Neurology Flashcards
What should be ruled our initially as causes of Status Epilepticcus?
Hypoxia
Hypoglycaemia
If a child under the age of three months presents with meningitis what is the treatment?
IV Amoxicillin and Ceftrioxone or Cefotaxim
If a child over 3 months present with meningitis what is the treatment?
IV ceftriaxone
What are indications for the use of steroids in children with meningitis?
Purulent CSF
>1000 blood cells in CSF
Bacteria in CSF
What antibiotic is used for prophylaxis in close family contacts in meningitis?
Ciprofloxacin
In a suspected meningitis. If the CT shows temporal lobe changes or the patient presents with seizures. What must you consider and how does this change your management?
Herpes Simplex encephalitis
IV acyclovir
What is used in the secondary prevention of a stroke?
Clopidogrel and a statin if indicated.
What medication are linked to Idiopathic Intracranial Hypertension?
COCP Steriods Tetracyclines Lithium Vitamin A
How should a patient under 55 with no explanation on routine examinations for a stroke be investigated?
Autoimmune and Thrombophilia screens
Whats a good way of differentiating Progressive Supranculear Palsy from Multi System Atrophy
Progressive Supranuclear Palsy - Vertical Gaze issue + poor levodopa response
Multi System Atrophy - More prominent autonomic issues + No levodopa response
If the forehead is spared what side is the lesion?
Contralateral UMN
If forehead is involved what side is the lesion?
Ipsilateral LMN
If someone has had a diagnosed TIA what medication are they given? For secondary prevention
Clopidogrel 75mg
Aspirin 75mg + Dipydramol 200mg
Contraindications to thrombolysis.
Hemorrhagic stroke, Inter-cranial neoplasm, Major surgery in last three weeks, BP >185 or an active bleed
What’s Rolandic Epilepsy
Seizures occur during sleep
Generally younger patients
Focal seizures can generalise
Resolves by adolescence.
Jacksonian March - What is it and what does it indicate.
Epileptic seizure - focal jerks starting distally and moving proximally
Frontal Lobe Epilepsy
What pathogen would you suspect if the CSF sample was positively stained with India ink?
Cryptococcus Neoformens
Post Stroke Secondary prevention
Stroke + AF = 300mg aspirin for 2 weeks -> DOAC
Stroke = 300mg aspirin for 2 weeks -> Clopidogrel 75mg
Pain + loss of motor function + reduced digital dexterity + reduced sensory function +/- reduced autonomic function
Degenerative Cervical Myelopathy
Referral to neurosurgery within 6 months of symptoms is the target - urgent referal is suspicious
What sign maybe positive in Degenerative Cervical Myelopathy ?
Hoffmans signs
Flicking one finger causes all the others to twitch
What is levodopa always mixed with to reduce side effects?
Decarboxylase Inhibitor
If the main complaint of someone with Parkinsons is motor what is used first line?
Levodopa
If the main complaint of someone with Parkinson’s is non motor what is the management?
Dopamine Agonist - Bromocriptine
How is an initial presentation of query Parkinsons managed?
Urent referral
Diagnosis and treatment can only be started by a neurologist
A patient on anticoagulation presents with a head injury. What investigation is required?
CT scan within 8 hours even if no other indications
A raise in serum prolactin post ictally would indicate what?
More likely to be a real seizure rather than. pseudo seizure
Young child
Sudden uncontrollable movement starting with flexing of the head torso and limbs before extending the arms - salaam attacks
Attacks can last 1-2 seconds but can be repeated up to 50 times
Infantile spasms
Underlying cause of infantile spasm
Serious Neurological abnormality
What is the gold standard imagining for TIA?
MRI diffusion weighted
Lip smacking or other automatism
Deja Vu
Hallucinations
Dysphasia post ictally
Temporal lobe seizure
Head leg movements
Posturing
Post ictal weakness
Jacksonian marche
Frontal lobe seizure
Paraesthesi post ictally
Parietal
Floaters and flashers during the seizure
Occipital lobe seizure
Spinal Chord transection at C1 - C3
No function below the head
Requires a ventilator
Spinal Chord transection C4 - C5
Quadraplegia
Can breath by themselves
Spinal Chord transection C6 - C8
Loss of trunk and lower limb function
Can feed themselves and mobilise in a wheel chair
Spinal Chord transection T1 - T9
Paraplegia
Trunk control depends on level
Spinal Chord transection T10 - L3
Some lower limb dysfunction
BrownSequard Lesion
Ipsilateral loss of
DCML - Fine touch proprioception
Motor - LMN at that specific level - hyporeflexia + flaccid paralysis
- UMN below that spinal level - spastic paralysis hyper-reflexia up going plantar.
Contralateral loss of
Spinothalamic - Pain and Temperature
A hemisection at the level of T1 can present with
Ipsilateral Horners Syndrome
Anterior spinal chord stroke.
Spinothalamic - bilateral pain and temperature lost
Anterior horn - LMN presentation at that specific level. Muscle paralysis and atrophy
Lateral Corticospinal - UMN presentation below level of the lesion - spastic paralysis and hyperreflexia develops over days.
At what spinal level is the anterior spinal artery particularly susceptible during AAA repair?
Below T8
Posterior Spinal Chord Stroke
DCML alone is affected
Fine touch and proprioception
Describe the timeline of symptoms in a syringomelia.
First to develop - Cape like bilateral loss of pain and temperature due to destruction of anterior white commissure where spinothalamic tracts cross over.
Secondly, Ventral horns can be destroyed leading to LMN symptoms - flaccid paralysis.
What investigations should be undertaken in a syringomelia?
MRI + contrast of brain and spinal column.
What is the commonest cause of syringomelia?
Budd Chiari Malformation
Tabes dorsals is caused by what?
Tertairy Syphilis
Lose of the DCML - fine touch and proprioception
Sensory ataxia and +ve Romberg test
History of syphilis
Tabes Dorsalis
B12 deficiency
Subacute Combined Degeneration - SCD
S pinocerbellar - DANISH
C orticospinal - UMN spastic paralysis Hyperreflexia
D CML - loss of two point discrimination Fine touch etc
Atrophic glossitis and other signs of anaemia
Sudden onset
Headache N+V and reduced consciousness
CT scan normal
Slightly elevated D dimer
Venous sinus thrombosis
What investigation should be used in a suspected venous sinus thrombosis?
MRI venography
CT contrast is normal in 70%
D dimer may be mildly elevated
What is the management of a venous sinus thrombosis?
LMWH acutely
Warfarin for long term INR 2-3
- one episode but identifiable risk factors - 3-6 months
- one episode no explainable risk factors -6-12 months
- 2 episodes despite treatment - lifelong
Venous sinus thrombosis symptoms +
Seizures and hemiplegia
Empty delta sign on MRI
Sagittal Sinus Thrombosis
Which nerve is affected first in a cavernous sinus thrombosis?
6th cranial nerve
3rd and 4th affected later
Trigeminal nerve can lead to hyperaesthesia
Cavernous sinus thrombosis
Periorbital oedema
Ophthalmoplegia
Nerve palsy
What nerves can be affected in a lateral sinus thrombosis?
Cranial Nerves 6 and 7
Before what age should steroid be avoided in meningitis?
3 months
In meningitis in children when should you avoid a Lumbar puncture?
Signs of raised ICP
Meningococcal - treat first use Blood cultures and PCR
DIC
Stroke Treatment time scales
4.5 hours = Thrombolysis
6 hours = Thrombectomy
Ipsilateral - Ataxia Nystagmus Dysphagia Facial Numbness and Cranial Nerve Palsy
Contralateral - Limb sensory loss
Lateral Medullary Syndrome - Posterior Inferior Cerebellar artery
Ipsilateral III palsy
Contralateral limb weakness
Webers syndrome
If someone has cerebellar ataxia which involves the inability to complete the finger to nose test. What is affected?
Cerebellar Hemisphere
Cerebellar vermis = without finger to nose ataxia
When is the damage likely to occur to cause cerebral palsy?
Antenatal - 80% - malformation, congenital infections ( rubella, toxoplasmosis, CMV)
Intrapartum - asphyxia and trauma
Postpartum - intraventricular haemorrhage, meningitis, head trauma
What is someone with cerebral palsy also likely to have?
learning difficulties
epilepsy
squints
hearing impairments
What is the commonest form of cerebral palsy and how does it present?
Spastic - hemiplegia, diplegia, quadriplegia - UMN signs
What are some treatments used in spastic cerebral palsy?
Oral diazepam
Baclofen
Botulinum toxin injections
How does dyskinetic cerebral palsy present? and where in the brain is damaged to cause this?
Athetoid movements - slow writhing involuntary movements
Oro motor issues
Substantia nigra and basal ganglia
Ataxic cerebral palsy will present like this. And where in the brain is damaged to cause this?
DANISH - Dysdiadochokinesia, Ataxia, Nystagmus, Intention tremor, Staccato speech, Hypotonia
Cerebellum
Similar presentation to lateral medullary syndrome - Ipsilateral facial spinothalamic loss, Contralateral limb spinothalamic loss, Ataxia and nystagmus
+ facial paralysis and deafness
Anterior Inferior cerebellar artery occlusion
Vertical diplopia going down stairs
Head tilt
Tilts objects
Affected eye sits superiorly and laterally
CN 4 lesion
Superior Oblique
Definition of Status Epilepticus
1 seizure lasting over 5 minutes
> 2 seizures occurring within 5 minutes
Describe how anhidrosis can indicate where about the lesion is that is causing horners sydnrome.
Face Arm Trunk = central lesion from syringomelia or stroke
Face = Preganglionic lesion from cervical rib pan coast tumour etc
No anhidrosis = post ganglionic lesion from carotid artery dissection
Describe how a TIA is diagnosed
It is done on tissue damage not duration of symptoms. So along as no signs of infarction on Diffusion weighed MRI then its a TIA
Management of TIA
300mcg aspirin unless on an anticoagulant or low dose aspirin
+
If presenting within 7 days urgent <24 hr assessment
If presenting over 7 days since TIA = assessment within 7 days
MRI diffusion weighted + USS carotid arteries
List of tri nucleotide repeat genetic diseases
Fragile X
Huntingtons
Myotonic dystrophy
Freidrichs ataxia
What is used in the prophylaxis of meningitis and how do people qualify for it?
CirPROfloxacin
Close household contact within the last 7 days
Two commonest focal neurological lesions associated with HIV
Toxoplasmosis
Primary CNS lymphoma
Headache confusion drowsiness
CT shows multiple ring enhancing lesions
Thalium SPECT -ve
Toxoplasmosis = commonest HIV associated CNS lesion
Sulfadiazine + Pyrimethamine
CT shows homogenous enhancing lesion
Thalium SPECT +ve
Primary CNS lymphoma
Linked to EBV
Steroids + methotrexate +/- irradiation
Advice for patients wanting to get pregnant whilst on epileptic medication?
Start 5mg folic acid now
See specialist but until then continue to use protection
BDZ in status epilepticus
Oral - Midazolam 10mg
IV - Lorazepam 10mg
Rectal - Diazepam 10mg
How is meningeal TB managed?
12 month treatment court of RIPE
HIV + Neuro symptoms + widespread demyelination
Progressive Multifocal Leucoencephalopathy
JC virus
If you are starting phenytoin in status epileptics what must be started?
Cardiac Monitoring
What is the first line intervention in an intracranial aneurysm?
Interventional radiology coiling
How is normal pressure hydrocephalus managed?
Venticuloperitoneal shunt
10% risk of haemorrhage infection etc
What is first line for pain in post herpetic neuralgia?
Amitriptyline
If someone presents with dizziness during and after they extend their neck. What might it be?
Vertebrobasilar Ischaemia
Atherosclerosis + narrowing caused by extending neck lead to temporary ischaemia to cerebellum.
Management of a brain abscess
IV Ceftriaxone + Metronidazole
+/-
flucloxacillin if S.Aureus
vancomycin if MRSA or pen allergic
Sudden onset headache, visual field defect and signs of pituitary insufficiency i.e hypotension hyponatraemia
Pituitary apoplexy
MRI is diagnostic
Steroid replacement
Careful fluid replacement
Surgery
Rapid onset Dementia and Myoclonus is the hallmark of…
CJD
Management of spasticity in MS
Baclofen and Gabapentin - first line
Diazepam - second line
Bladder dysfunction in MS
USS before treating
If significant fluid retained post void - intermittent self catheterisation
If little fluid left post void - Oxybutynin
Visual field oscillation in MS
Gabapentin is first line
Develop over years - clumsy and high stepping gait
Peripheral LMN signs - lower leg wasting
Peripheral sensory defect
High arched foot and clawed toes
Family History
Charcot Marie Tooth
Management of someone post 1st seizure
Don’t start medication until seen by a specialist
Unless - seizure seen on EEG, Brain structure deformity, neurological defect, family see it as too high a risk
When can buccal midazlolam be given to a patient too self administer if needed?
Previous prolonged seizure or history of status epileptics
Horners syndrome - Central lesion
Anhidrosis of face arm and trunk
Stroke Syringomelia MS Tumour Encephalitis
Horners syndrome - preganglionic lesion
Anhidrosis of face
Pancaost tumour
Erbs palsy
Cervical rib
Thyroidectomy
Horners Syndrome - Post ganglionic lesion
No anhidrosis Carotid artery aneurysm Carotid artery dissection Cavernous sinus thrombosis Cluster headache
Guillian Bare - investigations
Lumbar puncture - increased protein + normal WBC
Nerve conduction studies - reduced transmission due to generalised demyelination
Guillian Bare - miller Fischer varient
Starts proximally within the eyes and spreads distally
ophthalmoplegia, areflexia and ataxia
SAH - diagnosis and management
Non contrast CT if -ve CSF at 12 hours
Whilst waiting for positive result - bed rest well controlled BP + Nimodipine
Positive result = CT angiogram -> guided clipping of aneurysm
If falls start soon after diagnosis of Parkinsons what should yo be considering?
Parkinson + syndrome = test cranial nerves and autonomic function
Commonest cause of acute radiculopathy
Disc prolapse
Ataxia Weakness visual changes disturbance in speech + HIV or immunosuppressed
Multifocal non enhancing lesions
JC virus
Progressive Multifocal Leukoencephalopathy
CSF - increased opening pressure
Immunosupressed
Increased protein and glucose
India ink stain
Cryptococcal Meningitis
Comprehension preserved + Non fluent laboured speech
Brocas ‘expressive’ Aphasia
Inferior Frontal Gyrus
Comprehension reduced + fluent word salad
Wernickes ‘receptive aphasia’
Superior Temporal Gyrus
Parkinsons + unsafe swallow - medication
Dopamine agonist patch
What are some reasons the time frame for a thrombectomy may be increased to 6-24 hours?
If MRI diffusion weighted scan identifies salvageable tissue or a limited infarct core.
First line investigation in narcolepsy
Multiple Sleep Latency EEG
Management of Alzheimers
1st line - Donepezil Rivastigmine
2nd line - Memantine - moderate to severe in addition to Donepezil
- mono-therapy in severe
Reduced GCS
Miosis (constricted pupils)
No horizontal eye movements
Quadraplegia
Pontine Haemorrhage
Someone with a spinal nerve lesion above T6 presents with
Flushing, Extreme Hypertension, sweating
Autonomic Dysreflexia
Over sympathetic stimulation due to obstructed parasympathetic output due to central chord lesion.
Generally triggered by faecal impaction or urinary retention
Autonomin Dysreflexia - Management
Finding and reversing the trigger is first line
Control extreme hypertension or bradycardia if removing the trigger hasn’t helped.
How is tight CO2 control used to help an increased ICP
Reducing CO2 causes vasoconstriction - reducing ICP
Bilateral resting tremor
Disease doesn’t progress from presentation
Drug induced Parkinsonism
Which emergency surgery is preferred in an increasing ICP?
Decompressive craniotomy > Burr holes
What surgery is preferred for the management of chronic subdural haematoma?
Burr Hole wash out
Contraindication to lumbar puncture
Increased ICP
Meningococcal septicaemia
Internuclear ophthalmoplegia
Stroke or demyelination
Failure to adduct on affected side + Nystagmus on contralateral side
Demyelination uses causes bilateral
Absence seizure
Sodium Valproate or Ethosuximate
Tonic Clonic seizure
Sodium Valproate
Lamotrigine
Myoclonic seizure
Sodium Valproate - if not child bearing age
Levetiracetam or Topiramate
Gold standard diagnostic investigations for an acoustic neuroma
Audiogram + gadolinium enhanced MRI
A chronic subdural will present like what on CT
Hypodense (dark) Crescent shaped
MS management
Natilizumab - First line
Fingolimod
Beta Interferon
Alcohol withdrawal symptoms
Symptoms 6-12 hours later
Seizures 36 hours later
Delerium Tremens 72 hours later
Gradual onset
Confusion, movement disorders, behavioural changes, emotional liability, reduced consciousness
Presence of antibodies
Autoimmune encephalitis
Onset is faster in younger people
Management of autoimmune encephalitis
Full neurology exam, FBC, MRI, LP, EEG
Steroids + IVIG
If over 2 weeks and no response add in rituximab and cyclophosphamide
Antibodies linked to autoimmune encephalitis
Anti Hu - Small cell lung cancer
NMDA receptor antibody - ovarian cancer
Anti Yo - breast cancer
Viral meningitis
Enterovirus e.g. coxsackie virus are the commonest
HSV-2 causes meningitis
HSV-1 causes encephalitis
Management of a Pituitary Incidentaloma
Pituitary Function tests even if asymptomatic
PWID + descending paralysis + diplopia + bulbar palsy
Clostridium Botulinum
Indications for an nil by mouth and an urgent SALT swallow assessment
Coughs during or within 1 minute of a swallow Delayed swallow initiation Drooling Wet sounding voice Dysphonia
A third nerve palsy occurs on which side in regards to a bleed?
Ipsilateral side
How can creutzfelt Jakob disease be diagnosed pre autopsy?
Tonsillar biopsy - doesn’t change prognosis
What can a sub arachnoid haemorrhage trigger (cardio)
Toursades De pointes
Which steroid is used to reduce ICP secondary to metastasis
Dexamethasone
What is the definition of chronic insomnia?
Inability to fall or stay asleep for more than 3 nights a week for over 3months
B12 replacement
1mg IM 3x a week then
1mg every 3 months
What is used to control levodopa induced nausea
Domperidone
Tremor which gets worse with sustained muscle tone.
Can also affect vocal chords - new onset vibrato
Essentail Tremor
Propanolol
What dementia is MND linked to?
Frontotemporal
What is an absolute contraindication to thrombolysis
INR >1.7 >180mmHg Brain neoplasm Recent major surgery <2 weeks Active major bleeding
Hyper-attenuation on a non contrast CT indicates what?
Haemorrhage
Causes of Autonomic neuropathy
Diabetes Mellitus
HIV, Lymes, Chagas
Autoimmune ( SLE)
Amyloidosis
Signs of amyloidosis autonomic neuropathy
Autonomic dysregulation
Glove and stocking paraesthesia
Oedema, Purpuric lesions around their eyes.
The anterior cerebral artery affects which regions of the body/
Lower limbs > upper limbs
MND subtypes and presentation
Amytrophic Lateral Sclerosis - Spinal - Upper and Lower MN - Progressive Bulbar Palsy - Early tongue and bulbar involvement Progressive Muscular Atrophy - LMN Primary Lateral Sclerosis - UMN
Management of MND
Riluzole
Non Invasive Ventilation
Early NG and PEG insertion to meet increased metabolic demands
