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FACEM Written > Neurology > Flashcards

Neurology Flashcards

1
Q

Stroke Mimics (10)

A
  • Structural
    • ICH - subdural or Extra-dural
    • Brian tumour
    • Brain abscess
  • Vascular
    • Aortic dissection
    • Carotid/vertebral artery dissection
    • Migraine - Vestibular
    • Giant cell arteritis
    • Polyarteritis nodosa
    • Lupus / vasculitis
    • Cerebral Venous sinus thrombosis
    • AGE
  • Infectious
    • Bell’s Palsy
    • Labrynthitis
    • Vestibular neuronitis
  • Demyelination/Peripheral Neuropathy
    • Peripheral nerve palsy
    • Demyelinating disease - MS
    • Meniere’s disease
  • Metabolic
    • Hypoglycaemia
    • Hyponatraemia
    • Wernicke’s encephalopathy
    • Todd’s paresis
  • Toxicological
    • Intoxicated states
    • Methanol → blindness
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2
Q

Seizure differential

A

ALWAYS CONSIDER PRE-ECLAMPSIA IN FEMALE!

  • Drugs - abuse / accidental / acquired / TOX / intoxication or withdrawal
  • Infection - Febrile rigors
  • Metabolic - Hypoxia, BSL, Electrolytes, Encephalopathy, Uraemia, TSH
  • Environmental - heat stroke, dysbarism,
  • Structural - Epilepsy, SOL, SAH, ICH
  • Other - pre-eclampsia, syncope, pseudoseizure
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3
Q

HINTS EXAM

A

PERIPHERAL

  • Head impulse abnormal
  • Nystagmus unidirectional
  • No veritcal skew
  • No new hearing loss

CENTRAL

  • Head impulse normal
  • Nystagmus bidirectional
  • Veritcal skew
  • May have new hearing loss
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4
Q

Rinne vs Weber

A
  • Weber test: Place the base of a struck tuning fork on the bridge of the forehead, nose, or teeth. In a normal test, there is no lateralization of sound. With unilateral conductive loss, sound lateralizes toward affected ear. With unilateral sensorineural loss, sound lateralizes to the normal or better-hearing side.
  • Rinne test: Place the base of a struck tuning fork on the mastoid bone behind the ear. Have the patient indicate when sound is no longer heard. Move fork (held at base) beside ear and ask if now audible. In a normal test, AC > BC; patient can hear fork at ear. With conductive loss, BC > AC; patient will not hear fork at ear.
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5
Q

Bulbar Palsy (7)

LMN lesion - IX, X, XII

A
  • MND
  • Syringobulbia
  • GBS
  • Polio
  • Subacute meningitis
  • Neurosyphilis
  • Brainstem CVA
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6
Q

Pseudobulbar Palsy (5)

UMN lesion - IX, X, XII

A
  • Bilateral Internal Capsul CVA
  • MS
  • MND
  • High brainstem tumour
  • Head injury
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7
Q

Bulbar vs Pseudobulbar Palsy

Compare and contrast (14)

A
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8
Q

BP Targets for CVA

A
  • AIS / TIA <220/120
  • AIS with tPA <185/110
  • ICH <180/90
  • SAH <160/90
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9
Q

Stroke Syndromes

A
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10
Q

Complete Cord Transection

A

Total loss of sensory, autnomic and motor function below level of spinal cord injury

Acute or subacute process

Trauma, infarction, haemorrhage and extrinsic compression

Flaccid paralyis

Loss of sensation with sensory level - NO sacral sparing - no perianal sensation, rectal pshincter tone or gt toe movement)

Autonomic dyfsunction

Reflexes can still occur as they are mediated by spinal levels

DTRs - may be lost, present or AbN

Autonomic dysfunction - neurogenic shock, priapism

Urinary retention

Bradycardia, hypotension, hypothermia, ileus

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11
Q

Multiple Sclerosis

A

Auto-immune demyelinating disorder of brain and spinal cord (CNS)

Relatively sparing of axons

25-30yrs, F:M 2:1, latitude

Very variable clinical presentation

  • CN - optic/trigeminal neuraliga
  • Spinal cord - transverse myelitis
    • Paraesthesia/weakness of limbs
    • Bladder urgency, constipation
    • Sexual difficulties
  • Cerebellar
  • Cerebral
    • Hemiplegia
    • Seizures
    • Neuropsych

Dx

  • 2 or more discrete episodes evolving over days to weeks
  • CSF - Oligoclonal bands (IgG)
  • MRI - demyleinating lesions
  • Nerve conduction studies

Rx

  • Acute exacerbation - IV methylpred 1g daily for optic neuritis / paraplegia / brainstem lesions
  • Inhibit progression
    • Immunosuppression - methotrexate, azathioprine, mitozantrone
    • Immunomodulators - B-interferons, glatiramer, natalizumab
  • Rx complications
    • Depression / bladder dysfunction, spasticity, tremors
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12
Q

Raised ICP

A

Normal 5-15mmHg

Raised >20mmHg

CPP = MAP - ICP

When ICP > MAP - brain doesnt get O2

Causes

  • Trauma - HI, NAI (kids and elderly)
  • Haemorrhage
  • Tumours
  • Infections
  • Extra CSF - ICH
  • CVA

Signs/Sx

  • GCS < 9
  • Fixed dilated pupils
  • Cushing’s reflex - SNS activation
    • HTN / ↑ widened pulse pressure
    • ↓ HR - bradycardia
    • ↓ RR

Mx

  • Osmotherapy
    • Mannitiol 0.5-1g/kg - target 300-320mOsmol/kg
    • Hypertonic saline - target 145-155mmol/L
  • Surgical
    • EVD
    • Evacuation of haematoma
  • Supportive
    • Head up 30 degrees
    • Avoid hypoxia, hypercarbia, HTN
    • Target PaCO2 35-45mmHg
    • Target MAP approx 80
      • CPP = MAP - ICP
      • Aim CPP > 60mmHg
    • Avoid raising ICP - prevent coughing, vomiting
    • Decrease cerebral metabolic rate
      • Sedation, paralysis
      • Treat seizures
      • Consider hypothermia
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13
Q

Motor Weakness

A
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14
Q

Motor Weakness Additional findings

A
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15
Q

Neuropathy vs myopathy vs NMJ weakness

A
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16
Q

Bedside Pulmonary Function Tests - GBS and MG

A

25% with motor weakness due to GBS or MG will need intubation

Consider 20/30/40 rule

FVC < 20mls/kg

MIP < 30cm H2O

MEP < 40cm H2O

Only FVC useful

  • likely to need ETT when FVC < 10-15mls/kg

Rule out other causes of respiratory failure

Do NOT chase autonomic dysfunction

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17
Q

Myaesthenia Gravis

A

Post-synaptic autoimmune disorder

Younger females and older men (bimodal)

Sx

Descending motor power loss

Bulbar symptoms, Ptosis

Sensation, reflexes and pupillary reflexes should be spared

Fatigable and fluctuate

DDx

Lambert-Eaton Syndrome

  • pre-synaptic Ca channels
  • Improves with activity

Botulism

  • Impaired pupillary responses

Ix

Ice test - ice pack over eye for 3 minutes improves ptosis and upward gaze

Tensilon test - IV edrophonium + monitor for improving ptosis and diplopia

Tips

Avoid sux - unpredictable response

Lower doses of roc (0.5mg.kg) due to impaired receptor response

Rx

Physostigmine

Immunosuppression

IVIG

Plasmaphoresis

Treat underlying cause

Electrolyte replacement

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18
Q

MG - drugs to avoid

A

Aminoglycosides

Fluoroquinolones

BB

MgSO4

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19
Q

SAH - World Federation Neurosurgeons Scale

A

Most important porgnosticating factors are level of consciousness + level of hemiparesis

Grade I (45%) = GCS 15 + NO motor deficit

Grade II (22%) = GCS 14-13 + NO motor deficit

Grade III (3%) = GCS 14-13 + motor deficit

Grade IV (17%) = GCS 12-7 +/- motor deficit

Grade V (14%) = GCS 6-3 +/- motor deficit

20
Q

SAH - Hunt and Hess classification

A
21
Q

SAH - Fisher Scale

Radiological

Risk of vasospasm

A
22
Q

SAH Risk Factors and Complications

A

Risk Factors
HTN
Smoking
F>M
Previous SAH / Known Aneurysm
CT disorders - PKD, Marfan’s, Ehler’s Danlos

Complications
Immediate
* Neurological deficit
* MI
* APO
Delayed
* Rebleeding
* Vasospasm
* Prevented with nimodipine 60mg q4-6hr PO/NG 1/52
* Hydrocephalus
* Usually communicating
* Hyponatraemia
* Seizures

23
Q

SAH sites

A
24
Q

Seizure + fever differentials

A

Epilepsy

CNS - meningitis, encephalitis, cerebral abscess

Raised ICP - SOL, cerebral oedema, blocked VP shunt

Febrile seizure

Toxic ingestion

25
Q

Status Epilepticus Mx Options

A

Def: seizure > 5 minutes duration OR 2 or more seizures without full recovery in between

1st line

Midazolam

0.15mg/kg IV/IM

2nd line

Levetiracetam 40mg/kg

Valproate 40mg/kg up to 3g

Phenytoin 20mg/kg

3rd line

Phenobarbitone 20mg/kg

Propofol 2.5mg/kg, infusion @ 1-3mg/kg/hr

Thiopentone 2-5mg/kg, infusion @ 1-4mg/kg/hr

Ketamine 1-2mg/kg

Pyridoxine 100mg IV in children < 6mo with refractory seizures

26
Q

Seizure related Complications

A

Airway - Hypoxia, aspiration

Injury - fractures, Avulsions of bone/tendons, tongue laceration, posterior shoulder dislocation

Metabolic - hypoglycaemia, hyperthermia, lactic acidosis, rhabdomyolysis

CNS - Todd’s paresis, Neuronal damage (prolonged)

27
Q

LP Contra-indications

A

Absolute

  • GCS <8 or deteriorating/fluctuating level of consciousness
  • Signs raised ICP
  • A bulging fontanelle + raised ICP

Relative

  • Septic shock or haemodynamic compromise
  • Significant respiratory compromise (eg apnoeas in a baby)
  • New focal neurological signs or seizures
  • Seizure within previous 30 min +/- normal conscious level has not returned following a seizure
  • INR >1.5 or platelets <50 or child on anticoagulant medication

Complications

  • Failure to obtain a specimen/traumatic bloody tap (common)
  • Post-dural puncture headache (uncommon) 5-15%
  • Transient/persistent paraesthesia/numbness (very uncommon)
  • Respiratory arrest from positioning (rare)
  • Infection introduced by needle causing meningitis, epidural abscess or osteomyelitis (very rare)
  • Spinal haematoma (very rare)
  • Brain herniation (extremely rare in the absence of contraindications above)
28
Q

CVA + Speech deficits

A

Speech area Left side of brain

  • 99% right handed
  • 70% left handed

L hemisphere → dyphasia

R hemisphere → neglect, visuo-spatial + cognitive problems

Wernicke’s area = posterior first temporal gyrus →expressive dysphasia

Broca’s = posterior third frontal gyrus

→ receptive dysphasia

29
Q

Diplopia

A

Critical

  • Basilar artery thrombosis
  • Botulism
  • Basilar meningitis
  • Aneurysm

Emergent

  • Vertebral dissection
  • MG
  • Wernicke’s encephalopathy
  • Orbital Apex syndrome / Cavernous sinus process

Urgent

  • Brainstem Tumour
  • Miller-Fischer syndrome
  • MS
  • Thyroid myopathy (Grave’s)
  • Ophthalmoplegic migraine
  • Ischaemic Neuropathy
  • Orbital Myositis
  • Orbital Apex Mass
30
Q

Internuclear ophthalmoplegia

A

Def = inability to perform conjugate lateral gaze

Pathophysiology

Damage to the interneuron (level of MLF) between 2 nuclei of CN III and CN VI at the level of the midbrain or pons

Mechanism:

Demyelination

Ischaemia - basilar artery supply

Neoplastic

Inflammatory

31
Q

CN VII Palsy

A

Peripheral

  • Infective - HSV, HZV, CMV, EBV, AOM
  • Trauma - base skull
  • Neurological - MS, GBS, mononeuropathy
  • Neoplastic - post fossa, parotid
  • Autoimmune - Sjogren’s
  • HTN + eclamplsia
  • Melkersson’s syndrome

Central

  • CVA
  • Intra-cranial tumours
  • MS
  • HIV
  • Vasculitides
32
Q

Conus medullaris vs Cauda Equina Syndrome

A
33
Q

Dermatomes

A
34
Q

Myotomes

A

C4: shoulder shrugs
C5: shoulder abduction and external rotation; elbow flexion
C6: wrist extension
C7: elbow extension and wrist flexion
C8: thumb extension and finger flexion
T1: finger abduction
L2: hip flexion
L3: knee extension
L4: ankle dorsiflexion
L5: big toe extension
S1: ankle plantarflexion
S4: bladder and rectum motor supply

35
Q

Incomplete Cord Syndromes

A

Sensory - Ascending Tracts
Anterolateral tract
- fibres cross at level of input
- sacral > trunk > cervical (lateral to medial)
Anterior spinothalamic tract (light touch and pressure pathway)
Lateral spinothalamic tract (pain and temperature pathway)

Dorsal Columns
Touch, pressure, vibrations, proprioception
Cross at medulla
Sacral fibres medial, cervical fibres lateral

Motor
Lateral Corticospinal tract (80%)
Distal limb muscles
Fine motor
Fibres corss in spinal cord
Cervical medial, lumbar lateral

Ventral Corticospinal Tract (20%)
Axial and proximal limb muscles
Postural and gross limb movements
Descends ipsilaterally and does not cross until level of synapse with LMN

36
Q

Anterior Cord Syndrome

A

Common following diving injury, flexion injuries
Injury:
- bonu impaction into cord
- anterior spinal artery injury or thrombosis
Symptoms
Loss of motor, pain and tmeeprature sensation below lesion
Light touch and proprioception preserved
Prognosis: poor

37
Q

Central Cord Syndrome

A
38
Q

Brown-Sequard Syndrome

A
39
Q

Head Injury Risk Comparison

A
40
Q

Head injury High Risk Features

A
41
Q

SAH CT head features

A
42
Q

Ix SAH

A

Key points
CT within 6 hours effectively rules out diagnosis
LP may be useful when presentation is delayed
- CSF blood is the hallmark feature of SAH, but may be difficult to distinguish from a traumatic tap
- CSF xanthochromia is a more specific finding for SAH, however takes >12 hours to manifest
- Xanthochromia from a SAH is nearly always accompanied by more than 1000 RBCs in the CSF (usually > 10000)

Traumatic Tap vs SAH
Traumatic tap occurs in 20% of LP’s
Traumatic tap and SAH may co-exist
None of the following criteria are 100% accurate
- Normal CSF CSF pressure
- Clearing of blood in tubes 1-3 / marked decrease in RBC count in tubes 1 to 3
- Proportion of white cells to red cells the same as in blood - i.e. RBC:WBC = 500 - 1,000:1
- Clot formation
- No xanthochromia

43
Q

DDx Thunderclap Headache

A

More common:
1. SAH (subarachnoid hemorrhage)
2. RCVS (reversible cerebral vasoconstriction syndrome)
3. Acute hypertensive crisis
4. Cervical artery dissection (carotid or vertebral)
5. CCVT (cerebral venous thrombosis)
6. ICH (intracerebral hemorrhage)
7. Benign Post Coital HA
8. Benign post exertional headache
9. Pituitary apoplexy
10. Ischemic stroke
11. Primary thunderclap headache.

Rarer causes: (LaHue 2021)
Spontaneous intracranial hypotension.
Cerebral vascultiis.
Sphenoid sinusitis.
Aqueductal stenosis.
Colloid cyst of the third ventricle.
Giant cell arteritis.
Cardiac cephalgia (pain referral related to myocardial ischemia).

44
Q

Cervical Artery DIssection

A
45
Q

Spinal vs Neurogenic Shock

A
46
Q

Vertigo Causes

A
47
Q

Peripheral vs Central Vertigo

A

FACEM Written (34 decks)

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