Neurology Flashcards
Bilateral upper motor neuron DD:
Disc prolapse
SOL or demyelinating lesion
Motor Neuron Disease (mixed picture)
Spine specific —> Syringomyelia, Cervical myelopathy
Proximal Weakness DD:
Drugs (statins, steroids)
Endocrine —> Diabetes, Cushing’s, hypo/hyperthyroidism
Neuromuscular —> Myasthenia Gravis, Lambert-Eaton syndrome
Inflammatory —> IBM, dermatomyositis
Unilateral upper motor neuron DD:
Stroke
SOL
Multiple Sclerosis
Disc prolapse
Bilateral lower motor neuron DD (normal sensation):
Peripheral neuropathy
Motor Neuron disease
Guillaume-Barré syndrome
CIDP
Myotonic dystrophy
Inclusion-body myositis
Bilateral lower motor neuron DD (with sensory deficits):
GBS & CIDP
Alcohol
B12 and thiamine deficiencies
Cancer (anti-Hu) + Charcot-Marie-Tooth
Diabetes + Drugs (Amiodarone, Vincristine)
Every autoimmune thing (RA, PAN, SLE) and a
Few infections (HIV, syphilis)
Proximal leg weakness with distal arm weakness
Inclusion-body myositis
Causes of Mononeuritis multiplex
Diabetes
Infectious (HIV, Lyme’s disease, syphilis)
Vasculitis (PAN, Wegener’s, Goodpasture’s)
Amyloidosis
Autoimmune (RA, SLE, Sjogren)
Causes of Cerebellar syndrome:
Acute onset:
Demyelinating lesion
SOL
Stroke
Progressive onset:
Alcohol
Inherited – Friedreich’s ataxia, spinocerebellar ataxia
Causes of Horner’s syndrome:
1st order (central) – MS, SOL, stroke
2nd order (pre-ganglionic) – Pancoast tumour, thyroid goitre
3rd order (post-ganglionic) – carotid artery dissection, cavernous sinus thrombosis
Causes of Carpal tunnel syndrome
Local extrinsic pressure, e.g. ganglion, lipoma, fracture, haematoma
Diabetes
Hypothyroidism
Acromegaly
Gout
Rheumatoid arthritis
Causes of pale optic disc (optic atrophy)
Glaucoma
Optic neuritis
Ischaemic optic neuropathy from GCA or atherosclerosis
Compression from SOL
Thyroid eye disease
Causes of internuclear ophthalmoplegia
Stroke
MS
SOL
Diabetic retinopathy
Dot and Blot haemorrhages
Macular oedema
Cottonwool spots, hard exudates
Microaneurysms
If proliferative —> neovascularisation around optic disc
Hypertensive retinopathy
Silver wiring
AV nipping
Cotton wool spots
Flame haemorrhages
Papilloedema
Retinitis pigmentosa symptoms & treatment
Autosomal dominant
Tunnel vision
Night blindness
Hearing loss
Can give Vitamin A palmitate
Unilateral ptosis
Horner’s syndrome
3rd nerve palsy
Myasthenia Gravis
Bilateral ptosis
Myasthenia gravis
Myotonic dystrophy
Miller-Fisher variant of GBS
Medication for Motor Neuron Disease
Riluzole
Management of Parkinson’s disease
Selegiline (MAO-B inhibitor)
Ropinirole (dopamine agonist)
Levodopa
Myotonic dystrophy mutation?
Autosomal dominant
Type 1 (distal wasting): Triple repeat expansion of DMPK gene on Chrom 19
Type 2 (proximal wasting & weakness)
Extra-neurological complications of myotonic dystrophy?
DM
Cataracts
Subfertility in men (testicular atrophy)
Arrhythmias & cardiomyopathies
OSA
Sensitivity to GA
Functions of the Facial nerve?
Raising eyebrows, blinking & closing eyes
Smiling
Lacrimation & salivation
Taste in the anterior ⅔rds of tongue
Stapedius muscle in inner ear
Parkinson’s differentials
Idiopathic - asymmetric, Anosmia, REM sleep disturbance
MSA - cerebellar + postural hypotension
PSP - gaze palsy + messy tie
Wilson’s disease - young
Corticobasal degeneration - alien limb, myoclonus
Causes of CN3 palsy
Eye down & out + ptosis
Diabetes
SOL, MS
Posterior communicating artery aneurysm
Causes of CN 6 palsy
Diabetes
Trauma
SOL
Raises intracranial pressure
Argyll Robertson pupil
Small (miotic) irregular pupils
Constricts for accommodation but not to light
Caused by diabetes and tertiary syphilis
Holmes Adie pupil
Unilateral dilated pupil
Accommodates easily
Sluggish response to light
Anhydrous, hyporeflexia
Middle-aged woman
Caused by viral infection
CN3 palsy description
Ptosis
Down & out eye
If mydriatric –> surgical cause, otherwise medical cause.
Causes of Flaccid Paraparesis
LMN signs
MND (fasciulations)
Post-Polio syndrome (shortened leg)
Cauda Equina Syndrome (sensory level)
Myasthenia Gravis / Guillain-Barre Synd
Anterior Horn diseases
Motor neurone disease - mixed UMN & LMN signs
Post-Polio syndrome - monoparesis with limb hypoplasia and wasting
Sensation will always be normal
Causes of Radiculopathy
Dermatomal sensory loss
Disc herniation
Degenerative disc disease
Osteoarthritis
Causes of plexopathy
Trauma
Congenital
Neoplastic infiltration
Unilateral facial nerve palsy
Bell’s palsy
Ramsay-Hunt syndrome
SOL
Lyme disease
Bilateral facial nerve palsy
Bell’s palsy
Guillaume-Barré syndrome
Sarcoidosis
Lyme disease
Myotonic dystrophy differentials
Myasthenia gravis
Acquired myopathies (IBM, polymyositis)
Muscular dystrophies
Differentials for Myasthenia gravis
Lambert-Eaton syndrome
Miller-Fisher syndrome
Botulism
Précipitants of Myasthenic crisis
Infections
Stress
Non-compliance with treatments
Drugs (Verapamil, bisoprolol, tetracyclines)
Loss of proprioception
B12 deficiency
Syphilis
Guillain-Barre syndrome
Paraneoplastic / Sjogren syndrome
Causes of foot drop with LMN signs
Sciatic nerve palsy
Common peroneal nerve palsy (from trauma, surgery, mononeuritis multiplex)
Spinocerebellar ataxia genetics
Autosomal dominant
Trinucleotide CAG repeats
Anticipation phenomenon
Miller-Fisher syndrome symptoms and cause
Triad:
- Ophthalmoplegia
- Ataxia
- Hyporeflexia
GQ1b antibodies
Absent ankle jerks + upgoing plantars
Friedrich’s ataxia
SCAD
Syphilis
MND
(But most commonly Peripheral neuropathy combined with a myelo- or myeloradiculopathy)
Causes of Miosis
Horner syndrome
CN3 palsy
Argyll-Robertson syndrome
Opiates
Differentials ulnar nerve palsy
C8/T1 radiculopathy
Cubital tunnel syndrome
Guyon’s canal syndrome (cyclist’s wrist)
Charcot Marie Tooth syndrome
Autosomal dominant but lots of mutations
No disease modifying treatment
Type 1 —> demyelinating
Pseudoathetosis
Involuntary writhing of the fingers
Difference between cerebellar and sensory ataxia
Cerebellar will have eye signs and staccato speech
Sensory only have past-pointing with eyes closed
Sensory have pseudoathetosis, impaired proprioception & vibration
Sensory will have everything worse with eyes closed
Causes of sensory ataxia
Central:
- dorsal column damage from B12 deficiency or tabes dorsalis
- subacute degeneration of the cord
- demyelinating lesion
Peripheral:
- large fibre neuropathy (DM, alcohol, B12 def)
Management of non-proliferative diabetic retinopathy
Observation
If macular oedema then intravitreal anti-VEGF therapy +/- laser therapy
Management of proliferative diabetic retinopathy
Urgent pan-retinal photocoagulation
Advanced diabetic retinopathy
Vitreous haemorrhage
Retinal detachment
Progressive glaucoma
Causes of papilloedema
SOL or other causes of intracranial hypertension
Optic neuritis
Uveitis (from sarcoidosis, TB)
Malignant hypertension
Causes of optic atrophy
ICING:
Ischaemia
Compression of the optic nerve
ICP increased
Neuritis
Glaucoma
Differentials for motor neurone disease
Cervical myelopathy
Syringomyelia
Co-existent upper and lower motor neurone pathology
Management of MND
MDT approach
Neurologist for Riluzole
Assess respiratory function as at risk of T2RF requiring NIV
Screen for neuropsychiatric symptoms of Lewy Body dementia
Brown-Séquard syndrome
Ipsilateral paralysis and loss of proprioception
Controlateral loss of pain and temperature
Differentials for retinitis pigmentosa
Congenital deafness + ataxia —> Usher syndrome
Cardiac arrhythmias + ataxia Kearney-Sayre syndrome
Leber’s optic neuropathy
Myasthenia Gravis antibody
Anti-Acetylcholine nicotinic receptor antibody at the neuromuscular junction
Anti-MuSK antibody
Myasthenia Gravis management
MDT approach
Pyridostigmine
Consider IV Ig, plasmapheresis, steroids
Thymectomy
Monitor FVC
Difference between Lambert-Eaton syndrome and Myasthenia Gravis
Lambert Eaton syndrome:
- voltage-gated calcium channel antibody
- worse in lower limbs
- does not affect eyes/face
Symptoms improve after exercice
Different forms of motor neuron disease
ALS - mixed UMN/LMN, spastic paraparesis
Primary lateral sclerosis - UMN
Progressive muscular atrophy - LMN signs
Friedrich’s ataxia gene mutation
Autosomal recessive disease
Frataxin gene on chromosome 13
Criteria for MS
McDonald’a Criteria - dissemination in time & space
Classic features of Multiple sclerosis
Uhthoff’s phenomenon - symptoms worse after hot bath/exercise
Lhermitte’a sign - lightening pains in spine on neck flexion
Examples of drugs for multiple sclerosis
Ocrelizumab
Natalizumab
Glatiramer acetate
Can’t get reflexes so you do a … manoeuvre?
Reinforcement
Non-motor symptoms of Parkinson’s disease
Anosmia
Cognitive impairment with mood disorders
REM sleep disturbance
Constipation
Side-effects of Levodopa
Nausea
On/off phenomenon
Dyskinesia
Side-effects of Dopamine Agonists
Pramipexole, Ropinirole, Apomorphine pump
Nausea, drowsiness
Impulsivity, compulsivity
Speech examination
Spontaneous
Dysarthria:
- baby hippopotamus
- west register street
Dysphasia:
- one and two and three step commands
- recognise pen & badge
- no ifs, ands or buts
Mutation causing Huntington’s disease
Autosomal dominant CAG triplet repeat expansion on chromosome 4
Abnormal movements in Huntington’s disease
Chorea (large volume, unpredictable, jerky movements)
Hemiballismus (violent, flinging movements)
Atethosis (slow, writhing movements)
Medications for Huntington’s disease
Tetrabenazine (anti-chorectic)
Baclofen (anti-spasmodic)
Differentials for Huntington’s disease
SLE
Wilson’s disease
Vascular cause if unilateral chorea
Myasthenia Gravis cranial nerves findings (4)
Fatigable ptosis
Complex ophathlamoplegia with restricted eye movements and diplopia
Low voice volume, poor swallow
Reduced shoulder abduction
Drugs to avoid in Myasthenia Gravis
Antibiotics (Cipro, Tetracycline)
Beta-blockers
Lithium
Friedrich’s ataxia examination findings
Nystagmus
High arched palate
Spastis paraparesis (UMN)
Cerebellar syndrome
Loss of proprioception and vibration
Parkinson’s disease - adjuncts to Levodopa
Dopamine agonists (ropinorole) —> reduce motor comps
COMT inhibitors (entocapone) —> reduce off time
Apomorphine SC—> rescue therapy for off time
Muscles supplied by ulnar nerve
Flexor carpi ulnaris
Flexors of the distal phalanx of 4th and 5th finger
All intrinsic muscles of the hand except the thénar éminence
Froment’s sign
Weakness in thumb addiction elicited by failure to grip a piece of paper
Muscles supplied by radial nerve
Triceps
Brachioradialis
Supinator
Wrist & finger extensors
Causes of radial nerve palsy
Trauma to brachial plexus or radial nerve
Saturday night palsy
Muscles supplied by median nerve
Lateral two limb rivals
Opponens pollicus
Abductor pollicus
Flexor pollicus brevis
Causes of common peroneal nerve palsy
Trauma
Fibular fracture
Knee surgery
Compression (plaster cast, weight loss)
Clinical difference between L5 Radiculopathy and common peroneal nerve palsy?
Larger extent of sensory loss
Branches of the common peroneal nerve
Superficial
Deep
Causes of acute peripheral neuropathy
Guillain Barre syndrome
Botulism
Acute porphyria
Carpal tunnel borders
Sup: flexor retinaculum
Radial: pisiform, hamate
Inf: carpal bones
Medial: scaphoid, trapezium
Management of carpal tunnel syndrome
Treat associated condition
Physio and wrist splint
Steroid injection
Surgery
Causes of ulnar neuropathy
Supra onduler fracture
Compression
Cubital tunnel syndrome
Mononeuritis multiplex
Causes of cervical myelopathy (4)
Degenerative (spondylitis)
Trauma
Tumour
TB
Differentials for cervical myelopathy
MS
MND
SACD
