Neurology Flashcards
Treatment for trigeminal neuralgia?
Carbamazapine 100mg BD starting dose
When do you start antiepileptics?
After second epileptic seizure, OR:
- the patient has a neurological deficit
- brain imaging shows a structural abnormality
- the EEG shows unequivocal epileptic activity
- the patient or their family or carers consider the risk of having a further seizure unacceptable
Choice of antiepileptic for generalised tonic-clonic seizures?
sodium valproate
second line: lamotrigine, carbamazepine
Choice of drug for absence seizures (petit mal)?
sodium valproate or ethosuximide
sodium valproate particularly effective if co-existent tonic-clonic seizures in primary generalised epilepsy
Choice of treatment for myoclonic seizures?
sodium valproate
second line: clonazepam, lamotrigine
Focal seizures medication choice?
carbamazepine or lamotrigine
second line: levetiracetam, oxcarbazepine or sodium valproate
Most common psychiatric diagnosis in PD pts?
Depression (40%)
GCS scale?
Motor response
- Obeys commands
- Localises to pain
- Withdraws from pain
- Abnormal flexion to pain (decorticate posture)
- Extending to pain
- None
Verbal response
- Orientated
- Confused
- Words
- Sounds
- None
Eye opening
- Spontaneous
- To speech
- To pain
- None
Driving rules with seizures/epilepsy?
If one unprovoked seizure: 6 months off
If diagnosis of epilepsy have to be 12 months seizure free before driving.
Driving rules for stroke/TIA?
1 month off
If multiple strokes/TIAs then 3 months (and inform DVLA)
Craniotomy driving rules?
1 year, unless pituitary trans-sphenoid then 6 months.
Syncope driving rules?
simple faint: no restriction
single episode, explained and treated: 4 weeks off
single episode, unexplained: 6 months off
two or more episodes: 12 months off
Adverse effects of phenytoin?
Acute:
initially: dizziness, diplopia, nystagmus, slurred speech, ataxia
later: confusion, seizures
Chronic:
common: gingival hyperplasia (secondary to increased expression of platelet derived growth factor, PDGF), hirsutism, coarsening of facial features, drowsiness
megaloblastic anaemia (secondary to altered folate metabolism)
peripheral neuropathy
enhanced vitamin D metabolism causing osteomalacia
lymphadenopathy
dyskinesia
Idiosyncratic:
fever rashes, including severe reactions such as toxic epidermal necrolysis hepatitis Dupuytren's contracture* aplastic anaemia drug-induced lupus
Stroke thrombolysis window?
4.5hrs
Thrombectomy consideration guidelines?
If ischaemic and PACS:
- Thrombectomy within 6 hrs AND thrombolysis
- If ‘potential to salvage’ seen on imaging then can be within 6-24hrs
If ischaemic and posterior circulation
- 6-24hrs and ‘potential to salvage’
Features of common peroneal nerve injury?
weakness of foot dorsiflexion
weakness of foot eversion
weakness of extensor hallucis longus
sensory loss over the dorsum of the foot and the lower lateral part of the leg
wasting of the anterior tibial and peroneal muscles
What nerve is the common fibular nerve a part of?
Common peroneal
It is prone to damage
How to remember brain lobes for quadrantinopia?
PITS (Parietal-Inferior, Temporal-Superior)
If there is a homonymous hemianopia is it the same side or opposite side tract that is damaged?
Opposite
If it is incongruous it would be the optic tract
Diagnostic criteria for migraine without aura?
A At least 5 attacks fulfilling criteria B-D
B Headache attacks lasting 4-72 hours* (untreated or unsuccessfully treated)
C Headache has at least two of the following characteristics:
- unilateral location*
- pulsating quality (i.e., varying with the heartbeat)
- moderate or severe pain intensity
- aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)
D During headache at least one of the following:
- nausea and/or vomiting*
- photophobia and phonophobia
E Not attributed to another disorder (history and examination do not suggest a secondary headache disorder or, if they do, it is ruled out by appropriate investigations or headache attacks do not occur for the first time in close temporal relation to the other disorder)
DCM symptoms?
Pain (affecting the neck, upper or lower limbs)
Loss of motor function (loss of digital dexterity, preventing simple tasks such as holding a fork or doing up their shirt buttons, arm or leg weakness/stiffness leading to impaired gait and imbalance
Loss of sensory function causing numbness
Loss of autonomic function (urinary or faecal incontinence and/or impotence) - these can occur and do not necessarily suggest cauda equina syndrome in the absence of other hallmarks of that condition
Hoffman’s sign: is a reflex test to assess for cervical myelopathy. It is performed by gently flicking one finger on a patient’s hand. A positive test results in reflex twitching of the other fingers on the same hand in response to the flick.
Temporal ateritis presentation?
Typically patient > 60 years old Usually rapid onset (e.g. < 1 month) of unilateral headache Jaw claudication (65%) Tender, palpable temporal artery Raised ESR
Do you need contrast in your MRI if looking for demyelination?
Yep
Management of PD?
For first-line treatment:
- if the motor symptoms are affecting the patient’s quality of life: levodopa
- if the motor symptoms are not affecting the patient’s quality of life: dopamine agonist (non-ergot derived), levodopa or monoamine oxidase B (MAO‑B) inhibitor
If a patient continues to have symptoms despite optimal levodopa treatment or has developed dyskinesia then NICE recommend the addition of a dopamine agonist, MAO‑B inhibitor or catechol‑O‑methyl transferase (COMT) inhibitor as an adjunct.
Dopamine receptor agonists SEs? (e.g. cabergoline)
Have been associated with pulmonary, retroperitoneal and cardiac fibrosis.
What is Amaurosis fugax?
Amaurosis fugax is a form of stroke that affects the retinal/ophthalmic artery
Primary open angle glaucoma visual field defect?
Peripheral field loss
Bitemporal hemianopia causes and upper or lower?
lesion of optic chiasm:
upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour
lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma
Most common presenting Symptom of posterior circulation stroke?
Dizziness
Bilateral acoustic neuromas are associated with….?
NF2
What is cataplexy?
temporary loss of motor function following emotion e.g. laughing lots and lost function of legs
Reflexes and corresponding nerve routes?
Ankle S1-S2
Knee L3-L4
Biceps C5-C6
Triceps C7-C8
Features of a Lacunar stroke?
purely motor e.g. clumsy hand
purely sensory
mixed
Features of Total anterior circulation stroke?
unilateral weakness of the face, arm and leg; as well as a homonymous hemianopia and a symptom of higher cerebral dysfunction.
Features of posterior circulation stroke?
cerebellar or brainstem syndrome, or loss of consciousness, or an isolated homonymous hemianopia.
Features of partial anterior circulation stroke?
two of: unilateral weakness, homonymous hemianopia and higher cerebral dysfunction.
Dermatomes?
C2 Posterior half of the skull (cap)
C3 High turtleneck shirt
C4 Low-collar shirt
C5 Ventral axial line of upper limb
C6 Thumb + index finger
- Make a 6 with your left hand by touching the tip of the thumb & index finger together - C6
C7 Middle finger + palm of hand
C8 Ring + little finger
T4 Nipples
- T4 at the Teat Pore
T5 Inframammary fold
T6 Xiphoid process
T10 Umbilicus
- BellybuT-TEN
L1 Inguinal ligament
- L for ligament, 1 for inguinal
L4 Knee caps
Down on aLL fours - L4
L5 Big toe, dorsum of foot (except lateral aspect)
- L5 = Largest of the 5 toes
S1 Lateral foot, small toe
- S1 = the smallest one
S2, S3 Genitalia
MS management?
Acute episode
- High dose steroids
Beta-interferon has been shown to reduce the relapse rate by up to 30%. Certain criteria have to be met before it is used:
- relapsing-remitting disease + 2 relapses in past 2 years + able to walk 100m unaided
- secondary progressive disease + 2 relapses in past 2 years + able to walk 10m (aided or unaided)
- reduces number of relapses and MRI changes, however doesn’t reduce overall disability
Other drugs used in the management of multiple sclerosis include:
- glatiramer acetate: immunomodulating drug - acts as an ‘immune decoy’
- natalizumab: a recombinant monoclonal antibody that antagonises Alpha-4 Beta-1-integrin found on the surface of leucocytes, thus inhibiting migration of leucocytes across the endothelium across the blood-brain barrier
- fingolimod: sphingosine 1-phosphate receptor modulator, prevents lymphocytes from leaving lymph nodes. An oral formulation is available]
Baclofen and gabapentin for spasticity.
Most appropriate antiemetic for PD pts?
Domperidone
What is Lhermitte’s sign/syndrome in MS?
Parasthesia to the limbs on neck flexion
If someone has had a ?TIA on anticoagulants what is the appropriate management?
Urgent CT Head
Rescue opiate for use in neuropathic pain?
Tramadol
Side effect of excess vitamin B6 (pyridoxine) ingestion
Peripheral neuropathy
Featurs of motor neurone disease?
There are a number of clues which point towards a diagnosis of motor neuron disease:
- fasciculations
- the absence of sensory signs/symptoms*
- the mixture of lower motor neuron and upper motor neuron signs
- wasting of the small hand muscles/tibialis anterior is common
Other features:
- doesn’t affect external ocular muscles
- no cerebellar signs
- abdominal reflexes are usually preserved and sphincter dysfunction if present is a late feature
Management of ?TIA - resolved, within 7 days.
Patients who have a clinically suspected TIA should be loaded on aspirin therapy (300mg) immediately and be referred for specialist review within 24 hours of presentation. NICE recommend also giving gastric protection (e.g. PPI) if clinically indicated.
Features of acoustic neuroma?
The classical history of vestibular schwannoma includes a combination of vertigo, hearing loss, tinnitus and an absent corneal reflex. Features can be predicted by the affected cranial nerves:
- cranial nerve VIII: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
- cranial nerve V: absent corneal reflex
- cranial nerve VII: facial palsy
Adverse effects of valproate?
Adverse effects:
- Teratogenic
- P450 inhibitor
- gastrointestinal: nausea
- increased appetite and weight gain
- alopecia: regrowth may be curly
- ataxia
- tremor
- hepatotoxicity
- pancreatitis
- thrombocytopaenia
- hyponatraemia
- hyperammonemic encephalopathy: L-carnitine may be used as treatment if this develops
What % does the carotids need to be for endarterectomy?
> 50% at least (or 70%) - according to criteria reported
Contrast of non contrast CTH for stroke workup?
Non-contrast
Saturday night palsy presents with what? What nerve is damaged?
Inability of wrist extension, radial nerve damaged.
Causes of brain abscesses?
Extension of sepsis from middle ear or sinuses, trauma or surgery to the scalp, penetrating head injuries and embolic events from endocarditis.
Features of brain abscesses?
headache
- often dull, persistent
fever
- may be absent and usually not the swinging pyrexia seen with abscesses at other sites
focal neurology
- e.g. oculomotor nerve palsy or abducens nerve palsy secondary to raised intracranial pressure
other features consistent with raised intracranial pressure
- nausea
- papilloedema
- seizures
Acute treatment for migraine?
offer combination therapy with an oral triptan and an NSAID,
OR an oral triptan and paracetamol
NSAIDs only if the above fails
How long after an en injury would you expect a subdural haematoma to present?
4-7 weeks
Contraindications for triptans?
patients with a history of, or significant risk factors for, ischaemic heart disease or cerebrovascular disease
Types of drugs that may cause hallucinations in Parkinson’s disease?
Dopamine agonists, e.g. ropinirole
Features of third nerve palsy?
- eye is deviated ‘down and out’
- ptosis
- pupil may be dilated (sometimes called a ‘surgical’ third nerve palsy)
Difference in Neurofibromatosis and Tuberous sclerosis?
Tuberous sclerosis:
- Epilepsy
- Neurocutaneous features: Ash leaf spots; Adenoma sebaceum; Shagreen patches; Subungal fibromata
- Developmental issues
- Retinal hamartomas
Neurofibromatosis:
- Axillary/groin freckles
- Phaeochromocytoma
- NF2 May have acoustic neuromas
- iris hamartoma
Alternative to clopidogrel post stroke?
Dipyridamole and aspirin lifelong
What does Hoffmans sign show?
UMN issue - i.e. MS or DCM
Sciatic nerve root supply?
L4-5, S1-3
What cytotoxics cause lung fibrosis?
Methotrexate (also liver)
Bleomycin
What cytotoxics cause peripheral neuropathy?
Cisplatin
Vincristine, vinblastine
What cytotoxics cause cardiomyopathy?
Anthracyclines (e.g doxorubicin)
What cytotoxics cause hypomagnesaemia?
Cisplatin
Difference in AFP levels in seminomatous testicular cancer?
Non-seminomatous - raised AFP
Seminomatous - not raised
Cancer that is least likely to be hereditary?
Gastric
Divide by what for sc dose of morphine (from oral)?
divide by 2
Control of hiccups in palliative care?
Haloperidol or Chlorpromazine
Breakthrough dose of opiates?
1/6 of the daily dose
Malignant bone pain management?
Opiates, bisphosphonates and radiotherapy
CKD opiate choices?
Alfentanil, buprenorphine and fentanyl
Asthma diagnosis investigations according to age?
Patients >= 17 years
patients should be asked if their symptoms are better on days away from work/during holidays. If so, patients should be referred to a specialist as possible occupational asthma
all patients should have spirometry with a bronchodilator reversibility (BDR) test
all patients should have a FeNO test
Patients 5-16 years
all patients should have spirometry with a bronchodilator reversibility (BDR) test
a FeNO test should be requested if there is normal spirometry or obstructive spirometry with a negative bronchodilator reversibility (BDR) test
Patients < 5 years
- diagnosis should be made on clinical judgement
How long do you wait to anticoagulate if someone has AF and a stroke?
2 weeks
What are the adrenaline doses (adult)
anaphylaxis: 500mcg (0.5ml 1:1,000) IM
cardiac arrest: 10ml 1:10,000 IV or 1ml of 1:1000 IV
