Neurology Flashcards
Cranial nerves
12
- Olfactory
(Smell in each nostril) - Optic
(Visual acuity, fields, pupils, ophthalmoscopy) - Occulomotor
(Ptosis, large pupil, pupil down and out) - Trochlear
(Diplopia on looking down and in) - Trigeminal
(Motor - ask to open mouth)
(Sensory - over 3 areas V1 Ophthalmic; V2 Maxillary; V3 Mandibular) - Abducens
(Eye can’t look laterally) - Facial
(UMN lesion gives ‘upper sparing’; Bell’s palsy —> LMN) - Vetsibulocochlear
(Hearing test, Rinne’s & Weber’s) - Glossopharangeal
(Gag reflex - afferent part of reflex tested) - Vagus
(Gag reflex - efferent part of reflex tested) - Accessory
(Ask to shrug shoulder, push head to one side) - Hypoglossal
(Tongue out - deviates to side of lesion)
Dermatomes
C5-8, S1-5
= area of skin supplied by a single nerve
C5 - antecubital fossa
C6 - thumb
C7 - middle finger
C8 - little finger
S1 - lateral heel
S2 - popliteal fossa
S4-5 - perianal area
Myotomes
C6, L2-4, S1
= groups of muscles innervated by a single nerve
C6 - wrist extension
L2 - hip flexion
L3 - knee extension
L4 - ankle dorsiflexion
S1 - ankle plantarflexion
Parkinsonism
Fx 7; Causes 4; Referral; Meds 5
Classic features:
- Bradykinesia (slow)
- Hypokinesia (less range)
- Rest tremor (4-6 Hz)
- Cog-wheel rigidity
- Postural instability
- Shuffling gait (festinant)
- Micrographia
Causes:
- Parkinson’s disease (degenerative condition, commonest cause: substantia nigra affected —> low dopamine)
- Vascular, e.g. stroke
- Medications, e.g. haloperidol, metoclopramide, prochlorperazine
- Alzheimer’s
Refer all suspected Parkinson’s urgently and untreated (even if potential drug cause - stop the drug and refer!)
Medications:
1. Levodopa (+/- dopa decarboxylase inhibitor as co-careldopa or co-beneldopa)
- MAO-B inhibitors, e.g. selegiline
- Dopamine agonists, e.g. pramipexole, ropinerole
- COMT inhibitors, e.g. entacapon
- Amantadine
Epilepsy
Defn
= neurological condition characterised by RECURRENT ABNORMAL ELECTRICAL ACTIVITY in the brain
—> problems with consciousness
Epilepsy classification (Gen [4] v partial [2] and examples)
GENERALISED - activity of both sides of brain affected
- Tonic-clinic (stiffening-jerking)
- Absence (usually childhood - ‘staring’ for up to 30 seconds)
- Myoclonus seizures (shock-like contraction of limbs, usually normal consciousness)
- Atonic seizures (sudden loss of tone, usually with impaired consciousness)
PARTIAL - originate from one hemisphere
- Focal motor or focal sensory
- Partial which then become generalised
Most are idiopathic but can have causes e.g. head injury, stroke, meningitis, etc
Epilepsy Ix
4
- ECG
- EEG
(May see classic ‘3 per second spike and wave’ pattern) - CT/MRI
- Bloods
- including FBC, U&E, LFT, calcium, glucose
First suspected seizure Mx
Assess —> admit or 2 week urgent neurology referral
Acute tonic-clinic seizure (known epilepsy) Mx
If reaches 5 mins OR 3 in an hour:
Buccal midazolam first-line in community (can use rectal diazepam)
—> ambulance if no benefit
General management of seizures
3 types of seizures
Tonic-clonic:
1st line valproate/lamotrigine
Myotonic:
1st valproate
(Levetiracetam/topiramate if not suitable)
Focal:
1st line carbamazepine/lamotrigine
(Levetiracetam/oxcarbazepine if not suitable)
Absence:
1st line ethosuximide/valproate
NB Remember sodium valproate linked with birth defects and developmental disorders in children —> not used in females of child-bearing age unless strict ‘pregnancy prevention programmes are in place’ (MHRA 2018)
Status epilepticus
Defn; Mx
= continuous seizure for 30 minutes or recurrent seizures with unconsciousness for 30 minutes
Mx:
IV lorazepam in hospital (1st line)
(IV diazepam if not possible)
MS: main presentations
4
- Optic neuritis
- Transverse myelitis
(E.g. weakness, paraesthesia, bladder dysfunction) - Cerebellar symptoms
- Brainstem syndromes
MND
=; Sx 3; Clinical patterns 3; Prognosis; Key Rx; Mx 5
= neurodegenerative condition brain/cord
Mix of UMN and LMN Sx:
- Weakness
- Cramps
- Slurred speech
Clinical patterns:
- Bulbar palsy
- ALS (amyotrophic lateral sclerosis)
- Progressive muscular trophy
Prognosis:
Incurable
2-3 years
Key Rx: RILUZOLE
Symptomatic Mx, e.g.:
- SALT
- Gastrostomy
- Physio/splints
- Meds for spasticity/cramps
- NIV
Myasthenia Gravis
=; Sx 3; Assoc 3; Worsening 6; Dx 3; Mx 4
= autoimmune disorder —> muscle weakness
Sx of muscular fatigue:
- Ocular muscles
- Resp muscles
- General muscles
Can be assoc w thymic conditions: e.g. hyperplasia or tumours, hyperthyroidism
Worsening weakness can occur due to:
- Pregnancy
- Fatigue
- Stress
- Infection
- Exercise
- Drugs (e.g. opiates/gentamicin)
Dx:
ACh receptor antibodies
EMG
Tensilon test (—> symptom improvement after short-acting anticholinesterase med - edrophonium)
Mx:
- Anticholinesterase medication (e.g. pyridostigmine) —> short term symptoms improvement
- Steroids (e.g. prednisolone)
- Immunosuppressants (e.g. azathioprine)
- Occasionally thymectomy
Bulbar palsy
LMN
Problem with CN VII-XII —> weakness of muscles of articulation —> dysarthria + problems swallowing and facial muscles
Weak and fasciculations of tongue, tremulous lips, drooling, dysphonia, dysarthria
Multiple causes, e.g. polio, MND
Pseudobulbar palsy
UMN
Paralysis of tongue, ‘Donald Duck speech’, dribbling, paralysis of facial muscles, brisk jaw jerk
Multiple causes, e.g. CVA, MS
Bell’s Palsy
=; presentation; prognosis; Mx; Refer
= acute facial nerve paralysis or weakness of unknown cause
LMN pattern facial nerve presentation
Most will start to recover even without treatment in 2-3 weeks. Many have full recovery by 4 months.
Mx:
1. Eye care (e.g. lubrication/patches)
2. Steroids - prednisolone if in first 72 hours
E.g. 50mg for 10 days, or 60mg for 5 days then reduce by 1mg per day for a total course of 10 days
(Anti-viral treatment + steroid may be of benefit but specialist discussion advised)
Refer to specialist if no improvement in 3 weeks or atypical features
Amitriptyline
= TCA
Indications:
- Depression
- Neuropathic pain
- Anxiety disorders
CI:
- Acute porphyrias
- Arrythmias
- Heart block
- Severe hepatic impairment
- During manic phase of bipolar
- Post MI recovery
- w MAOI
Gabapentin
Indications:
- Focal seizures
- Neuropathic pain
- Menopausal symptoms
Cautions:
- Hx of substance abuse
- Hx of psychosis
- Mixed seizures
- Diabetes
- Renal impairment
- Elderly
- Low body weight
- Risk of suicide
Phenytoin
Indications:
- Peripheral and central neuropathic pain
- Seizures
- GAD
Cautions:
- Substance abuse Hx
- Diabetes
- HF
- Renal impairment
- Conditions which may precipitate encephalopathy
- Elderly
- Falls risk
- Suicide risk
Brain tumours
2 peaks - children and late middle age
Children - think astrocytomas, medulloblastomas
Adult - think gliomas, meningiomas, metastases
Referral for suspected CNS cancer:
Adult —> 2 week direct MRI (or CT if unavailable) if progressive, sub-acute loss of central neuro function (e.g. vision, motor loss)
Child —> 48 hour appt w newly abnormal cerebellar or other central neurological function
