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Neurology Flashcards

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1
Q

What are the signs of a migraine without aura?

A 
Unilateral throbbing headache
Worse upon activity 
Nausea and vomiting 
Photophobia
Phonophobia
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2
Q

How long does a migraine episode last?

A

4-72 hours

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3
Q

What are the signs of a migraine with aura?

A

Visual: blurred vision, loss of visual fields, lines
Motor: dysarthria
Somatosensory: Paraesthesia
Speech: dysphasia

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4
Q

What are the triggers of migraine?

A 
CHOCOLATE 
Chocolate
Hangovers
Orgasms
Cheese
Oral contraceptives
Lie ins 
Alcohol
Tumult
Exercise
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5
Q

How would you medically treat a migraine?

A

Paracetamol
Triptan
NSAIDs
Antiemetics

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6
Q

What type of drugs are triptans?

A

5HT (serotonin receptor) receptor agonist

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7
Q

Which can be used for migraine prophylaxis?

A

Propranolol
Topiramate
Amitriptyline
Acupuncture

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8
Q

What sign on fundoscopy is a sign of raised ICP?

A

Papilloedema

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9
Q

What are the causes of raised ICP?

A

Brain tumour
Benign intracranial hypertension
Intracranial bleed

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10
Q

What are the symptoms of a tension headache?

A

Tight band around forehead

Scalp muscle tenderness

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11
Q

What is associated with tension headaches?

A

Stress
Depression
Alcohol
Dehydration

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12
Q

How would you treat tension headaches?

A

Analgesia

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13
Q

Name the 3 branches of the trigeminal nerve.

A

Ophthalmic
Maxillary
Mandibular

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14
Q

Which condition is associated with trigeminal neuralgia?

A

MS

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15
Q

What are the signs of trigeminal neuralgia?

A

Spontaneous facial pain, can last seconds-hours

Shooting pain

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16
Q

What are the triggers of trigeminal neuralgia?

A 
Cold weather
Spicy food
Caffeine 
Touching affected area
Eating
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17
Q

What is the first line treatment for trigeminal neuralgia?

A

Carbamazepine

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18
Q

What is the surgical treatment for trigeminal neuralgia?

A

Surgery at trigeminal ganglion

Microvascular decompression

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19
Q

Cluster headaches come in clusters of attacks and then disappear for a while. For example, a patient may suffer 3 – 4 attacks a day for weeks or months followed by a pain-free period lasting 1-2 years. How long does an attack episode last?

A

15 minutes - 3 hours

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20
Q

What are the symptoms of cluster headaches?

A 
Red, swollen watering eye
Miosis 
Ptosis
Unilateral severe unbearable pain, usually around eye
Facial sweating
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21
Q

What is a risk factor for cluster headaches?

A

Smoking

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22
Q

How would you manage a cluster headache?

A

High flow 100% oxygen

Sumatriptan

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23
Q

What can be done for the prophylaxis of cluster headaches?

A

Verapamil
Lithium
Prednisolone

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24
Q

A TIA is sudden onset of focal CNS phenomena due to temporary occlusion of cerebral circulation. What are the risk factors for TIA?

A 
Hypertension
Smoking 
Obesity
Diabetes
High alcohol intake
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25
What are the features of a TIA?
``` Symptoms <24 hours Amaurosis fugax Aphasia Hemiparesis Vomiting Vertigo Ataxia ```
26
What is amaurosis fugax?
Occlusion of retinal artery, leading to unilateral progressive vision loss (like curtain descending)
27
What are the differentials of a TIA?
Hypoglycaemia Migraine aura Focal epilepsy Stroke
28
Which score is used to predict risk of stroke after a TIA?
ABCD2 score
29
Outline the components of the ABCD2 score.
``` Age >60 - 1 pt BP >140/90 - 1pt Unilateral weakness - 2pts Speech disturbance without weakness - 1pt Symptoms >1 hour - 2 pts Symptoms <1 hour - 1pt Diabetes - 1pt ```
30
How would you manage a TIA?
Start 300mg aspirin daily | Prevent CVS disease e.g. smoking cessation, control diabetes, statin
31
What are the two types of stroke?
Ischaemic | Haemorrhagic
32
What are the cause of ischaemic stroke?
``` MI AF Prosthetic valves Endocarditis Atherothromboembolism ```
33
What are the cause of haemorrhagic stroke?
Trauma Anaeurysm rupture Anticoagulation + thrombolysis Subarachnoid haemorrhage
34
What are the risk factors of stroke?
``` CVS disease Previous TIA/stroke AF Hypertension Diabetes Smoking Vasculitis Thrombophilia Combined OCP Carotid artery dissection ```
35
What are the signs of stroke?
Sudden onset: Facial weakness, limb weakness, dysphasia, vision loss, locked in syndrome
36
What are the differentials of a stroke?
``` Migraine with aura Epilepsy Intracranial tumour Hypoglycaemia Subdural haemorrhage ```
37
What is the immediate management for someone with stroke?
Admit patient to stroke centre Exclude hypoglycaemia Immediate CT brain to exclude haemorrhage Aspirin 300mg stat after CT
38
How would you manage an ischaemic stroke?
IV alteplase Thrombectomy 300mg aspirin for 2 weeks
39
What kind of drug is alteplase?
Tissue plasminogen activator
40
What is the time frame to give alteplase?
Within 4.5 hours of stroke
41
What is the time frame for a thrombectomy?
Within 24 hours of stroke
42
Outline secondary prevention of stroke after a TIA
Clopidogrel 75mg OD Atorvastatin 80mg Carotid endarterectomy/stenting Treat modifiable risk factors
43
What are the causes of subarachnoid haemorrhage?
Berry aneurysm rupture | Aterio-venous malformations
44
What are the risk factors for subarachnoid haemorrhage?
``` Hypertension Smoking Excess alcohol Cocaine FH ```
45
Where does subarachnoid haemorrhage occur?
Subarachnoid space, between pia mater nd arachnoid membrane
46
What are the signs of a subarachnoid haemorrhage?
``` Sudden onset thunderclap headache - can occur during strenuous activity Neck stiffness Photophobia Vision changes Weakness Speech changes Seizures Kernig's sign: inability to straighten knee when hip is flexed at 90 degrees ```
47
What are the differentials of subarachnoid haemorrhage?
Meningitis Migraine Intracerebral bleeds
48
What investigations would you do if you suspect subarachnoid haemorrhage?
CT head, Lumbar puncture, angiography
49
How would a subarachnoid haemorrhage appear on CT?
Hyperattenuation in subarachnoid space, star shaped bleed
50
What are the signs of subarachnoid haemorrhage on lumbar puncture?
CSF will show: raised RBC and xanthochromia caused by bilirubin
51
How would you manage subarachnoid haemorrhage?
Coiling/clipping to treat aneurysm Antiepileptic Nimodipine to prevent vasospasm Lumbar puncture to treat hydrocephalus
52
Where does subdural haemorrhage occur?
Bleeding from bridging veins between cortex and venous sinuses. Leads to hameatoma between dura and arachnoid
53
What occurs if a subdural haemorrhage is not treated?
ICP rises, midline structures are shifted away from clot. Tentorial hernia and coning occurs.
54
What are the causes of subdural haemorrhage?
Trauma, however sometimes this can be up to 9 months ago | Dural mets
55
What are the risk factors for subdural haemorrhage?
Elderly Epileptics (increased fall risk + atrophy) Alcoholics (increased fall risk)
56
What are the signs of subdural haemorrhage?
``` Fluctuating levels of consciousness Sleepiness Personality change Seizure Local neurological symptoms ```
57
How would a subdural haemorrhage appear on CT?
Crescent shaped collection of blood
58
How would you manage subdural haemorrhage?
Craniotomy | Burr hole washout
59
Laceration of which vessel causes extradural haemorrhage?
Middle meningeal artery in temporo-parietal region
60
Where does extradural haemorrhage occur?
Between skull and dura mater. Associated with fracture of temporal bone
61
What are the signs of extradural haemorrhage?
``` Traumatic head injury leads to headache Period of improving consciousness followed by rapid decline Vomiting Seizures Coma ```
62
How would an extradural haemorrhage appear on CT?
Bi-convex shape of bleed, that cannot cross cranial sutures
63
How would you manage extradural haemorrhage?
Clot evacuation | Ligation of bleeding vessel
64
Multiple sclerosis (MS) is a chronic and progressive condition that involves demyelination of the myelinated neurones in the central nervous system. This is caused by an inflammatory process involving the activation of immune cells against the myelin. Which cells have myeli n the PNS and CNS?
PNS: Schwann cells CNS: Oligodendrocytes
65
A characteristic feature of MS is that lesions vary in their location over time, meaning that different nerves are affected and symptoms change over time. What term is used to describe this phenomena?
Disseminated in time and space
66
What are the risk factors for MS?
EBV, low vitamin D, smoking, obesity
67
Name focal weakness symptoms of MS
Horner's syndrome, Bells palsy, limb paralysis, incontinence
68
Name focal sensory symptoms of MS
Trigeminal neuralgia, numbness, paraesthesia, Lhermitte's sign: electric shock travelling down spine when flexing neck
69
Name the types of ataxia that occur in MS
1. Sensory ataxia: loss of proprioception | 2. Cerebellar ataxia
70
What results in demyelination of the optic nerve?
Optic neuritis
71
Name the two abnormalities that occur with a sixth nerve (abducens) palsy
Internuclear opthalmoplegia + conjugate lateral gaze disorder (eye will not be able to adduct)
72
State the 3 types of disease progression in MS.
1. relapsing-remitting 2. primary progressive (no relapses) 3. secondary progressive (relapsing at first but now progressive worsening)
73
How would MS appear on lumbar puncture?
Oligoclonal bands in CSF
74
What are the key features of optic neuritis?
Central scotoma = enlarged blind spot Pain on eye movement Impaired colour vision Relative afferent pupillary defect
75
Which drugs can be used to treat relapses of MS?
IV methylprednisolone | Monoclonal antibodies
76
Outline symptomatic management for MS
Exercise Gabapentin for spasticity Oxybutynin for incontinence Botox for tremor
77
What type of genetic inheritance is Huntington's disease?
Autosomal dominant
78
Huntington's chorea is a trinucleotide repeat disorder that involves a genetic mutation in the HTT gene on chromosome 4. Which trinucleotide is affected?
CAG
79
What is the term given to the phenomena where successive generations have more repeats in the gene, resulting in: Earlier age of onset Increased severity of disease?
Anticipation
80
What are the signs of Huntington's?
``` Mood problems Chorea = involuntary abnormal movements Eye movement disorders Dysarthria Dysphagia ```
81
How would you manage Huntington's?
No treatment to stop disease. Counsel, offer speech and language therapy
82
Which chemical becomes progressively lower in Parkinson's?
Dopamine
83
Which part of the brain is there reduced dopamine in Parkinson's?
Substantia nigra in basal ganglia
84
What are the clinical features of Parkinson's?
``` Unilateral tremor Cogwheel rigidity Bradykinesia: shuffling gait, handwriting gets smaller and smaller Depression Insomnia Anosmia - loss of smell Postural instability Cognitive impairment Asymmetrical reduction in arm swing Dribbling ```
85
Outline the features of a Parkinson's tremor
Unilateral, worse at rest, improves with movement, no change with alcohol
86
Outline the features of a benign essential tremor
Bilateral, improves at rest, worse with movement, improves with alcohol
87
What are the complications of Parkinson's?
Multiple system atrophy Cerebellar dysfunction Dementia with Lewy bodies
88
How would you manage Parkinson's?
Dopamine agonist e.g. ropinirole Monoamine oxidase-B inhibitors COMT inhibitors L-dopa - give last
89
What are the side effects of L-dopa?
Chorea, dystonia, athetosis
90
What is a significant side effect of dopamine agonists?
Pulmonary fibrosis
91
Guillain-Barré syndrome is an “acute paralytic polyneuropathy” that affects the peripheral nervous system. It causes acute, symmetrical, ascending weakness and can also cause sensory symptoms. It is usually triggered by which infections?
EBV, campylobacter jejuni and cytomegalovirus
92
Guillain-Barré is thought to occur due to a process called molecular mimicry. The B cells of the immune system create antibodies against the antigens on the pathogen that causes the preceding infection. These antibodies also match proteins on the nerve cells. They may target proteins on the myelin sheath of the motor nerve cell or the nerve axon. What are the symptoms of this?
Symmetrical ascending weakness from feet up Reduced reflexes Neuropathic pain Peripheral loss of sensation
93
How is Guillain-Barré syndrome diagnosed?
Nerve conduction studies (reduced signal) | Lumbar puncture: raised protein and normal WCC
94
How would you manage Guillain-Barré syndrome?
IV immunoglobulins or plasma exchange Ventilation VTE prophylaxis - PE is a leading cause of death
95
Myasthenia graves is an autoimmune condition that causes muscle weakness that gets progressively worse with activity and improves with rest. Which condition is a risk factor for myasthenia gravis?
Thymoma
96
In around 85% of patients with myasthenia gravis, acetylcholine receptor antibodies are produced by the immune system. These bind to the postsynaptic neuromuscular junction receptors, preventing muscle contraction. These antibodies also activate the complement system within the neuromuscular junction, leading to damage to cells at the postsynaptic membrane. This further worsens the symptoms. Which other antibodies cause myasthenia gravis?
Muscle specific kinase (MusK) and low-density lipoprotein receptor-related protein 4 (LRP4) - both are needed to create acetylcholine receptors
97
What are the clinical features of myasthenia gravis?
``` Weakness that gets worse with use and improves with rest Diplopia Ptosis Slurred speech Weak swallow ```
98
What investigations would you do for myasthenia gravis?
ACH-R, MuSK and LRP4 antibodies CT of thymus Edrophonium test - briefly relieves weakness
99
How would you manage myasthenia gravis?
Reversible acetylcholinesterase inhibitor Prednisolone Thymectomy Rituximab
100
Myasthenic crisis is a severe complication of myasthenia gravis. It can be life threatening. It causes an acute worsening of symptoms, often triggered by another illness such as a respiratory tract infection. This can lead to respiratory failure as a result of weakness in the muscle of respiration. How would you manage this?
Intubation and ventilation IV immunoglobulins Plasma exchange Monitor FVC
101
Which nerve is compressed in carpal tunnel syndrome?
Medial nerve
102
What are the risk factors for carpal tunnel syndrome?
``` Repetitive strain Obesity RA Diabetes Acromegaly Hypothyroidism ```
103
arpal tunnel syndrome causes sensory symptoms in the distribution of which branch of the median nerve?
Palmar digital cutaneous branch
104
What are the sensory symptoms of carpal tunnel syndrome?
``` Thumb, index, middle and lateral ring finger: Numbness Paraesthesia Burning sensation Pain Relieved by shaking hand Worse at night ```
105
What are the motor symptoms of carpal tunnel syndrome?
Weakness of thumb movements Wasting of thenar muscles Weakness of grip
106
Which two special tests can be done to diagnose carpal tunnel syndrome?
Phalen's: maximal wrist flexion for 1 min induces parathesia Tinel's: tapping over nerve induces paraesthesia
107
How would you manage carpal tunnel syndrome?
Wrist splint, steroid injections, decompression surgery
108
Motor neurone disease is an umbrella term that encompasses a variety of specific diagnoses. Motor neurone disease is a progressive, ultimately fatal condition where the motor neurones stop functioning. There is no effect on the sensory neurones and patients should not experience any sensory symptoms. State 4 types of MND.
1. ALS: amyotrophic lateral sclerosis 2. Progressive bulbar palsy 3. Progressive muscular atrophy 4. Primary lateral sclerosis
109
In MND, there is a progressive degeneration of both upper and lower motor neurones. The sensory neurones are spared. What are the risk factors for developing MND?
Positive FH, smoking, exposure to heavy metals, pesticides
110
What are the symptoms of MND?
- insidious, progressive weakness of the muscles throughout the body affecting the limbs, trunk, face and speech. - increased fatigue when exercising - clumsiness, dropping things more often or tripping over - slurred speech (dysarthria)
111
What are the UMN signs of MND?
Increased tone or spasticity Brisk reflexes Up-going plantar responses
112
What are the LMN signs of MND?
Muscle wasting Reduced tone Fasciculations (twitches in the muscles) Reduced reflexes
113
How would you manage MND?
- riluzole for ALS - non invasive ventilation - NG feeding tube - diazepam for spasticity - propantheline for excess saliva
114
How can you distinguish between MND and myasthenia gravis?
MND never affects eye movements
115
In ALS, there is moss of motor neurones in anterior horn and motor cortex. What are the features of ALS?
Weakness, LMN wasting
116
In progressive bulbar palsy, cranial nerves 9-12 are affected. What are the features of this?
LMN lesion of tongue: flaccid, fasiculating tongue | Hoarse speech
117
Progressive muscular dystrophy is due to lesions in the anterior horn cells. Would this present as UMN or LMN signs?
LMN
118
In primary lateral sclerosis, there is loss of Bletz cells in the motor cortex. Would this present as UMN or LMN signs?
UMN
119
Epilepsy is an umbrella term for a condition where there is a tendency to have seizures. Seizures are transient episodes of abnormal electrical activity in the brain. There are many different types of seizures. State the types of seizures
``` Generalised tonic clonic Absence Atonic Myoclonic Focal Infantile spasms ```
120
What are the features of a general tonic clonic seizure?
- There is loss of consciousness and tonic (muscle tensing) and clonic (muscle jerking) episodes. - associated tongue biting, incontinence, groaning and irregular breathing. After the seizure there is a prolonged post-ictal period where the person is confused, drowsy and feels irritable or depressed.
121
How would you manage a tonic clonic seizure?
First line: sodium valproate | Second line: lamotrigine or carbamazepine
122
What are the features of focal seizures?
``` Focal seizures start in temporal lobes: Hallucinations Memory flashbacks Déjà vu Doing strange things on autopilot ```
123
How would you manage focal seizures?
First line: carbamazepine or lamotrigine | Second line: sodium valproate or levetiracetam
124
What are the features of atonic seizure?
Atonic seizures are also known as “drop attacks”. They are characterised by brief lapses in muscle tone. These don’t usually last more than 3 minutes.
125
How would you manage atonic seizures?
First line: sodium valproate | Second line: lamotrigine
126
What are the features of absence seizures?
The patient becomes blank, stares into space and then abruptly returns to normal. During the episode they are unaware of their surroundings and won’t respond. These typically only lasts 10-20 seconds.
127
How would you manage absence seizures?
First line: sodium valproate or ethosuximide
128
What are the features of myoclonic seizures?
Myoclonic seizures present as sudden brief muscle contractions, like a sudden “jump”. The patient usually remains awake during the episode. They typically happen in children as part of juvenile myoclonic epilepsy.
129
How would you manage myoclonic seizures?
First line: sodium valproate | Other options: lamotrigine, levetiracetam or topiramate
130
What are the features of infantile spasms?
Also known as West syndrome. Starts at 6 months of age. It is characterised by clusters of full body spasms. There is a poor prognosis: 1/3 die by age 25, however 1/3 are seizure free
131
How would you manage infantile spasms?
Prednisolone | Vigabatrin
132
How would you diagnose epilepsy?
- EEG - MRI of brain - ECG
133
State the non-epileptical causes of seizure
- Trauma - Stroke - Raised ICP - Alcohol withdrawal - Infection e.g. HIV, syphillis - Cocaine use
134
What is a severe side effect of sodium valproate?
Teratogenic
135
Define status epilepticus
seizures lasting more than 5 minutes or more than 3 seizures in one hour.
136
How would you manage status epilepticus?
Secure the airway Give high-concentration oxygen Check blood glucose levels IV lorazepam 4mg, repeated after 10 minutes if the seizure continues If seizures persist: IV phenobarbital or phenytoin
137
What is a sign of raised ICP on fundoscopy?
Papilloedema
138
What are the causes of raised ICP?
Brain tumours Intracranial haemorrhage Idiopathic intracranial hypertension Abscesses or infection
139
What are the most common cancers to metastasise in the brain?
Breast Lung Prostate Renal cell carcinoma
140
State 2 types of benign brain tumour
Neurofibroma | Meningioma
141
State types of malignant brain tumour
Glioma Lymphoma Medulloblastoma
142
What are the symptoms of raised ICP?
``` Nausea Headache that is nocturnal and worse on lying down and in morning Worse when coughing Altered mental state Visual field defects Seizures (particularly focal) Unilateral ptosis Third and sixth nerve palsies Papilloedema (on fundoscopy) ```
143
If someone presented with personality change due to a brain tumour, where would the lesion be located?
Frontal lobe
144
Papilloedema is the swelling of what structure?
Optic disc
145
Gliomas are tumours of the glial cells in the brain or spinal cord. What are the 3 key types of glioma?
Astrocytoma Oligodendroglioma Ependymoma
146
What occurs when pituitary tumours press on the optic chiasm?
Bitemporal hemianopia
147
Acoustic neuromas are tumours of which cells?
Schwann cells surrounding auditory nerve
148
What are the symptoms of acoustic neuroma?
Hearing loss Tinnitus Balance problems
149
How would you investigate a suspected brain tumour?
- CT/MRI of brain - Brain biopsy - Do not do lumbar puncture if you suspect raised ICP as this can cause coning
150
How would you manage a high grade tumour?
- IV dexamethasone to reduce cerebral oedema - Resection of tumour - Radiotherapy - Chemo No cure
151
How would you manage a pituitary tumour?
Trans-sphenoidal surgery Radiotherapy Bromocriptine to block prolactin-secreting tumours Somatostatin analogues (e.g. ocreotide) to block growth hormone-secreting tumours

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