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Neurology Flashcards

1
Q

Cranial nerves

12

A
  1. Olfactory
    (Smell in each nostril)
  2. Optic
    (Visual acuity, fields, pupils, ophthalmoscopy)
  3. Occulomotor
    (Ptosis, large pupil, pupil down and out)
  4. Trochlear
    (Diplopia on looking down and in)
  5. Trigeminal
    (Motor - ask to open mouth)
    (Sensory - over 3 areas V1 Ophthalmic; V2 Maxillary; V3 Mandibular)
  6. Abducens
    (Eye can’t look laterally)
  7. Facial
    (UMN lesion gives ‘upper sparing’; Bell’s palsy —> LMN)
  8. Vetsibulocochlear
    (Hearing test, Rinne’s & Weber’s)
  9. Glossopharangeal
    (Gag reflex - afferent part of reflex tested)
  10. Vagus
    (Gag reflex - efferent part of reflex tested)
  11. Accessory
    (Ask to shrug shoulder, push head to one side)
  12. Hypoglossal
    (Tongue out - deviates to side of lesion)
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2
Q

Dermatomes

C5-8, S1-5

A

= 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

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3
Q

Myotomes

C6, L2-4, S1

A

= groups of muscles innervated by a single nerve

C6 - wrist extension

L2 - hip flexion

L3 - knee extension

L4 - ankle dorsiflexion

S1 - ankle plantarflexion

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4
Q

Parkinsonism

Fx 7; Causes 4; Referral; Meds 5

A

Classic features:

  1. Bradykinesia (slow)
  2. Hypokinesia (less range)
  3. Rest tremor (4-6 Hz)
  4. Cog-wheel rigidity
  5. Postural instability
  6. Shuffling gait (festinant)
  7. Micrographia

Causes:

  1. Parkinson’s disease (degenerative condition, commonest cause: substantia nigra affected —> low dopamine)
  2. Vascular, e.g. stroke
  3. Medications, e.g. haloperidol, metoclopramide, prochlorperazine
  4. 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)

  1. MAO-B inhibitors, e.g. selegiline
  2. Dopamine agonists, e.g. pramipexole, ropinerole
  3. COMT inhibitors, e.g. entacapon
  4. Amantadine
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5
Q

Epilepsy

Defn

A

= neurological condition characterised by RECURRENT ABNORMAL ELECTRICAL ACTIVITY in the brain
—> problems with consciousness

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6
Q 
Epilepsy classification
(Gen [4] v partial [2] and examples)
A

GENERALISED - activity of both sides of brain affected

  1. Tonic-clinic (stiffening-jerking)
  2. Absence (usually childhood - ‘staring’ for up to 30 seconds)
  3. Myoclonus seizures (shock-like contraction of limbs, usually normal consciousness)
  4. Atonic seizures (sudden loss of tone, usually with impaired consciousness)

PARTIAL - originate from one hemisphere

  1. Focal motor or focal sensory
  2. Partial which then become generalised

Most are idiopathic but can have causes e.g. head injury, stroke, meningitis, etc

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7
Q

Epilepsy Ix

4

A
  1. ECG
  2. EEG
    (May see classic ‘3 per second spike and wave’ pattern)
  3. CT/MRI
  4. Bloods
    - including FBC, U&E, LFT, calcium, glucose
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8
Q

First suspected seizure Mx

A

Assess —> admit or 2 week urgent neurology referral

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9
Q

Acute tonic-clinic seizure (known epilepsy) Mx

A

If reaches 5 mins OR 3 in an hour:

Buccal midazolam first-line in community (can use rectal diazepam)

—> ambulance if no benefit

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10
Q

General management of seizures

3 types of seizures

A

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)

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11
Q

Status epilepticus

Defn; Mx

A

= 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)

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12
Q

MS: main presentations

4

A
  1. Optic neuritis
  2. Transverse myelitis
    (E.g. weakness, paraesthesia, bladder dysfunction)
  3. Cerebellar symptoms
  4. Brainstem syndromes
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13
Q

MND

=; Sx 3; Clinical patterns 3; Prognosis; Key Rx; Mx 5

A

= neurodegenerative condition brain/cord

Mix of UMN and LMN Sx:

  1. Weakness
  2. Cramps
  3. Slurred speech

Clinical patterns:

  1. Bulbar palsy
  2. ALS (amyotrophic lateral sclerosis)
  3. Progressive muscular trophy

Prognosis:
Incurable
2-3 years

Key Rx: RILUZOLE

Symptomatic Mx, e.g.:

  • SALT
  • Gastrostomy
  • Physio/splints
  • Meds for spasticity/cramps
  • NIV
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14
Q

Myasthenia Gravis

=; Sx 3; Assoc 3; Worsening 6; Dx 3; Mx 4

A

= autoimmune disorder —> muscle weakness

Sx of muscular fatigue:

  1. Ocular muscles
  2. Resp muscles
  3. 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:

  1. Anticholinesterase medication (e.g. pyridostigmine) —> short term symptoms improvement
  2. Steroids (e.g. prednisolone)
  3. Immunosuppressants (e.g. azathioprine)
  4. Occasionally thymectomy
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15
Q

Bulbar palsy

A

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

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16
Q

Pseudobulbar palsy

A

UMN

Paralysis of tongue, ‘Donald Duck speech’, dribbling, paralysis of facial muscles, brisk jaw jerk

Multiple causes, e.g. CVA, MS

17
Q

Bell’s Palsy

=; presentation; prognosis; Mx; Refer

A

= 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

18
Q

Amitriptyline

A

= 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
19
Q

Gabapentin

A

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
20
Q

Phenytoin

A

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
21
Q

Brain tumours

A

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

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