Neurology 1 Flashcards
How does trochlear nerve CN IV palsy present?
Palsy results in defective downward gaze → vertical diplopia
How does facial nerve palzy present? May have (5)
- trigeminal neuralgia
- loss of corneal reflex (afferent)
- loss of facial sensation
- paralysis of mastication muscles
- deviation of jaw to weak side
Uvula deviation towards or away from pathology?
Tongue deviation towards or away from pathology?
Uvula- CN X AWAY from pathology
Tongue- CN XII- TOWARDS pathology
Syringomyelia (‘syrinx’ for short)
What is it?
features:
1STEM
2
3
a collection of cerebrospinal fluid within the spinal cord.
features:
1. ‘cape-like’ (neck, shoulders and arms) loss of sensation to temperature but the preservation of light touch, proprioception and vibration- due to the crossing spinothalamic tracts in the anterior commissure of the spinal cord being the first tracts to be affected
2.spastic weakness (predominantly of the lower limbs)
3. neuropathic pain
4. autonomic features:
Horner’s syndrome due to compression of the sympathetic chain, but this is rare
bowel and bladder dysfunction
scoliosis will occur over a matter of years if the syrinx is not treated
Anti-emetics
Class
5-HT3 antagonists
eg. 1/2
+ve = (1)
Adverse effects = (2)
Class
5-HT3 antagonists
eg. ondansetron, palonosetron
+ve = reduced effect on the QT interval
Adverse effects =
prolonged QT interval
constipation is common
CSK dripping from someone’s nose
Quick way of testing its CSF?
Gold standard for testing is CSF?
Circulation of CSF classique (6 steps)
Quick way of testing its CSF?
- Glucose test would show positive, not present in mucus and is present in CSF.
Gold standard for testing is CSF?
- Beta-2-transferrin would be the gold standard
Circulation
1. Made in choroid plexus - Lateral ventricles (via foramen of Munro)
2. 3rd ventricle
3. Cerebral aqueduct (aqueduct of Sylvius)
4. 4th ventricle (via foramina of Magendie and Luschka)
5. Subarachnoid space
6. Reabsorbed into the venous system via arachnoid granulations into superior sagittal sinus
How will cavernous sinus syndrome present? (doesn’t have to be a clot)
Cavernous sinus thrombosis
= absent corneal reflex + proptosis
Management of restless legs syn.
1. conservative
2. conservative
3. first-line-
4 and 5 are alternatives
- simple measures: walking, stretching, massaging affected limbs
- treat any iron deficiency
- dopamine agonists are first-line treatment (e.g. Pramipexole, ropinirole)
- benzodiazepines
- gabapentin
What nerve is Saturday night palsy?
Radial nerve
Where does an acoustic neuroma grow?
Features? (3)
Cerebella pontine angle
Features:
- Progressive hearing loss
- Vertigo attacks
- Tinnitus
humeral shaft fracture affects what nerve and causes what sign?
Radial nerve
wrist drop
Name a handful of meds which can cause ideopathic increase in ICP
tetracycline antibiotics
isotretinoin
contraceptives
steroids
levothyroxine
lithium
cimetidine
Apart from gastro infection, what can be a trigger for Guillain-Barre syn?
Recent GI surgery (bowel resection) or surgery of respiratory tract!
Why is it important to give PD patients a dopamine agonist patch when admitted as a rescue medicine?
dopamine agonist transdermal patch will prevent a life-threatening dystonic withdrawal.
Cluster headache management
Acute
1.
2.
Prophylaxis
1.
2. Some supported evidence for…
Acute
1. 100% oxygen (80% response rate within 15 minutes)
2. subcutaneous triptan (75% response rate within 15 minutes)
Prophylaxis
1. verapamil is the drug of choice
2. Some supported evidence for…a tapering dose of prednisolone
What is neuroleptic malignant syndrome?
-
-
-
Can be caused from taking atypical anti-psychotics- the dopamine blockade induced triggers massive glutamate release and subsequent neurotoxicity and muscle damage.
- pyrexia
- muscle rigidity
- autonomic lability: typical features include hypertension, tachycardia and tachypnoea
- agitated delirium with confusion
neuroleptic malignant syndrome
KEY BLOOD RESULTS?! (2)
Management
1.
2.
3.
4.
+/-
- Increase in CK - can cause AKI from rhabdomyolysis
- Increase WCC
Management
1. Stop antipyshotic
2. Transfer to medical ward / ITU
3. IV fluids! (protect from renal failure)
4. Dontrolene
-/+ Bromocriptine (DA agonist)
migraine acute management
1. 1st line
what if young aged 12-17?
- If not effective?
What should you be wary of in step 2?
- Combination of
oral triptan + NSAID
oral triptan + paracetamol
what if young aged 12-17?
Consider nasal triptan
- If not effective?
Metoclopramide or procholperazine and consider adding an NSAID or triptan
What should you be wary of in step 2?
Caution with metoclopramide in young as can cause acute dystonic reaction
Migraine management prophylaxis!
-
-
Step 2.
Step 3, can advise…
what if women having migraine which is predictable with menstrual cycle?
Step 1. One from the following 3:
- Propranalol
- topiramate- avoid in child baring in age and can decrease contraception effectiveness
- amytriptyline
step 2. 10 sessions of acupuncture
Step 3, can advise… riboflavin 400mg maybe
Menstrual- frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) as a type of ‘mini-prophylaxis’
Management of raised ICP
obvs treat underlying cause
1
2
3
4 Methods of removing CSF (3)
- head elevation to 30º
- IV mannitol may be used as an osmotic diuretic
- controlled hyperventilation
to reduce pCO2 → vasoconstriction of the cerebral arteries → reduced ICP
this is rapid, temporary lowering of ICP. However, caution needed as may reduce blood flow to already ischaemic parts of the brain - removal of CSF, different techniques include:
drain from intraventricular monitor (see above)
repeated lumbar puncture (e.g. idiopathic intracranial hypertension)
ventriculoperitoneal shunt (for hydrocephalus)
What is Cushings triad?
other features… (4)
widening pulse pressure
bradycardia
irregular breathing
signs of raised ICP
- N + V
- Headache
- papilloedema
- dec GCS
generalized seizure prophylaxis
focal seizure prophlyaxis
Generalised
male- sodium valporate
female- lamotragine + Levatericitam
Focal
- Lamotrigine or levetiracetam
triad for normal pressure hydrocephalus classic!!
imaging sign?
Mx
Urinary incontinence + gait abnormality + dementia = normal pressure hydrocephalus
ventriculomegaly in the absence of, or out of proportion to, sulcal enlargement
ventriculoperitoneal shunting
damage to the common peroneal nerve causes what?
weakness of foot dorsiflexion and foot eversion
side effects of triptans 4
MOA?
contrainidcations 2
tingling, heat, tightness (e.g. throat and chest), heaviness, pressure
MOA- 5-HT1B and 5-HT1D agonist
patients with a history of, or significant risk factors for, ischaemic heart disease or cerebrovascular disease
subdural haemorrhage
what vessel has bled?
What see on CT?
Who?
Bridging veins
Cresent shape
Elderly or alcoholic
Bitemporal hemianopia
lesion of the optic chiasm
upper quad defect = cause
lower quad defect = cause
upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour
lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma
anti-emetic/ nausea what rug do you use?
chemotherapy-induced nausea
intracranial causes (raised ICP, direct effect of tumour)
vestibular causes
gastrointestinal causes
Chemo- Ondansetron ( 5-HT3 antagonist)
Intercranial- Haloperidol (anti-psychtoic)
Vestib- Prochlorperazine (dopamine rec antag)
GI- Metoclopramide (central DA anatag at chemoreceptor trigger zone)
B12 def causes…
features of this (3)
subacute combined degeneration of the spinal cord
affects dorsal column
- loss of proprioception and vibration
- muscle weakness
- hyperreflexia
