Neurology Flashcards
syringomyelia
- Lateral spinothalamic tract > loss of pain and temp
- Ventral horns»_space; flaccid paresis (usually affects intrinsic hand muscles)
cape like loss of sensation to temperature
most common cause of viral meningitis in adults
enteroviruses (coxsackie, echovirus)
ramsay hunt tx
oral aciclovir + steroids
bacterial meningitis abx and ?
Bacterial meningitis: IV dex prior to or with 1st abx dose and then every 6h
neuropathic pain tx
Neuropathic pain: 1st line options = amitryptyline, duloxetine, gabapentin or pregabalin
If 1 doesn’t work, try one of the others NB they are used as monotherapy - SWITCH don’t add
aphasia: what is it, where is damaged
- wernicke’s
- broca’s
- conduction
- global
- Wernicke’s (receptive): lesion of superior temporal gyrus (inf division of L MCA) - comprehension impaired. Fluent speech that makes no sense
- Broca’s (expressive): lesion of inf frontal gyrus. Superior div of L MCA. Normal comprehension. Non-fluent speech/laboured/halting, impaired repetition
- Conduction aphasia: lesion to arcuate fasciculus (connection between W and B) - fluent speech, poor repetition, aware of errors they’re making, normal comprehension
Global aphasia: large lesion affecting all 3 of the above areas > severe expressive and receptive aphasia. May still communicate with gestures.
Broca: front to back (frontal lobe lesion)
Frontal lobe: primary motor cortex, so it’s involved in the act of speaking
Temporal: memory/understanding, so don’t understand words and speak words that make no sense
essential tremor:
- symptoms improved by? worsened by?
- how do you get it
- most common cause of what?
- tx?
- Symptoms improved by alcohol and rest
- Worse when arms outstretched
- AD condition
- Most common cause of head tremor (titubation)
Tx: propranolol (sometimes use primidone)
breast feeding and anti-epileptics?
Breast feeding is acceptable with nearly all anti-epileptic drugs
except poss barbituates
lambert eaton syndrome
- key features?
- associations?
- Ass w SCLC (less: breast and ovarian cancer)
- Can occur indep as an AI disorder
Features - limb-girdle weakness (affects lower limbs first)
- hyporeflexia
- autonomic symptoms: dry mouth, impotence, difficulty micturating
- Can occur indep as an AI disorder
DETAILS
- Repeated muscle contractions > increased muscle strength (opposite to MG)
○ In reality only see in 50%, after prolonged msucle use, eventually muscle strength falls
- ophthalmoplegia and ptosis not commonly a feature (unlike in myasthenia gravis)
EMG: incremental response to repetitive electrical stimulation
Tx: tx cancer, immunosup w pred or azathioprine
head injury with lucid interval
extradural
3rd nerve palsy
eye down and out
ptosis
pupil may be dilated
if painful can be due to posterior communicating artery aneurysm
can be a false localising sign due to uncal herniation through tentorium if raised ICP
weber’s syndrome
ipsilateral third nerve palsy with contralateral hemiplegia -caused by midbrain strokes
MS tx for: - fatigue spasticity bladder dysfunction oscillopsia
- Fatigue: excl other problems, then trial of amantadine
- Spasticity: baclofen and gabapentin 1st line
- Bladder dysfunction: US 1st to assess bladder emptying. If sig residual: ISC. If no sig residual: anticholinergics
Oscillopsia (VFs oscillate): gabapentin
Lhermitte’s syndrome:
Uhthoff’s phenomenon:
- Uhthoff’s phenomenon: worsening of vision following rise in body temp
- Lhermitte’s syndrome: paraesthesiae in limbs on neck flexion
tx of acute relapse ms and longer term
Acute relapse: high dose steroids for 5ds (oral or IV methylprednisolone) - shortens length of relapse
Beta-interferon
- Reduces relapse rate and MRI changes; doesn’t reduce overall disability
- Criteria to start
○ relapsing-remitting disease + 2 relapses in past 2 yrs + able to walk 100m unaided
secondary progressive disease + 2 relapses in past 2 years + able to walk 10m (aided or unaided)
meniere’s
- features
- mx
Episodic vertigo, tinnitus and hearing loss
Mx
-acute attacks: buccal or IM prochlorperazine. Admission is sometimes required
-prevention: betahistine and vestibular rehabilitation exercises may be of benefit
extra features: aural fullness/pressure, nystagmus, positive romberg test
episodes last mins-hours
usually unilateral
otosclerosis
Conductive hearing loss, tinnitus, positive FHx
10% redness of promontory of cochlea seen through tympanic membrane (schwartz sign); flamingo tinge
AD
Mx: hearing aid, stapedectomy
spastic paraparesis - presentation, causes?
SPASTIC PARAPARESIS = UMN pattern of weakness in LLs - Increased tone - Brisk reflexes - Weakness
Causes • demyelination e.g. MS • cord compression: trauma, tumour • parasagittal meningioma • tropical spastic paraparesis • transverse myelitis e.g. HIV • syringomyelia • hereditary spastic paraplegia osteoarthritis of the cervical spine
stroke pictures
- ACA
- MCA
- PCA
ACA: contralateral hemiparesis and sensory loss (more in LL)
MCA: contralat hemiparesis and sensory loss (more in UL) + aphasia + contralat homonymous hemianopia
PCA: contralat homonoymous hemianopia w macular sparing + visual agnosia
ipsilateral 3rd nerve palsy, contralat weakness of UL + LL
- what has been affected?
Webers’s syndrome = branches of PCA that supply the brainstem = ipsilateral 3rd nerve palsy, contralat weakness of UL + LL
PICA stroke
AICA stroke
PICA stroke
- Lateral medullary syndrome (wallenberg syndrome) - Ipsilateral: facial pain and temperature loss - Contralateral: limb/torso pain and temperature loss - Ataxia, nystagmus
AICA stroke
- Lateral pontine syndrome - Laterally medullary syndrome & Ipsilateral: facial paralysis and deafness
stroke of retinal/ophthalmic artery?
of basilar artery?
Retinal/ophthalmic artery: amaurosis fugax
Basilar artery: locked in syndrome
lacunar strokes - features? ass w ? common sites?
Lacunar strokes
• isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
• strong association with hypertension
• common sites include the basal ganglia, thalamus and internal capsule
when to use mechanical thrombectomy in a stroke
- Need good pre-stroke functional status
- Do alongside thrombolysis (so always give thrombolysis if within 4.5h of sym onset)
- Within 6hs of onset: do for confirmed occlusion of prox ant circulation
- Within 6-24h: if prox ant occlusion + limited infarct core volume
- Within last 24h if proximal posterior circulation + limited infarct core volume
when to use thrombolysis in stroke
CI?
Thrombolysis with alteplase if:
• within 4.5 hours of onset of symptoms
• haemorrhage has been definitively excluded (i.e. Imaging has been performed)
absolute CI
- Previous intracranial haemorrhage
- Seizure at onset of stroke
- Intracranial neoplasm
- Suspected SAH
- Stroke or traumatic brain injury in preceding 3 months
- Lumbar puncture in preceding 7 days
- Gastrointestinal haemorrhage in preceding 3 weeks
- Active bleeding
- Pregnancy
- Oesophageal varices
- Uncontrolled hypertension >200/120mmHg
relative CI
- Concurrent anticoagulation (INR >1.7)
- Haemorrhagic diathesis
- Active diabetic haemorrhagic retinopathy
- Suspected intracardiac thrombus
- Major surgery / trauma in the preceding 2 weeks
parkinsonism w cerebellar signs?
MSA
1. Parkinsonism 2. Autonomic disturbance: erectile dysfunction, postural hypotension, atonic bladder Cerebellar signs: ataxic gait etc
area of the brain affected by
- wernicke’s/korsakoffs
- huntingtons
- PD
- kluver bucy syndrome
· Wernicke’s, korsakoff’s: medial thalamus + mamillary bodies of hypothalamuss
· Hemiballism: subthalamic nucleus of BG
· Huntington’s: striatum of BG (caudate nucleus)
· PD: SN of BG
· Kluver-Bucy syndrome: amygdala
○ Hypersexuality, hyperorality, hyperphagia, visual agnosia
features of parietal lobe lesion
- sensory inattention
- apraxias
- astereognosis (tactile agnosia)
- inferior homonymous quadrantanopia
- Gerstmann’s syndrome (lesion of dominant parietal): alexia, acalculia, finger agnosia and right-left disorientation
features of occipital lobe lesion
• homonymous hemianopia (with macula sparing)
• cortical blindness
visual agnosia
features of temporal lobe lesion
• Wernicke’s aphasia: this area ‘forms’ the speech before ‘sending it’ to Brocas area. Lesions result in word substituion, neologisms but speech remains fluent
• superior homonymous quadrantanopia
• auditory agnosia
prosopagnosia (difficulty recognising faces)
fts of frontal lobe lesion
• expressive (Broca's) aphasia: located on the posterior aspect of the frontal lobe, in the inferior frontal gyrus. Speech is non-fluent, laboured, and halting • disinhibition • perseveration • anosmia inability to generate a list
fts of cerebellum lesion
• midline lesions: gait and truncal ataxia
hemisphere lesions: intention tremor, past pointing, dysdiadokinesis, nystagmus
tx of
- generalised tonic clonic
- absence
- myoclonic
- focal
Generalised tonic-clonic
1. Valproate 2. Lamotrigine, carbamazepine
Absence: valproate or ethosuximide
Myoclonic
1. Valproate 2. Lamotrigine or clonazepam
Focal
1. Carbamazepine or lamotrigine 2. Levetiracetam, valproate or oxcarbazepine
rinne and weber’s
- normal
- sn hearing loss
- conductive hearing loss
Normal
- Air conduction > bone conduction bilaterally - Weber: midline
SN hearing loss
- Air > bone conduction bilat - Lateralises to UNAFFECTED EAR
Conductive hearing loss
- Bone conduction > air conduction in affected ear - Weber's lateralises to affected ear
spinal anatomy
- corticospinal tract
- dorsal columns
- spinothalamic tract
Main desc motor path: CS tract. Crosses in midbrain
2 main sensory paths:
- Dorsal columns: vibration, proprioception. Fibres cross in midbrain - ST tract: pain and temp. Fibres cross immediately in spinal cord.
brown sequard syndrome
Brown-sequard (spinal cord hemisection)
1. Lateral corticospinal tract > same side spastic paresis below the lesion 2. Dorsal columns > same side loss of propioception and vibration 3. Lateral spinothalamic tract > opposite side loss of pain and temp
Loss of motor func and DC sensation ipsilateral because these this stuff croses in midbrain
Loss of pain and temp on the other side because the fibres cross in the SC
Subacute combined degen of SC
Subacute combined degen of spinal cord
- Vit B12 deficiency 1. Lateral corticospinal tracts > bilateral spastic paresis 2. Dorsal columns > bilat loss of proprioception and vibration 3. Spinocerebellar tracts > bilat limb ataxia
friedrich’s ataxia
same damage as SCDC + cerebellar ataxia (intention tremor etc)
anterior spinal artery occlusion
Anterior spinal artery occlusion: affects the level and below
1. Lateral corticospinal tracts > bilateral spinal paresis 2. Lateral spinothalamic tracts > bilat loss of pain and temp sensation
more
- Supplies anterior 2/3 of the SC
Intact dorsal column function because its at the very back of the SC (intact vibration, proprioception)
neurosyphilis
Neurosyphilis (tabes dorsalis): dorsal columns > loss of proprioception and vibration
localising features of focal seizures
- temporal lobe
- frontal lobe
- parietal lobe
- occipital lobe
Temporal lobe (HEAD)
Hallucinations (auditory/gustatory/olfactory)
Epigastric rising/Emotional
Automatisms (lip smacking/grabbing/plucking)
Deja vu/Dysphasia post-ictal)
Frontal lobe (motor) Head/leg movements, posturing, post-ictal weakness, Jacksonian march Parietal lobe (sensory) Paraesthesia Occipital lobe (visual) Floaters/flashes
neurofibromatosis v tuberous sclerosis
NFM - CAFE SPOT cafe au lait axillary/groin freckles fibromas eye hamartoma in iris scoliosis phaeo ocular tumour
tuberous sclerosis - ASHLEAF - ashleaf spots, adenoma sebaceum - shagreen patches, subungal fibromata - heart rhabdomyomas lung lymphandioleiomyomatosis epilepsy (from cortical tubers), developmental problems angiomyolipoma in kidney facial angiofibromas
BPPV
diagnostic?
tx?
dix-hallpike = dx epley = tx
migraine mx - acute and prevention
- Acute: triptan + NSAID or triptan + paracetamol
- Prevention: topiramate or propranolol (prop in women as topiramate teratogenic)
general rule
use 5-ht rec agonists in acute tx
and antagonists in prevention
give prevention if 2 or more attacks a month
myasthenia gravis
- pathophysiology?
- tx?
Abs against ACh receptors
tx: pyridostigmine longacting acetylcholinesterase inhibitor
most common comp after meningitis
SN hearing loss
most common psych problem in PD
depression
association of anti-NMDA receptor encephalitis
ovarian teratoma
pelvic US
wernicke’s encephalopathy features
korsakoff’s features
wernicke's: Confusion Ataxia Nystagmus Ophthamoplegia PEripheral Neuropathy
korsakoff’s: retrograde amnesia, confabulation
selegeline
MAO B inhibitor
what is internuclear ophthalmoplegia
= Due to lesion in medial longitudinal fasciculus
- Located in paramedian area of midbrain and pons
NOTES
Features
• impaired adduction of eye on SAME SIDE as lesion
• horizontal nystagmus of abducting eye on the other side
Causes: MS, vascular disease
sudden worsening of neuro syms in prev stable recent SAH - what is it? Ix?
sudden worsening of syms 72h-8ds after?
rebleed > repeat CT (eg sudden worsening of neuro syms)
Vasospasm
• Transcranial dopplers can be used to evaluate for the presence of vasospasm.
• usually begins no earlier than 72 hours following the onset of bleeding
• peak incidence on days 7-8.
• also present with sudden deterioration in neurological status.
• All patients should receive nimodipine
• and euvolaemia should be maintained to reduce the risk of poor outcomes from vasospasm and ensuing delayed cerebral ischaemia.
HSMN
HSMN type I
- AD - defect in PMP-22 gene (which codes for myelin) - features often start at puberty - motor syms predominate - distal muscle wasting, pes cavus (high arched feet), clawed toes - foot drop, leg weakness often first features
DETAILS
= Hereditary sensorimotor neuropathy (HSMN)
- encompasses Charcot-Marie-Tooth disease (peroneal muscular atrophy).
Over 7 types have been characterised - however only 2 are common to clinical practice
• HSMN type I: primarily due to demyelinating pathology
• HSMN type II: primarily due to axonal pathology
itchy sore ear. O/E canal is inflamed
- what is it?
- mx?
otitis externa
1st line: topical steroid + aminoglycoside
Causes
• infection: bac (Staph aureus, Pseudomonas aeruginosa) or fungal
• seborrhoeic dermatitis
• contact dermatitis (allergic and irritant)
• recent swimming is a common trigger
Features
• ear pain, itch, discharge
• otoscopy: red, swollen, or eczematous canal
Mx:
• topical antibiotic or a combined topical antibiotic with a steroid
• if the tympanic membrane is perforated aminoglycosides are traditionally not used
• if there is canal debris then consider removal
• if the canal is extensively swollen then an ear wick is sometimes inserted
2nd line
• consider contact dermatitis secondary to neomycin
• oral antibiotics (flucloxacillin) if the infection is spreading
• taking a swab inside the ear canal
• empirical use of an antifungal agent
fails to respond to topical antibiotics: refer to ENT.
cataplexy
Laughter > fall/collapse = cataplexy
NOTES
- sudden and transient loss of muscular tone
- caused by strong emotion (e.g. laughter, being frightened).
- Can see phasic muscle jerking around the mouth
- 2/3 of pts with narcolepsy have cataplexy.
○ In context of extreme fatigue cataplexy is very specific for narcolepsy
Features range from buckling knees to collapse.
Ipsilat optic atrophy;
contralat papilloedema
Foster-kennedy syndrome
- Frontal lobe tumour - Ipsilat optic atrophy (direct damage from SOL) - contralat papilloedema
where does ondansetron act
- Ondansetron, granisetron
- Anti-emetics used in mx of chemo-related nausea
- Act in chemoreceptor trigger zone of medulla oblongata
SE: constipation, prolonged QT interval
mnd 2 mx options which is better
- NIV (usually BIPAP): used at nt, survival benefit of 7 months
- Riluzole: prolongs life by 3 mos. Prevents stim of glutamate recs. Mainly used in ALS
triptans
mech of action
se
ci
KEY BITS
= serotonin 5-HT1b and 5-HT1d rec agonists
NOTES
SE: ‘triptan sensations’ - tingling, heat, tightness (e.g. throat and chest), heaviness, pressure
CI: hx of or sig RF for IHD or cerebrovascular disease
common peroneal nerve lesion
CPN lesion»_space; foot drop
- weakness of foot dorsiflexion & foot eversion - weakness of EHL - wasting of anterior tibial and peroneal muscles - sensory loss over dorsum of foot and lower lateral part of leg
gingival hyperplasia 3 drug causes 1 other cause
Drug causes:
- Phenytoin - CCBs (esp nifedipine) - Ciclosporin
Other cause: AML (myelomonocytic and monocytic types)
