Neurology Flashcards
1
Q
Findings suggesting not mononeuritis multiplex
A
Would do full exam but…
in generalised inflammatory neuro condition would expect some degree of arreflexia
2
Q
Management of neuropathic pain
A
Amitryptiline
Pregabalin/gabapentin
Duloxetine
Topical therapies eg capsasum
3
Q
Further investigation of neuropathy
A
NCS
NMG - shows any regeneration
MRI neck if worried about radiculopathy
4
Q
Causes of (sensory) peripheral neuropathy
(Chronic conditions/Nutrition/Toxins/Autoimmune)
A
Chronic; Diabetes, Hyperthyroidism, malignancy
Nutrition: B12, B1, B6
Toxins; Uraema, ETOH, Chemo, ABx
Auto immune: CIDP, sarcoid, ANCA +ve vasculitis, RA
5
Q
What bedside tests could you do to narrow down possible causes of peripheral neuropathy?
A
Opthalmoscopy ?diabetic retinopathy
Urine dip ?glucose
BM
6
Q
Blood tests to Ix peripheral neuropathy
A
FBC ?macro anaemia
U+Es ?uraemia
LFTs ?alcohol
TFTs
B12
Auto immune screen, ESR
immunoglobulins, electrophoresis
HbA1c
7
Q
Further Examination if ?stroke
A
AF - heart, pulse
Right Carotids ?bruit
Heart murmur
BP
8
Q
Further Ix for stroke
A
MRI
ECG/24 hr/ 5 day tape
Echo ?Structural issue
BP
Carotid doppler
9
Q
What does macular sparing (in homonymous hemianopia) suggest?
A
Posterior cerebral artery stroke (as occipital lobe gets blood from MCA)
10
Q
Significance of corneal reflex
A
Lost in trigeminal nerve palsy but remaisn if hemispheric issue
11
Q
Limb signs you would expect if ?Stroke
A
increased tone
weakness
sensory loss
hyperreflexia
12
Q
Secondary prevention of stroke
A
ACEi/BP control
statin
antiplatelet
13
Q
What does high stepping gait/foot drop suggest?
A
Sensory ataxia
14
Q
What questions are important when taking history in Charcot Marie Tooth?
A
FHx
Auto dom
would expect family member to be affect
15
Q
What tests do you do to investigate for Charcot Marie Tooth?
A
Neurophysiology - demyleinating vs axonal
Genetic testing
16
Q
Why is the distinction between demyelinating and axonal neuropathies helpful or
important in the investigation of Charcot-Marie-Tooth?
A
Multiple types of CMT
Type I - demyelinating
may mutations can cause CMT phenotype
17
Q
What treatments are available for CMT?
A
No disease modifying treatments
Need to diagnose and test family members
MDT
Physio
Orthotics eg to help drive, correct foot drop
OT
18
Q
Examination findings for CMT
A
Orthotics
Foot drop/high stepping gait
Distal muscle wasting
High arched feet/pes cavus
inverted champagne bottle (preserved thigh muscle)
19
Q
Cause of sudden onset myelopathy (spastic paraparesis)
A
Spinal infarct
20
Q
What other features would suggest MS?
A
Cranial nerve - optic neuropathy RAPD with pale optic disc, intranuclear opthalmoplegia
hx of relapse/remittign
21
Q
Ix ?MS
A
MRI brain and spine
LP - oligoclonal bands
22
Q
Initial tx of MS
A
High dose IV steroids eg methylprednisolone (needs neg urine ip and infection ruled out first). Counsel for steroids
23
Q
What to counsel for steroids?
A
Insomnia
Personality change/mania
GI upset/ulcer
AVN of hip
High BMs
24
Q
Differentials of cerebellar syndrome
A
Stroke
MS
ETOH
Genetic/paraneoplastic
25
What imaging do you use to Ix cerebellar syndrome
MRI
much better than CT at visualising posterior fossa
26
Management of cerebellar syndrome?
MDT
PT to maintain strength and function
OT for adaptions at home
27
Lifestyle advice for cerebellar syndrome
Occupation - risk, adaptions
PMHx and meds - anything worsening sx eg dizziness
ETOH will exacerbate cerebellar sx
28
Cerebellar ataxia vs Sensory ataxia
CA - nystagmus, dysarthria, wide gait
SA - impaired sensation, proprioception and vibration
29
Rhombergs positive - Sensory or Cerebellar ataxia?
Sensory
30
UMN signs
weakness without atrophy
hyperreflexia
increased tone
spasticity
rigidity
tremor
chorea
31
Differentials for MND
Spinal muscular atrophy (X linked)
Kennedys disease
Multifocal motor neuropathy with conduction block
32
Ix for ?MND
EMG
MRI
33
Features of MND
Upper and lower motor neurone, axonalwasting and fasiculation, weaknessusually spastic but cna be flaccid
Asymmetrical
speech disturbance
Rapid and aggressive
Cognitive/behaviour disturbance - frontotemporal dementia ax
NO SENSORY LOSS or cerebellar
34
Features of Multifocal motor neuropathy with conduction block
Distal weakness
Clumsiness
35
Management of MND/ALS
Specilist neuro team and neuro nurses
**Riluzole** (expnesive and only short increase in survival)
MDT/PT/OT
SALT/dietician - weight, swallowing ?PEG
Resp - early morning ABG, **FVC** (may need **NIV, cough assist**)
Comms aids
Cognitive testing
36
Compressive causes of Brown Sequard
Tumour (Primary/secondary)
Disc Herniation
Spinal stenosis
37
Auto immune Causes of Brown Sequard
MS
SLE
Sarcoid
38
Infective causes of Brown Sequard
HIV
Varicella
39
Nutritional causes of Brown Sequard
B12 deficiency
Copper deficiency
Hereditary spastic paraparesis
40
Time frames of causes of myelopathy
Minutes - vascular
Days - Traums/disc herniation
Days- weeks - Demylenation/lupus
Month - Nutrition
Years - genetic
41
What is Brown Sequard
Weakness/paralysis one side,
Loss of sensation other
42
Nutritional deficincies causing peripheral neuropathy
B1
B6
B12
43
Drug causes of peripheral neuropathy
ETOH
TB meds (ethambutol, isoniazid)
ABx - Nitro, Dapsone, Metro
Cardio - Hydralazine, Amiodarone, Propanalol
Phenytoin, Clochinine, Chloroquinine
44
Immune causes of peripheral neuropathy
RA
GPA
CIDP
GBS
HIV
45
Follow up ix for Diabetic neuropathy
Fundoscopy
HbA1c
L/S bp
Urinalysis
46
Differentials of Motor Neurone Disease
Spinal Muscular Atrophy
Kennedys (peri oral fasiculation)
47
Managament of Motor Neurone Disease
Riluloze
MDT
esp SALT ?PEG
Resp ?NIV
48
Weakness + wasting + fasiculations +UMN
NO SENSORY disturbance
Most likely Motor Neurone Disease
49
What is Kennedys syndrome
**X linked spino bulbar** muscular atrophy
Only LMN
**Peri oral fasiculations** are pathognomonic
X linked recessive w **androgen insentivity**
Progresses v slowly (unlike ALS)
50
Cerebellar syndrome + hyperreflexia + up going plantars
Spinocerebellar syndrome
51
What specifically would you like to know in Hx for cerebellar syndrome to ax cause?
Fhx - Fredreichs or ataxia telangectasia
Drugs - phenytoin
Stroke risk factors
Relapsing remitting sx ?MS
Endo probs
Red flags malginancy ?paraneoplastic
ETOH
52
Muscle wasting + scars + deformity + older patient + weakness + NO sensory issues +LMN signs
Post polio syndrome
53
How would you manage GBS?
Monitor FVC, if FVC \<1.5 ?vent support, ABG
IV immunoglobulin/plasma exchange
If unwell ICU
54
How would you manage CIDP?
Neuropathic pain management
DMARD
Steroids/IV immunogloubin/DMARDS
MDT
55
Presentation fo Hereditary Spastic Parapesis
Increased tone
Non sustained clonus
Brisk reflexes
Promixal weakness
Spastic gait
Decreased vibration and proprioception, sensation
56
Differentials of Spastic Parapesis
Acute w back pain - Compressive eg **disc hernia**
Sudden - vasular eg **spinal stroke** (althought spascity comes later)
Days - inflammatory - **MS, transverse myelitis, VZV**
Chronic - **B12**
**HIV, TLV1, tumours, lateral sclerosis**
57
How would you investigate spastic parapesis
MRI spine
Genetic testing
Reversible causes eg B12, infection
58
Differentials of flaccid paralysis
1) MND, poliomyelitis
2) Cauda equina
3) trauma/tumour abcess
4) Motor neuropathies
: inflam - GBS, CIPD
Infectious - HIV, lyme disease
Toxins - lead, arsenic
Metabollic - diabetes
Drugs - gold, ciclosporin
Congenital - CMT
5) NMJ - MG, Lambert Eaton
6) Myopathies
59
Casues of spastic paraparesis
1) Demyelination - MIS
2) Cord compression
3) Trauma
4) Anterior horn cell disease
5) Cerebral palsy
60
Cuases of spastic paraparesis with sensory level
1) Cord compression
2) Cord infarct
3) Transverse myelitis
61
Spastic paraparesis and dorsal column loss (joint position sense and vibration):
Demyelination (Multiple sclerosis)
Friedreich’s ataxia
Subacute combined degeneration of the cord
Syphilis
Parasagittal meningioma
Cervical myelopathy
62
Spastic paraparesis and spinothalamic loss (pain and temperature):
Syringomyelia
Anterior spinal artery infarction
63
Spastic paraparesis and cerebellar signs:
Demyelination (Multiple sclerosis)
Friedreich’s ataxia
Spinocerebellar ataxia
Arnold Chiari Malformation
Syringomyelia
64
Spastic paraparesis and small hand muscle wasting
Cervical myelopathy (C5-T1)
Anterior horn cell disease (motor neuron disease)
Syringomyelia
65
Spastic paraparesis and UMN signs in upper limbs:
Cervical myelopathy (above C5)
Bilateral strokes
66
What other questions would you ask of PD?
Hallucinations
Cognitive dysfunction
67
Differentials of Parkinsonism
Lewy Body - sx preceding by cog impairment or hallucinations
MSA - postural hypotension, urinary incontinence, cerebellar signs
PSNP - can't look up
Vascular Parkinsonism - lower limbs, B/L sx
68
Non motor sx of Parkinsons
Anosmia
Cognitive impairment
Mood disorder
Pain
Constipation
69
Treatment options for Parkinsons
* anti cholinergics
* COMT inhibitors
* MOAB
* Dopaminergics
* levodopa
* dopamine agonists
70
Side effects of dopaminergic tx for Parkinsons
Impulsivitiy
Disinhibition
71
Side effects of dopaminergic treatments for Parkisnsons
Levodopa - on/off
Dose related dyskinesia
72
Dx if Parkinsons sx + cerebellar signs
MSA
73
74
Features suggestive of migraine
Unilateral
throbbing
Light aversion
phonophobia
nausea
Aura
Triggers
75
Red flags of headache
Thunderclap headache
Reaches maximal pain within 1-2 mins
Confusion
Pyexia
Neck stiffness photophobia
Early morning/ postural cariation
Neurology
1st headache \>55
76
Causes of chorea
| (tic like sudden movements)
Stroke - acute onset, asymmetric
Hyperglycaemia, polycythaemia
SLE
Huntingtons
Syndehams chorea (Group A strep)
Meds - levodopa, neuroleptics
77
Tell me about Huntingtons
trinucleotide repeat
Genetic anticipitation - affected earlier/ more severe each generation
No disease modifying treatments
**Autosomal dominant**
AIDs
78
How can you differentiate between NMJ disordersn (eg myasthenia) and myopathy
ACH antibodies, anti MUSK
EMG - MG decreases with repetitive stimulation
79
How do you manage myasthenic crisis?
Steroids
FVC monitoring ?ventilation
d/w ICU
80
Management of myasthenia
CT chest ? thymoma ?resection
Pyridostigmine
Steroids/steroid sparing agents
IV immunoglobulin
?thymectomy
81
Management of Freidrichs ataxis
**Echos, ECGS** (inc exercise induced) - risk of arrhytmias and cardiomyopathy. May need ICD
MDT
Genetic counselling
Auto recessive, problem with frataxin gene
Check B12 and vit E as deficiency can mimic
82
83
Anterior cerebral artery stroke
Contralateral hemiparesis and sensory loss, lower extremity \> upper
84
Middle cerebral artery stroke
Contralateral hemiparesis and sensory loss, upper extremity \> lower
Contralateral homonymous hemianopia
Aphasia
85
Posterior cerebral artery stroke
Contralateral homonymous hemianopia with macular sparing
Visual agnosia
86
Weber's syndrome (branches of the posterior cerebral artery that supply the midbrain) stroke
Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity
87
Posterior inferior cerebellar artery (lateral medullary syndrome, Wallenberg syndrome)
Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus
88
Anterior inferior cerebellar artery (lateral pontine syndrome)
Symptoms are similar to Wallenberg's (see above), but:
Ipsilateral: facial paralysis and deafness
89
Basilar artery
'Locked-in' syndrome
90
TACS
All three:
1. Unilateral weakness and/or sensory deficit of the face, arm and leg
2. Homonymous hemianopia
3. Higher cerebral dysfunction (dysphasia, visuospatial disorder)
91
PACS
Two of:
1. Unilateral weakness (and/or sensory deficit) of the face, arm and leg
2. Homonymous hemianopia
3. Higher cerebral dysfunction (dysphasia, visuospatial disorder)
92
POCS
| (brainstem/cerebellum)
One of POCS:
* Cranial nerve palsy and a contralateral motor/sensory deficit
* Bilateral motor/sensory deficit
* Conjugate eye movement disorder (e.g. horizontal gaze palsy)
* Cerebellar dysfunction (e.g. vertigo, nystagmus, ataxia)
* Isolated homonymous hemianopia
93
LACS
One of the following:
Pure sensory stroke
Pure motor stroke
Sensori-motor stroke
Ataxic hemiparesi
94
Lateral medullary (WALLENBURG) syndrome
Occlusion of posterior inferior cerellar artery
Ipsilateral: cerebellar, horners, loss of trigeminal pain/sensation
Contra: loss of pain and sensation
95
Lower limb dermatomes
96
Upper limb dermatomes
97
Shoulder abduction myotome
C5
98
Shoulder adduction myotome
C6/7
99
Elbow flexion myotome
C5/6
100
Elbow extension myotome
C7
101
Wrist extension myotome
C6
102
Finger extension mytome
C7
103
Finger and thumb abduction myotome
T1 (ulnar and median respectively)
104
Presentation of syringomyelia
Weakness/**wasting small muscles hand**
**Loss of reflexes** upper limbs
Loss of **_pain and temp_** (spinothalamic) in upper limbs and chest, **preserved joint and vibration**
**Charcot joints**
**Upgoing plantars**, kyphoscoliosis
Can have cerebellar, cranial nerve or horners
105
What is syringomyelia
Fluid filled expanding caivty in C spine
Expands ventrally, so affects
1. spinothalamic pain and temp, then
2. anterior horn cells - LMN
3. Corticospinal - UMN signs below syrinx
usually spares dorsal column proprioception
ax with Arnold Chiari/spina bifida
106
Hereditary Sensory Motor Neuropathy - Charcot
Features
107
Causes of predominatnly sensory peripheral neuropathy
DM
ETOH
Drugs - isoniazid, vincristine
Vit deficiency - B12, B1
108
Causes of predominantly motor peripheral neuropathy
GBS, botulism (acute)
Lead toxicity
Porphyria
HSMN
109
Causes of mononeuritis multiplex
DM
SLE/RA
PAN/Churg Strauss
HIV
Malignancy
110
Presentation of Friedreichs Ataxia
Young, **wheelchair**, **visual/hearing** impairment
Pes cavus, kyphoscoliosis
**B/L cerebellar ataxia**
Leg wasting, absent reflexes, up going plantars
Posterior column - vibration and joint positiion
**High arched palate**
HCOM
DM
111
Inheritance of Fredreichs
Auto recessive
Onsent in teenage years
20 year surival from diagnosis
HCOM, dementia
112
Facial Nerve Palsy + VI palsy
MS + stroke
| (Pons affected)
113
Facial nerve palsy + V, VI ,VII palsy and cerebellar signs
Tumour eg acoustic neuroma
Cerebellar pontine angle
114
Facial nerve palsy + VIII palsy
cholestaetoma/abcess
| (auditory/facial canal)
115
Facial nerve palsy + scars/parotid mass
Tumour/trauma
116
Features of Bells Palsy
Rapid onset 1-2 days
HSV-1
Swelling and compresion of nerve within facial canal causes demyelination and conduction block
More common and worse outcome in pregnancy
**All of the face so LMN**
(UMN spares forehead)
117
Management of facial nerve palsy
Steroids if within 72 hour of onset
Aciclovir if severe
Eye protection
70-80% fully recover
118
Causes of facial nerve palsy
Herpes Zoster - Ramsay Hunt
Mononeuropathy - Lyme disease, DM, sarcoid
Tumour/trauma
MS/stroke
B/L: GBS, Sarcoidm Lyme, MG, B/L Bells
119
120
Features of MG
B/L ptosis, snarl trying to smile
Nasal speech
Proximal muscle weakness with fatiguability
Sternotomy scars from thymectomy
121
Lambert Eaton
Diminshed reflexes - become **brisker after exercise**
Lower limb girdle weakness
Ax with malignancy eg **SCLC**
Antibodies block pre synaptic calcium channel
**Anti voltage gated calcium antibodies**
122
Causes of B/L extra ocular palsies
| (Opthalmoplegia)
* MG
* Graves
* Mitochondiral cytopathies eg Kearns Sayre syndrome
* Miller Fisher GBS
* Cavernous sinus pathology
123
Causes of B/L ptosis
Congenital
Senile
MG
MD
Kearns Sayre
B/L Horners
124
Features of Tuberous Sclerosis
Skin • Ash leaf, Shagreen
Respiratory • Cystic lung disease
Abdominal • Renal enlargement - polycystic ,renal angiomyolipomata • Transplanted kidney • Dialysis fistulae
Eyes • Retinal phakomas (dense white patches) in 50%
CNS • Mental retardation may occur • **Seizures**
**Auto dom**
Railroad track on XR Skull
125
Skin changes Tuberous Sclerosis
Angiofibromas
Periungual fibroma
Shagreen Patches
Ash Leaf Marks
126
Ash Leaf
Neurofibromatosis
127
Shagreen patch
Varying spider neavi usually on lower back
Tuberous Sclerosis
128
Features of neurofibromatosis
Cutaneous neurofibromas
6 or more cafe au lait
Axillary freckling
Lisch nodules - harmatomas iris
**HTN** (RAS, phaeochromocytoma)
**Lung fibrosis**
Neuropathy with **palable enlarged nerves**
**Visual** impairment
Auto dom
129
Cafe au lait spots
\>6 neurofibromatosis
130
Lisch nodules
Neurofibromatosis
131
Cutaneous neurofibromas
Neurofibromatosis
132
Features of Horners syndrome
| (PEAS)
**P**tosis
**E**nopthalmos
**A**nhydrosis
**S**mall pupil (myosis)
+- flushed skin ipsiaterally to Horners pupul due to loss of sympathetic vasomotor tone
Look for scare in nek
133
Causes of Horners syndrome
Tumour in neck/chest
Pancoast tumour
Carotid dissection
Stroke
Syringomyelia
134
3rd nerve palsy
Partial ptosis
eye is down and out due to unopposed lateral rectus and superior oblique
135
Causes of a pale disc
PALE DISCS
**P**RESSURE\* : tumour, glaucoma and Paget’s
**A**TAXIA: Friedreich’s ataxia
**LE**BER’S
**D**IETARY: ↓B12, **D**EGENERATIVE: retinitis pigmentosa
**I**SCHAEMIA: central retinal artery occlusion
**S**YPHILIS and other infections, e.g. CMV and toxoplasmosis
**C**YANIDE and other toxins, e.g. alcohol, lead and tobacco
**S**CLEROSIS\* : MS
136
ARMD
Drusens spots
wet if new vessel formation
Risk factors • Age, white, FHx, smoking
• Wet - higher incidence CAD/Stroke
Tx • Ophthalmology referral
• Wet - intravitreal anti‐VEGF ( can increase CBV CB risk)
Prognosis • most blind in affected eye within 2 years
137
Retinitis pigmentosa
Blind, loss of peripheral vision, begins with reduced nigth vision
"bone spicule" pigmentation, optic atrophy, ax cataracts
ax with ataxia - Fredreichs, Kearns-Sayre, deafness - Kearns Sayre
Cogenital/acquired (post retinits), vit A can slow progression
138
Causes of proximal myopathy
polymyositis/dermatomyositis. SLE, vasculitis, RA, systemic sclerosis. Cancer (paraneoplastic: carcinomatous neuromyopathy) Drugs (statins, steroids) Infections (bacterial infections, HIV, CMV, EBV, Hepatitis) Endocrine (thyroid, addisons, osteomalacia, cushings, acromegaly, diabetic amyotrophy) Toxins (alcohol)
139
Anti epileptics in pregnancy
* If seizure-free before conception , likely to remain so
* Most have normal pregnancies
* Some low risk, but inadequate seizure control is higher risk - aim for lower appropriate dose
* **Valproate is contraindicated** in preg ( birth defects and developmental disorders, cardiac+NTD ) so only if really necessary
* Lamotrogine effectiveness may be reduced by oestrogen contraception
**Lamotrigine or Keppra are best**
* Risks of Status to m+b - more common in preg due to preg + sometimes changing meds , but also reg repeated seizures carries risk (esp tonic-clonic)
* Remember folate replacement
