Neurology 1 Flashcards

1
Q

How do migraines typically present?

A

Recurrent, severe headache which is usually unilateral and throbbing in nature
May be be associated with aura, nausea and photosensitivity
Aggravated by, or causes avoidance of, routine activities of daily living. Patients often describe ‘going to bed’.
In women may be associated with menstruation

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2
Q

How do tension headaches typically present?

A

Recurrent, non-disabling, bilateral headache, often described as a ‘tight-band’
Not aggravated by routine activities of daily living

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3
Q

How do cluster headaches typically present?

A

Pain occurs once or twice a day, each episode lasting 15 mins - 2 hours with clusters typically lasting 4-12 weeks
Intense pain around one eye (recurrent attacks ‘always’ affect same side)
Patient is restless during an attack
Accompanied by redness, lacrimation, lid swelling
More common in men and smokers

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4
Q

How does temporal arteritis typically present?

A

Typically patient > 60 years old
Usually rapid onset (e.g. < 1 month) of unilateral headache
Jaw claudication (65%)
Tender, palpable temporal artery
Raised ESR

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5
Q

How does a medication overuse headache typically present?

A

Present for 15 days or more per month
Developed or worsened whilst taking regular symptomatic medication
Patients using opioids and triptans are at most risk
May be psychiatric co-morbidity

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6
Q

Give some causes of an acute onset single episode of headache

A

meningitis / encephalitis
subarachnoid haemorrhage
head injury
sinusitis
glaucoma (acute closed-angle)

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7
Q

Give some causes of chronic headache

A

chronically raised ICP
Paget’s disease
psychological causes

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8
Q

Give some red flags for a headache

A

Fever, photophobia or neck stiffness (meningitis)
History of head trauma (haemorrhage)
History of cancer (brain mets)
Postural , triggered by coughing / straining (raised ICP)
Visual disturbance (GCA, glaucoma, tumours)
New-onset neurological deficit
Change in personality
Impaired level of consciousness

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9
Q

What may tension headache be associated with?

A

Stress
Depression
Alcohol
Skipping meals
Dehydration

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10
Q

How can tension headaches be managed?

A

Reassurance
Simple analgesia (e.g., ibuprofen or paracetamol)
Low dose amitriptyline is generally first-line for chronic or frequent tension headaches

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11
Q

What is a common trigger for cluster headaches?

A

drinking alcohol

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12
Q

How should cluster headaches be investigated?

A

most patients will have neuroimaging - underlying brain lesions are sometimes found even if the clinical symptoms are typical for cluster headache

MRI with gadolinium contrast is the investigation of choice

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13
Q

How should cluster headaches be managed?

A

NICE recommend seeking specialist advice from a neurologist

acute:
100% oxygen (80% response rate within 15 minutes)
subcutaneous triptan (75% response rate within 15 minutes)

prophylaxis: verapamil

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14
Q

Which patients are most at risk of developing medication overuse headaches?

A

patients using opioids and triptans are at most risk

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15
Q

How should medication overuse headaches be managed? What is the risk with this?

A

simple analgesics and triptans should be withdrawn abruptly (may initially worsen headaches)

opioid analgesics should be gradually withdrawn

Withdrawal symptoms such as vomiting, hypotension, tachycardia, restlessness, sleep disturbances and anxiety may occur

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16
Q

Headache following lumbar puncture (LP) occurs in approximately one-third of patients.

What features does it present with?

A

usually develops within 24-48 hours following LP but may occur up to one week later
may last several days
worsens with upright position
improves with recumbent position

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17
Q

How can headache following LP be managed?

A

supportive initially (analgesia, rest)

if pain continues for more than 72 hours then specific treatment is indicated, to prevent subdural haematoma

treatment options include: blood patch, epidural saline and IV caffeine

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18
Q

Migraine is a complex neurological condition causing episodes of headache and associated symptoms. It tends to affect women more than men and is most common in young adults.

What are the 4 main types?

A

Migraine without aura
Migraine with aura
Silent migraine (migraine with aura but without a headache)
Hemiplegic migraine

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19
Q

What are the 5 stages of migraine?

A

Premonitory or prodromal stage (can begin several days before the headache)
Aura (lasting up to 60 minutes)
Headache stage (lasts 4 to 72 hours)
Resolution stage (the headache may fade away or be relieved abruptly by vomiting or sleeping)
Postdromal or recovery phase

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20
Q

Give some typical features of migraine

A

Usually unilateral but can be bilateral
Pounding or throbbing in nature
Photophobia (discomfort with lights)
Phonophobia (discomfort with loud noises)
Osmophobia (discomfort with strong smells)
Aura (visual changes)
Nausea and vomiting

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21
Q

What is aura?

A

sensory disturbance commonly associated with migraines

Visual symptoms are the most common.
These may be:
Sparks in the vision
Blurred vision
Lines across the vision
Loss of visual fields (e.g., scotoma)

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22
Q

What are hemiplegic migraines?

A

migraines associated with hemiplegia (unilateral limb weakness). Other symptoms may include ataxia and impaired consciousness

may be familial

can mimic a stroke or TIA so should be investigated urgently

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23
Q

Give some common migraine triggers

A

Stress
Bright lights
Strong smells
Certain foods (e.g., chocolate, cheese and caffeine)
Dehydration
Menstruation
Disrupted sleep
Trauma

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24
Q

What are the medical options for managing an acute migraine attack?

A

NSAIDs (e.g., ibuprofen or naproxen)
Paracetamol
Triptans (e.g., sumatriptan)
Antiemetics if vomiting occurs (e.g., metoclopramide or prochlorperazine)

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25
What are triptans? How do they work to treat migraines?
5-HT receptor agonists (they bind to and stimulate serotonin receptors) They have various mechanisms of action: Cranial vasoconstriction Inhibiting the transmission of pain signals Inhibiting the release of inflammatory neuropeptides
26
When can you NOT use triptans in migraine mx?
Triptans are taken as soon as a migraine starts and should halt the attack. If the attack resolves and then reoccurs, another dose can be taken. If it does not work the first time, another second dose should NOT be taken for the same attack. Risks associated with vasoconstriction: hypertension, coronary artery disease or previous stroke, TIA or MI
27
What can be used in migraine prophylaxis?
headache diary to identify and avoid triggers Propranolol (a non-selective BB) Amitriptyline (TCA) Topiramate (teratogenic!!!) CBT, mindfullness and acupuncture may also be used
28
What is Parkinson's disease?
a chronic, progressive, degenerative neurological condition leading to disorders of movement due to reduction in dopamine in the basal ganglia symptoms are characteristically asymmetrical, with one side of the body affected more
29
What is the Parkinson's disease (PD) triad?
Resting tremor Rigidity (resisting passive movement) Bradykinesia (slowness of movement)
30
What factors are thought to be protective against developing PD?
smoking caffeine aerobic exercise
31
What factors are thought to increase risk of developing PD?
Family history - particularly evident if onset of disease is in people less than 50-years-old Previous head injury
32
Outline the pathophsyiology of PD
selective loss of dopaminergic neurons in the substantia nigra = in a reduction in dopaminergic output
33
What features may PD present with?
Pill-rolling tremor Cogwheel rigidity Bradykinesia: movements getting slower and smaller Shuffling gait , difficulty in initiating movement Mask-like facies (hypomimia) Dysarthria and dysphagia Micrographia Postural Instability : increased risk of falls!
34
Describe the tremor seen in PD
'Pill-rolling' resting tremor, 4-6 hertz frequency Usually unilateral or worse on one side than another Exacerbated by rest, and improves when a person engages in purposeful actions Exaggerated when the other hand is being used to do something else (can ask someone to mime painting a fence)
35
How does muscle rigidity in PD manifest for the patient?
muscular stiffness, stooped posture, and reduced arm swing when walking
36
What may a patient who is experiencing bradykinesia due to PD describe in the history?
reduction in manual dexterity of finger movements (e.g. fastening buttons, picking up small items), difficulty standing from a seated position, and troubles when walking (e.g. dragging feet)
37
What non-motor sxs may a patient with PD experience?
Depression Sleep disturbance and insomnia Loss of the sense of smell (anosmia) Cognitive impairment and memory problems
38
How can you differentiate between a Parkinson's tremor and a Benign Essential tremor?
39
How may Parkinson's Disease be investigated and diagnosed?
Usually a clinical diagnosis: UK Parkinson's Disease Society Brain Bank Clinical Diagnostic Criteria Investigations to differentiate from other disorders: Single photon emission computed tomography (SPECT) to distinguish Parkinson's disease from an essential tremor and Parkinsonism Structural MRI to exclude structural abnormalities as the cause of the symptoms
40
What is the diagnostic criteria for PD?
Presence of bradykinesia plus at least one of the following: * Muscular rigidity * Resting tremor (4-6 Hz frequency) * Postural instability (not caused by a visual, vestibular, cerebellar or proprioceptive dysfunction)
41
Give some ddx for PD
Essential tremor Multiple system atrophy Lewy-body dementia Secondary Parkinsonism
42
What are the similarities and differences between Multiple System Atrophy and PD?
Similarities: Both may initially present with Parkinsonian features Both may respond to levodopa therapy Both have an element of autonomic dysfunction (although more pronounced in MSA) Differences: In MSA, there is usually cerebellar involvement, which is part of the exclusion criteria for Parkinson's disease Cognition is well preserved in MSA
43
What are the differences between Lewy-Body dementia and PD?
In Lewy-body dementia, the dementia usually occurs alongside, or prior to, the development of parkinsonism (and must occur no later than a year after onset of motor symptoms) In PD, motor symptoms appear before cognitive decline
44
What may cause secondary Parkinsonism?
Drug induced: Anti-psychotics and anti-emetic drugs which act via dopaminergic antagonism Vascular: due to multiple infarcts affecting the basal ganglia
45
How can drug-induced Parkinsonism be differentiated from PD?
Can be distinguished via a thorough medication history Other movement disorders also caused by these drugs can help differentiate, such as akathisia, tardive dyskinesia and acute dystonia Usually causes symmetrical symptoms (PD is asymmetrical)
46
How can vascular Parkinsonism be differentiated from PD?
Usually can be identified via a thorough history and radiological findings Probably step-wise progression rather than continuous
47
What are the treatment options for PD?
Levodopa (combined with peripheral decarboxylase inhibitors) COMT inhibitors Dopamine agonists Monoamine oxidase-B inhibitors
48
What is Levodopa?
precursor to dopamine which is converted both in the CNS and periphery can be taken orally patients may build a tolerance so not usually given first line
49
What are the main side effects of Levodopa?
Dyskinesia: Dystonia (where excessive muscle contraction leads to abnormal postures or exaggerated movements) Chorea (abnormal involuntary movements that can be jerking and random) Athetosis (involuntary twisting or writhing movements, usually in the fingers, hands or feet)
50
What can be used to manage dyskinesia associated with levodopa?
Amantadine - a glutamate antagonist
51
Give some examples of Monoamine oxidase B (MAO-B) inhibitors. How do they work?
rasagiline and selegiline inhibitors of MAO-B which degrades dopamine, therefore increasing the amount of circulating dopamine available used to delay the use of levodopa, then in combination with levodopa to reduce the “end of dose” worsening of symptoms
52
Dopamine agonists mimic the action of dopamine in the basal ganglia, stimulating the dopamine receptors. Give some examples
Bromocriptine Pergolide Cabergoline
53
What is the main side effect of prolonged use of dopamine agonists?
Pulmonary fibrosis
54
What are COMT Inhibitors (e.g. entacapone)? How do they work?
inhibitors of catechol-o-methyltransferase (COMT) enzyme which metabolises levodopa in both the body and brain Entacapone is taken with levodopa (and a decarboxylase inhibitor) to slow the breakdown of the levodopa in the brain Extends the effective duration of the levodopa
55
The first-line treatment for early stage Parkinson's disease depends on what?
depends on the impact of the motor symptoms on the patient's quality of life If motor symptoms impact on quality of life - levodopa If motor symptoms do not impact on quality of life - dopamine agonist, levodopa or MAO-B inhibitors
56
What can you use to help guide which medications to use to manage someone's PD?
The patient's current symptom profile Patient age (UptoDate indicate that for patients over 65-years-old, levodopa is better tolerated than dopamine agonists) Current co-morbidities and existing medications (need to consider the risk of polypharmacy and medication interactions) Possible risks and side effects of each medication
57
What can be used as an adjuvant to medical therapy for PD?
Deep brain stimulation- if sxs not controlled by medication Physio Speech therapy Occupational therapy
58
What complications may be experienced by patients with PD?
Autonomic dysfunction Recurrent falls Cognitive impairment
59
Autonomic dysfunction occurs when the autonomic nervous system fails to work appropriately, and may be seen in patients with progressive PD. How may this manifest?
Postural hypotension with no compensatory tachycardia - dizziness, light-headedness and subsequent falls Constipation -due to dysregulated colonic smooth muscle activity Urinary dysfunction - increased urinary frequency and urgency
60
Why are patients with PD at 2 fold greater risk of falls than their peers?
postural instability and impaired corrective reflexes orthostatic hypotension
61
What does onset of dementia symptoms at different stages of someone's PD experience suggest?
If dementia develops >1 year after Parkinson's disease diagnosis, it is considered to be Parkinson's disease dementia However, if dementia begins prior or alongside the Parkinson's disease diagnosis (<1 year), Lewy-body dementia is more likely
62
Motor neuron disease is a neurological condition which can present with both upper and lower motor neuron signs, usually in patients > 40 years old. What features does it present with?
mixture of LMN and UMN signs asymmetric limb weakness is the most common presentation wasting of the small hand muscles/tibialis anterior fasciculations no sensory signs/symptoms
63
What motor functions are spared in motor neurone disease?
doesn't affect external ocular muscles no cerebellar signs abdominal reflexes are usually preserved and sphincter dysfunction if present is a late feature
64
Give some signs of lower motor neurone disease
Muscle wasting Reduced tone Reduced reflexes Fasciculations (twitches in the muscles)
65
Give some signs of upper motor neurone disease
Increased tone or spasticity Brisk reflexes Upgoing plantar reflex
66
What are the different types of MND?
Amyotrophic lateral sclerosis (50% of patients) Progressive bulbar palsy (second most common) Primary lateral sclerosis Progressive muscular atrophy
67
How does ALS present?
typically LMN signs in arms and UMN signs in legs in familial cases the gene responsible lies on chromosome 21
68
How does progressive bulbar palsy present?
palsy of the tongue, muscles of chewing/swallowing and facial muscles due to loss of function of brainstem motor nuclei carries worst prognosis
69
How can MND be diagnosed?
Clinical diagnosis Nerve conduction studies will show normal motor conduction and can exclude a neuropathy MRI is usually performed to exclude cervical cord compression and myelopathy
70
How can MND be managed?
Riluzole: used mainly in amyotrophic lateral sclerosis Respiratory care: non-invasive ventilation (usually BIPAP) is used at night Nutrition: Percutaneous gastrostomy tube (PEG) is the preferred way to support nutrition in patents with MND
71
What is the prognosis like for MND ?
Prognosis generally poor: 50% of patients die within 3 years Riluzole prolongs life by about 3 months
72
What is myasthenia gravis?
an autoimmune condition affecting the neuromuscular junction. It causes muscle weakness that progressively worsens with activity and improves with rest. typically affects women under 40 and men over 60
73
What antibodies are usually found in patients with myasthenia?
Acetylcholine receptor (AChR) antibodies
74
What other conditions is myasthenia gravis associated with?
thymomas in 15% thymic hyperplasia in 50-70% autoimmune disorders: pernicious anaemia, autoimmune thyroid disorders, rheumatoid, SLE
75
What features does myasthenia present with?
proximal muscle weakness that exhibits fatiguability Difficulty climbing stairs, standing from a seat or raising their hands above their head Extraocular muscle weakness, causing diplopia Eyelid weakness causing ptosis Weakness in facial movements Difficulty with swallowing Fatigue in the jaw when chewing Slurred speech
76
How can you elicit fatiguability in the muscles when examining for myasthenia gravis?
Repeated blinking will exacerbate ptosis Prolonged upward gazing will exacerbate diplopia on further testing Repeated abduction of one arm 20 times will result in unilateral weakness when comparing both sides
77
What should you look for on examination of Myasthenia gravis?
Check for a thymectomy scar Test the forced vital capacity (FVC)
78
How can Myasthenia gravis be investigated?
Antibody testing: AChR antibodies (around 85%) MuSK antibodies (less than 10%) LRP4 antibodies (less than 5%) A CT or MRI of the thymus gland is used to look for a thymoma. The edrophonium test can be helpful where there is doubt about the diagnosis
79
How can Myasthenia Gravis be managed?
Long acting acetylcholinesterase inhibitor (Pyridostigime) that prolongs the action of ACh and improves symptoms Immunosuppression (e.g., prednisolone or azathioprine) suppresses the production of antibodies Thymectomy can improve symptoms, even in patients without a thymoma Rituximab (a monoclonal antibody against B cells) is considered where other treatments fail
80
What is Myasthenic crisis? How can it be managed?
a potentially life-threatening complication of myasthenia gravis where there is an acute worsening of symptoms, often triggered by a viral illness Respiratory muscle weakness can lead to respiratory failure and patients may require NIV or mechanical ventilation. Treatment is with IV immunoglobulins and plasmapheresis
81
What is Guillain-Barré syndrome?
an immune-mediated demyelination of the peripheral nervous system often triggered by an infection (classically Campylobacter jejuni)
82
What is the pathophysiology of Guillain-Barré syndrome?
molecular mimicry B cells create antibodies against the antigens on the triggering pathogen. These antibodies also match proteins on the peripheral neurones. They may target proteins on the myelin sheath or the nerve axon itself.
83
What is the timeline of Guillain-Barré syndrome?
84
What symptoms does Guillain-Barré syndrome present with?
around 65% of patients experience back/leg pain in the initial stages of the illness progressive, symmetrical weakness of all the limbs the weakness is classically ascending i.e. the legs are affected first reflexes are reduced or absent sensory symptoms tend to be mild (e.g. distal paraesthesia)
85
What less common symptoms may GBS present with?
respiratory muscle weakness cranial nerve involvement: * diplopia * bilateral facial nerve palsy * oropharyngeal weakness autonomic involvement urinary retention / diarrhoea
86
How can GBS be investigated?
nerve conduction studies: * decreased motor nerve conduction velocity (due to demyelination) * prolonged distal motor latency * increased F wave latency lumbar puncture (diagnostic) rise in protein with a normal white blood cell count
87
How can GBS be managed?
Supportive care: VTE prophylaxis (pulmonary embolism is a leading cause of death) IV immunoglobulins (IVIG) first-line Plasmapheresis is an alternative to IVIG Severe cases with respiratory failure may require intubation, ventilation and admission to the intensive care unit
88
What is Duchenne Muscular Dystrophy?
an X-linked recessive inherited disorder in the dystrophin genes required for normal muscular function
89
How does Duchenne Muscular Dystrophy present?
progressive proximal muscle weakness from 5 years calf pseudohypertrophy Gower's sign: child uses arms to stand up from a squatted position 30% of patients have intellectual impairment
90
How may Duchenne Muscular Dystrophy be investigated and managed?
Investigation raised creatinine kinase genetic testing to obtain a definitive diagnosis Management is largely supportive as unfortunately there is currently no effective treatment
91
What is the prognosis for Duchenne Muscular Dystrophy?
most children cannot walk by the age of 12 years patients typically survive to around the age of 25-30 years associated with dilated cardiomyopathy
92
What is Becker muscular dystrophy?
x-linked recessive dystrophinopathy, often thought of as a 'less severe' version of Duchenne muscular dystrophy develops after the age of 10 years intellectual impairment much less common than in Duchenne
93
What is Multiple Sclerosis?
a chronic cell-mediated autoimmune disorder characterised by demyelination in the central nervous system (immune system attacks myelin sheath) In early disease, re-myelination can occur, and the symptoms can resolve. In the later stages of the disease, re-myelination is incomplete, and the symptoms gradually become more permanent MS lesions are described as 'disseminated in space and time' - they pop up and affect different sites causing different symptoms
94
What is the epidemiology of MS?
3 times more common in women most commonly diagnosed in people aged 20-40 years much more common at higher latitudes
95
What are the subtypes of MS?
Relapsing-remitting disease (MOST COMMON: 85%) Secondary progressive disease Primary progressive disease
96
How does relapsing-remitting MS present?
most common form, accounts for around 85% of patients acute attacks (e.g. last 1-2 months) followed by periods of remission
97
How does secondary progressive MS present?
relapsing-remitting patients who have deteriorated and have developed neurological signs and symptoms between relapses around 65% of patients with relapsing-remitting disease go on to develop secondary progressive disease within 15 years gait and bladder disorders are generally seen
98
How does primary progressive MS present?
accounts for 10% of patients progressive deterioration from onset more common in older people
99
What non-specific feature do patients with MS often experience?
75% of patients have significant lethargy
100
What are the visual manifestations of MS?
optic neuritis: common presenting feature optic atrophy Uhthoff's phenomenon: worsening of vision following rise in body temperature internuclear ophthalmoplegia
101
Optic neuritis is the most common presentation of MS due to demyelination of the optic nerve. How does it present?
unilateral reduced vision, developing over hours to days Central scotoma (an enlarged central blind spot) Pain with eye movement Impaired colour vision Relative afferent pupillary defect
102
What sensory symptoms may be caused by MS?
pins/needles numbness trigeminal neuralgia Lhermitte's syndrome: paraesthesiae in limbs on neck flexion
103
What is the most common motor manifestation of MS?
spastic weakness: most commonly seen in the legs
104
How may cerebellar MS manifest itself?
ataxia: more often seen during an acute relapse than as a presenting symptom tremor
105
What is Uhthoff's phenomenon?
where neurological symptoms are exacerbated by increases in body temperature typically associated with multiple sclerosis
106
What is Lhermitte's syndrome?
paraesthesiae in limbs on neck flexion also known as 'Barber Chair phenomenon' may be seen in MS
107
How can MS be investigated?
MRI high signal T2 lesions periventricular plaques Dawson fingers: hyperintense lesions perpendicular to the corpus callosum CSF oligoclonal bands (and not in serum)
108
What is seen on this MRI?
multiple white matter plaques perpendicular to the corpus callosum - Dawson's fingers characteristic of MS
109
What is seen on this MRI?
multiple high signal T2 lesions young patient with MS
110
How can acute relapses in MS be managed?
High-dose steroids (methylprednisolone 500 mg orally or 1g IV ) may be given for 5 days to shorten the length of an acute relapse N.B. shortens the duration but does not alter the degree of recovery (i.e. whether a patient returns to baseline function)
111
What are the indications for disease modifying drugs in MS?
relapsing-remitting disease + 2 relapses in past 2 years + able to walk 100m unaided secondary progressive disease + 2 relapses in past 2 years + able to walk 10m (aided or unaided)
112
Give an example of a disease modifying drug that can be used to reduce risk of relapse in MS
natalizumab (monoclonal antibody)
113
How can fatigue in MS be managed?
exclude other issues e.g. anaemia, thyroid or depression trial of amantadine other options include mindfulness training and CBT
114
How can spasticity in MS be managed?
baclofen and gabapentin are first-line physiotherapy is important
115
How can bladder dysfunction in MS be managed?
USS first to assess bladder emptying - anticholinergics may worsen symptoms in some patients if significant residual volume → intermittent self-catheterisation if no significant residual volume → anticholinergics may improve urinary frequency
116
What is oscillopsia? How may it be managed?
visual fields appear to oscillate - may be seen in MS gabapentin is first-line
117
Describe diabetic neuropathy
sensory loss in a 'glove and stocking' distribution
118
How can diabetic neuropathy be managed?
first-line treatment: amitriptyline, duloxetine, gabapentin or pregabalin tramadol may be used as 'rescue therapy' for exacerbations of neuropathic pain pain management clinics may be useful in patients with resistant problems
119
As well as the classic peripheral neuropathy, diabetes can cause gastrointestinal autonomic neuropathy. How may this present?
Gastroparesis: symptoms include erratic blood glucose control, bloating and vomiting management options include metoclopramide and domperidone (prokinetic agents) Chronic diarrhoea: often occurs at night GORD: caused by decreased lower oesophageal sphincter pressure
120
Give some causes of peripheral neuropathy
A – Alcohol B – B12 deficiency C – Cancer (e.g., myeloma) and Chronic kidney disease D – Diabetes and Drugs (e.g., isoniazid, amiodarone, leflunomide and cisplatin) E – Every vasculitis
121
Give some causes of peripheral neuropathy with predominately motor loss
Guillain-Barre syndrome Charcot-Marie-Tooth diphtheria porphyria lead poisoning chronic inflammatory demyelinating polyneuropathy (CIDP)
122
Give some causes of peripheral neuropathy with predominately sensory loss
diabetes alcoholism vitamin B12 deficiency amyloidosis uraemia leprosy
123
How does alcoholism cause peripheral neuropathy?
secondary to both direct toxic effects and reduced absorption of B vitamins sensory symptoms typically present prior to motor symptoms
124
How does B12 deficiency cause peripheral neuropathy?
subacute combined degeneration of spinal cord dorsal column usually affected first (joint position, vibration) prior to distal paraesthesia
125
Give some examples of medications which may cause peripheral neuropathy
amiodarone isoniazid vincristine nitrofurantoin metronidazole A I's Very Nearly Mastered
126
What is Charcot-Marie Tooth Disease?
the most common hereditary peripheral neuropathy usually autosomal dominant, results in predominantly motor loss sxs usually start to appear before the age of 10 but can be delayed until 40 or later
127
What features does Charcot-Marie Tooth present with?
Distal muscle weakness and atrophy There may be a history of frequently sprained ankles Foot drop (due to weakness of ankle dorsiflexion) High-arched feet (pes cavus) Hammer toes Hyporeflexia Stork leg deformity
128
How can Charcot-Marie Tooth disease be managed?
there is no cure Analgesia for neuropathic pain (e.g., amitriptyline) Physiotherapy to maintain muscle strength and joint range of motion Occupational therapy Podiatry input for insoles and orthoses to improve symptoms Orthopaedic surgery for severe joint deformities
129
Cervical spondylosis (degeneration of the cervical vertebrae) is an extremely common condition that results from osteoarthritis. How does it present?
most commonly presents as neck pain although referred pain may mimic headaches complications include radiculopathy and myelopathy
130
Degenerative disc disease (or spondylosis) refers to the natural deterioration of the intervertebral disc structure over time. What factors may influence this?
Ageing Environmental factors: Sedentary lifestyle, occupation, smoking Increased body weight (especially in lumbar spine)
131
Outline the cascade of changes seen in degenerative disc disease
Dysfunction - outer annular tears and cartilage destruction Instability – disc resorption and loss of disc space height Restabilisation – osteophyte formation and canal stenosis
132
How may degenerative disc disease (spondylosis) present?
localised back pain radicular pain or paraesthesia On examination: local spinal tenderness or contracted paraspinal muscles, hypomobility, or painful extension of the back or neck
133
Lumbar spondylosis may cause a positive Lasegue sign on examination- what is this?
When back pain is reproduced by passively raising the extended leg
134
Give some ddx for degenerative disc disease (spondylosis)
cauda equina syndrome, infection (such as discitis), or malignancy (including metastatic disease)
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Give some red flags for back pain
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How may suspected degenerative disc disease (spondylosis) be investigated?
Imaging should be warranted in cases of suspected degenerative disc disease if: Red flags present Radiculopathy with pain for more than 6 weeks Evidence of a spinal cord compression Imaging would significantly alter management An MRI spine is the gold standard investigation
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What may be seen on MRI for degenerative disc disease (spondylosis)?
signs of degeneration, reduction of disc height, the presence of annular tears, and endplate changes
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Bell's palsy may be defined as an acute, unilateral, idiopathic, facial nerve paralysis. Who does it most commonly present in?
peak incidence is 20-40 years and the condition is more common in pregnant women
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What features does Bell's palsy present with?
lower motor neuron facial nerve palsy → forehead affected (in contrast, an upper motor neuron lesion 'spares' the upper face) patients may also notice: post-auricular pain (may precede paralysis) altered taste dry eyes hyperacusis
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How can Bell's palsy be managed?
commence on a course of prednisolone (if present within 72 hours of onset) and give eye care advice Eye care is important in Bell's palsy - drops, lubricants and night time taping should be considered to prevent exposure keratopathy
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How should Bell's palsy be followed up?
if the paralysis shows no sign of improvement after 3 weeks, refer urgently to ENT most people with Bell's palsy make a full recovery within 3-4 months if untreated around 15% of patients have permanent moderate to severe weakness
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What does the facial nerve and its branches supply?
'face, ear, taste, tear' face: muscles of facial expression ear: nerve to stapedius taste: supplies anterior two-thirds of tongue tear: parasympathetic fibres to lacrimal glands, also salivary glands
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What can cause bilateral facial nerve palsy?
sarcoidosis Guillain-Barre syndrome Bell's palsy Lyme disease bilateral acoustic neuromas (as in neurofibromatosis type 2)
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How can you differentiate between upper and lower motor neurone lesions on the facial nerve?
upper motor neuron lesion 'spares' upper face i.e. forehead lower motor neuron lesion affects all facial muscles
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Give some lower motor neurone causes of facial nerve palsy
Bell's palsy Ramsay-Hunt syndrome (due to herpes zoster) acoustic neuroma parotid tumours HIV diabetes mellitus
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What is the main cause of unilateral upper motor neurone facial nerve palsy?
Stroke can also be caused by tumours
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Carpal tunnel syndrome is caused by compression of median nerve in the carpal tunnel. What symptoms does it present with?
pain/pins and needles in thumb, index, middle finger unusually the symptoms may 'ascend' proximally patient shakes his hand to obtain relief, classically at night
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How does carpal tunnel syndrome present on examination?
weakness of thumb abduction (abductor pollicis brevis) wasting of thenar eminence (NOT hypothenar) Tinel's sign: tapping causes paraesthesia Phalen's sign: flexion of wrist causes symptoms
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What can cause carpal tunnel syndrome?
idiopathic pregnancy oedema e.g. heart failure lunate fracture rheumatoid arthritis
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How may carpal tunnel syndrome be investigated and managed?
Ix with electrophysiology: motor + sensory: prolongation of the action potential Treatment: 6-week trial of conservative treatments if the sxs are mild: corticosteroid injection wrist splints at night Severe/ persistent sxs: surgical decompression (flexor retinaculum division)