Neurology Flashcards
How does a lacunar stroke present?
Pure sensory/pure motor/ataxic hemiparesis
How does a posterior circulation stroke present?
Isolated homonymous hemianopia / LOC / Cerebellar syndrome
What are contraindications to thrombolysis in stroke?
Previous intracranial haemorrhage Seizure at onset of stroke Lumbar puncture in last 7 days Active bleeding Pregnancy Uncontrolled HTN
How long after symptom onset do you need to wait before doing a lumbar puncture in subarachnoid haemorrhage?
At least 12 hours
What are side effects of Levodopa?
Stops being effective Dyskinesia - involuntary movements Psychosis Dry mouth Anorexia Red discolouration of urine
What is the management of myasthenia gravis?
Pyridostigmine
What is the management of Lambert Eaton?
Amifampridine + treat underlying malignancy
How does a parietal lobe lesion present?
Contralateral inferior homonymous quadrantinopia
Inability to identify objects by feel
Inability to perform movements on command
How does a temporal lobe lesion present?
Contralateral superior homonymous quadrantinopia
Wernicke’s aphasia
Inability to recognise familiar sounds/voices
How does an occipital lobe lesion present?
Homonymous heminopia with macular sparing
Visual agnosia - inability to recognise familiar people/objects
How does a frontal lobe lesion present?
Broca’s aphasia
Disinhibition
Perserveration
Anosmia
What is the prophylaxis of a cluster headache?
Verapamil
What is seen on LP in bacterial meningitis?
Raised neutrophils
Raised protein
Low glucose
What is seen on LP in viral meningitis?
Raised lymphocytes
Normal protein
Normal glucose
What is seen on LP in HSV encephalitis?
Raised lymphocytes
Raised protein
Normal glucose
What are features of neurofibromatosis type 1?
Café au lait spots
Lisch nodules
Phaechromocytoma
Axillary/groin freckles
What are features of tuberous sclerosis?
Ash leaf spots
Shagreen patch
Adenoma sebaceum
Subungal fibromata
Developmental delay
Epilepsy
Intellectual impairment
How does a third nerve palsy present?
Eye = down and out position
Ptosis
Fixed dilated pupil (in surgical)
How does a fourth nerve palsy present?
Defective downward gaze - eye is up and in
Vertical diplopia
How does a sixth nerve palsy present?
Defective abduction - eye points inwards
Horizontal diplopia
Freidrich’s ataxia vs. Ataxic telangiectasia?
Both autosomal recessive
Freidrich’s ataxia = Ataxia, kyphoscoliosis, HOCM, pes cavus (high arch)
Ataxia telangiectasia = Ataxia, telangiectasia, IgA deficiency leading to recurrent infections
What are drug causes of IIH?
Lithium, COCP, Steroids, tetracyclines, Isotretinoin
How does a pituitary apoplexy present? How is it managed?
Meningism –> Sudden severe headache, neck stiffness, vomiting
Bitemporal superior quadrantinopia
Features of hypopit –> Hyponatraemia, hypotension (secondary to adrenal insufficiency)
Acute management = IV hydrocortisone (Definitive - surgery)
What is raised in a true seizure?
Prolactin
How can you calculate GCS?
E4
M6
V5
Eyes 4= opens spontaneously 3= open on command 2= open on pain 1= no opening
Motor 6= moving spontaneously 5= localises to pain 4= withdraws from pain 3= abnormal flexion 2= abnormal extension 1= no movement
Verbal 5= Oriented 4= confused but can answer questions 3= not making sense, inappropriate words 2= incomprehensible sounds 1= No speech
Imaging – TIA vs. stroke?
TIA = diffusion weighted MRI and carotid artery doppler ultrasound (Only get CT head if on blood thinning medication) Stroke = non contrast CT , then diffusion weighted MRI
Which cranial nerve palsy occurs in IIH?
6th nerve palsy – inability to abduct affected eye
Which eye defect is associated w/ pituitary tumours?
Bitemproal superior quadrantinopia
Bitemporal hemianopia causes – inferior vs. superior?
Superior = Inferior optic chiasm compression, due to pituitary tumour
Inferior = superior optic chiasm compression, due to craniopharyngioma
Where is the lesion in Wernicke’s aphasia?
Superior temporal gyrus
Where is the lesion in Broca’s aphasia?
Inferior frontal gyrus
Where is the lesion in conduction aphasia?
Arcuate fasciulus
Do temporal and parietal lesions give contralateral or ipsilateral visual defects?
Contralateral
Wernicke’s aphasia vs. Broca’s aphasia?
Wernicke’s aphasia:
Temporal lobe
Fluent speech but sentences make no sense
Impaired comprehension
Broca’s aphasia
Frontal lobe
Non fluent haltered speech but sentences make sense
Normal comphrension
What is conduction aphasia?
Fluent speech but sentences make no sense
Comprehension is normal
What is global aphasia?
Speech is non fluent and halted
Comprehension is impaired
What is the medical management of stroke?
300mg Aspirin daily for 2 weeks
If AF –> wait the 2 weeks before commencing anticoagulants, stop them if already on them
After 2 weeks is up..
Clopidogrel 75mg
Or Aspirin + Dipyridamole
Statin
Anti-hypertensives
If AF –> Start a DOAC
What is an extradural haematoma?
Rupture of the middle meningeal artery
What is internuclear ophthalmoplegia and what is it seen in?
Affected eye cannot adduct however baseline is fine
Vertical diplopia of other eye
Diff to sixth nerve palsy - sixth nerve palsy means eye is always facing inwards
MS
What is seen on LP in MS?
Oligoclonal bands
How is Parkinson’s disease managed?
If motor symptoms affecting quality of life: Levodopa (Co-careldopa or Co-beneldopa)
If motor symptoms not affecting quality of life: Dopamine agonist – Bromocriptine/Cabergoline/Ropinirole .
How does a temporal lobe focal seizure present?
Déjà vu, hallucinations, memory flash backs, lip smacking/grabbing
How does a frontal lobe focal seizure present?
Jacksonian march
Post-ictal weakness
How does an occipital lobe focal seizure present?
vision loss
forced eye closure, eyelid fluttering, eye deviation and nystagmus
What is the management of myasthenia gravis?
Pyridostigmine
Which lobe is associated with Wernicke’s aphasia?
Temporal lobe
What is the prophylaxis of a cluster headache?
Verapamil
How does a 5th nerve palsy present?
Trimeginal neuralgia
Loss of corneal reflex
Loss of facial sensation
Paralysis of mastication muscles
What is a SURGICAL third nerve palsy?
Involvement of the pupil - fixed dilation
Most common cause = posterior communicating artery aneurysm
How is intracranial venous thrombosis treated?
LMWH
Multi system atrophy vs. progressive supranuclear palsy?
Multi system atrophy - postural hypotension, constipation, urinary retention
Progressive supra nuclear palsy - postural instability, impairment of vertical gaze, Parkinsonism, frontal lobe dysfunction
Which lobe does HSV encephalitis characteristically affect?
Temporal lobe
Single ring-enhancing lesion on MRI - most likely cause?
Toxoplasmosis
/Abscess
What are causes of third nerve palsy?
DM Vasculitis - temporal arteritis, SLE Posterior communicating artery aneurysm Weber’s syndrome Cavernous sinus thrombosis
What is the main cause of a PAINFUL third nerve palsy?
Posterior communicating artery aneurysm
Why is the 300mg Aspirin changed to 75mg Clopidogrel after 2 weeks in acute stroke?
Due to risk of haemorrhage transformation
Do you get 2 weeks of 300mg Aspirin in TIA?
No just one off - can give any time in 2 weeks after having the TIA
Which sensations are lost in Syringomyelia?
Pain + temperature
What can withholding Parkinson’s meds cause?
Neuroleptic malignant syndrome
What level does a spinal injury have to occur for patient to be at risk of autonomic dysreflexia?
At or above T6
How is a post-lumbar puncture headache managed?
Caffeine + fluids
What are side effects of sodium valproate?
VALPROATE Valproate Appetite and weight gain Liver failure Pancreatitis Reversible hair loss Oedema Ataxia Tremor + teratogenicity + thrombocytopenia Encephalopathy
Which opioid is best for neuropathic pain?
Tramadol
How does controlled hyperventilation work in raised ICP?
Hyperventilation —> reduce co2 —> Vasoconstriction of cerebral arteries —> reduced ICP
What is the main risk factor for spontaneous idiopathic hypotension?
Marfan’s
Which nerve palsy can raised ICP cause and why?
3rd nerve palsy due to herniation
What does isolated raised protein the CSF indicate?
Guillan-barre syndrome
True seizure vs pseudo seizure
X
Pupil: Unilateral dilation
3rd nerve palsy due to herniation
Pupil: Bilateral dilation
Poor CNS perfusion or bilateral 3rd nerve palsy
Pupil: Unilateral dilation which is cross-reactive? Marcus-Gunn
Optic nerve injury
Ptosis + dilated pupil
3rd nerve palsy
Ptosis + constricted pupil
Horner’s syndrome
What are neurological manifestations of Wilson’s disease?
1) Akathisia/Rigidity-similar to Parkinson’s
2) Pseudosclerosis - tremor
3) Ataxia
4) Dystonic syndrome
Other - drooling, spasticity, chorea
Can also have psychiatric - impulsive, personality changes, depression, psychosis
How does a space occupying lesion present? How is it diagnosed?
Headache - worse on waking, lying down, coughing/straining
May be associated with vomiting
May be evidence of cranial nerve palsies - in particular abducens nerve
Cushing’s triad = bradycardia, hypertension, abnormal breathing
Diagnosis = MRI head.
What is the first line medication for a generalised seizure in a woman of child-bearing potential?
Lamotrigine
How is motor neurone disease managed?
Riluzole
MND with all of the symptoms upper motor neurone lesions?
Primary lateral sclerosis
MND with all of the symptoms only lower motor neurone?
Progressive muscular atrophy
MND with both UMN and LMN?
Amyotrophic lateral sclerosis
Do middle or anterior cerebral artery strokes more commonly cause aphasia and vision?
Middle cerebral artery
Which side of the brain is usually affected in a stroke which leads to aphasia?
Left
Which drugs should be avoided in patients with Myasthenia gravis? And why?
Beta blockers Lithium Phenytoin Penicillamine Abx – gentamicin, macrolides, quinolones,tetracyclines
Can precipitate myasthenic crisis
What further investigation is needed for everyone with a stroke/TIA?
Carotid doppler for consideration of carotid endarterectomy
What is paroxysmal hemicrania? How is it managed?
Attacks of severe unilateral headache
Often associated with autonomic features – Nasal congestion, tearing
Management – Indomethacin
What is Hoover’s sign?
Manoevure to distinguish between organic and non-organic paresis of leg
How is autoimmune encephalitis treated?
First line = IV methylprednisolone + IV immunoglobulins
If no response within two weeks – rituximab/Cyclophosphamide
How does myotonic dystrophy present?
Frontal Balding Mytonic face – droopy, haggard appearance Proximal weakness and muscle wasting Bilateral ptosis Cataracts Dysarthria Myotonia DM1 - distal weakness most prominent DM2 - proximal weakness most prominent
How does degenerative cervical myopathy present and how is it diagnosed?
Pain Loss of motor function (digital dexterity, holding a fork, doing up buttons) Numbness Urinary/faecal incontinence Hoffmann’s sign Diagnosed with MRI cervical spine
What is autonomic dysreflexia?
Occurs in patients who have had a spinal cord injury at or above T6
Hyperstimulation of the nervous system
Often triggered by faecal impaction/urinary retention
Causes extreme HTN, flushing and sweating, dilated pupils, headache, lightheadedness
Can cause haemorrhagic stroke
What are classic features seen in someone with Charcot-Marie-Tooth disease?
(Most common hereditary cause of peripheral neuropathy)
History of frequently sprained ankles
High foot arches
Distal muscle wasting - inverted champagne bottle legs
Hammer toes
Peripheral sensory loss
What are contra indications for Triptans?
Ischaemic Heart disease or cardiovascular disease
Severe or uncontrolled hypertension
Concurrent use of an SSRI
Common triggers for a migraine attack?
- tiredness, stress
- alcohol
- combined oral contraceptive pill
- lack of food or dehydration
- cheese, chocolate, red wines, citrus fruits
- menstruation
- bright lights
How does Huntington’s present?
Initially cognitive/psychiatric/mood problems Then movement disorders: Chorea Eye movement disorders Dysarthria Dysphagia
How is Huntington’s disease managed?
No drug therapies that can affect prognosis
Tetrabenzine can help w chorea
Depression - SSRIs
Psychosis - Antipsychotics
What drugs can lower seizure threshold?
- Antibiotics: Imipenem, penicillins, cephalosporins, metronidazole, isoniazid
- Antipsychotics
- Antidepressents: Bupropion, Tricyclics, Venlafaxine
- Tramadol
- Fentanyl
- Ketamine
- Lidocaine
- Lithium
• Antihistamines
Which nerve is responsible for corneal reflex?
Trigeminal nerve
Management of chronic subdural bleed?
Chronic = burr holes if symptomatc
If on blood thinner, imaging is still needed to rule out haemorrhage stroke even if transient
What is the most common neuro manifestation of sarcoidosis?
Facial nerve palsy
What is herniation?
Intracranial pressure causes normal brain structures to become displaced
Displacement of brain —> Compression of important structures
Most importantly = brain stem.
What is coning?
Brain stem compression
Neurosurgical emergency
Can present with 3rd nerve palsy
Which antiemetic is recommended in migraine?
Metoclopramide
How is Guillan-barre diagnosed?
LP showing rise in protein with normal WCC
Nerve conduction studies showing decreased motor nerve conduction velocity
How can a cerebellar stroke present?
A cerebellar stroke presents similar to vestibular neuritis
Vertigo
Vertical nystagmus
What is the most common complication of meningitis?
Sensorineural deafness
When to start a statin after having a stroke?
48 hours
Management of bacterial meningitis?
In adults = IV Cefotaxime
In infants <3 months and adults >50 years - also add Amoxicillin
Also give Dexamethasone
Don’t give dexamethasone if septic/meningococcal meningitis/under 3 months of age
What are complications of bacterial meningitis?
Sensorineural hearing loss
Focal neurological deficit
Waterhouse-Freidrichsen syndrome
