Neurology Flashcards
what is multiple sclerosis?
MS is an acquired, autoimmune condition that results in teh demyelination of nerves in teh brain and spinal cord (does not affect the peripheral nerve system)
what are the three main patterns of clinical presenationof MS?
- relapsing remitting
- secondary progressive
- primary progressive
what are the inital syptoms of MS and what age do they usually present?
20-40s
- visual distubrnaces (optic neuritis, double vision)
- sensory disturbances in face or limbs
- weakness in limbs due to UMN involvemnts
- impaired balance/clumsiness of limbs
- bladder symptoms
- neuropathic symptoms (trigeminal neuralgia)
what are the triggers of MS?
- low vit D levels
- EBV ifnection
- smoking
- obesity
- lack of sleep
what is the clinical diagnosis of MS based on the 2010 McDonald criteria?
- lesions consistent with an ainflammatory process
- no alternative diagnosis
- multiple lesions in time and space (RRMS)
- progressive neurological deterioration for 1 year (PPMS)
what investigations are done to support a diagnosis od MS?
- MRI of brain or spinal cord - show demyelination of plaques (white areas in brain)
- immunoelectrophoresis of CSF - show oligoclonal bands of IgG
what drugs can be given to help spasticity in pts with MS?
- physio !!
- baclofen (muslce relaxant and antispasmodic)
- possible botulism injections
what drugs can be given in pts with MS who have neuropathic pain?
amitriptylline, gabapentin, pregabalin
what drugs to help depressiion in pts with MS?
- duloxetine if have fatigue or neuropathic pain
- or SSRIs
what drugs needed in MS pts with incontinence?
oxybutynin
botulism injection
may need catherisation
drugs given to MS pts with fatigue
encourage physical activity and treat depression
then possible modafinil
what drugs are given in pts with MS who are relapsing?
- steroids (oral or IV methylprednisolone)
- PPI
- pay attention to mental health and changes in blood glucose
what is the definition of status epilepticus?
single seziure lasting mroe than 5 mins or recurrent without gainign consiousness
managment fro status epilepticus?
GIVE IV lorazepam 4mg over 2mins (or buccal midazolam or rectal diazepam)
wait 5-10mins -> if not resolved give second dose
if does not respond to two doses of benzodiazepine then give phenytoin infusion 20mg/kg
if still not repsonding then thiopentone/anaesthesia needed
** check glucose levels bcos high chance of hypoglyceamia
what does teh presence of xanthochromia show in CSF?
xanthochromia is the yellow discoloration of teh CSF showing bilirubin in the CSF = diagnosis of SAH
what is the deifnition of epilepsy?
neurological disorder in which a person experiences recurring seizures
- At least two unprovoked seizures occurring more than 24 hours apart
- one unprovoked seizure and a probability of further seizures simialr to the general recurrence risk after two unprovoked seizures
- diagnosis of an epilepsy syndrome
how would you investigate someone with suspected seziures
- ECG to rule out cardiac causes + bloods
- MRI (/ CT)
- EEG
what are teh differences between focal and generalised seizures?
generalised - involving the whole brain (both hemispheres)
focal - onyl involving focal segment of the brain (one hemisphere)
what are teh features of aprimary generalised seizure?
include absence, atonic, tonic, clonic, tonic-clonic, myoclonic, and febrile seizures
- pt lose consiousness
what are teh features of a seocndary generlaised seizure?
partial seizure that develops into a genenrlaised seizure
what are the features of an absence seizure ?
- msot commonyl in chidlren
- very breif loss of awareness
- blank stare with/without subtle body movements e.g. lip smacking, eye blinking
what are the features of a focal aware (simple partial) seizure?
- patient remains conscious
hearing/tasting things
can get muscle movements
pt usually remembers seizure
what are the features of a focal impaired awareness (complex partial) seizure/
- patient has impaired consiousness - pt doesnt remember seizure
name some common antiepileptic drugs used in epilepsy
- levatiracetam (reduces NMDA/glutamate release)
- lamotrigine (Na+ channel blocker + Ca+ effects)
- sodium valproate (GABAa and Na+ channel blocker)
- topiramate
- carbamazepine(Na+ channel blocker)
- phenytoin (Na+ channel blocker)
- phenobarbitone
name soem red flags for headaches?
- thunderclap headache
- associated fever
- meningism +/ non blnaching skin rash
- raised ICP (papilloedema, headache worse on waking/lying down, coughing)
- new neurological deficit
- new cognitive dysfunction
- personality change
- impaired / deteriorating consious level
- trauma to head
- new onset headache in elderly (GCA)
- change in pattern of chronic headache
- Hx of malignancy or impaired immunity
- postural headaches
in what situations would a lumbar puncture be useful?
- suspected SAH
- suspected meningitis/enchephalitis
- immunlogical disorders e.g. MS or Guillain barre
what woudl typical CSF findiings in bacterial meningitis?
- cloudy
- high WCC
- high protein
- low glucose
what woudl typical CSF findiings in viral meningitis?
- clear
- low WCC
- normal to high protein
- normal glucose (50-80)
what woudl typical CSF findiings in TB meningitis?
- clear
- high WCC
- low to normal protein
- low glucose
- negative gram stain culture
what woudl typical CSF findiings in SAH?
xanthochromia (yellow) due to bilirubin
can be red or yellow BUT yellow AFTER centrifugation whereas a traumatic tap will still be red
what woudl typical CSF findiings in guillian barre syndrome?
normal WCC but elevated protein
what is a contraindication for a lumbar puncture?
- raised ICP
- space occupying lesion
- trauma to lumbar vertebrae
- mass on lumbar vertebrae
- skin infection overlying puncture site
what is parkinsonism?
syndrome which manifests as bradykinesia and rigidity +/- tremors
what are the different types of parkinsonism?
- IPD (idiopathic parkinsons disease)
- vascular pseudoparkinsonism
- drug-induced parkinsonism
- benign essential tremor
- dementia with lewy bodies
- progressive supranuclear palsy
- multiple system atrophy
what are the clinical features of vascular pseudoparkinsonism ?
(from small strokes linked to motor region of brain)
“lower body parkinsons” = problem with walking and balance
less liekly to experience tremor
can have problems with memory,sleep and mood
what are the clinical features of drug-induced parkinsonsim?
(due to neuroleptic drugs used to treat schizophrenia and other psychotic disorders)
tremor, rigidity, bradykinesia, and gait disturbance - more likely to be symmetrical
** features stop after drug is stopped
what are the clinical features of a benign essential tremor?
neurological disorder that causes your hands, head, trunk, voice or legs to shake
what are the clinical features of dementia with lewy bodies?
Lewy body dementia causes visual hallucination, changes in alertness and attention.
+ rigid muscles, slow movement, walking difficulty and tremors (parkinsonism featureS)
what is idiopathic parkinsons disease?
progressive degenerative disorder characterised by neuronal loss in brainstem and basal ganglia
loss of dopaminergic neurones in substantia nigra = reduced dopamine transmission
also get lewy body formation in affected neurones
which investigations are doen to diagnose parkinsons
none !
based on clinical daingosis and improvemnt to medication (levadopa)
how is parkinsons disease diagnosed?
- diagnosis of parkinsonism: bradykinesia + ONE OF muscular rigidity, rest tremor 4-6Hz, postural instability not caused by visual, vestibular, cerebellar or propioceptive dsyfunction
- exclusion of OTHER cuases of parkinsonism
- supportive prospective +ve criteria for parkinsons disease. 3 or more from:
- unilateral onset
- rest tremor presen t
- progressive disorder
- persistent asymmetry affecting side of onset most
- excellent response to levodopa
- severe levodopa induced chorea
- levodopa response fro 5+ yrs or mroe
- clinical course of 10 yrs or more
name some non motor symptoms of parkinsons?
fatigue
low BP
bowel (constipation) and bladder problems
restless legs
skin and sweating problems
anxiety
dementia
depression
memory and thinking problems
hallucinations and delusiosn
what rating scales are used to diagnose severity of parkinsons?
hoehn and Yahr scale and Unified Parkinsons Disease Rating Scale (UPDRS)
what is the initial (MAIN) therapy for parkinsons?
main aim: increase dopamine levels
- levodopa (works for 4-6 yrs) given with DDCI
- dopamine agonsits (e.g. ropinirole, pramipexole)
- MAO-B inhibitors e.g. rasagiline
name the ‘other’ medications given to pt. with parkinsons to control motor symptoms?
- COMT inhibitors e.g. entacapone to inhibit the peripheral breakdown of levodopa
- Anti-muscarinics (e.g. procyclidine) to help dyskinesia
- Apomorphine (non-selective dopamine agonist) - subcut injection for advanced disease
what surgical options are availbale for patients with parkinson?
thalamic or subthalamic surgery
or
deep brain stimulation -> electrodes into the basal ganglia
what are teh 4 distinct phases of parkinsons disease?
- early stage: soon after diagnosis, symptoms mild
- maintenance stage: good response to treatment, no major dsiability
- advanced stage - poor response to drugs with motor SE
- pallaitive stage - unable to live independently and in need multidisciplinary support
name some of teh complications of advancing IPD?
motor:
- motor on off fluctuations
- freezing in gait
- dyskinesia
- falls
- ‘wearing off’ phenomenon towards end of dose
non motor complications:
- Aspiration pneumonia
- Nutritional deficiency
- dysphagia & weight loss
- Bladder, bowel & sexual dysfunction
- Pressure sores
- Sleep disorders
- Dementia & depression
- Postural hypotension
- Impulse control disorders and psychosis
what is MND?
motor neurone disease is a progressive, degenerative neurological disease with rapid progression and poor prognosis
which motor neurones (upper or lower) are involved in MND?
both upper and lower in the spina cord and brainstem - therefore get mixed upper and lower motor neurone signs
how is the diagnosis of MND made?
electromyography (EMG)
plus clinical diagnosis using the presense of both mixed upper and lower motor neurone signs
what is EMG?
using fine needles to record naturally occurring electrical impulses in the nerves. IN MND muscles have lost their nerve supply + show an abnormal pattern
what drug is used to manage MND?
glutamate inhibitor (riluzole)
- mildly slows rate of MND BUT MND is incurable
- average survival 3 yrs
what are the clinical variants of MND?
- amyotrophic lateral sclerosis
- progessive bulbar palsy
- progressive muscular atrophy (LMN) - rare
- progressive lateral sclerosis - rare
how is dysphagia in pts. with MND managed?
enteral feeding
how is resp failure in pts. with MND managed\/
NIV (non invasive ventilation)
which medications when overused can cuase chronic headaches?
- paracetamol, aspirin, or NSAIDs used for 15 days per month or more
- triptans, opioids or ergot preps for 10 days or more a months
how would a headache caused by a space occupyin g lesion present?
- gradual onset
- progressive
- associated neuro features e.g. visual disturbances or focal signs
- features of raised ICP: early morning headache, N+V, worse on coughing and bending
what are the clinical features of a migraine?
- female twice as common
- most have first attack before age 30
- unilateral, frontal, throbbing, 4-72hrs
- can have aura preceding, n+v
- caused by photophobia or phonophobia, sleep + dark room helps
what is teh treatment for migraines?
NSAIDs
triptans
what are teh clinical features of a tension headache?
- young > old
- frontal, bilateral, band tightening, neck muscle tension
- most common type of headahce (due to stress, poor posture, lack of sleep)
- possible mild nausea
- worse at end of day
definition between episodic and chronic tension headaches?
chronic is > 15 times per month
episodic if <15 times a month
what is the treatment for tension headaches?
simple analgesics
clinical features of medication overuse headache?
30-40 yo, female> male
- present @ least 15 days of month and using analgesics for @ least 10 days per month
treatment for med overuse headache?
discontinue meds
what are the clinical features of a cluster headache?
- males> female
- 20-40 yo
- around one eye, unilateral, stabbing, red eye, watery, ptosis, severe
- 15mins - 3hrs (1-2x per day)
-clusters of attacks followed by remissions - alcohol + smoking = aggravatign factors
what is the treatment fro cluster headaches?
simple analgesics
what are the clinical features of trigeminal neuralgiA?
- 50-60yo
- unilateral over distribution of CN V, sharb and stabbing, electric shock, severe
- lasts seconds to 2 mins
- aggravated by light touch to face, eating, cold wind, vibrations
- numbness and tingling preceding an attack
Tx for trigeminal neuralgia?
carbamazepine
clinical features of temporal arteritis?
- unilateral headahce,
- jaw claudication
- scalp tenderness
- visual symptoms: blurring, amaurosis fugax
treatment for temporal arteritis?
oral prednisolone
what are teh clinical features of a SAH?
- Hx of trauma (but also can be spontaenous)
- sudden onset or thunderclap headache
- photophobia
- neck stiffness
- n+v
Ix for suspected SAH?
- A-E
- CT scan to confirm presence of SAH
- cerebrospinal fluid analysis to confirm presence by lumbar puncture (needed if CT done > 6hrs after onset of symptoms) - LP needs to be at least 12 hrs after to allow RBC to lyse = bilirubin
initial Mx of SAH?
- analgesia, anti-emetics + IV fluids
- nimodipine 60mg every 4 hours for 21 days
- external ventricular drain (EVD) if hydrocpehalus present to reduce ICP
Tx of SAH?
aneurysm coiling (DSA) or clipping (craniotomy)
features fo raised ICP?
- headache
- visual distirbances e.g. blurry or transient loss
- papilloedema
- tinnitus
Ix done in raised ICP?
- neuroimaging (MRI or CT) to diagnose cause
- lumbar puncture - see opening pressure (20+ mmHg = elevated)
what is the Tx for idiopathic intracranial hypertension?
Acetazolamide 500 mg orally BD
- carbonic anhydrase inhibitor which reduces production of CSF
what si teh idfference between GBS and MS?
GBS = demyelination of axons in the peripheral nervous system
MS = demyelination of axons in the brain and spinal cord
what is guillain barre syndrome?
acute, inflammatory polyneuropathy causing progressive, ascending neuropathy
name the causes of GBS?
- campylobacter (most common!)
- cytomegalovirus
- EBV
- mycoplasma pneumoniae
what Ix are done to diagnose GBS?
electromyography, nerve conduction studies
- lumbar puncture - shows high protein with normal WCC
Mx of GBS?
- plasmapheresis
- IV immunoglobulin
- immunosuppression
what is MG?
autoimmune disorder, which is due to antibody-mediated blockage of neuromuscular transmission
acetylcholine receptor antibodies that bind to ACh receptors at the NMJ
clinical features of MG?
- increased muscle weakness with use
- ocular: ptosis, diplopia
- resp: breathlessness, resp failure
- bulbar: dysarthria, dysphagia, weak chewing
- limbs/neck: dropped head, arms>legs, proximal>distal
how is MG diagnosed?
- ice pack test - ptosis reduced after put ice pack on eye (NMJ works better wehn cold)
- serological: look for AChR-Ab OR MuSK and LRP4
- Repetitive nerve stimulation - shows muscle fatiguing
- electromyography
treatment for MG?
- MAIN: pyridostigmine, which is an acetylcholinesterase inhibitor.
- Corticosteroids (e.g. prednisolone)
- immunsuppression e.g. azathioprine
which cranial nerves does acute bulbar palsy affect?
CN 9-12
what is bells palsy?
unilateral facial nerve palsy of unknown cause
*thought to be related to inflammation and oedema of the facial nerve secondary to a viral infection or autoimmunity
clinical features of bells palsy?
- unilateral facial weakness
- difficulty chewing
- drooling
- unilateral ear pain
- incomplete eye closure
- NO forehead sparing!
- onset acute (<72 hrs)
Tx of bells palsy?
normally resolves itself within 6 months
sometimes croticosteroids can help reduce inflammatoin and speed up recovery
name the three cuases of an ischaemic stroke?
- embolic e.g. from afib
- thrombotic e.g. atherosclerotic plaque burst
- lacunar e.g. atherosclerotic plaque blocking smaller vessels
what are teh two types of heamorrhagic strokes?
- subarachnoid
- intracerebral
frist line Ix for stroke
non contrast CT scan
Mx for ischaemic stroke?
– If within 4.5 hours of onset –> thrombolysis (alteplase)
– If within 6 hours + confirmed occlusion of anterior circulation –> thrombectomy
– If later/other options unavailable –> loading dose of 300mg aspirin.
after a pt has had a stroke what is teh ongoing treatment given?
– Antiplatelet therapy e.g. clopidogrel/prasugrel.( if contraindicated give aspirin + dipyridamole)
– If cholesterol >3.5mM, give statin
– Anticoag for AF -> started after 2 weeks to reduce risk of bleed e.g. DOAC
– Carotid endarterectomy –> recommended if stroke/TIA in carotid area and carotid stenosis >70%
when is carotid endarterectomy recommneded after stroke?
if a pt had stroke/TIA in carotid are and carotid stenosis >70%
what is a TIA?
ischaemic event with same symptoms as stroke that last <24 hours. without intervention, patients will probs have a stroke within a week
management of TIA?
– Aspirin 300mg + maintenance antiplatelet therapy.
– If more than 1 TIA or carotid stenosis (>70%) –> refer for carotid endarterectomy
– If TIA within last 7 days –> arrange assessment within 24 hours by specialist stroke physician
– It TIA > 7 days ago –> refer to specialist within 7 days
what is the managemnt of a intracerebral haemorrhage?
- surgery if heamatoma is >3cm - drained
what is amaurosis fugax?
transient monocular visual loss of vision that lasts less than 24 hrs.
- due to occlusion of large arteries or small artery occlusion
- may represent TIA deu to clot in retinal/opthalmic artery
Tx for amaurosis fugax?
treated as TIA: 300mg apsiring and refer to specialist
symptoms of intracranial venous thrombosis?
- sudden onset headache
- n+v
- seizures or hemiplegia (sagittal sinus)
- 6th + 7th nerve palsies (transverse sinus)
- central retinal vein thrombosis, perioribital oedema, hyperparaesthesia of face (cavernous sinus)
what are teh investigations done to diagnose intracranial venous thrombosis?
- CT head to exclude SAH
- thrombophilia screen blood test
- CT/MRI venogram is the diagnostic test
Tx of intracranial venous thrombosis?
- anticoagultation with heparin/LMWH then warfarin
- if deterioration -> endovascualr thrombolysis
what are teh classifications of strokes based on the oxford classifications?
- TACS
- PACS
- POCS
- LACS
what three features have to be present to diagnose a TACS?
- homonymous hemianopia
- unilateral weakness (and/or sensory deficit) of face, arm and leg
- higher cerebral dysfunction (dysphasia, visuospatial disorder)
what 2 features have to be present to diagnose a PACS stroke?
2 of:
- homonymous hemianopia
- unilateral weakness (and/or sensory deficit) of face, arm and leg
- higher cerebral dysfunction (dysphasia, visuospatial disorder)
** or higher cerebral dysfunction alone = PACS
What signs/symptoms need to be present to diagnose a POCS stroke?
1 of the following:
- CN palsy and contralateral motor/sensory deficit
- bilateral motor/sensory deficit
- conjugate eye movement disorder (e.g. horizontal gaze palsy
- cerebellar dsyfunction (vertigo, nystagmus, ataxia)
- isolated homonymous hemianopia
what clinical features have to be present to diagnose a LACS?
1 of the following:
- pure sensory stroke
- pure motor stroke
- sensori-motor stroke
- ataxic hemiparesis
