Neurology Flashcards
What is crescendo TIA?
2+ TIAs in a week
What is the clinical scoring tool for stroke?
ROSIER. Anything above 0= likely
What dose is the stat dose of aspirin in stroke?
300mg
What is the treatment window for thrombolysis in stroke?
4.5 hours
What is the secondary prevention of stroke?
Clopidogrel 75mg OD and Atorvastatin 80mg
How is GCS calculated
E4V5M6
Eyes: Spontaneous=4 Speech=3 Pain=2 None=1
Verbal: Orientated=5 Confused=4 Inappropriate words=3 Incomprehensible=2 None=1
Motor: Obeys commands=6 Localises pain=5 Withdraws from pain=4 Abnormal flexion=3 Extends=2 None=1
What is the lowest possible GCS?
3/15
What are the features of a subdural haemorrhage?
Caused by bridging veins
CT scan shows crescent shape
Not limited by cranial sutures
What are the features of a extradural haemorrhage?
Usually caused by rupture of the middle meningeal artery
Bi-convex shape
Limited by cranial sutures
What causes are subarachnoid haemorrhages particularly associated with?
Cocaine and sickle cell anaemia
also strenuous activity such as weight lifting and sex
What causes MS?
Inflammatory process activating the immune cells against myelin
Which cells are attacked in MS?
Oligodendrocytes
What is the diganostic criteria for MS
Disseminated in SPACE and TIME
What is the most common presentation of MS?
Optic neuritis
What are the features of a 6th cranial nerve palsy?
Internuclear opthalmoplegia and conjugate lateral gaze disorder
What is Lhermitte’s sign?
Electric shock sensation that travels down the spine and into limbs when flexing the neck
what are the two types of ataxia which can be seen in MS?
Sensory and cerebellar
What are the 3 patterns of progression in MS?
Relapsing-Remitting
Primary Progressive
Secondary progressive
How is MS diagnosed?
MRI
Lumbar puncture- oligoclonal bands
What are the key features of optic neuritis
Central scotoma
Pain
Impaired colour vision
Relative afferent pupillary defect
How can MS be managed?
DMARDs and biologic therapy
Methylprednisolone for relapses (500mg orally daily)
Symptomatic treatment
What is progressive bulbar palsy?
Second most common form of motor neurone disease which affects the muscles of talking and swallowing
What is affected in MND?
There is progressive upper and lower motor neurone degeneration. Sensory neurones are spared
What are the signs of lower motor neurone disease?
Muscle wasting
Reduced tone
Fasciculations
Reduced reflexes
What are the signs of upper motor neurone disease?
Increased tone or spasticity
Brisk reflexes
Upgoing plantar responses
What is the management of MND?
Riluzole can slow the progression
Non-invasive ventilation
End of life care planning
What is the triad of parkinson’s disease?
Resting tremor
Rigidity
Bradykinesia
What type of tremor is found in parkinson’s?
“pill-rolling tremor”
Name 4 parkinson’s plus syndromes?
multisystem atrophy
Dementia with Lewy Bodies
Progressive supranuclear palsy
Corticobasal degeneration
What is the management of parkinsons?
Levodopa +carbidopa (can be given as combination drugs co-benyldopa/ co-careldopa)
COMT inhibitors (entacapone)
Dopamine agonists (bromocryptine)
MAO-B inhibitors (selegiline)
What is the main side effect of levodopa?
Dyskinesias (excessive motor activity)
What is a notable side effect of dopamine agonists? give an example of this drug.
Bromocryptine
Pulmonary fibrosis
What are the features of a benign tremor?
Fine
Symmetrical
More prominent on voluntary movement
Worse when tired, stress, caffeine
What is the management of benign tremor?
Propanolol
What investigations should be done in epilepsy?
EEG
MRI brain
ECG
Whats the first line and second line management of tonic-clonic seizures?
1st= sodium valporate
2nd lamotrigine or cabamazipine
Where do focal seizures start?
temporal lobes
Whats the first line and second line management of focal seizures?
1st= cabamazipine or lamotrigine 2nd= sodium valporate
Whats the management of juvenile myoclonic epilepsy?
Sodium valporate
What is West syndrome?
Infantile spasms. Starts at around 6 months and is characterised by full body spasms
How is West syndrome managed?
Prednisolone
What are the notable side effects of sodium valporate?
Teratogenic
Liver damage
Hair loss
Tremor
What are the notable side effects of carbamazapine?
Agranulocytosis
Aplastic anaemia
What are the notable side effects of phenytoin?
Folate and vitamin D deficiency
Megablastic anaemia
Osteomalacia
gum bleeding
What are the notable side effects of lamotrigine?
Stevens- johnson syndrome
Leukopenia
How is status epilepticus defined?
seizures lasting more than 5 mins or more than 3 seizures in an hour
How should status epilepticus be managed?
ABCDE
After 10 mins, 4mg IV lorazepam, 10mg diazepam PR
IV phenytoin 20mg/kg if not working after 2 repeats
What are the 4 first line treatments for neuropathic pain?
Amitriptyline
Duloxetine (SNRI)
Gabapentin
Pregabalin (both anticonvulsants)
What are the features of complex regional pain syndrome?
Neuropathic pain Skin flushing Colour change Temperature change Abnormal sweating Abnormal hair growth Swelling
How does facial nerve palsy usually present?
Unilateral facial weakness
What is the cause of an upper motor neurone facial palsy?
Stroke or tumour
How do you differentiate between an upper and lower motor neurone facial nerve palsy?
Upper= can move forehead. It is spared Lower= cannot move forehead, cant blink
How long can recovery from Bell’s palsy take?
12 months
How is bell’s palsy managed?
Prednisolone (50mg for 10 days, 60mg for 5 days, 5 days of reducing)
Lubricating eyedrops
Which virus causes Ramsey Hunt sydrome?
Varicella zoster virus
How does Ramsey Hunt syndrome present?
Unilater lower motor neurone facial palsy with painful vesicles behind the ear
What is the key finding on fundoscopy in brain tumours?
Papilloedema
What are headache red flags?
Constant Nocturnal Worse on wakening Worse on coughing, straining or bending forward Vomiting
Name 4 cancers which commonly metastasise to the brain
Lung
Breast
Renal cell carcinoma
Melanoma
What visual field defect do pituitary tumours cause and why?
Bitemporal hemianopia because they press on the optic chiasm
Where do acoustic neuromas usually occur?
Cerebellopontine angle
Which condition are bilateral acoustic neuromas associated with?
Neurofibromatosis type 2
Which drug can be used to block prolactin secreting tumors?
Bromocriptine
What is the genetic mutations which causes huntington’s chorea?
Tricnucleotide repeat in the HTT gene on chromosome 4
What is genetic anticipation?
This is diplayed in Huntington’s. Successive generations have more repeats in the gene which results in earlier age of onset and increased severity of disease
What are the features of Huntington’s?
Chorea
Eye movement disorders
Dysarthria
Dysphagia
Which medications can be used to suppress the disordered movement in Huntington’s?
Anti-psychotics
Benzodiazepines
Dopamine-depleting agents (tetrabenazine)
Which condition has a strong link to myasthenia gravis?
Thymoma
Which antibodies cause the problem in myasthenia gravis?
Acetylcholine receptor antibodies
How does myasthenia gravis present?
Weakness gets worse with use and better with rest
Most affects the proximal muscles
Dipolopia
Ptosis
How can the fatiguability of muscles be assessed in myasthenia gravis?
Repeated blinking will exacerbate ptosis
Prolonged upward gazing will exacerbate diplopia
Repeated abduction of one arm 20 times will cause profound unilateral weakness
What investigations should be done for myasthenia gravis?
Acetyl choline receptor antibodies
CT or MRI of thymus
Edrophonium test
What is the edrophonium test?
Give an IV dose of edrophonium chloride (or neostigmine). This blocks the cholinesterase enzymes, increases the concentration of ACh and briefly relieves the symptoms of myasthenia gravis
What is the management of myasthenia gravis?
Reversible acetylcholinesterase inhibitors (pyridostigmine or neostigmine)
Immunosupression
Thymectomy
Rituximab
Whats is myasthenic crisis?
Acute worsening of symptoms, sometimes triggered by another illness such as URTI
What is the management of myasthenic crisis?
BiPAP/ intubation
IV immunogloblins and plasma exchange
Which condition is lambert-eaton myasthenic syndrome often associated with?
Small cell lung cancer
What is the presentation of lambert-eaton?
Affects proximal muscles slow onset Diplopia Ptosis Dysphagia Post-tetanic potentiation (tense muscles and reflexes are improved after)
What is the management of lambert eaton?
Sort the small cell lung cancer
Amifampridine allows more acetylcholine to be released
What is the inheritance pattern of charcot-marie-tooth disease?
Autosomal dominant
Affects the peripheral motor and sensory nerves
When do symptoms of charcot-marie-tooth disease appear?
Either <10 years or after 40 years of age
What are the features of charcot-marie-tooth?
High foot arches (pes cavus)
Distal muscle wasting causing inverted champagne bottle legs
Weakness in lower legs (particularly ankle dorsiflexion)
Weakness in hands
What are the causes of peripheral neuropathy?
ABCDE A-alcohol B-B12 deficiency C-Cancer and CKD D-diabetes and drugs E-Every vasculitis
What is the management of charcot-marie-tooth disease?
Supportive
What is Guillain Barré associated with?
Campylobacter jejuni
Cytomegalovirus
Epstein-Barr
What is the presentation of Guillian Barre?
Symmetrical ascending weakness (glove and stocking)
Reduced reflexes
Peripheral loss of sensation or neuropathic pain
When do symptoms of guillain barre occur after the preceding infections?
4 weeks after
What are the diagnostic criteria for guillian barre?
the brighton criteria
What investigations should be done for guillian barre syndrome?
Nerve conduction studies Lumbar puncture (shows raised protein, normal WCC and glucose)
What is the management of guillian barre?
IV immunoglobulins or plasma exchange
Supportive care
VTE prophylaxis
What is neurofibromatosis?
Genetic condition that causes neuromas to develop throughout the nervous system
Which is the more common type of neurofibromatosis?
Type 1
What is the inheritance pattern of neurofibromatosis?
Autosomal dominant
What are the diagnostic criteria for neurofibromatosis?
2 of the 7. Remember by the mnemonic CRABBING
C- cafe-au-lait spots (6 or more) R-relative is affected A-Axillary or inguinal freckles BB- Bony dysplasia such as Bowing of a long bone I- Iris haemotomas N-Neurofibromas G-Gliomas
What are the investigations for neurofibromatosis?
Genetic testing
X-rays
CT and MRI
What is the characteristic feature of Tuberous Sclerosis?
The development of hamartomas
What are the skin signs of tuberous sclerosis?
Ash leaf spots Shagreen patches Angiofibromas Subungal fibromatoma Cafe-au-lait spots Poliosis
What are the neurological features of tuberous sclerosis?
Epilepsy
Learning difficulties
Which type of migraine can mimic stroke?
Hemiplegic
What are triptans?
5HT receptor agonists (serotonin receptor agonists)
Which medications can be used as migraine prophylaxis?
Propanolol
Topiramate
Amitriptyline
What is the acute management of a cluster headache?
Triptans
100% oxygen for 15-20 mins
What is used for cluster headache prophylaxis
Verapamil
Lithium
Prednisolone
