Neurology Flashcards
Motor neuron disease
Symptoms/signs
Management
Complications
a combination of upper motor neuron (UMN) and lower motor neuron (LMN) findings.
No sensory or bladder/bowel deficits!!!
Limb weakness Poor gait/balance Painful muscle spasms Head drop/poor posture Hyperreflexia Progressive dysphagia, dysarthria Emotional incontinence May present with frontotemporal dementia
Clincal diagnosis, consider EMG
Riluzole + treatment of symptoms
Respiratory failure
Brain tumor symptoms?
headaches
seizures (fits)
persistently feeling sick (nausea), being sick (vomiting) and drowsiness
mental or behavioural changes, such as memory problems or changes in personality
progressive weakness or paralysis on one side of the body
vision or speech problems
Multiple sclerosis Symptoms/signs Investigations Management Complications
Classically presents in white women, aged between 20 and 40 years, with temporary visual or sensory loss.
Visual disturbance - pain, blurring, loss of colour discrimination
Sensory phenomenon - patch of wetness/burning/tingling/numbness, hemibody sensory loss , Lhermitte’s sign(tingling may occur in the limbs on neck flexion), trigeminal neuralgia. symptoms may worsen in heat or with exercise
Cerebellar dysfunction signs - ataxia, nystagmus, intention tremor
Weakness e.g. in legs, foot dragging, spasticity, cramping, paraplegia
Urinary frequency, bowel dysfunction
Optic neuritis
MRI brain and spinal cord = 1st line = periventricular plaques MRI brain, demyelinating lesions in the spinal cord, particularly the cervical spinal cord lumbar puncture (oligoclonal IgG bands)
acute attack = IV steroids - methylprednisolone
Prevention of future attacks = disease-modifying therapies(B interferon)
spasticity = baclofen
State 3 causes of raised ICP
Symptoms, ivestigations?
Too much cerebrospinal fluid Bleeding into the brain, Swelling in the brain Aneurysm Brain or head injury, Brain tumor Infections such as encephalitis or meningitis Hydrocephalus High blood pressure Stroke
Headache
Blurred vision
Weakness, vomiting
LP, MRI
Myasthenia gravis Symptoms/signs Investigations Management Complications
Antibodies to the POST-SYNAPTIC
ACh receptor at the neuromuscular junction in skeletal muscle
muscle weakness that worsens with continued activity and improves on rest.
Ptosis, diplopia Bulbar symptoms - dysphagia, dysarthria Proximal limb weakness Facial paresis Dyspnea - resp involvement
Serum AchR antibody analysis = 1st line
Acetylcholinesterase inhibitor = pyridostigmine
70% patients have thymic hyperplasia
10% have a thymoma
No ocular involvement if anti Musk antibodies present
Idiopathic intracranial hypertension/ pseudomotor cerebri
Symptoms/signs
Investigations
Management
mainly in overweight women of childbearing years
- Visual field loss, decreased visual acuity, transient visual obscurations, retrobulbar pain, photophobia, diplopia
- Ocular motility defects - cranial nerve 6 paresis
- Optic disc swelling/papilloedema
- Headaches
- Tinnitus
eliminating causal factors, such as drugs - vitamin A, danazol, tetracyclines
Weight reduction
acetazolamide when indicated
Refractive cases = CSF shunt
Optic nerve sheath fenestration for visual loss
Cauda equina syndrome
Symptoms
Management
Compression of spinal roots L2 and below often due to intervertebral disc herniation or tumour
Loss of bladder and anal sphincter control - finding it hard to start peeing/cant pee, cant control when you poo
Saddle anesthesia - numbness around genitals or anus
Weakness or numbness in both legs that is severe/getting worse
Bilateral Sciatica
Surgery
- Cauda equina compression causes flaccid paralysis with loss of reflexes. Cord compression usually causes spastic paralysis with brisk reflexes. Both cause sensory and power loss.*
What is syringomelia?
Symptoms?
Development of fluid filled cyst (syrinx) within your spinal cord.
Bilateral loss of sensitvity to pain and temperature
What is brown sequard syndrome?
Hemisection of the spinal cord
Weakness of paralysis on one side of the body
Loss of sensation on the other side - read up more on condition
WERNICKE’S ENCEPHALOPATHY
Symptoms/signs
Management
Classic triad = confusion, ophthalmoplegia, ataxia
Causes by b1 deficiency. Therefore other signs may be seen e.g peripheral neuropathy (dry beri beri) high output cardiac failure (wet beri beri) and koraskoff syndrome
Oculomotor findings - gaze palsies, sixth nerve palsies, and impaired vestibulo-ocular reflexes
Acute = Thiamine + magnesium + multivitamins
Bells Palsy
Symptoms/signs
Management
Unilateral facial palsy
Abscence of constitutional symptoms
Deviation of mout to normal side
Upper motor neurone lesion like stroke is forehead sparing! Bell’s palsy is not
- dry eye, hyperacusis and dysgeusia can also occur!!
High-dose corticosteroids/prednisolone!!!
Migraine
Symptoms + managament
nausea/vomiting
Photophobia, phonophobia
Unilateral, pulsatile, aura
Acute = NSAIDs, Triptans if severe
anti-CGRP(e.g erenumab) in disabling cases
Prophylaxis = topiramate, propranolol, amitriptyline
Parkinsons disease
Symptoms
Management
Bradykinesia, resting tremor
Masked facies, micrographia
MPTP in illegal drugs = RF
Levodopa = FIRST line control of motor symptoms
MAO-B inhibitor (rasagiline, selegiline), dopamine agonists(pramipexole, ropinirole), amantadine to increase dopamine availability, carbidopa/levodopa, amantadine,
Tension headache
Management
Acute = analgesia. Chronic = TCAs (e.g. amitriptyline, doxepin), CBT
Subarachnoid hemorrhage
Symptoms/signs
Investigations
Management
Depressed levels of consciousness
Neck stiffness, muscle aches and other signs of meningismus
Photophobia, nausea, vomiting
Rfs: age, HTN, alcohol, smoking, connective tissue disease, cocaine use, family history, ADPKD
Urgent non-contrast CT - hyperdense areas in the subarachnoid space/basal cisterns
If CT is negative with high suspicion = LP = bloody CSF (xanthochromia
Nimodipine + analgesia
Consider endovascular coiling/surgical clipping
Subdural hemorrhage
Symptoms
Investigations
Management
RFS: age>65, trauma, anticoagulant use/coagulopathy,
Headache, nausea/vomiting, confusion
Non contrast CT - crescent shaped hemorrhage. Hypodense on CT if chronic
Acute hematoma of small size = monitoring + prophylactic antiepileptics
Acute of large size = surgery + anti-epileptics
Extradural hemorrhage
Symptoms/signs
Investigation
Management
Transient loss of consciousness followed by recovery period then rapid deterioration
Scalp hematoma
Non-contrast CT - hyper dense blood collection that doesn’t cross suture lines
Management - craniotomy
Caused by rupture of middle meningeal artery
Axillary nerve lesion results in?
Flattened deltoid
Loss of arm abduction at shoulder
(Loss of sensatoon over deltoid and lateral arm)
Musculocutaneous nerve lesion results in?
Weakness of forearm flexion
Loss of sensation over lateral forearm
Radial nerve lesion results in?
Wrist drop(loss of extension) (Loss of sensation over posterior arm, forearm and dorsal hand)
Median nerve lesion results in?
Loss of wrist flexion, flexion of lateral 3.5 fingers(POPES blessing when you try and make a fist), thumb opposition(APES hand), lateral lumbricals
Loss of sensation thenar eminence and lateral 3.5 digits
(M) edian nerve affects thu(M)b
Ulnar nerve lesion results in?
Ulnar claw on digit extension
Loss of sensation medial 1.5 fingers & hypothenar eminence
Loss of wrist flexion, flexion of medial fingers, abduction and adduction/interossei, medial 2 lumbricals
u(L)nar (L)ittle finger
Erbs palsy affects which muscles?
How does it present?
- deltoid, infraspinatus, biceps brachii
- arm hangs by side, medially rotated, pronated
Klumpke palsy
Presentation?
Total claw hand
Infants - upward force on arm during delivery
Adults - grabbing a tree branch to break a fall
Thoracic outlet syndrome presentation
Vascular compromise to arm- pain, pallor, edema, ischemia
Due to extra cervical rib or pancoast tumour
Winged scapula results from a lesion to?
Long thoracic nerve - serrattus anterior affected
Clawing occurs with _ lesions of median and ulnar nerves
Distal
Iliohypogastric nerve lesion
Presentation?
Cause?
Burning/tingling radiating to inguinal and suprapubic region
Abdominal surgery
Genitofemoral nerve lesion
Presentation?
Cause?
Decrease in upper medial thigh and anterior thigh sensation
Absent cremasteric reflex
Laparoscopic surgery
Lateral femoral cutaneous nerve lesion
Presentation
Cause
Decrease in thigh sensation anterior and Lateral
Tight clothing, obesity, pregnancy, pelvic procedures
Obturator neve lesion
Presentation
Cause
Decrease in medial thigh sensation and adduction
Pelvic surgery
Femoral nerve lesion presentation
Decreased leg extension
Decreased sensarion to anterior thigh, medial leg
Common peroneal nerve lesion presentation?
Foot drop
Tibial nerve lesion
Presentation
Cause
Loss of sensation on sole
Foot everted at rest
Cant stand on tip toes
Knew trauma, tarsal tunnel syndrome
Superior gluteal nerve lesion presentation
Trendelenburgs sign
injury during IM injection
Inferior gluteal nerve lesion presentation
Cause
Difficulty climbing stairs, rising from seated position, loss of hip extension
Posterior hip dislocation
Pudendal nerve lesion presentation
Cause
Decrease in sensation in perieum
Fecal/urinary incontinence
Stretch injury during childbirth
Prolonged cycling
Horseback riding
L4 radiculopathy results in?
weakness of knee extension, decrease in patellar reflex
L5 radiculopathy results in?
weakness of dorsiflexion, difficulty in heel walking, pain down lateral leg
S1 radiculopathy results in?
weakness of plantar flexion, difficulty in toe walking, decreased achilles reflex, pain down back of leg
Alzheimers investigations
Management
CT/MRI - may show atrophy especially in temporal and parietal lobes, enlarged ventricles, senile plaques, neurofibrillary tangles
Mild = cholinesterase inhibitors e.g. donepezil, galantamine, and rivastigmine
2nd line/ severe = memantine (NMDA receptor antagonist)
Vascular dementia
Symptoms
Investigations
Management
Focal neurological signs - UMN signs
Symptom onset that was Abrupt, stepwise or related to stroke
Signs of frontal cognitive syndrome
CT/MRI - white matter hypodensities, evidence of old infarcts
Antiplatelets, lifestyle changes, control of other comorbidities e.g. hypertension with medication
Fronto-temporal dementia
Symptoms
Investigations
Management
Disinhibition and significant changes in behavior and personality early in the disease
Loss of language fluency and comprehension - primary progressive subtype - progresses to mutism or agnosia
Memory impairment, disorientation, apraxias - later on
CT/MRI - Atrophy of frontal AND temporal lobes
symptomatic treatment e.g. agitation with benzodiazepines
Lewy Body Dementia
Symptoms
Investigations
Management
Physical: parkinsonism symptoms: bradykinesia, rigidity, tremor
Cognitive: attention, memory, etc
Psychiatric symptoms e.g. hallucinations, delusions
REM sleep disturbances
Rule out other types of dementia with CT/MRI
Differentials - PSP/Steele Richardson(would have limited upgaze), Parkinson’s
Symptomatic management
Normal pressure hydrocephalus
Symptoms
Investigations
Management
Triad of dementia, gait apraxia(magnetic with feet glued to the floor) and urinary incontinence. Gait apraxia does not respond to levodopa.
CT/MRI shows ventricular enlargement out of proportion to sulcal atrophy
LP - normal CSF pressures
LP or continuous lumbar CSF drainage for several days may cause improvement
if this fails = surgical ventriculo-peritoneal shunting
CREUTZFELDT-JAKOB DISEASE
Symptoms
Investigations
Management
Subacute dementia, ataxia and or startle-induced myoclonic jerks
Psychiatric symptoms - depression may occur
Visual changes may occur
Parkinsonism symptoms my occur
EEG may show periodic sharp wave complexes
Diabetic neuropathy management
Without pain = glycemic control and supportive measures
With pain = Pregabalin or gabapentin and or duloxetine + glycemic control
Siezure investigations?
1st line = EEG
HOWEVER
If a patient has a seizure and does not recover to baseline/fluctuating consciousness or has focal neurological deficits, then a CT BRAIN should be performed to rule out structural lesions/ pathology!!!
Essential tremor
Symptoms
Investigations
Management
a progressive tremor of the upper extremities. Usually absent at rest and present during posture and intentional movements No other associated symptoms Gradual onset over years Symmetrical Problems with fine motor tasks
Clinical diagnosis- rule out aneamia and hypothyroidism
Propranolol or primidone = 1st line. Deep brain stimulation = 2nd
Trigeminal neuralgia
Symptoms
Management
sharp pain running from the mouth to the jaw or less commonly as pain from the upper lip to the orbit. Symptoms in an exclusively ophthalmia (V1) distribution typically referred to as headache.
Management - in order of escalation = anticonvulsants -> baclofen -> microvascular decompression/ surgical ablation
1st line treatment for delirium?
haloperidol 0.5mg PO
lorazepam 0.5mg PO if patient has parkinsons or lewy body dementia
avoid IV treatment
What are the different types of epilepsy?
Epilepsy treatment
Side effects of epilepsy drugs?
How do you treat status epilepticus?
- Generalised: this includes tonic-clonic, myoclonic, tonic, atonic, and absence.
- partial/focal seizures (in simple focal siezures patient is conscious but may experience twitching in muscle group, changes in sensation such as smell, hallucinations. in complex focal seizures, impaired consciousness occurs.
- > Generalised seizures 1st line = sodium valproate. give lamotrigine to women of childbearing age!!
- > Focal seizures 1st line = carbamazepine/ lamotrigine(always give in young women)
Side effect of lamotrigine = SJS
Side effects of carbamezapine = neutropenia and osteoporosis
Treat in community with buccal midazolam or rectal diazepam. IV lorazepam in hospital
Guillain barré cause?
Symptoms?
Investigations?
usually triggered by infections like URTI, Gastroenteritis(usually due to campylobacter jejuni).
2-3 weeks after infection it causes peripheral neuropathy (ascending paresthesias and bilateral limb weakness, HYPOREFLEXIA, back or leg pain and respiratory distress may occur).
Do nerve conduction studies
