Neurology Flashcards
What does this CT show?
Extradural haematoma
Between which meningeal layers does a subarachnoid haemorrhage occur?
Between the arachnoid mater & pia mater
Status epilepticus is pronounced after a generalised seizure has been ongoing for how long?
What is the 1st line management of status epilepticus?
~ when should it be given?
What is the 2nd line management of status epilepticus?
What is the 3rd line management of status epilepticus?
5 minutes
1st line: Buccal midazolam or IV lorazepam
~ given at 5 minutes
~ repeat again at 10 minutes if still ongoing
2nd line: Sodium valproate
3rd line: Anaesthesia and intubation (propofol)
What are the 3 divisions of the trigeminal nerve & what numbers are they given? (eg V1, V2, V3)
V1 = ophthalmic nerve
V2 = maxillary nerve
V3 = mandibular nerve
What area of the brain is responsible for memory storage & is usually atrophied in Alzheimers?
~ What lobe(s) are affected in Alzheimers?
What lobe(s) are affected in Frontotemporal dementia?
Hippocampus
~ Parietal lobe & temporal lobe
Frontal lobe & temporal lobe
List 5 signs of an UMN lesion:
Muscle weakness
Hyper-reflexia
Hypertonia
Positive clonus
Positive babinski sign (big toe moves up)
What condition does the following statement indicate a diagnosis of?
” 50y with gradual change in behaviour over past 2 years. Clear personality change & quite withdrawn “
Frontotemporal dementia
What are some common triggers of trigeminal neuralgia? (5)
Cold
Wind
Chewing
Talking
Touching face
If there is a lesion on the R accessory nerve, which way would the tongue deviate towards?
Right deviation
(The tongue deviates TOWARDS the side of the lesion)
What drug class is used as the 1st line treatment to manage an acute migraine attack?
Give an example of a commonly used drug from this class.
Triptan
Sumatriptan
Amyotrophic lateral sclerosis is a type of what disease?
List some features of this condition: (4)
What gene mutation is associated with this condition?
What is the treatment of this condition?
What type of penetrance does the disease have? - What does this mean for family members with the gene?
Motor neurone disease
ONLY motor symptoms!!!!!!
• Progressive muscle weakness (LMN)
• Muscle wasting (LMN)
• Hyper-reflexia (UMN)
• Spasticity (UMN)
SOD gene
NO TREATMENT
Incomplete penetrance:
~ People with the gene don’t always develop the disease so offspring may/ may not be affected
~ Environmental factors ‘switch’ the gene on - nobody knows how/ why
What are the key clinical features in lewy body dementia? (3)
Fluctuating confusion throughout the day
Visual hallucinations
Parkinsonism symptoms (poor mobility, tremor)
What is the function of the oculomotor nerve?
Eye movements
Describe a cluster headache.
How long do they usually last for?
Sudden onset, unilateral pain behind one eye
Typically last between 15 mins - 3 hours
Describe what you might see in the following seizures:
a) Tonic-clonic seizure
b) Myoclonic seizure
c) Absence seizure
d) Atonic seizure
Tonic-clonic seizure: Muscles stiffen (go rigid = tonic) before generalised jerking of limbs (clonic)
Myoclonic seizure: Sudden jerking of one limb - patient may be conscious!
Absence seizure: Patient ‘pauses’ for a few seconds before restarting activity - patient often has no recollection
Atonic seizure: Muscles suddenly loose all tone - patient falls over
What is the function of the trigeminal nerve?
Motor function to muscles of mastication
Sensation of face
There are 2 extremes of delirum. What are they called? List some symptoms seen in each: (3, 3)
Hyperactive delirium:
→ Aggression/ aggitation
→ Hallucinations
→ Restlessness
Hypoactive delirium:
→ Sleepiness/ fatigue
→ Withdrawn
→ Memory problems (temporary dementia)
If someone presents with a thunderclap headache, what is the most likely diagnosis?
Subarachnoid haemorrhage
What are the first 2 clinical features to show in Alzheimers disease?
Loss of memory
Loss of executive function
What is the function of the vagus nerve?
Motor & sensory innervation to pharynx (back of throat), heart, resp tract, GIT
What is the textbook cause of an extradural haematoma?
Trauma to the head, eg car crash/baseball bat to the head
What neuropathological features would be seen on imaging of someone with Alzheimer’s disease? (2)
Amyloid plaques
Tau protein tangles
What is the 1st line medication used in mild/moderate Alzheimers?
Donepezil
Which cranial nerves are responsible for the afferent & efferent pathways of the corneal reflex?
Afferent = V1 nerve (ophthalmic)
Efferent = VII nerve (facial)
What is the mode of inheritance of Huntington’s Disease?
~ What is the repeated gene?
Explain what anticipation is:
List some symptoms/ signs of huntingtons: (4)
What type of penetrance does the disease have? - What does this mean for family members with the gene?
Autosomal dominant
~ CAG gene repeats
Anticipation: Successive generations inherit more CAG repeats in the gene → earlier onset & increased severity of the disease
- Chorea (involuntary, abnormal movements)
- Dementia (poor memory/ cognitive function)
- Personality change
- Depression/ psychosis etc
Full penetrant - all family members with the gene will develop the disease at some point
A lesion at the optic chiasm produces what visual defect?
Bitemporal hemianopia
If there is a lesion on the Right accessory nerve, which side would the uvula deviate towards?
Left deviation
(The uvula deviates away from the side of the lesion)
What is an extradural haemorrhage?
A collection of blood between the skull and the dura mater
Which cranial nerves are responsible for the afferent & efferent pathways of the gag reflex?
Afferent = IX nerve (glossopharyngeal)
Efferent = X nerve (vagus)
Name the 4 lobes of the brain.
Frontal lobe
Temporal lobe
Parietal lobe
Occipital lobe
If a patient presents with “the worst headache they’ve ever had”, what diagnosis is this suggestive of?
Subarachnoid haemorrhage
Commonly presents with a thunderclap headache
What is the management of tension headaches?
Simple analgesia: NSAIDs / paracetemol
What is the 1st line medication for Parkinson’s disease?
What is this medication usually given with & why?
Levodopa
Co-administered with Carbidopa - prevents L-dopa being converted into it’s active form in the systemic circulation thus more reaches the brain
What is the first presenting symptom of:
a) Alzheimers dementia
b) Vascular dementia
c) Lewy-body dementia
d) Fronto-temporal dementia
a) Alzheimers: Loss of recent memory
b) Vascular: Step wise decrease in ADL (language affected first)
c) Lewy-body: Fluctuating confusion & visual hallucinations (+ parkinsonism symptoms)
d) Fronto-temporal: Personality change
List 5 signs of an LMN lesion:
Muscle weakness
Muscle wasting
Hypo-reflexia
Hypotonia
Fasiculations
What is the classic triad of presenting symptoms seen in normal pressure hydrocephalus?
Dementia, urinary incontinence, gait disturbance
What is the 1st line medication used to treat trigeminal neurlagia?
This medication is also used in the treatment of what?
Carbamazepine
Epilepsy!
What is a subdural haematoma?
Damage to which blood vessels cause a subdural haematoma?
A collection of blood between the dura mater and arachnoid mater
Tear in the bridging veins between the cortex and dura mater
What is the function of the abducens nerve?
What muscle does it innervate?
Eye movements
Lateral rectus muscle
What type of hallucinations are common in lewy body dementia?
Visual hallucinations:
→ animals in the house
→ faces in the wallpaper
Name the main neurones involved in the reward pathway & state which NT they release
How is activation of the reward pathway involved in addiction?
VTA neurones → nucleus accumbens → pre-frontal cortex
~ release dopamine
Release of dopamine creates feeling of pleasure → psychological cravings of this feeling then occur which result in dependence
** VTA = Ventral tegmental area
Define what dementia is:
Dementia is a syndrome (a collection of different symptoms) associated with an progressive decline in brain functioning
What drug class is used as the 1st line treatment to manage an acute migraine attack?
Give an example of a commonly used drug from this class.
Triptans
Sumatriptan
What is often the first clinical feature seen in vascular dementia?
Aphasia (problems with communication)
* Memory is often spared until advanced disease
What is the 1st line medication used to treat trigeminal neurlagia?
Carbamazepine
Which anticonvulsant should be avoided in women of child bearing age & why?
Valproic acid - it causes neural tube defects
To be diagnosed with dementia, what type of imaging is required?
None. Dementia is a clinical diagnosis - imaging is done occasionally to confirm the diagnosis
Which vessels remove deoxygenated blood from the brain?
Where do these veins drain into?
Bridging veins
Drain into venous sinuses → internal jugular vein
Which cranial nerves are responsible for the afferent & efferent pathways of the pupillary reflex?
Afferent = II nerve (optic)
Efferent = III nerve (oculomotor)
What is a common trigger of tension headaches?
Stress
What is found within the subarachnoid space?
CSF (cerebralspinal fluid)
Name the 3 meninges from the skull inwards.
Dura mater (underneath skull)
Arachnoid mater
Pia mater
What type of headache is associated with autonomic symptoms? (Ptosis, miosis, lacrimation, nasal congestion)
Cluster headache
What is a subdural haematoma?
Damage to which blood vessels cause a subdural haematoma?
A collection of blood between the dura mater and arachnoid mater
Tear in the bridging veins between the cortex and dura mater
What are the 2 commonest causes of a subarachnoid haemorrhage?
Ruptured aneurysm, commonly in the cirle of willis
Severe head injury
What type of dementia is characterised by a step wise decline?
Vascular dementia
What is the maximum score of a GCS?
Explain each point in the GCS: (6 5 4, MOVE)
~ Eyes
~ Verbal response
~ Motor response
15/15
Motor response:
6 = Obeys commands
5 = Localised to pain
4 = Normal flexion
3 = Abnormal flexion
2 = Extends
1 = Nothing
Verbal response:
5 = Orientated
4 = Confused conversation
3 = Inappropriate words
2 = Incomprehensible sounds
1 = Nothing
Eyes:
4 = Spontaneously opens
3 = Opens to speech
2 = Opens to pain
1 = Nothing
What is the treatment of mild-moderate Alzheimers disease? (Drug & drug class)
~ Name a common S/E of this.
What is the treatment of severe Alzheimers disease/ if previous treatment has failed?
What is the treatment of Vascular dementia?
What is the treatment of Lewy-Body dementia? (Drug & drug class)
~ Name a common S/E of this.
What is the treatment of Fronto-temporal dementia?
Anticholinesterase inhibitors: donepezil
S/E = GI upset (nausea, vomiting, diarrhoea)
Memantine
Management of underlying vascular risk factors
Anticholinesterase inhibitors: donepezil
S/E = GI upset (nausea, vomiting, diarrhoea)
No current treatment..
What is expressive dysphasia?
Damage to which area of the brain causes expressive dysphasia?
When someone has comprehension of language (they know what they want to say) but they are unable to physically say the words
Broca’s area
What is the 1st line treatment of generalised seizures?
What is the 1st line treatment of focal (partial) seizures?
What is the treatment of absence seizures?
Generalised seizures: Sodium valproate (lamotrigine for females)
Focal seizures: Lamotrigine
Absence seizures: Ethosuximide
What muscles does the oculomotor nerve innervate? (7)
Superior rectus muscle
Inferior rectus muscle
Medial rectus muscle
Inferior oblique muscle
Leveator palpebrae superioris muscle (eyelid)
Ciliary muscle (accomodation of pupils)
Constrictor pupillae (pupil size)
What type of dementia is most common in the under 65’s age group?
Alcohol related brain damage (ARBD)
What are the 3 pathological features seen in the brains of patients with Alzheimers disease?
Amyloid plaques
Tau protein tangles
Reduced Ach
A 65 year old man with diabetes has developed painful peripheral diabetic neuropathy.
Name a medication & it’s drug class, used as 1st line in treating this.
Amitriptylline - tricyclic antidepressant
What is the function of the vestibulocochlear nerve?
Vestibular = hearing
Cochlear = balance
What is the function of the olfactory nerve?
Sense of smell
Erb’s palsy results in damage to what nerves of the brachial plexus?
What obstetric emergency can result in Erb’s palsy?
C5 & C6
Shoulder dystocia
What is the typical presentation of a subdural haematoma? (5)
Older person had a fall days-weeks ago
Progressive headache
Nausea / vomiting
Confusion
Reduced GCS
What is the management of an acute cluster headache attack?
100% oxygen through a mask
What is the classic traid of clinical features seen in Wernicke’s encephalopathy?
Ataxia (lack of coordination of movements)
Ophthalmoplegia (paralysis of the eye muscles)
Encephalopathy (brain damage)
What is the typical presentation of trigeminal neuralgia?
Recurrent, short episodes of severe stabbing pain, affecting one side of the face, in the trigeminal nerve distribution (usually V2 / V3)
Name all of the 12 pairs of cranial nerves and state their numbers.
I = olfactory nerve
II = optic nerve
III = oculomotor nerve
IV = trochlear nerve
V = trigeminal nerve
→ V1 = ophthalmic nerve
→ V2 = maxillary nevre
→ V3 = mandibular nerve
VI = abducens nerve
VII = facial nerve
VIII = vestibulocochlear nerve
IX = glossopharyngeal nerve
X = vagus nerve
XI = accessory nerve
XII = hypoglossal nerve
An extradural haemorrhage is commonly caused by a tear in which artery?
A # in which part of the skull usually causes this tear?
Middle meningeal artery
A # of the pterion - the pterion is weakest part of the skull & lies above the middle meningeal artery
How long does a migraine attack usually last for?
4 - 72h
What is the definition of epilepsy?
State the difference between generalised and partial (focal) seizures:
State whether the following types of epilepsy are generalised or partial:
a) tonic-clonic
b) simple partial
c) complex partial
d) absence seizures
e) myoclonic seizures
f) secondary generalised
g) tonic seizures
h) atonic seizures
i) clonic seizures
Epilepsy - More than 1 unprovoked seizure
Generalised seizures: electrical activity spreads across both hemispheres of brain
Partial (focal) seizures: electrical activity only involves one hemisphere/ lobe
- *a) tonic-clonic:** generalised seizure
- *b) simple partial:** partial seizure
- *c) complex partial:** partial seizure
- *d) absence seizures:** generalised seizure
- *e) myoclonic seizure:** generalised seizure
- *f) secondary generalised:** partial seizure
- *g) tonic seizure:** generalised seizure
- *h) atonic seizure:** generalised seizure
- *i) clonic seizure:** generalised seizure
What are the common symptoms of a migraine? (5)
Unilateral, throbbing headache that’s aggravated by movement
Photophobia (light makes it worse)
Phonophobia (loud noises make it worse)
Nausea / vomiting
+/- Aura
In which age group is a subdural haematoma most common?
What is the most common cause of a subdural haematoma?
Older population
Common cause is a minor head injury
List the 5 most prevelant types of dementia:
Alzheimers disease
Vascular dementia
Lewy body dementia
Mixed dementia (when someone has a mixture of 2 dementia’s)
Frontotemporal dementia
List the triad of symptoms that Parkinsons Disease presents with.
Bradykinesia
Tremor (pin-rolling)
Rigidity (cog-wheel)
What is the classic triad of symptoms seen in normal pressure hydrocephalus?
Urinary incontinence
Dementia
Gait abnormality
Which lobes of the brain are usually affected first in Alzheimers disease?
Parietal & temporal lobes
What is the function of the optic nerve?
Vision
What does this CT show?
Subdural haematoma
What is the function of the facial nerve? (3)
Supplies muscles of facial expression
Taste to anterior 2/3 of tongue
Innervates submandibular & sublingual glands
What are 2 common triggers of cluster headaches?
Smoking
Alcohol
What is the function of the accessory nerve?
Innervates trapezius & sternocleidomastoid muscles
What are common signs of raised ICP? (4)
Headache that is worse in the morning & when bending over/coughing
Headache that is relieved by lying down
Papillodema
Vomiting
What are some common triggers for a migraine? (5)
Stress
Combined contraceptive pill
Chocolate
Sleep deprivation
Changes in the weather
What is a common presentation of a cluster headache? (6)
Male with sudden onset, severe pain, behind one eye
Associated with:
~ watery, bloodshot eye
~ lacrimation
~ ptosis
~ miosis
~ runny nose (rhinorrhea)
What investigation is essential in order to diagnose meningitis in children?
~ What would be an absolute contraindictation to this?
Lumbar puncture
~ signs of raised ICP
Describe a cluster headache.
How long do they usually last for?
Sudden onset, unilateral pain behind one eye
Typically last between 15 mins - 3 hours
What drug class is used for the treatment of Alzheimers disease & Lewy Body dementia?
Give an example of a medication from this class.
Acetylcholinesterase inhibitors
Donepezil
What is the function of the glossopharyngeal nerve? (3)
Taste to posterior 1/3 of tongue
Sensation from pharynx & tonsils
Movement of throat muscles (stylopharyngeus muscles)
What is the function of the trochlear nerve?
Which muscle does it innervate?
Eye movement
Superior oblique muscle
What is the typical presentation of someone with an extradural haemorrhage? (symptoms)
Head trauma +/- unconsciousness followed by lucid period (as the blood is pooling)
Progressive headache
Nausea / vomiting
Decreasing GCS
How might someone describe a tension headache?
Bilateral, non-pulsatile headache
“Feels like a tight band around my forehead”
Describe what nociceptive pain is:
Describe what neuropathic pain is:
Note whether they have a protective function or not.
Nociceptive pain = pain when there is tissue injury or illness (eg when you cut yourself)
~ has a protective function (the pain causes you to stop whatever is causing the pain)
Neuropathic pain = pain caused by nervous system damage / abnormality
~ no protective function, often occurs long after there has been trauma!
What is receptive dysphasia?
Damage to which area of the brain results in receptive dysphasia?
When someone is unable to comprehend language but is able to physically say words (as a result they often say things that don’t make sense)
Wernicke’s area
What is the function of the hypoglossal nerve?
Movement of the tongue
What classical position will the eyes fall into if there is a CN III palsy?
What other things may you notice in the affected eye? (2)
‘Down and out’ position
- Ptosis
- Dilated pupil
Which nerve is responsible for the afferent pathway of the pupillary reflex?
Which nerve is responsible for the efferent pathway of the pupillary reflex?
Afferent: Optic nerve (CN II)
Efferent: Occulomotor nerve (CN III)
What 3 branches does the trigeminal nerve (CN V) split into?
V1: ophthalmic nerve
V2: maxillary nerve
V3: mandibular nerve
List some of the symptoms associated with Bells Palsy: (5)
- Unilateral droopy face
- Auricular pain
- Decreased taste
- Hypersensitivity to sounds
- Dry eye
Should you be worried if someone with a suspected bells palsy can raise their eyebrows? - why?
YES
If the eyebrows can be raised then this suggests an UML (eg, stroke)
If someone with a suspected bells palsy can raise their eyebrows, what condition MUST you rule out?!
STROKE
The triad of: vertigo, unilateral hearing loss and tinnitus suggest which condition?
Vestibular schwannoma (tumour of the vestibular nerve)
What type of NT is GABA?
What type of NT is Glutamate?
- *GABA:** inhibitory NT
- *Glutamate:** excitatory NT
What is the 1st line pharmacological management of tonic-clonic seizures? (aka, grand mal seizures)
Which population group may this medicine be avoided in? - why?
~ which medication would be 1st line in this group of people?
Sodium valproate
Women of child bearing age - it can cause neural tube defects
~ lamotrigine
What is the 1st line pharmacological management of simple partial seizures? (aka, focal seizures)
Lamotrigine
What is the 1st line pharmacological management of frontal lobe seizures? (a type of focal seizure)
Lamotrigine
In general terms, what pharmacological management is 1st line in males/females for:
~ Generalised seizures
~ Focal (partial) seizures
Generalised: males - sodium valproate, females - lamotrigine
Focal: males & females - lamotrigine
If all investigations are normal, how long after 1 seizure can you not drive for?
6 months (normal car)
5 years (HGV)
Damage to which cranial nerve results in bells palsy?
CN VII (facial nerve)
Bilateral vestibular schwannomas are usually seen in which underlying genetic condition?
~ what is this condition?
Neurofibromatosis type 2
~ a genetic condition that causes tumours (usually benign) to grow along the nerves
A 66y/o woman states that during the past 6 months she has had several episodes of a sharp, shooting ‘electric shock’ like pain on the left side of her face, which occur when she is combing her hair.
What is the most likely diagnosis?
What is the management of this condition?
Trigeminal neuralgia (electric shock like pain, think TN!!)
Carbemazepine
A mid-shaft humeral fracture is associated with which nerve injury?
Radial nerve
In the GCS calculation, how many points are awarded for:
1. Motor
- Verbal
- Eye opening
- Motor: 6
- Verbal: 5
- Eye opening: 4
* 654 MoVE*
A stroke involving the anterior cerebral artery would cause what associated effects? (1)
Contralateral hemiparesis (weakness) + sensory loss affecting LOWER body (legs) > upper body (arms)
Explain the visual field defects in homonymous hemianopia (eg, caused by a defect in the L side of the brain):
Loss of vision in L eye in NASAL field
Loss of vision in R eye in TEMPORAL field
A stroke involving the middle cerebral artery would cause what associated effects? (3)
- Contralateral hemiparesis (weakness) + sensory loss affecting UPPER body (arms) > lower body (legs)
- Contralateral homonymous hemianopia
- Aphasia (problems with speech)
A stroke involving the basilar artery would cause what associated effects? (1)
Locked-in syndrome
Locked-in syndrome can be caused by a stroke involving which artery?
The basilar artery
A stroke involving the posterior cerebral artery would cause what associated effects? (2)
- Contralateral homonymous hemianopia with macular sparing
- Visual agnosia (inability to recognise visually presented objects)
A 61y/o female presents with sudden onset weakness in her right lower leg. She had a similar episode 2 days ago but these symptoms resolved within an hour. She can speak well and fully understands what you tell her, but there is decreased touch sensation on the right leg.
PMH: T2DM, hypertension, hypercholesterolaemia
A CT scan at 12 hours showed hypo-attenuation in a region of the brain.
Which artery is most likely to be occluded to cause this presentation? (be specific, include the side of the brain)
Left anterior cerebral artery
EVERYONE that presents with symptoms of a stroke should get which investigation?
Why is this?
CT head
To determine whether they had an ischaemic stroke OR a haemorrhagic stroke
A patient presents to ED with left sided weakness and slurred speech. A CT head reveals the patient has had an ischaemic stroke.
Within what timeframe would the patient be eligible for thrombolysis?
What medication is used in thrombolysis?
If the patient presented outside this timeframe, what initial management would they recieve?
Within 4.5 hours of symptom onset
(after this time, the tissue damage is irreversible)
IV alteplase
300mg aspirin
A patient presents to ED with left sided weakness and slurred speech that started 8 hours ago. A CT head reveals the patient has had an ischaemic stroke.
What would their initial management be?
300mg aspirin
A patient presents to ED with left sided weakness and slurred speech that started 3 hours ago. A CT head reveals the patient has had an ischaemic stroke.
What would their initial management be?
Thrombolysis with IV alteplase + 300mg aspirin
A 46y/o woman presents to A&E at 8am with an acute onset headache which started at 21:00 the previous night whilst watching TV on her sofa.
She describes this as the worst headache that she has ever had.
An initial CT scan of the head is normal.
What is the most likely diagnosis?
What would be the most appropriate next step in her management?
Subarachnoid haemorrhage
Lumbar puncture 12 hours after the onset of symptoms
A subdural haematoma is caused by bleeding from which vessel?
Bridging veins
An extradural haematoma is caused by bleeding from which vessel?
Middle meningeal artery
A 46y/o woman presents to A&E at 8pm with an acute onset headache that started at 5pm the earlier that evening whilst watching TV on her sofa.
She describes this as the worst headache that she has ever had.
An initial CT scan of the head is normal.
What would be the most appropriate next step in her management?
Think of an alternative diagnosis (as CT head was done within 6 hours of symptom onset, if there was a bleed then you would see it)
*** NO lumbar puncture is required ***
A 24y/o male was brought to ED by ambulance after being involved in an RTA. On initial assessment he withdraws from pain, groans in response to your questioning and wont open his eyes.
What is his GCS?
GCS = 7
~ M = 4
~ V = 2
~ E = 1
Name the most likely causative organism that causes bacterial meningitis in newborns (0-3 months):
Group B strep
Name the most likely causative organism that causes bacterial meningitis in children aged 3m-6y:
Strep pneumoniae
Name the most likely causative organism that causes bacterial meningitis in teenagers/young adults (<60y):
Neisseria meningitidis
Name the most likely causative organism that causes bacterial meningitis in older adults (>60y):
Strep pneumoniae
A 17y/o boy has repeated episodes characterised by a funny rising sensation in his abdomen followed by a loss of awareness. Friends have also noticed that during these episodes he stares into space and waves his left arm around in a writing manner.
Where is the most likely cranial site of origin of these episodes?
Right temporal lobe - commonest site of origin for focal seizures
~ it starts as a focal lesion and then spreads over the brain
~ the fact that he has the funny abdominal sensation = an aura → aura’s before headaches are associated with the temporal lobe!
Where is the commonest site of origin of focal seizures?
Temporal lobe
Where is the commonest site of origin of generalized tonic-clonic seizures?
Frontal lobe
A 25y/o patient attends the neurology clinic reporting several episodes of involuntary movement in their right hand. These episodes usually last around 2 minutes and return to normal immediately afterwards.
What is the most likely diagnosis?
Focal aware seizure
~ focal as it’s only involving certain myotomes
Lhermitte’s sign is associated with which neurological condition?
How do you elicit this sign and if it’s positive, what would you expect to happen?
Lhermitte’s sign = multiple sclerosis
Flexing the neck will cause an electric shock sensation to travel down the spine and into the limbs
Name the first symptom that people with MS commonly present with:
OPTIC NEURITIS!
unilateral reduced vision +/- pain on eye movements
Name the 3 disease patterns in MS:
Which one of the above is the most common pattern at initial diagnosis of MS?
- Relapsing-remitting - commonest pattern at initial diagnosis
- Secondary progressive
- Primary progressive
Name 2 investigations that can be used to support a diagnosis of MS and state the evidence they’d prove to support an MS diagnosis:
MRI scan
~ show’s typical lesions
Lumbar puncture
~ this will detect oligoclonal bands in the CSF (indicates inflammation in the CNS)
Name the class of medications that are used in **MS to treat relapses**: ~ give the commonly used drug from this class that is used for this purpose
Steroids: methylprednisolone
Motor neurone disease is an umbrella term that encompasses a variety of specific diagnoses in which the motor neurones stop functioning.
Name the commonest type of motor neurone disease:
~ name the gene associated with this disease
Name the type of MND that primarily affects the muscles involved in talking and swallowing:
Amylotropic lateral sclerosis (ALS)
~ SOD gene
Progressive bulbar palsy
Motor neurone disease is an umbrella term that encompasses a variety of specific diagnoses in which the motor neurones stop functioning.
Currently there are no treatments that will stop progression of the disease, however one medication is used to slow the progression of amylotropic lateral sclerosis (ALS). Name this medication.
Riluzole
A 68y/o woman presents to her GP complaining of chronic and progressive weakness in her legs, and a recently worsened tendency to trip over when walking.
Her past medical history was unremarkable and there was no family history of neurological disease. On closer questioning, she did report a recent tendency to cough when eating.
O/E: she had reduced power bilaterally (more pronounced distally) with evidence of fasciculations in the large thigh muscles. In addition, she was briskly hyper-reflexive with upgoing plantars. Sensory examination and cranial nerve assessment were normal.
She is referred to a specialist who excludes reversible causes of her presentation and performs an MRI of the spine which is structurally normal.
What is the most likely diagnosis?
What is the most appropriate management for this patient?
Amylotropic lateral sclerosis (ALS) - a type of motor neurone disease
Management: riluzole (slows progression of disease)
A 60y/o man presents to clinic complaining of pain and weakness in his legs over the last few months. He has also noticed a change in his gait. On examination, his reflexes are brisk bilaterally in the legs. His gait is also noticed to be ‘scissoring’ and a cranial nerve examination reveals a brisk jaw jerk. His voice sounds ‘strained’. His sensory examination is normal and Mini-Mental State Examination is completely normal.
What is the diagnosis? - what group of conditions does this disease fall under?
~ Why is this the diagnosis and not another type of this condition?
Primary lateral sclerosis - MND
~ the man is is only presenting with UMN symptoms
A 61y/o man accompanied by his wife, present to clinic complaining of slurred speech and dysphagia over the past couple of months. On further questioning he mentions that he has felt very tired recently and generally weaker.
O/E you note tongue fasiculations, however sensory and cranial nerve examinations were normal aside from this.
What is the diagnosis? - what group of conditions does this disease fall under?
~ Why is this the diagnosis and not another type of this condition?
Progressive bulbar palsy - MND
~ the man is presenting with bulbar symptoms: slurred speech, dysphagia, tongue fasiculations!
A lumbar pubcture shows an isolated raised protein in the CSF.
What condition does this most likely indicate?
Guillan-Barre
A 67y/o female with rheumatoid arthritis attends a clinic for her annual review. She reports that she has noticed a loss of sensation in both her hands over the last 4 months and that it has been getting worse. In addition to arthritis, she also has hypertension and diabetes. She is currently taking infliximab, metformin, glipizide, and amlodipine. Her last HbA1c was 53 mmol/mol.
O/E: there is bilateral loss of temperature and pain sensation on the medial aspect of both hands and elbows. Proprioception and vibration sensation are preserved.
What is the most likely diagnosis?
Nerve fibres in which spinal tract are affected in this condition? (eg the tract that carries temperature & pain sensation!)
Syringomyelia
~ a cavity filled with CSF that commonly forms in the middle of the spinal cord at the cervical level
~ it classically presents with cape-like loss of pain and temperature sensation due to compression of the spinothalamic tract fibres when they cross over the middle of the spinal cord (therefore the cavity compresses them!)
Pyridostigmine is a long-acting acetylcholinesterase inhibitor.
What condition would pyridostigmine form part of the management?
Myasthenia gravis
A 76y/o man presents to ED. His wife is struggling to cope with him. The wife tells you that he has been getting confused and more forgetful since last month. She is worried as he’s been more unsteady on his feet and has fallen in the last week, she was unable to help him up as he is too heavy. When you examine him you notice that he has been incontinent of urine.
What is the most likely diagnosis?
Which triad of symptoms indicate this diagnosis?
Normal pressure hydrocephalus
- Urinary incontinence
- Dementia (confusion/forgetfullness)
- Gait abnormalities (eg falls)
In regards to** muscle fatigue/weakness**, state the difference between **Lambert-Eaton Myasthenic Syndrome **and Myasthenia Gravis:
Name the enzyme/electrolyte/molecule that the antibodies are targetted against in each of the above conditions:
Which cancer is Lambert-Eaton Myasthenic Syndrome associated with?
Lambert-Eaton Myasthenic Syndrome: muscle fatigue/weakness improves with exercise
~ antibodies against voltage gated calcium channels
~ small cell lung cancer
Myasthenia Gravis: muscle fatigue/weakness worsens with exercise
~ antibodies against nicotinic acetylcholine receptors
