Neurology Flashcards
List the main causes of epilepsy.
Remember *VITAMINS*
Vascular (Ischaemic/Haemorrhagic Stroke)
Infection (Meningitis/Encephalitis/Brain Abscess)
Trauma / Toxins (Amphetamine overdose/Alcohol withdrawal/ Isoniazid (TB drug)
Autoimmune (CNS vasculitis or SLE)
Metabolic (Hyponatraemia/Hypocalcaemia/Hypo or Hyper glycaemia/ Hyperthyroidism/ Uraemic Hepatic and Wernickes Encephalopathy)
Idiopathic (epilepsy)
Neoplasm
Syncope
3 signs of cerebellar disease
Ataxia
Dysarthria
Nystagmus
ADN or DNA to remember
or remember DANISH
Disdiadokinesia
Ataxia (wide set gait)
Nystagmus
Intentional tremor
Slurred speech (dysarthria)
Hypotonia
Parkinson’s disease signs
Tremor (rolling pin - 3-5Hz)
Bradykinesia
Rigor/rigidity
Postural instability
Facial drooping
3 forms of management for MND used to slow the progression of the disease.
Riluzole
Edaravone (not licenced yet in uk)
NIV
Myasthenia gravis is associated strongly with which other condition?
Thymoma (tumours of the thymus)
Name the three antibodies used for diagnosis of Myasthenia Gravis?
Ach - R
MuSK (muscle specific kinase antibodies)
LRP- 4 (lipoprotein related protein)
Management options for myasthenia gravis.
Medical:
Reversible Acetylcholine esterase inhibitors (e.g neostigmine / pyridostigmine)
Immunosuppressives (e.g Prednisolone or azathioprine)
If this fails monoclonal antibodies can be a treatment option (e.g rituximab)
Surgical:
Thymectomy
What is the management options for generalised seizures?
(a) Generalised
1st Line : Sodium Valproate (beware teratogenic) - accentuates GABA activity
2nd Line: Carbamezapine / Lamotrogine both inhibit sodium channels and thus depolarization and glutamate release.
What is the management options for Focal Seizures?
(b) Focal
1st Line : Carbamezapine or Lamotrigine
2nd Line: Sodium Valproate or Levotiracetam
What are the side effects of Sodium Valproate in the treatment of epilepsy?
Teratogenic (30-40% risk) : To be completely avoided in women of child bearing age.
Liver damage and hepatitis (Raised lfts)
Hair loss
Tremor
What is the class and side effects of carbamezapine?
Na channel antagonist - prevent action potential and glutamate release.
Side effects:
Aplastic anaemia
Agranulocytosis
CYP450 lots of interactions - reduce effectgveness of contraceptives
Erythema multiforme
Arrhythmias
Hepatitis
*Not to be used in Asian patients as increased risk of SJS*
What side effect is to be worried about in the Na channel blocker lamotrigine?
Serious skin rashes:
Steven - Johnson and Dress Syndrome (both life threatening).
What side effect is common to all types of anti-epileptic drugs and can occur as soon as a week into medication?
Suicidal Thoughts and behaviour change
How does guillain-barre syndrome present?
Ascending weakness
Loss of peripheral sensation
Peripheral Pain or neuropathic pain
Facial weakness
Reduced Reflexes
Preceding infection (Campylobacter/Mycoplasma/EBV) followed by a Motor dominant peripheral neuropathy and areflexia is typical of guillain-barre syndrome.
Remember carl in bed couldnt move his arms when examining him and he was completely areflexic
Which criteria is used to diagnose GBS? And what are the two main components.
Brighton Criteria:
Nerve Conduction Studies Lumbar Puncture (expect high protein but normal cell count and glucose).
*High protein due to the presence of antibodies*
What is the management of guillan-barre syndrome?
First line: IV immunoglobulins
Second line: Plasma exchange
Most important is respiratory support and VTE prophylaxis as the leading cause of death in GBS is pulmonary embolism due to immobilisation in hospital.
Prognosis is good with 80% of patients making a full recovery.
Most important complication of GBS
Respiratory: PE and pneumonia (from lack of ventilation)
4 characteristics of UMN lesion
Hypertonia
Hyperreflexia / upgoing plantar
Spasticity
Weakness
4 characteristics of LMN lesion
Reduced reflexes - mute or downward plantar
Hypotonia
Wasting and Fasciculations
Weakness
Causes of polyneuropathy
ABCDE and infections
Alcohol/Autoimmune (ex. GBS)
B12 / Thiamine deficiency
Carcinoma (paraneoplastic syndrome - LE) /Charcot-Marie-Tooth disease (comprises genetic causes of neuropathy) and Chronic Kidney Disease (CKD)
Diabetes/Drugs (TB drugs - isoniazide / Metronidazole/Nitrofurantoin/ amiodarone)
Every Vasculitis (RA/SLE/Polyarteritis nodosa)
And Infections (Herpes Zoster/ HIV/ Lymes/ Syphillis and leprosy).
How does the distribution of nerve weakness differ between GBS and Myasthenia gravis/Labert-Eaton myasthenic syndrome?
GBS - Ascending (i.e distal to proximal)
Myasthenia Gravis (post synaptic AChR) and Lambert-Eaton Myasthenic syndrome (Pre-Synaptic Ca channels) (Both Proximal muscle wasting)
However MG gets worse on physical exertion (ex. bilateral ptosis on sustained upward gaze)
whereas
LEMS improves throughout the day with physical activity
Lambert - Eaton Myasthenic Syndrome is a paraneoplastic syndrome arising from ____ Lung cells and uses antibodies to target ___ channels on the ____ synaptic membrane.
Small cell
Ca channels
Pre
What are the 4 first line treatments for neuropathic pain?
Remember Mnemonic *A Dying GP”
Amitryptilline (TCA - Increase serotonin and NE in synaptic cleft)
Duloxetine (SNRI)
Gabapentin (Anticonvulsant - mimics gaba signalling but does not bind to GABA receptors)
Pregabalin (Anticonvulsant - same as above)
What does the mnemonic ‘SNOOP’ stand for when assessing red flags for headaches?
The mnemonic “SNOOP”, without the “D-O-double G”, summarizes some of the red flags.
“S” is for systemic symptoms like fever or weight loss.
“N” is for neurological symptoms, like weakness, sensory deficits, or vision loss.
The first “O” is for a new or sudden onset headache.
The second “O” is for other associated conditions, like trauma.
The “P” stands for progression or pattern, such as a headache that is worsening in severity or frequency.
**Remember COCP can also cause headache**
The mnemonic VIVID can be used to remember the sinister causes of headache. What does it stand for?
Vascular - Extradural or Subdural Hematoma/ Subarachnoid/ Cerebral venous sinus thrombosis/ cerebellar infarct.
Infection - Encephalitis/Meningitis
Vision threatening - Giant cell arteritis/ Glaucoma/ Cavernous sinus thrombosis/ Pituitary apoplexy (tumour outgrows blood supply and bleeds)
Intracranial pressure: SOLs: Neoplasm/ Brain abscess/ Cyst/ Cerebral oedema (trauma/altitude), hydrocephalus, malignant hypertension/ IIH/ Viagra or GTN
Dissection - Aortic/ Carotid/ Vertebral
Red Flags to look out for in Traumatic Brain Injury
Impaired consciousness
Impaired pupil dilatation
Focal neurological deficit or visual disturbances
Seizure or amnesia
Significant headache / nausea or vomiting
What is the abortive and prophylactic treatment of migraine?
Abortive
Mild :
- NSAIDs/Acetaminophen
Moderate/Severe:
- Triptans (Serotonin/5-HT agonist. ex Sumatriptan)
- Metaclopramide/Prochlorperazine (Dopamine antagonists) - for nausea and vomiting
- Aspirin
Prophylactic: (only useful if migraines are very frequent such as 2 weeks, and only effective 50% of the time)
1st line:
- Beta Blocker/ Candesartan (good side effect profile)/ Amitryptilline
2nd line:
- Anti-epileptics (ex. topiramate - teratogenic can cause cleft lip and palate and valproate) - not to be used in female of child bearing age.
Acupuncture Vitamin B2 (Riboflavin) supplementation
What is the prophylactic and abortive treatment of cluster headaches?
Abortive:
Oxygen (at least 12L/min) and/or Triptans (Ex sumatriptan 6mg subcutaneously or intranasally)
Prophylactic:
1st line: Verapamil (Ca Channel Blocker)
2nd line: Lithium
Prednisolone
What is the recommended treatment for someone with a tension headache?
Acetaminophen/NSAIDs
What are the 3 classical features of Cushing’s triad and what do they suggest?
Bradycardia
Widened pulse pressure (or high systolic pressure)
Altered respirations (irregular breathin)
Suggest raised intracranial pressure.
What is Cushing’s Ulcer?
A Peptic ulcer caused by raised intracranial pressure and resulting overstimulation of the vagus nerve. This causes increased gastric acid secretion and a resulting ulcer
Name 5 complications of Sub-Arachnoid Haemorrhage.
Vasospasm (hence nimodipine)
Hyponatraemia
Seizures
Hydrocephalus
Re-Bleeds (haemorrhage)
Name risk factors for Sub-Arachnoid Haemorrhage?
Smoking / Diabetes/ FH/ Alcohol/ Female/ Polycystic Kidney Disease / Connective Tissue Disorders (ex. Marfan’s/Ehler’s Danlos syndrome).
Name the two main causes of SAH?
Aneurysm (80%)
Stroke (5%)
The ____ artery runs through the ____ fissure and is responsible for supplying the outer portions of the brain.
Middle cerebral artery
Sylvian
Name the two key phrases used to describe a 6th Cranial Nerve or Abducens palsy.
Internuclear Ophthalmoplegia
and
Conjugate Lateral Gaze Disorder
____ sign is a electrical shock down the spinal cord and into the limbs when flexing the neck and indicates disease of the cervical spinal cord and the ____ column in particular as a result of stretching the demyelinated cord.
Lhermittes
Dorsal Column
Relapses of MS can be treated using which steroid and at what dose?
Methylprednisolone
500g orally for 5 days
Small cell lung cancer paraneoplastic syndrome can be remembered by the mnemonic SCLC
SiADH (Hyponatraemia)
Cushing’s Syndrome
Lambert-Eaton Myasthenic Syndrome (proximal muscle weakness improves with exercise)
What drug is classically used to treat Lambert- Eaton Myasthenic Syndrome?
Amifampridine - potassium channel blocker on pre-synaptic membrane - lengthens action potential
IV immunoglobulins
Steroids
Plasma exchange are also options
A Quadrantanopia occurs when there is a lesion in the ____ on the contralateral hemisphere. This leads to a superior quandrantanopia when the lesion is in the _____lobe and an inferior quadrantanopia when the lesion is in the _____ lobe.
Optic Radiation
Temporal
Patrietal
Remember the mnemonic “PITS”
Parietal Inferior
Temporal Superior
Which measure is used to monitor respiratory function in Guillain-Barre syndrome?
FVC - Maximal exhalation following inhalation
- Extremely important to monitor in patients with GBS as they can develop respiratory failure and ultimately arrest. Monitoring FVC gives time to establish prophylactic intubation etc.
In patients with ____% carotid stenosis and symptoms a _______ is recommended.
70
Carotid Edarterectomy
List a number of migraine triggers
Stress
Bright lights
Strong smells
Foods (ex. Chocolate/cheese/caffeine)
Abnormal sleep patterns
Menstruation (NSAIDS - mefanamic acid and triptans most suitable therapy)
Dehydration
Trauma
Physical overexertion
Which investigations are needed to rule out a sub-arachnoid haemorrhage?
1st line: CT Head (extremely sensitive within 6 hrs of insult)
2nd Line: Lumbar puncture (12 hours later) to test for xanthocromia - contraindicated if raised ICP.
CT angiogram (digital subtraction angiography or DSA scan is the specific type) if both of these are negative. - gold standard for detection of ruptured aneurysm
Which drug can be used in the treatment of an extradural haematoma?
Mannitol (Osmotic diuretic) - reduces ICP.
What is Ramsey-Hunt syndrome?
Unilateral facial nerve palsy with vesicular rash around the ear canal and pinna. Caused by a reactivation of Herpes Zoster Virus lying dormant in the CN7 root ganglion.
What are the treatment options for Ramsey-Hunt syndrome?
Prednisolone
Aciclovir
and lubricating eye drops!
“Champagne Bottle” legs is characteristic of which inherited autosomal _____ polyneuropathy?
Charcot-Marie Tooth disease (Type 1)
Dominant
What is the classical triad of Miller-Fisher Syndrome?
Ataxia
Ophthalmoplegia
Areflexia
Remember that GBS starts distally and works its way uo - Miller fisher starts proximally in the eyes.
What is the distinguishing factor bewteen an L5 radiculopathy (root lesion) and a common peroneal nerve palsy?
The tibial nerve is responsible for foot inversion and so is spared in common peroneal nerve palsy.
What Investigations should be ordered in a patient suspected to have Myasthenia Gravis?
Antibodies (Ach R / MuSK / LRP4)
CT chest - (60% thymus hyperplasia/12% thymoma)
Spirometry FVC - ( if < 15ml/kg - consider mechanical ventilation)
The clinical diagnosis of Optic Neuritis consists of the classical triad of _____
Visual loss
Periocular pain
Dyschromatopsia (Ex. Red desaturation - colours appear less red)
The most common cause of a surgical third nerve palsy is an aneurysm in the ________ artery.
Posterior Communicating Artery (PCOM)
A third nerve palsy causes: ptosis (due to impaired innervation to levator palpebrae superioris) and a ‘down and out’ pupil (due to unopposed activation of lateral rectus and superior oblique).
In a ‘surgical’ third nerve palsy there is pupil involvement. This is because the parasympathetic (constrictive) fibres run on the outside of the nerve. External compression will impair function of these fibres, causing pupil dilation.
The most common cause of a surgical third nerve palsy is a posterior communicating artery aneurysm due to their proximity to eachother. Other causes include cavernous sinus lesions (infection, thrombosis, tumour infiltration)
In a medical 3rd nerve palsy (often seen in diabetes), the pupil is spared as the parasympathetic nerves are unaffected as the primary pathology is due to infarction of the blood supply to the oculomotor nerve.
Ipsilateral cranial nerve palsy and contralateral limb weakness is suggestive of _____ syndrome
Weber’s syndrome
_____ Diuretics are associated with _____ toxicity
Loop
Ototoxicity
Acoustic Neuroma (Schwannomas) usually present with ____ hearing loss and progress to involve cranial nerves _____, ____, ____ and ____. Can also present with vertigo and tinnitus.
There can also be an _____ reflex.
Unilateral
5, 6, 9, 10
Absent Corneal Reflex
Cognitive impairment and visual hallucinations are suggestive of which parkinson plus syndrome?
Lewy-body dementia
_____ is the most common cause of _____ Haemorrhage
Hypertension
Intracerebral/parenchymal
What are the side effects of Topiramate?
Weight loss
Renal stones
Cognitive and behavioural changes
_____ classification system is used to determine the severity of a spinal cord lesion.
Frankel
The ____ criteria is used to assess the risk of multiple sclerosis when looking at an MRI scan.
McDonalds
Remember that MRI is first line in MS and looking for oligoclonal bands on lumbar puncture is reserved for atypical cases.
_______is a syndrome caused by compression of the _________ nerve of the thigh underneath the inguinal ligament. It is characterised by shooting pains along the outer aspect of the upper leg.
Meralgia paresthetica
Lateral cutaneous
Neurofibromatosis type 1 is associated with _____ tumours whereas NF type 2 is associated with ____
Optic gliomas
Meningiomas
______ is the preferable intervention for a subdural haematoma
Burr-hole craniostomy
Name the classification system used to determine risk of stroke in patients in A+E.
Stroke is likely if patients score anything above ____
ROSIER
Stroke is likely if patients score anything above 1
Name 5 signs of a base of skull fracture
Raccoon eyes
Battle’s sign
Haemotympanium
CSF Otorrhoea
CSF Rhinorrhoea
Halo ring (may appear on the pillow - bullseye of red (blood) with CSF surrounding it)
What time limit cut off (from initial onset of symptoms) is there to give a patient thrombolysis and thrombectomy respectively?
4.5 hrs for Thrombolysis
6 hrs for Thrombectomy
If bilateral acoustic neuroma then think ____
Neurofibromatosis type 2
Ischaemic stroke accounts for ____% of strokes and can be seen as an area of ______ attenuation/density on a CT scan.
85%
Hypoattenuation
Remember non-contrast needs to be used as contrast can be mistaken for blood.
Blood is hyperdense and indicates haemorrhagic stroke.
Areas of hypoattenuation indicated underperfusion and thus Ischaemic stroke
Haemorrhagic stroke accounts for ____ % of strokes and can be seen as an area of ______ attenuation/density on a CT scan.
15%
Hyperattenuation
Chronic stroke management can be remembered using the mnemonic _____
HALTSS
Hypertension
Antiplatelet/Anticoagulant - 75 mg clopidogrel daily unless patient has AF - Warfarin or DOAC (apixaban/rivaroxaban)
Lipid lowering - Statin (atorvastatin 20-80mg)
Tobacco - Smoking cessation
Sugar control - manage underlying diabetes
Surgery - > 70% of carotid artery is stenosed on doppler - consider endarterectomy.
Don’t forget! - occupational therapists/physiotherapists/neuro rehab/ and speech and language teams.
What are the principles of managing an acute haemorrhagic stroke.
Refer to neurosurgery and ICU teams and keep blood pressure low.
What are the principles of acute management of stroke?
ABCDE
CT head - if negative - treat as ischaemic stroke
Thrombolyse if no contraindications and if onset of symptoms < 4.5 hrs ago with IV alteplase.
If not within 4.5hr window give 300 mg aspirin for 2 weeks and then 75mg clopidogrel once daily.
If large vessel thrombus on CT consider thrombectomy.
What are the contraindications to Thrombolysis?
- *Hypertension** (>185/110)
- *Anticoagulation** (heparin within last 48hrs)
- *Recent head Trauma or previous ischaemic stroke** (< 3 months
- *GI haemorrhage** (<21 days) or other site of haemorrhage
- *Recent surgery** (< 14 days)
- *High INR** (> 1.7 is absolute indication not to thrombolyse)/PTT >15 secs / Platelets < 100,000)
Risk Factors for Stroke
Age
Male sex
Hypertension
Smoking
Diabetes
Atrial fibrillation
Family history
High cholesterol
Obesity
Oestrogen therapy
Migraine
In a subdural haematoma blood is hypodense (black) if the bleed is ____. The bleed will appear hyperdense (white) if ____.
Chronic (bleed there for 1-2 weeks - blood is broken down and thus less dense)
Acute (remember blood clots and is like jelly and so quite dense)
Encephalitis is usually of ____ aetiology, with _____ as the most common culprit
viral
herpes simplex virus type 1
_____ scoring system is used to grade cervical myelopathy
mJOA - modified japanese orthopaedic association
What is the first line treatment for optic neuritis?
IV Methylprednisolone (given orally can increase risk of a second episode)
Benign positional paroxysmal vertigo (BPPV).
The presence of debris/otoliths in the _____ of the ears causes vertigo upon head movement.
The _____ is diagnostic, where certain movements of the head causes fatiguable _____.
______ manoeuvres treat BPPV by clearing the debris.
semi-circular canals
hallpike manoeuvre
nystagmus
Epley
In any major bleed on warfarin, it is necessary to ____ warfarin and start ____ 5mg intravenously , and _____.
Stop
Vitamin K
Prothrombin complex concentrate
____ is the first line treatment for benign essential tremor (BET)
Propanolol
What is the classical triad of Huntingtons Disease?
Autosomal Dominant inheritance
Choreathetosis (chorea or involuntary jerk like movements)
Dementia (and death in 10 yrs following diagnosis- usualyl 40’s)
Loss of ____ and ____ sensation in a ‘cape-like’ distribution is characteristic of which pathology?
Pain
Temperature
Syringomyelia
In status epilepticus ____mg lorazepam is given intravenously.
4mg
Which have a better prognosis, Ischaemic or haemorrhagic strokes?
Ischaemic
A total anterior cerebral infarct (TACI) affects the _____ AND the ____ arteries and causes which 3 distinct symptoms.
Anterior and Middle cerebral arteries
Hemiparesis
Homonymous Hemianopia
Higher cortical dysfunction
PACI affects just one of the arteries and only gives two of the 3 symptoms.
Lacunar only gives one focal sign.
Focal epilepsy in the ____ lobe that causes a stroke like weakness is called ____ paralysis.
Frontal lobe
Todd’s paralysis
Alien limb and myoclonus are characteristic features of which parkinson plus syndrome?
Corticobasal degeneration
____ instability gait, vertical gaze paresis and a “surprised look” are characteristic features of which parkinson plus syndrome?
Progressive supranuclear palsy
Alpha synuclein is the protein responsible for which parkinson disorders?
Parkinson’s disease
Lewy body dementia
Multiple system atrophy
The Tau protein is responsible for which parkinson plus syndromes?
Progressive supranuclear palsy
Corticobasal degeneration
Beta amyloid build up in the brain parenchyma is associated with which pathology?
Alzheimers disease
Carbidopa and _____ are examples of ______ that prevent the breakdown of levadopa (synthetic dopamine).
Benserazide
Peripheral decarboxylase inhibitors
Without peripheral decarboxylase inhibitors 99% of levadopa would be broken down by peripheral decarboxylase enzymes before it reached the target site (i.e the brain)
Dopamine cannot cross the BBB and that is why we give it and not Levadopa.
A pseudobulbar palsy can be thought of as an ‘____ motor neurone’ lesion of ____ and ____.
upper
speech
swallow
Foot ____ and Hip _____ are impaired in L5 radiculopathy.
Inversion
Abduction
____ herniation is the most common cause of L5 radiculopathy (root lesion) and can present with failure of both inversion/eversion and loss of sensation in the L5 dermatome and sciatica like shooting pain.
Lumbosacral disc herniation
Automatisms (eg. lip-smacking); déjà vu or jamais vu, emotional disturbance (eg. sudden terror); olfactory, gustatory, or auditory hallucinations are characteristic of which focal seizure ________.
Temporal lobe (most common focal seizure - around 60%).
Hippocampus is in the temporal lobe and that is why you get the deja vu automatisms.
Motor features such as Jacksonian features, dysphasia, or Todd’s palsy are suggestive of a ____ focal seizure
Frontal lobe
Sensory symptoms such as tingling and numbness; motor symptoms - due to spread of electrical activity to the pre-central gyrus in the frontal lobe are suggestive of focal seizures arising from the ______.
Parietal lobe
Visual symptoms such as spots and lines in the visual field can often precede a focal seizure arising from the ____ lobe
Occipital lobe
The groggy post-ictal phase following a seizure is usually quite severe and is _____ to epilepsy. Urinary incontinence and tongue biting are _____ features of epileptic seizures but non-specific.
Specific
Sensitive
Risk factors for haemorrhagic stroke
Male
Age
Hypertension
Anticoagulation
Coagulopathies/haemophilia
Cerebral Amyloid Angiopathy (amyloid plaque grows into and weakens vessel wall)
Sympathomimetic drugs (cocaine/amphetamine)
The propagation of electrical activity throughout the primary motor cortex resulting in a spread of motor symptoms is known as _____ march.
Jacksonian
What are the common drugs that induce CYP450 enzyme activity?
Remember mnemonic *CRAP GPS induce me to rage*
Carbamezapine
Rifampicin
Alcohol (chronic)
Phenytoin
Griseofulvin
Phenobarbital
Sulfonylureas
Single episode of MS is referred to as _____
Clinically isolated syndrome
____ and ____ are two key investigations for MS
MRI Lumbar puncture (Oligoclonal bands)
What is the significant side effect that may occur with prolonged use of dopamine agonists?
Pulmonary fibrosis
Give 4 examples of dopamine agonists used in parkinsons disease?
PCR bro
Bromocriptine
Pergolide
Cabergoline
Ropinirole
____ is an example of a comt inhibitor.
Entacapone
What are the two management options for Benign Essential Tremor (BET)?
Propanolol Primidone (barbiturate)
Carbamazepine worsens _____ and _____ seizures.
Absence
Myoclonic
Pain following a shingles rash is known as ______
Post-herpetic neuralgia
1st line option in the treatment of trigeminal neuralgia is _____
Carbamezapine
What are the most common brain metastases?
Breast
Lung
Renal cell carcinoma
Melanoma (40%)
Colon
A ___ ( ___ ) test is a specific test used to to diagnose Myasthenia Gravis.
Tensilon
(Edrophonium - rapid acting reversoble Ach esterase inhibitor - improves symptoms in nerve conduction studies)
Wallenberg syndrome can be characterised using the mnemonic ______.
DANVAH
Dysphagia
Ataxia (ipsilateral)
Nystagmus (ipsilateral)
Vertigo
Anaesthesia (ipsilateral facial numbness and contralateral loss of pain on the body)
Horner’s syndrome (ipsilateral too)
The ankle reflex is typically ____ in a patient with foot drop
Present
Most common cause of a “Surgical” 3rd nerve palsy (pupil is dilated due to compression of the parasympathetic supply) is a _____
POCM aneurysm
“posterior communicating artery”
Can also be because of a cavernous sinus lesions (thrombosis/tumour/infection)
Orbital cellulitis presents similarly to preseptal cellulitis, but there are 3 important features that set it apart:
Painful eye movements
Diplopia
Visual impairment
There is a strong association between Giant Cell Arteritis and which other condition?
Polymyalgia Rheumatica
Name 4 complications of Burns Injury.
Respiratory Compromise/Failure
Fluid loss and electrolyte imbalances
Hypothermia
Compartment syndrome
What are the 3 S’s that are central causers of Horner’s Syndrome?
Stroke
Syringomyelia
Multiple Sclerosis
There are 3 key questions to assessing red eye:
Is acuity affected?
Is the eye painful?
Are pupil reflexes affected?
Diagnoses to rule out:
Acute angle-closure glaucoma
Anterior uveitis
Scleritis
Acute angle-closure glaucoma
Patients typically present as systemically unwell with nausea and headaches.
In some, but not all, there is severe ocular pain associated with blurred vision and haloes around lights.
The pupil is typically in a fixed-dilated position.
Acute angle-closure glaucoma is an emergency, patients must be referred to ophthalmology immediately to prevent the progression of visual loss.
Anterior uveitis
Patients typically present with red eye, pain, blurred vision and photophobia.
Patients also commonly note increased lacrimation from the affected eye.
The pupil may be irregular due to adhesions between the lens and iris (termed synechiae).
Typically, conjunctival injection is concentrated around the junction of the cornea but this may not always be the case in practice.
Scleritis
Severe inflammation of the sclera, patients complain of severe pain in the orbit and pain on eye movement.
~50% of patients are systemically ill with associated rheumatological conditions such as rheumatoid arthritis or granulomatosis with polyangiitis, so look for systemic symptoms.
Episcleritis features
Inflammation of the episclera (the layer underneath the conjunctiva).
Patients present with red eye and tenderness over the inflamed area.
Differences between Episcleritis and Scleritis:
In episcleritis pain is often mild, severe pain should raise the suspicion of scleritis. Also, scleral vessels do not move or blanch whereas episcleral vessels do when pressed with a cotton bud.
Conjunctivitis
Inflammation of the conjunctiva which can be categorized into allergic, viral and bacterial.
Patients present with itchy, irritated eyes that lacrimate excessively.
The type of discharge depends on the cause but patients often complain of eyelids sticking together.
Visual acuity and pupillary reflexes are intact.
Subconjunctival haemorrhage
Alarming but harmless haemorrhage into the space between the conjunctiva and the sclera due to rupture of a fragile blood vessel.
Common causes include coughing, sneezing and eye trauma but ask about warfarin and check blood pressure.
A ____ ulcer is pathognomonic of ______ infection and may cause a painful red eye. Treatment is with ____.
Dendritic (branching)
Herpes Simplex virus
Topical antivirals
It is caused by reactivation of Herpes Simplex, which is latent in the trigeminal nerve. Risk factors for reactivation include systemic illness and immunosuppression. A dendritic ulcer is pathognomonic.
Topical steroids should be avoided.
_____ Infection will present with a classic ‘cottage cheese’ retinitis.
Cytomegalovirus (CMV)
A left middle cerebral stroke causes which ocular defect?
A right homonymous hemianopia (remember both left and right eye affected)
Acute anterior uveitis is associated with HLA-B27 related conditions, such as:
Ankylosing spondylitis
Inflammatory bowel disease
Reactive arthritis.
And Diabetes
The link between uveitis and diabetes mellitus is not fully understood, but it is clear that there is some immunoregulatory association, with diabetics more likely to suffer from uveitis than non-diabetics.
Most cases of _____ conjunctivitis will self-resolve after 1/2 weeks, therefore, a watch and wait approach should be used. Patients should be educated on good hygiene to avoid spreading (avoid sharing towels/flannels, rubbing eyes, contact lens use).
If the infection does not clear, ____ or ______ eye drops can be used as topical _____.
bacterial
chloramphenicol or fusidic acid
antibiotics
Hypermetropia or longsightedness is a risk factor for ____.
Increasing age and ____ sex are also important risk factors in this case.
Drugs that increase the risk include ____ and ____.
Acute angle closure glaucoma (blockage of the anterior chamber of the eye causes aqueous humour build up and increased intraocular pressure can damage optic nerve irreversibly)
This is due to the patient having a shallow anterior chamber.
Female
Corticosteroids and Anticholinergics (ex. oxybutyline) also increase the risk of acute angle-closure glaucoma
Hydroxychloroquine causes a ____ maculopathy
Bulls eye
Tamsulosin (alpha blocker BPH) causes ___ iris
Floppy
Anticholinergics such as oxybutynin and tolteridine can precipitate ______ in the eye.
Angle closure glaucoma
Which anti-arrythmytic can cause cornea verticallata?
Amiodarone
Idiopathic intracranial hypertension can be precipitated by which two classes of drugs?
COCP/ Oral contraceptive pill Tetracyline antibiotics (doxycycline)
Which TB drug classically causes optic neuritis?
Ethambutol
Other than a pituitary tumour, what is the other important cause of a bitemporal hemianopia?
Anterior communicating artery aneurysm pressing on the optic chiasm
Drugs that can precipitate acute angle closure galucoma?
Tricyclic antidepressants
Sulfonamides (sulfasalazine)
Antimuscarinics
Anticholinergics
The commonest eye symptom of Rheumatoid arthritis is_____
____ is a known complication of rheumatoid arthritis but is relatively less common.
Keratoconjunctivitis sicca (dry eye syndrome), which produces a gritty foreign body sensation. It is often associated with a low tear output on Schimer’s test.
Scleritis
Risk factors for retinal detachment (most common), include:
Age >40
Male
Myopia (near-sightedness)
Family history of retinal detachment
Previous ocular surgery
Trauma
Retinal detachment in the contralateral eye
Name common differentials for an acutely painful red eye.
Acute angle-closure glaucoma
Scleritis
Keratitis
Anterior uveitis.
Idiopathic/non-pathological anisocoria (pupil size mismatch) is common - but must present with a pupillary size difference ______ for it to be unlikely to be pathological.
< 0.5 mm
Which cranial nerve is responsible for the presentation of otalgia in pharyngeal malignancy?
Glossopharyngeal (IX)
Remember posterolateral SCC in CBL, glossopharyngeal nerve supplies sensory innervation to posterior 1/3 tongue.
The tympanic nerve (a branch of cranial nerve IX) directly innervates the ear but also has pharyngeal, lingual, and tonsillar branches to supply the posterior one-third portion of the tongue, tonsillar fossa/pillars, pharynx, eustachian tube, parapharyngeal and retropharyngeal spaces. Any pathologic process involving these areas can result in referred otalgia
The uvea or uveitis indicates the involvement of which anatomical structures of the eye?
Iris
Ciliary body
Choroid
Anterior Uveitis treatment.
1st line: Topical steroid eye drops (prednisolone or dexamethasone)
2nd line: Peri-ocular dexamethasone injection can also be used but has an increased risk of cataracts.
3rd: Oral prednisolone (be wary of adrenal suppression)
Choroidal neovascularization is only found in ____ age-related macular degeneration (AMD), which is characterised by the presence of neovascularisation within the macula,
Wet
Central retinal vein occlusion, vitreous haemorrhage and retinal detachment can all cause sudden painless loss of vision but only _____ gives a cherry red spot.
Central retinal artery occlusion
The cherry red spot is created as the retina becomes ischaemic turning the retina white (like a large cotton wool spot), with a red spot remaining at the fovea where the retina is thinnest (due to the underlying choroidal blood flow being visible).
______ is the general term given to describe the constellation of eyelid and orbital changes that accompany the administration of topical prostaglandin analogue eye drops.
Prostaglandin Associated Periorbitopathy (PAP)
The exact clinical findings associated with PAP are upper lid ptosis, deepening of the upper lid sulcus, involution of dermatochalasis, periorbital fat atrophy, mild enophthalmos, inferior scleral show, increased prominence of lid vessels, and tight eyelids Other known side effects of prostaglandin analogues include lengthening of lashes and increased pigmentation of the iris and periorbital skin.
Main treatment for corneal infection?
Broad spectrum oral antibiotics
Ex. Ciprofloxacin +/- teicoplainin
What is the first and second line Investigation in a patient with Multiple Sclerosis?
1st Line : MRI (Hyperintense lesions in the brain and/or spinal cord on T-2 weighted images are characteristic of this disease.)
2nd Line: Lumbar Puncture
Although a lumbar puncture can demonstrate oligoclonal bands and increased concentration of IgG in the cerebrospinal fluid, this would not be next best step in diagnosis. Lumbar puncture in the context of MS is reserved for atypical cases.
What are the first and second line medications used in the treatment of Trigeminal Neuralgia?
1st Line: Carbamazepine
2nd Line: Baclofen (muscle relaxant) - If for any reason carbamazepine is contraindicated, refer or seek advice from a specialist.
Trigeminal neuralgia classically presents with sudden, severe facial pain that can be triggered by even mild stimulation of the face (eating/talking/cold weather). It happens in short and unpredictable bouts with the pain usually affecting the lower part of the face. It is mostly unilateral. Attacks can last from a few seconds to a couple of minutes. People with trigeminal neuralgia can have months to years without any attacks, but periods of remission tend to get shorter as you get older.
The combination of fluent speech with abnormal comprehension is known as Wernicke’s (receptive) aphasia. In this condition, repetition is also impaired. This is often due to damage to the _____ gyrus.
In comparison, Broca’s (expressive) ____ leads to non-fluent speech with normal comprehension, often due to a lesion in the _____ gyrus.
Aphasia
superior temporal
Aphasia
Inferior frontal
Complications of diabetic retinopathy?
Retinal detachment
Vitreous haemorrhage (bleeding in to the vitreous humour)
Rebeosis iridis (new blood vessel formation in the iris)
Optic neuropathy
Cataracts
In addition to retinopathy you can also get a Diabetic Maculopathy:
- Macular oedema
- Ischaemic maculopathy
A patient that demonstrates a “clasp knife” phenomenon is virtually pathognomonic for an _____ lesion.
Upper motor neuron
What is the eponymous name for the clinical sign whereby a young male patient has to use his arms to move forward from a seated position. (due to proximal weakness in the leg and arm muscles)
Gower’s sign
The history of a young male who is finding it increasingly difficult to walk with frequent falls and the appearance of hypertrophied calf muscles is highly suggestive of Duchenne Muscular Dystrophy. In this case, the appearance of the calf is actually pseudohypertrophy and is due to an increase in fat content and not an increase in the size of muscle tissue.
1st Line treatment for patient with allergic conjunctivitis?
This IgE mediated condition can be treated initially with mast cell stabilisers such as:
Sodium Cromoglycate.
___ is the most common ocular opportunistic infection. It presents with reduced visual acuity. On fundoscopy, there may be a classic ___ appearance. Treatment involves using intraocular injections of ganciclovir and systemic oral valganciclovir.
CMV
‘pizza pie’
Herpetic Simplex Virus of the eye can cause ulcerations of the cornea and is treated using _____
Topical antivirals (ex. ganglicilovor)
Vitreous detachment gives a ______ like floaters. Very common cause of new onset floaters. Vitreous gel is attached to retina in places and so if detaches can also lead to retinal tear/detachment.
“spiders web” “net curtain”
The _____ tract is responsible for temperature and pain sensation and decussates at the _____.
Spinothalamic tract
Level of the Spinal cord
The ____ tract is responsible for fine touch and proprioception and decussates at the ____.
Dorsal column–medial lemniscus pathway (DCML)
Medulla
The ____ tract is responsible for Voluntary motor movement and decussates at the ____.
Corticospinal tract
Medulla
In MND, if symptoms are all suggesting upper motor neurone lesions this is characteristic of _______ . This is caused by degeneration of the _____ in the motor cortex.
Primary lateral sclerosis
Betz Cells
_____ can cause tardive dyskinesia and drug-induced parkinsonism.
Typical (1st generation) antipsychotics
his lady has the characteristic ‘string of beads’ appearance on MRI angiography in her internal carotid arteries which is consistent with ____.
fibromuscular dysplasia.
Right hemisphere (i.e. non-dominant) ____ lesions are particularly prone to producing visual neglect/inattention
parietal
_____ is the first-line treatment of myoclonic seizures. (e.g every now and then head jerks violently to one side)
Sodium Valproate
Reduced sensation over the medial side of the thigh, with weakness of knee extension. What is the most likely source of the problem?
L3 (3 knee)
The ischaemic _____ describes the cerebral area surrounding the ischaemic event where there is ischaemia without _____. This area is amenable to recovery with thrombolysis.
Penumbra
Necrosis
Horner’s syndrome and a brachial neuropathy could be explained by a ______ Tumour from _____ lung cancer.
Pancoast
Squamous cell
A carotid artery dissection can cause ____ and a ____ nerve palsy.
Horners syndrome (sympathetic ganglion is near carotid bifurcation)
XII - hypoglossal (i.e tongue deviation)
Neurofibromatosis can be diagnosed when 2 of the follwoing 7 characteristics are present.
CRABBING
Cafe au lait spots (6 or more)
Relative with NF1
Axillary or Inguinal freckles
Bony Dysplasia such as Bowing of a long bone or sphenoid wing dysplasia
Iris hamartomas (Lisch Nodules) - 2 or more yellow/brown spots on the iris.
Neurofibromas (2 or more)
Glioma of the optic nerve
Contraindications to Lumbar Puncture in suspected CNS infection.
Focal Neurological Signs (facial/limb weakness)
Papilloedema
Recent onset seizures
Impairment of consciousness
Cushings triad (bradycardia/hypertension/altered breathing)
Immunocompromise
Other contraindications to LP in general:
Known raised ICP
Infection over site
Bleeding disorder
Anticoagulant therapy
Management of HSV encephalitis
IV Aciclovir 10mg/kg (3 times/day)
and
Repeat LP after 2 weeks to check virus has cleared
Kidney function should be monitored as aciclovir can cause crystal nephropathy
Causes of encephalitis
HSV type 1 (type 2 possible in immunocompromised patients)
Varicella Zoster Virus
Enterovirus
HIV
Autoimmine (ex. NMDA/NMDAR receptor and LGI-1 protein encephalitis) - in lecture
_____ are found on the temporal artery biopsy. This is what gives rise to the giant cell arteritis name. This is worth remembering for your exams as it is a popular question.
Multinucleated giant cells
Investigations/Diagnosis for Giant Cell Arteritis
A definitive diagnosis is based on:
Clinical presentation (scalp tenderness/jaw claudication/vision loss)
Raised ESR: usually 50 mm/hour or more
Temporal artery biopsy findings
TOM TIP: Multinucleated giant cells are found on the temporal artery biopsy. This is what gives rise to the giant cell arteritis name. This is worth remembering for your exams as it is a popular question.
Additional Investigations
Full blood count may show a normocytic anaemia and thrombocytosis (raised platelets)
LFT’s can show a raised alkaline phosphatase
C reactive protein is usually raised
Duplex ultrasound of the temporal artery shows the hypoechoic halo sign
The ischaemic ____ describes the cerebral area surrounding the ischaemic event where there is ischaemia without necrosis. This area is amenable to recovery with thrombolysis.
penumbra
Cranial nerve lesions are ipsilateral, except ____.
Trochlear (Superior Oblique)
Name a few dopamine agonists and the side effects we would be worried about in treating parkinson patients with these medications?
Pramipexole
Ropinirole
Rotigotine
Impulsivity
Somnolence (sudden falling asleep- think driving)
Confusion/Hallucinations/Delirium
Name the two common MAO-B inhibitors used in parkinsons.
1st line: Rasagiline (Less likely to cause confusion/hallucinations)
2nd line: Selegiline
*both drugs have lots of interactions*
Which anti-psychotic is a good option in patients with parkinsons?
Quetiapine
Drugs to avoid in parkinsons patients?
Anti-emetics (i.e Haloperidol/Metaclopromide/prochlorperizine)
Anti-Psychotics (Especially typical or 1st generation antipsychotics)
The most likely drug to be used in IIH is ____ , a _____.
acetazolamide
carbonic anhydrase inhibitor
Presentation of Multiple System Atrophy
This is a rare condition where the neurones of multiple systems in the brain degenerate. It affects the basal ganglia as well as multiple other areas. The degeneration of the basal ganglia lead to a Parkinson’s presentation. The degeneration in other areas lead to autonomic dysfunction (causing postural hypotension, constipation, abnormal sweating and sexual dysfunction) and cerebellar dysfunction (causing ataxia).
Progressive Supranuclear Palsy
Rockets Sign
Early falls
Dystonia
Vertical gaze palsy (restricted upward gaze)
