroke to the arcuate fasiculus - connection between Broca’s and Wernicke’s
Comprehension is normal, aware of the errors
Repetition is poor
Speech is fluent
Global aphasia
Results in both receptive and expressive aphasia, may still be able to communicate with gestures
What is ataxia telangiectasia?
AD/AR
Age of onset
Features (3)
Increased risk of which two cancers?
AR
1-5yo
- Cerebellar ataxia
- Telangiectasia
- Recurrent chest infections secondary to IgA deficiency
- Increased risk of lymphoma and leukaemia
Explain autonomic dysreflexia
Occurs in patients who have a spinal cord injury at or above T6
Triggered by faecal impaction or urinary retention causes a sympathetic spinal reflex up the spinal cord. But due to lesion/ injury at T6 or above it is unable to deliver it all the way to the brain. This results in sympathetic activation below T6 and parasympathetic response above T6 leading to:
HTN
Bradycardia
Sweating
Flushing
Agitation
Haemorrhagic stroke
Bell’s palsy
Age range
Common in which type of patient?
Forehead or no forehead sparing?
20-40yo
Pregnant women
No forehead sparing due to lower motor neuron facial nerve palsy
Bell’s palsy features (5)
Paralysis of one side of the face including forehead
Post-auricular pain
Altered taste
Dry eyes
Hyperacusis
Bell’s palsy
Mx (2)
When to refer to ENT?
Prognosis?
- Prednisolone PO if within 72 hours of onset of symptoms
- Artifical tears and eye lubricants
If no improvement after 3 weeks
Full recovery within 3-4 months
15% have permanent weakness
What situations may cannabis based medicinal products be used?
Chemotherapy induced N&V (nabilone)
Spasticity in adults with MS (sativex nasal spray)
Partial seizures
1st line mx
Carbamazepine
SE carbamazepine (3)
What is autoinduction?
Leucopenia and agranulocytosis
Hyponatraemia secondary to SIADH
Visual disturbances
May see a return of seizures after 3-4 weeks of treatment
What is cataplexy?
What condition is it associated with?
Sudden and transient loss of muscular tone caused by a strong emotion
2/3 of patients with narcolepsy have cataplexy
What is Charcot-Marie-Tooth disease?
Features (6)
Most common form of hereditary peripheral neuropathy
AD
Features:
Foot drop (frequently sprained ankles)
Pes cavus (high arched feet)
Hammer toes
Stork leg deformity
Hyporeflexia
Distal muscle weakness and atrophy
Cluster headaches
Trigger (1)
Mx acute (2)
Chronic (1)
ETOH
Mx
Acute 1. 100% oxygen, 2. SC triptan
Chronic 1. Verapamil
Foot drop is secondary to which nerve lesion?
Other features for this nerve lesion (3)
Common peroneal
Loss of dorsiflexion
Loss of eversion
Sensory loss of dorsum of the foot
Type I and Type II complex regional pain syndrome
Complex regional syndrome pain syndrome mx (3)
Type I - no demonstratable lesion to a major nerve
Type 2 there is a lesion to a major nerve
Physiotherapy
Neuropathic analgesia
Pain team
CN
I
II
V
I smell
II sight
V (trigeminal) facial sensation, muscles of masticatio
CN
III occulomotor
IV trochlear
VI abducens
Eye movement
III - MR, IO, SR, IR, constriction, accommodation, eyelid opening
IV - SO
VI - LR
Clinical signs with lesions on
Trigeminal (2)
Occulomotor (2)
Abducens (1)
Trochlear (2)
Trigeminal neuralgia, loss of corneal reflex
Occulomotor down and out eye, dilated fixed pupil
Abducens Horizontal diplopia
Trochlear downward gaze, vertical diplopia
CN
VII
VIII
IX
Function
Facial anterior 2/3 of tongue, lacrimation, salivation
Vestibulocochlear hearing balance
Glossopharyngeal posterior 1/3, swallowing
CN 10-12 function
X vagus gag reflex
XI accessory head and shoulder movement
XII hypoglossal tongue movement
Clinical signs
CN 7 (3)
CN 8 (2)
CN 9 (1)
7 loss of corneal reflex, taste, hyperacusis
8 hearing loss, vertigo
9 loss of gag reflex
Clinical signs 10-12
10 uvula deviates away from site
11 weakness turning head to contralateral side
12 tongue deviates towards side of lesion
Corneal + Lacrimation reflex afferent efferent
v1 trigeminal ophthalmic VII facial nerve
Jaw jerk afferent efferent
V3 mandibular mandibular
Gag + glossopharyngeal afferent efferent
In on 9 out on 10
Pupillary light reflex
In on 2 out on 3
What is Hoffman’s sign?
Reflex test for cervical myelopathy
Hand resting, flick one finger, +ve test = if other fingers on the same hand also flex
Gold standard Ix for degenerative cervical myelopathy (1)
Mx (2)
MR
Urgently refer to neurosurgery or ortho spinal surgery
Dermatome
Thumb and index finger =
Middle finger and palm =
Ring and little finger =
Nipples
C6
C7
C8
T4
Dermatome
Umbilicus
Knee caps
Big toe + dorsum
Lateral foot and small toe
T10
L4
L5
S1
Name five drugs that can cause peripheral neuropathy
HINT NAVIM
Nitrofurantoin
Amiodarone
Vincristine
Isoniazid
Metronidazole
DVLA seizures
First unprovoked seizure
6 months unless abnormalities on imaging or EEG in which case 12 months
DVLA
Epilepsy/ multiple unprovoked siezures
Need to have been free from seizures for 12 months
If no seizures in last 5 years then licence restored (until 70)
DVLA
Withdrawal of epilepsy medication
No driving whilst it is being withdrawn and for six months after the last dose
DVLA
Single episode syncope, explained and treated
=
4 weeks
DVLA single episode syncope unexplained
= 6 months
DVLA two or more episodes of syncope
12 months
DVLA
Stroke/ TIA
Multiple TIAs
1 month do not need to inform DVLA
3 months inform DVLA
DVLA
Craniotomy
Pituitary tumour
= 1 year off driving
= 6 months
Difference between Duchenne muscular dystrophy and Becker muscular dystrophy
Age of onset
5yo and >10yo
Intellectual impairment in Duchenne No intellectual impairment in Becker’s
What is Gower’s sign?
Uses arms to stand up from squatted position
Infantile spasms
Occur at what age?
Describe the seizure
AKA
EEG
First few months of life
Flexion of head, trunk, arms then extension of arms
Salaam attack
EEG: hypsarrhythmia (high amplitude waves with irregular spikes)
Lennox Gastaut syndrome
Age
EEG
Mx
Features (4)
Extension of infantile spasms
Aged 1-5yo
EEG slow spike
Mx ketogenic diet
Atypical absences, falls, jerks
Moderate to severe handicap
Benign rolandic epilepsy
Most common in
Gender
Features (2)
EEG
Childhood, males
Paraesthesia (unilateral face)
Characteristic partial seizures at night
Centro temporal spikes
Juvenile myoclonic epilepsy
AKA
Age of onset
Gender
Type of seizures
Usually when? caused by what?
Other features (2)
Mx (1)
Janz syndrome
Teenage
F>M
Infrequent generalised seizures
Often in the morning/ following sleep deprivation
Daytime absences
Shock like myoclonic seizures
Mx sodium valproate
When do you start anti-epileptics following the first seizure? (4)
Neurological deficit
Structural abnormality on imaging
EEG unequivocal epileptic activity
Patient/ family wishes
Mx
Generalised tonic clonic seizures
M (1)
F (2)
Males SV
Females lamotrigine or levetiracetam
Mx
Focal seizures
1st line
2nd line
1st line Lamotrigine or levetiracetam
2nd line carbamezapine, oxcarbazepine or zonisamide
Absence seizures
Mx
1st line
2nd line
Ethosuximide
M SV
F lamotrigine or levetiracetam
What medication can exacerbate absence seizures?
Carbamazepine
Myoclonic seizures mx
Tonic or atonic seizures mx
M SV
F Levetiracetam
M SV
SV Lamotrogine
Essential tremor
Worse when?
Improved by?
Mx 1st line 2nd line
Arms outstretched
ETOH and rest
Propranolol
Primidone
Vertical diplopia
Subjective tilting of objects
Head tilting
Affected eye may deviate upwards and rotate outwards =
Fourth nerve palsy (trochlear)
GCS explained
M6V5E4
M 1 none, 2 extend to pain, 3 abnormal flexion, 4 withdraws to pain, localises pain, obeys commands
V 1 none, 2 sounds, 3 words, 4 confused, 5 orientated
E 1 none, 2 open to pain, 3 open to voice, 4 spontaneous
Guillain Barre syndrome
Commonly which bacteria triggers it?
Antibodies present in 25% of pts
Immune mediated demyelination of the peripheral nervous system triggered by infection
Campylobacter jejuni
Anti-GM1 antibodies
What is Miller Fisher syndrome?
Antibodies present in 90% of cases
Ascending or descending
Features (3)
Similar to GBS however associated with ophthalmoplegia, areflexia and ataxia
Descending paralysis
Anti-GQ1b antibodies
Guillian Barre
Features (3)
LP findings (2)
Ascending paralysis
Reflexes absent or reduced
Mild/ few sensory signs
Raised protein
Normal WCC
Huntington’s
AD/AR
Age of onset
Features (4)
AD
Trinucleotide repeat disorder CAG
35yo
Chorea, personality changes, dystonia, saccadic eye movements
Idiopathic intracranial hypertension
RF (4)
Obesity
COCP
Female
Pregnancy
Name five drugs than can cause IIH
COCP
Tetracyclines
Steroids
Vitamin A
Lithium
IIH features (4)
Headache
Papilloedema
6th nerve palsy (abducens)
Enlarged blind spot
Mx IIH (3)
- Weight loss
- Acetazolamide
- Topiramate
Lamotrogine adverse effect
MOA
Steven Johnson syndrome
Sodium channel blocker
Leg cramps mx (3)
- Stretching exercises for calves
- Quinine - stop if no benefit
- Referral to secondary care
Migraine diagnostic criteria:
At least x5 attacks of criteria B-E
B Headache lasting 4-72 hours
AND
C x2 of:
- unilat
- pulsating
- mod to severe pain
- avoidance of routine activity
AND
D x1 of
nausea/vomiting
photophobia + phonophobia
AND
E not attributed to any other disorder
Migraine Mx
Acute
1st line (2)
If aged 12-17 consider
2nd line (2)
3rd line (2)
- Combi therapy with PO triptan + NSAID/paracet
If aged 12-17 nasal triptan instead
If not effective then for:
2nd line: non PO metoclopramide/ prochlorperazine
3rd line +/- non oral NSAID/triptan
Migraine prophylaxis
When should it be given?
Mx 1st line (2)
2nd line (1)
Recommendation
If 2 or more attacks per month
1st line Topiramate or propranolol
2nd line 5-8 session of acupuncture
Recommend riboflavin 400mg OD
Mx for menstrual migrane (2)
Frovatriptan 2.5mg BD or zolmitriptan
Migraine during pregnancy
Mx (2)
- Paracetamol
- NSAIDs (first and second trimester)
Migraine in children more typically have which symptoms? (3)
Bilateral
Shorter lasting
GI symptoms have more prominence
