Neurology Flashcards
1
Q
Pathological basis of meningitis
A
Inflammation of the pia and arachnoid mater
Microorganisms infect the CSF
Not always an infective cause e.g. can be post surgical
2
Q
Symptoms of meningitis
A
TRIAD: Stiffness of the neck, Severe headache, and Fever (infective)
Photophobia
Meningococcal meningitis: petechial non blanching rash
3
Q
Two most common bacterial causes of meningitis in adults
A
Diplococcus bacteria: Neisseria Meningitidis (meningococcal meningitis) -ve (non-blanching rash) Streptococcus Pneumoniae (pneumococcal meningitis) +ve
4
Q
Viral causes of meningitis
A
Mumps virus
Coxsackie virus
HSV
5
Q
Drug induced meningitis
A
NSAIDs
Trimethoprim
6
Q
Diagnosis of meningitis
A
Blood culture
Brain imaging
CSF sample (lumbar puncture at L4) for microscopy and sensitivity testing
- bacteria: turpid yellow colour, neutrophil polymorphs, raised protein, low glucose
- viral: lymphocytes, normal protein, normal glucose
- TB: lymphocytes, raised protein, low/normal glucose
PCR swab for viral
7
Q
Treatment for bacterial meningitis
A
If suspected, give broad spectrum antibiotics before tests come back
Cephalosporins: IV ceftriaxone/IV cefotaxime
Over 50/immunocompromised: add IV amoxicillin
8
Q
Treatment for viral meningitis
A
Supportive treatment
Self-limiting in 4-10 days
Acyclovir for HSV meningitis
9
Q
Types of STROKE
A
Cerebral infarction (ischaemic stroke)
Intracerebral haemorrhage
Subarachnoid haemorrhage
10
Q
Transient ischaemic attack Px
A
SUDDEN ONSET
Brief episode of neurological deficit
Symptoms are maximal at onset (usually last 5-15 mins)
LASTS <24 HOURS
WITHOUT INFARCTION (temporary, focal cerebral ischaemia)
11
Q
TIA epidemiology
A
MALES
African-Caribbean heritage (HTN and atherosclerosis)
12
Q
TIA and ischaemic stroke RFs
A
Age HTN Smoking Diabetes Combined pill Atrial fibrillation Male
13
Q
Causes of a TIA
A
Atherothromboembolism
- carotid artery = main cause (carotid bruit)
Cardioembolism
- atrial fibrillation
- post-MI
- valve disease/prosthetic
Hyperviscosity
Hypoperfusion
14
Q
DDx TIA
A
Hypoglycaemia Migraine aura Focal epilepsy Vasculitis Syncope
15
Q
Clinical presentation of a TIA (carotid territory Sx - 90%)
A
Amaurosis fugax Aphasia Hemiparesis Hemisensory loss Hemianopic visual loss
16
Q
Amaurosis fugax
A
Temporary occlusion of retinal artery (temporary retinal hypoxia)
Unilateral sudden vision loss
Transient (minutes)
“like a curtain descending”
17
Q
ABCD2 score
A
Risk of stroke after TIA
Age Blood pressure Clinical features (unilateral weakness, speech disturbance w/o weakness) Duration (<60 mins = 1, >60 mins = 2) Diabetes mellitus
18
Q
Ix for TIA
A
CLINICAL DIAGNOSIS based off symptoms description
Bloods: glucose, FBC (polycythaemia), ESR (vasculitis), U&Es, cholesterol, INR (if on warfarin)
Imaging: diffusion weighted MRI or CT
Carotid imaging: doppler ultrasound, MR/CT angiography if stenosis
ECG
Echocardiogram
19
Q
IMMEDIATE Mx for TIA
A
Aspirin 300mg
Refer to specialist (within 24h of symptom onset)
20
Q
Long term Mx of TIA
A
Control CV risk factors
- BP control
- Smoking cessation
- Statin e.g. simvastatin
- No driving (1 month)
Antiplatelet therapy: CLOPIDOGREL
AF: anticoagulation (e.g. warfarin)
> 70% carotid stenosis: carotid endartectomy (reduces stroke risk by 75%)
21
Q
Stroke
A
rapid onset neurological deficit lasting for over 24 hours
poor blood flow to the brain causes cell death
22
Q
Two types of stroke
A
Ischaemic (85%)
Haemorrhagic (15%)
1st line Ix: CT HEAD
23
Q
Penumbra
A
Infarcted area in ischaemic stroke is surrounded by a swollen area (oedema) which can regain function with neurological recovery
24
Q
Causes of ischaemic stroke
A
Small vessel occlusion by thrombus
Atherothromboembolism (e.g. from carotid artery)
Cardioembolism (AF, post-MI, valve disease, IE)
Hyperviscosity
Vasculitis
Hypoperfusion
25
Clinical Px of ischaemic stroke (cerebral infarct)
Depends on the site (ACA, MCA, PCA)
```
Contralateral sensory loss
Contralateral hemiplegia: initially flaccid, becomes spastic (UMN lesion)
UMN facial weakness (forehead sparing)
Dysphasia
Homonymous hemianopia
Visuo-spatial deficit
```
Weakness may recover gradually
26
Human homunculus blood supply
ACA (medial supply): lower limbs
MCA (lateral supply): face, upper limbs
27
Clinical Px of ischaemic stroke (brainstem infarct)
```
Quadriplegia
Locked-in syndrome
Facial numbness and paralysis
Vision disturbances
Vertigo, nausea
Cerebellar signs
```
28
Lacunar infarct
```
Small infarcts
Occur in single small perforating artery supplying a subcortical area
- Internal capsule
- Basal ganglia
- Thalamus
- Pons
```
Px one of: sensory loss, weakness (unilateral), ataxic hemiparesis, dysarthria (motor speech)
29
Ischaemic stroke and intracerebral haemorrhage Ix
CT scan
- distinguish ischaemic from haemorrhagic
- site of infarct
- identify mimics
Diffusion-weighted MRI:
- more sensitive
- CT may be -ve in first few hours
- unclear diagnosis
Bloods: glucose (rule out hypoglycaemia), FBC (polycythaemia), ESR (vasculitis), U&Es, Cholesterol, INR (warfarin)
ECG: AF, MI
30
Immediate ischaemic stroke Mx
EXCLUDE HAEMORRHAGE
loading dose: Aspirin 300mg
Admit to acute stroke unit
Thrombolysis (must happen within 4.5 hours of symptom onset for risk/benefit ratio)
- IV alteplase
- MANY contraindications
31
Long term ischaemic stroke Mx
Aspirin 300mg for 2 weeks
Clopidogrel daily long term
Anticoagulation (e.g. warfarin) for patients with AF
Rehabilitation
32
Intracerebral haemorrhage epidemiology
around 10% of strokes
| higher mortality: up to 50%
33
Pathophysiology of increased ICP in an intracerebral haemorrhage
Pooling blood puts pressure on skull, brain & blood vessels - healthy tissue can die
CSF obstruction - hydrocephalus
Midline shift
Tentorial herniation
Coning (compression of the brainstem)
34
Intracerebral haemorrhage RFs
HYPERTENSION
Anticoagulation
Thrombolysis
Age, Alcohol, Smoking, Diabetes
35
Two causes of intracerebral haemorrhage
HYPERTENSION: stiff and brittle vessels are prone to rupture + microaneurysms
SECONDARY to ischaemic stroke (bleeding after reperfusion)
36
Clinical presentation of intracerebral haemorrhage
- similar to ischaemic stroke -
```
Pointers to haemorrhage:
SUDDEN LOSS of consciousness
SEVERE HEADACHE
MENINGISM
COMA
```
37
Intracerebral haemorrhage Tx
Stop anticoagulants immediately
Control BP
Reduce ICP
- mechanical ventilation
- IV MANNITOL
Neurosurgical evaluation if:
- hydrocephalus
- coma
- brainstem compression
38
Vessels in subarachnoid space
circle of willis arteries
39
Vessels in subdural space
bridging veins (drain from cortex into dural venous sinus > IJV)
40
Vessels in extradural space
middle meningeal artery
41
most common type of brain aneurysm
```
berry aneurysm (90%) - bursting most commonly results in SUBARACHNOID
(70-80% of SAH cases) at circle of willis (ACA, MCA, PCA)
```
42
SAH typical age
35-65
43
RFs associated with berry aneurysms
Polycystic kidney disease
Coarctation of aorta
Connective tissue disorders
44
SAH RFs
```
Hypertension
Known aneurysm
Previous aneurysmal SAH
Berry aneurysm RF e.g. PKD
Smoking, alcohol
```
45
Berry aneurysms make up 70-80% of SAH cases, what are the other causes?
Traumatic injury
ARTERIOVENOUS MALFORMATIONS (15%): abnormal tangle of blood vessels connecting arteries and veins
IDIOPATHIC (15-20%)
46
Complications of SAH
Rebleeding
| Hyponatraemia
47
SAH pathophysiology
Tissue ischaemia
- less blood to reach tissue > less O2 + nutrients > cell death
Raised ICP
Space-occupying lesion (puts pressure on brain)
Meningism
- blood irritates meninges
- can obstruct CSF outflow (hydrocephalus)
Vasospasm
- bleeding irritates other vessels
- ischaemic injury
48
SAH symptoms
SUDDEN ONSET EXCRUCIATING HEADACHE
- "Thunderclap" "worst ever headache"
- Typically OCCIPITAL
Nausea, vomiting, collapse, loss of consciousness
Seizures, vision changes, coma
Mild photophobia/neck stiffness
Sentinel headache before main rupture in some cases
49
SAH signs
Meningeal irritation:
- Neck stiffness
- Kernig's sign
- Brudzinski's sign
Retinal bleed -/+ papilloedema (worse prognosis)
Focal neurological signs e.g. 3rd nerve palsy
Increased BP
50
DDx in SAH
Headache
- MIGRAINE
- Cluster headache
MENINGITIS
Intracerebral haemorrhage
51
CT scan in SAH
ASAP
Detects >95% of SAH in first 24 hours
Findings of subarachnoid or intraventricular blood
"Star" shaped sign
52
Lumbar puncture in SAH
Only do a lumbar puncture if NORMAL ICP (to prevent CONING)
Indication: if -ve CT but strong suspicion of SAH remains
- after 12 hours
Finding: XANTHOCHROMIA (yellowish CSF with RBC breakdown products e.g. bilirubin)
53
Mx in SAH
Immediately refer to neurosurgeon
IV fluids (maintain cerebral perfusion)
Hydrocephalus: ventricular drainage
NIMODIPINE: calcium antagonist, reduces vasospasm (reducing ischaemic risk)
Surgery: if angiography has shown aneurysm, endovascular coiling
54
Main cause of subdural haematoma
Head trauma
55
Px SDH
MASSIVE LATENT INTERVAL (weeks to months)
[often cannot remember the traumatic injury as it was so long ago]
Symptoms: fluctuating level of consciousness, drowsiness, headache, confusion
Signs: raised ICP, seizures, neurological signs (hemiparesis, unequal pupils)
56
SDH epidemiology + risk factors
BABIES: "shaking baby syndrome" traumatic injury
DEMENTIA, ELDERLY, ALCOHOLICS
- BRAIN ATROPHY (veins are more susceptible to rupture)
- more accident-prone (risk of falls) + epileptics
Anticoagulation
57
Ix SDH
CT:
- CRESCENT SHAPED (BANANA)
- Unilateral
- MIDLINE SHIFT
58
Subdural haemotoma pathophysiology
Bridging vein bleeding > haemotoma > bleeding stops > weeks/months later = haemotoma AUTOLYSES = massive increase in ONCOTIC and OSMOSTIC pressure = WATER SUCKED IN = haemotoma enlarges
Gradual rise in ICP over WEEKS
Midline structures shifted away from side of clot = tentorial herniation + coning
59
Ix SDH
```
CT:
Haematoma:
- CRESCENT SHAPED (BANANA)
- Unilateral
- MIDLINE SHIFT
```
MRI scan
60
Mx SDH
SURGERY
depends on clot SIZE, CHRONICITY, CLINICAL PICTURE
- clot evacuation
- craniotomy
IV MANNITOL (reduce ICP)
Reverse clotting abnormalities
Address cause of trauma (falls, abuse)
61
EDH epidemiology
mostly in YOUNG PEOPLE
more common in MALES
62
EDH pathophysiology
After LUCID INTERVAL:
- rapid rise in ICP
- midline shift
- tentorial herniation
- coning
63
EDH clinical Px
```
Lucid interval
Rapidly declining GCS (consciousness level)
Increasingly severe headache
Vomiting
Seizures
```
64
EDH Ix
CT:
- LENS SHAPED (LEMON)
- Doesn't cross suture lines (trapped in skull)
- Unilateral
- Midline shift
Skull X-Ray: fractures
65
EDH clinical Px
```
Lucid interval
RAPIDLY DECLINING GCS (consciousness level)
Increasingly severe HEADACHE
VOMITING
SEIZURES
Hemiparesis
UMN signs
COMA
Deep and irregular breathing (due to coning)
DEATH (respiratory arrest)
```
66
EDH Ix
```
CT:
Haematoma:
- LENS SHAPED (LEMON)
- DOESN'T cross suture lines (trapped in skull)
- Unilateral
- Midline shift
```
Skull X-Ray: fractures
67
What is a migraine?
RECURRENT throbbing UNILATERAL headache often preceded by an AURA and associated NAUSEA, VOMITING, and VISUAL CHANGES
68
Most common cause of episodic headaches
Migraines
69
Migraines epidemiology
90% onset before 40 years
| More common in females (roughly 3x)
70
Migraines RFs
Genetics (FHx)
Female
Age (majority of first ones occur in adolescence)
71
Migraine triggers
```
CHOCOLATE
Chocolate
Hangovers
Orgasms
Cheese
Oral contraceptives
Lie-ins
Alcohol
Tumult i.e. loud noises
Exercise
```
72
Migraine prodrome
yawning, cravings, mood/sleep changes
73
Aura
precedes migraine attack
variety of symptoms:
visual disturbance e.g. lines, dots, zig-zags
somatosensory e.g. parasthesia, pins & needles
migraines can be classified WITH or WITHOUT AURA
74
Aura preceding migraine attack
variety of symptoms:
visual disturbance e.g. lines, dots, zig-zags
somatosensory e.g. parasthesia, pins & needles
migraines can be classified WITH or WITHOUT AURA
75
Migraine diagnostic criteria
```
ATLEAST 2 OF:
Unilateral pain (usually 4-72 hours)
Throbbing-type pain
Moderate-severe intensity
Motion sensitivity
```
PLUS, AT LEAST 1 OF:
Nausea/vomiting
Photophobia/phonophobia
ALSO: NORMAL EXAMINATION & NO ATTRIBUTABLE CAUSE
76
Migraine Ix
Clinical diagnosis with few or no Ix required
Certain cases may require rule outs e.g. blood tests, CT/MRI, lumbar puncture
77
Migraine red flag indications for CT/MRI
```
Thunderclap headache
Change in pattern
Abnormal neuro exam
Onset > 50 years
Epilepsy
Posteriorly located headache
```
78
Migraine treatment
1st line acute = ORAL TRIPTANS E.G. SUMATRIPTAN
- c/i in IHD + uncontrolled HTN
- s/e: arrhythmias, angina
NSAIDs e.g. naproxen
Anti-emetics e.g. prochlorperazine
AVOID OPIOIDS & ERGOTAMINE
79
Migraine PROPHYLAXIS
Required if >2 attacks per month OR if acute meds are required >2 per week
Triad:
1. BETA BLOCKERS e.g. propranolol
2. TCAs e.g. amitriptyline
3. Anti-convulsant e.g. topiramate
80
Triptan MOA
5-HT receptor
at trigeminal nerve, prevents neuropeptide release that would lead to
- vasodilation
- neurogenic inflammation
- PAIN
on cranial vasculature, leading to vasoconstriction
81
Cluster headache definition
Episodic headaches lasting from 7 days up to 1 year (usually 2-3 weeks) with pain-free periods that last around 4 weeks
Considered the MOST DISABLING of primary headaches
82
Cluster headache epidemiology
Much rarer than migraines
More common in MALES (x4)
Typically affects adults with onset 20-40 years
83
Cluster headache risk factors
SMOKER
ALCOHOL
Male
Genetics (FHx)
84
Px of cluster headache
RAPID ONSET EXCRUCIATING PAIN, CLASSICALLY AROUND THE EYE
- other common areas = temples or forehead
UNILATERAL and LOCALISED PAIN
- rises to a crescendo
IPSILATERAL AUTONOMIC FEATURES
- watery & bloodshot eye
- miosis +/- ptosis
85
Management of acute cluster headache attack
15L 100% O2 for 15 minutes via non-rebreather mask
TRIPTANS e.g. SUMATRIPTAN
(Analgesics are UNHELPFUL)
86
Cluster headache prevention
1st LINE: VERAPAMIL (CCB)
Prednisolone
Reduce alcohol consumption & stop smoking
87
Is a tension headache episodic or chronic?
Usually chronic but can be episodic
- episodic <15 days/month
- chronic >15 days/month (for atleast 3 months)
88
Tension headache triggers
```
Stress
Sleep deprivation
Bad posture
Hunger
Eyestrain
Anxiety
Noise
```
89
Tension headache Px
Usually at least 1 of the following:
- BILATERAL
- Pressing/tight & NON-PULSATILE (like an elastic band)
- mild/moderate intensity
NO AURA, vomiting, or sensitivity to head movement
can be "pressure" behind eyes but the pain isn't localised here
90
Tension headache Mx
Avoidance of triggers & stress relief
Symptomatic relief: NSAIDs (aspirin, ibuprofen), paracetamol
AVOID OPIOIDS
limit analgesics to no more than 6 days per month to reduce the risk of medication-overuse headaches
91
Examples of secondary headaches
```
Giant cell/temporal arteritis
Sentinel headache
Thunderclap headache
Trauma
Medication overuse
Trigeminal neuralgia
Systemic infection
Meningitis
```
92
Epilepsy diagnostic criteria
At least 2 UNPROVOKED seizures occurring MORE THAN 24 HOURS apart
93
Epilepsy aetiology
2/3rds are IDIOPATHIC
```
Other:
Cortical scarring e.g. trauma, stroke, infection
Tumours/space-occupying lesions
Alzheimer's
Alcohol withdrawal (delirium tremens)
```
94
Epilepsy risk factors
FHx
Premature birth
Abnormal cerebral blood vessels
Drugs e.g. cocaine
95
Aura in seizures
Part of the seizure where the patient is AWARE and often PRECEDES other manifestations
- e.g. strange feelings in gut, deja vu, strange smells, flashing lights
- often implies a PARTIAL SEIZURE
96
Post-ictal period of seizures
PERIOD AFTER SEIZURES
Headache, confusion, myalgia, sore tongue (often bitten)
Post-ictal Todd's palsy = temporary weakness after focal seizure in MOTOR CORTEX
Dysphagia following temporal lobe seizure
97
Types of seizure
Primary generalised (40%)
- generalised = whole cortex
- ALWAYS ASSOCIATED WITH LOSS OF CONSCIOUSNESS & LACK OF AWARENESS
- BILATERAL and SYMMETRICAL motor manifestations
Partial (focal) (60%)
- SINGLE LOBE IN ONE HEMISPHERE e.g. temporal lobe
- often seen with underlying structural disease
- may later progress to generalised
98
Types of primary generalised seizure
Tonic = rigid, stiff limbs
Clonic = rhythmic muscle jerking
TONIC-CLONIC (Grand Mal) = stereotypical shaking seizures
Myoclonic = isolated jerking of a limb
Atonic = opposite to tonic: loss of muscle tone (floppy)
Absence (Petit Mal) = blank stare, common in childhood + increases risk of developing tonic-clonic as adult
99
Types of partial (focal) seziure
Simple partial seizure = no effect on consciousness or memory, no post-ictal symptoms
Complex partial seizure = memory/awareness is affected at some point, most commonly TEMPORAL (speech, memory, emotion), post-ictal confusion in temporal (frontal has swift recovery)
Partial seizure with secondary generalisation = 2/3 patients with partial seizures will develop generalised (usually T-C)
100
Temporal lobe seizure characteristics
AURA (80%)
Automatisms e.g. lip smacking
Anxiety, out-of-body experiences
101
Frontal lobe seizure characteristics
Motor features e.g. posturing, peddling legs
JACKSONIAN MARCH (seizures march up/down the motor homunculus)
Post-ictal Todd's palsy (starts distally in a limb and works its way up to the face)
102
Parietal lobe seizure characteristics
Sensory disturbances e.g. tingling/numbness
103
Occipital lobe seizure characteristics
Visual phenomena e.g. spots, lines, flashes
104
Non-epileptic seizure characteristics
Entirely situational e.g. metabolic disturbances, low Na+, hypoxia
Typically longer with closed eyes + mouth
DO NOT OCCUR DURING SLEEP
do not involve incontinence or tongue biting
Pre-ictal anxiety symptoms
105
Epilepsy Ix
ELECTROENCEPHALOGRAM (EEG)
Not diagnostic but can help support a diagnosis/type of epilepsy
MRI/CT HEAD
- rules out other potential causes e.g. space-occ lesion
BLOODS
- rules out other potential causes e.g. metabolic
Genetic testing
e.g. juvenile myoclonic epilepsy
106
Wernicke's encephalopathy
Depletion of thiamine (Vitamin B1)
Classic triad:
Confusion
Ataxia
Opthalmoplegia
Sign: Asterixis (liver flap) - sign of metabolic encephalopathy
107
Epilepsy Tx: generalised tonic-clonic, tonic, atonic
Sodium valproate for males & women unable to bear children
Lamotrigine for females of childbearing potential
108
Epilepsy Tx: myoclonic
Sodium valproate for males & women unable to bear children
Levetiracetam/Topiramate for females of childbearing potential
109
Epilepsy Tx: absence
Sodium valproate for males & women unable to bear children
Ethosuximide for females of childbearing potential
110
Epilepsy Tx: partial (focal)
Lamotrigine
111
Example of primary brain tumour
Much less common than secondary
Gliomas e.g. astrocytoma (most common)
Others e.g schwannoma
112
Most common origins of secondary brain tumours
```
Non-small cell lung cancers (most common)
SCLC
Breast
Renal cell carcinoma
GI
```
113
Alzheimer's disease epidemiology
Most common type of dementia
| Mainly affects >65
114
Parkinson’s disease patho
Progressive destruction of dopaminergic neurones in the substantia nigra of the basal ganglia
Basal ganglia = habitual movements, voluntary movements + learning of specific movement patterns
115
Clinical Px Parkinson’s disease
TRIAD:
Unilateral RESTING tremor (pill-rolling) - diminishes with intentional movement
Cogwheel rigidity (resistance to passive movement of the joint)
Bradykinesia: shuffling gait + ‘freezing’ when starting to walk (difficulty initiating movement)
Cognitive impairment
Depression
Visual hallucinations
Sleep disorders
NO WEAKNESS
116
PD Ix
DaT scan (injected drug assesses dopaminergic neurones)
A normal CT scan will show no pathology
117
PD Mx
1. Dopamine agonists e.g. carbergoline
2. MAO-B inhibitors e.g. sergeline
3. Co-careldopa (Levodopa + carbidopa)
118
PD vs Benign resting tremor
PD: worse at rest, improves with intentional movement
BRT: improves at rest, improves with ALCOHOL, worse with intentional movement
119
Parkinson’s histopathological findings
```
Loss of dopaminergic neurones
Lewy bodies (eosinophilic cytoplasmic inclusions made of alpha synuclein)
```
120
Huntingtons disease
HTT mutation on c4 = CAG trinucleotide repeat
>35 CAG = HD
Loss of GABAergic neurones = hyperexcitation of dopaminergic pathways in the striatum = excessive thalamic stimulation = chorea
121
Clinical Px of HD
```
Chorea
Dystonia
Incoordination
Cognitive + behaviour difficulties
Irritability, agitation, anxiety
```
122
HD Ix
GENETIC TESTING
MRI/CT = loss of striatal volume
123
HD Tx
Benzodiazepines/valproic acid (for chorea)
SSRIs (for depression)
Haloperidol (for psychosis)
124
HD prognosis
Poor
Most common cause of death = pneumonia
Second most common cause of death = suicide
125
Differential diagnosis in HD
Sydenham's chorea (Rheumatic fever)
126
Alzheimer's disease RFs
Down's syndrome
Depression
ApoE E4 allele homozygosity
127
Pathological hallmarks of AD
EXTRACELLULAR deposition of B-amyloid plaques
| INTRACELLULAR neurofibrillary tangles (tauopathy)
128
Alzheimer's treatment
Acetycholinesterase inhibitors e.g. rivastigmine, donepezil
129
AD Ix
Entirely clinical diagnosis
MRI = cerebral atrophy
Rule out: bloods (TFTs, B12)
130
Vascular dementia
Caused by MULTIPLE INFARCTS
Sudden onset
Stepwise deterioration
131
Lewy body dementia
Presence of Lewy Bodies in brainstem + occipto-parietal region (misfolded a-synuclein/eosinophilic inclusions)
Fluctuating cognitive dysfunction, visual hallucinations + parkinsonism
Tx: cholinesterase inhibitors
132
Frontotemporal dementia
```
Progressive
More common dementia in those under 65
Atrophy in frontal and temporal lobes with no plaque formation
Tauopathy (which leads to apoptosis)
Pick bodies
```
Px: behavioural issues e.g. disinhibition, progressive aphasia e.g. slow, difficult speech, dementia symptoms
Tx: cholinesterase inhibitors
133
Age of onset multiple sclerosis
Early adult life (20-40 years)
134
Pathophysiology of multiple sclerosis
```
Autoimmune destruction (CD4 mediated - Type 4 HS)
CNS oligodendrocyte myelin sheath attack = plaques (sclera)
Remission = regulatory T cells > remyelination in early disease
```
135
MS patterns
Relapsing remitting (most common)
Primary progressive
Secondary progressive
Progressive relapsing
136
Charcot’s neurological triad (MS)
Nystagmus (painful, shaking eyes) - optic nerve plaques: optic neuritis
Intention tremor - motor pathway plaques
Staccato speech (dysarthria) - brain stem attacks: conscious movement (eating, talking) + unconscious (swallowing)
137
What is Uhthoff’s phenomenon in MS?
Worsening symptoms with increase in body temperature
138
What is Lhermitte’s sign in MS?
Sudden electrical sensation passing down the neck, spine, radiating out to the limbs when bending the neck forward
139
McDonald’s diagnostic criteria for MS
2 or more CNS attacks, at least 30 days apart and affecting different parts of the CNS
“Disseminated in space and time”
140
MS Ix
Clinical diagnosis
LUMBAR PUNCTURE: Oligoclonal IgG bands
MRI: plaque detection, white matter abnormalities, periventricular lesions
141
MS Tx
Acute: IV METHYLPREDNISOLONE
```
Other:
Vitamin D supplements
B-IFN (decreases inflammatory cytokines in brain)
Biologicals e.g. Monoclonal antibodies
Symptomatic: baclofen, amitriptyline
DMARDs
```
142
Px MS
```
TEAM:
Tingling (parathaesia)
Eye: optic neuritis
Ataxia
Motor: paraparesis
```
Autonomic: bladder and bowel, sexual dysfunction
Decreased vibration sense
Dysphagia, constipation
Falls
143
Risk factors MS
Genetic: female, HLA DR2
Environmental: infections, vitamin D deficiency
144
UMN symptoms in MND
EVERYTHING GOES UP
Increased muscle tone
Brisk reflexes
Positive BABINSKI sign
Impaired fine movement
145
LMN symptoms in MND
EVERYTHING GOES DOWN
Decreased muscle tone and reflexes
Muscle WASTING
Fasciculations
146
MND epidemiology
>50 y/o males
147
Typical MND patient Px
```
>40
Stumbling, spastic gait
FOOT DROP, weak grip
NO SENSORY LOSS
NO EYE MOVEMENT DISTURBANCES
```
148
Types of MS
```
ALS: UMN+LMN
PBP (progressive bulbar palsy): UMN+LMN
PMA (progressive muscular atrophy): LMN only
PLS (primary LS): UMN only
Corticobulbar (pseudobulbar) palsy
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149
ALS Px
MOST COMMON
Weakness, UMN + LMN signs, fasciculations
Drifting thumb
Wrist, foot drop
150
Progressive bulbar palsy Px
WORST PROGNOSIS
Affects cranial nerves IX-XII
Dysarthria, dysphagia
151
Progressive muscular atrophy Px
Only LMN signs
| Affects muscles distally to proximally
152
MND Ix
Clinical diagnosis: LMN + UMN signs in 3 regions
Blood tests
MRI
Lumbar puncture
153
MND Tx
Antiglutamatergic drugs e.g. RILUZOLE (sodium channel blocker that inhibits glutamate release)
Spasticity: baclofen
Respiratory: non-invasive ventilation
154
What is myasthenia gravis?
Autoimmune destruction of acetylcholine receptors
155
What is myasthenia gravis exacerbated by?
Pregnancy
Infection
Emotion
Drugs
156
Myasthenia gravis Px
Symptoms worse after muscle use (increasing muscle fatigue)
157
Myasthenia gravis Ix
Acetylcholine receptor (ACh-R) antibodies (85% of patients)
Positive tensilon test
- edrophonium (neostigmine) injection = temporary relief (due to increase in ACh)
A CT or MRI of the thymus gland to look for a thymoma
158
Myasthenia gravis Tx
Immunosuppression
Neostigmine
Thymectomy
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Guillane-Barré pathophysiology
Peripheral neuropathy often occurring after infection (molecular mimicry against pathogenic antigen AND peripheral nerves)
160
Kernigs sign
Resistance to extension of the leg while the hip is flexed
+ve in meningitis
161
Brudinskis sign
Flexion of the hips and knees in response to neck flexion
+ve in meningitis
162
Syncope
Temporary loss of consciousness due to disruption of blood flow to the brain (Vasovagal)
163
Primary syncope
Dehydration
Missed meals
Extended standing in a warm environment
Stimuli E.g. sight of blood
164
Syncope Ix
ECG
24 hour ECG
Echocardiogram
Bloods
165
Spina bifida aetiology
Combination of genetic, nutritional and environmental risk factors e.g. folate deficiency
166
Autonomic vs somatic NS receptors
167
Cerebral stroke patterns: MCA vs ACA
168
Tonic seizure
169
Tonic clonic seizure
170
Selective colour vision deficit on red-green colour test
MS
171
Most common causative organism of meningitis in children 3 months-12 years
Strep pneumoniae (think snotty kids)
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Saddle anaesthesia
Associated with CAUDA EQUINA SYNDROME
Erectile dysfunction
Loss of bowel control
173
Change in CSF parameters BACTERIAL meningitis
Turbid (yellow) fluid, with neutrophils, raised protein (bacteria produce enzymes etc), low glucose
174
Change in CSF parameters VIRAL meningitis
Clear fluid, with lymphocytes, normal glucose, normal protein
175
Change in CSF parameters in FUNGAL meningitis
176
Change in CSF parameters TB meningitis
177
Uhthoff's phenomenon
MS symptoms get worse with heat (E.g. shower)
178
Resperidone
Dopamine receptor antagonist: manages aggression and chorea in HD
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Guillain Barre syndrome Tx
IV immunoglobulins
180
Encephalitis
Inflammation of the brain
Can be caused by herpes simplex virus
Triad: fever, altered mental state, headache
Community Tx: IM Benpen (suspect meningitis)
Hospital: acyclovir
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Shingles (Herpes Zoster) neurological manifestation
Post-herpetic neuralgia
182
Sciatica
183
Trigeminal neuralgia
Sudden severe facial pain in the trigeminal regions
184
Difference between Lambert Eaton syndrome and myasthenia gravis
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LES = autoimmune attack of calcium gated channels
MG = autoimmune attack of ACh receptor
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185
Brown Sequard syndrome
Ipsilateral loss:
Corticospinal
Dorsal column
Contralateral (1-2 levels down):
Spinothalamic
186
Charcot-Marie-Tooth syndrome
Autosomal dominant
Demyelination of peripheral motor and sensory nerves
Classical features: inverted champagne bottle legs, high foot arches
187
Duchenne Muscular dystrophy
X-linked recessive disease (only men can be affected)
Characterised by progressive muscle degeneration and weakness due to the alterations of a protein called dystrophin that helps keep muscle cells intact
188
Beckers muscular dystrophy
189
Cauda equina vs conus medullaris
Cauda Equina = L1/L2 (level at which spinal cord terminates) = LMN features only
Conus medullaris = UMN features (hyperreflexic)
190
Stroke definition
Sudden onset neurological deficit due to ischaemic or haemorrhagic compromise with symptoms lasting over 24 hours
