Neurology Flashcards
What is the maximum score from the GCS given to eye opening?
4
What are the different GCS scores for eye opening?
1 - No eye opening
2 - To pain
3 - To speech
4 - Spontaneous
What are the different GCS scores for Best Verbal Response?
1 - None
2 - Incomprehensible sounds
3 - Inappropriate words
4 - Patient confused
5 - Patient oriented
What are the GCS scores for Best Motor Response?
1 - None
2 - Extensor response to painful stimulus
3 - Flexion to painful stimulus
4 - Withdraws from pain
5 - Localises to pain stimulus
6 - Obeys commands
What does abnormal flexion from a painful stimulus indicate?
Decorticate Posturing
What is decorticate posturing?
Posturing caused by significant damage to areas such as cerebral hemispheres, internal capsule and thalamus
What is decerebrate posturing?
Posturing caused by damage to the brain stem.
Shown by people with lesions or compression in midbrain, cerebellum
What would abnormal extension upon painful stimulus imply?
Decerebrate posturing
What would progression from decorticate to decerebrate posturing be an indication of?
Coning
(Uncal or tonsilar brain herniation)
What are the diagnostic criteria of restless legs syndrome?
- An urge to move the legs
- Temporary relief with movement
- Onset or worsening of symptoms with rest or inactivity
- Worsening or onset of symptoms in the evening or night
What is neurapraxia?
Local myelin damage usually secondary to compression
What is axonotmesis and what are the degrees?
Damage to the axon
Second degree - Axon severed but endoneurium intact
Third degree - Axon discontinuity, endoneurial tube discontinuity, perineurium and fascicular arrangement preserved
Fourth degree - Loss of continuity of axons, endoneurial tubes, perineurium and fasciculi, epineurium intact
What is neurotmesis?
Complete physiologic disruption of entire nerve trunk
What would be the presentation of Cranial Nerve III Palsy?
Ptosis
Eye pointing “Down and Out”
Larger than normal pupil on one side - anisocoria
(Due to loss of parasympathetic pupillary constriction)
What would be the difference between idiopathic anisocoria and a pathological anisocoria?
Idiopathic anisocoria presents with a pupil size difference of less than 0.5mm
How would a patient with Horner’s Syndrome Present?
Unilateral pin-point anisocoria
Partial ptosis
Hemifacial lack of sweating (anhidrosis)
What type of dementia would be associated with hallucinations?
Lewy-body dementia
What would be the treatment of choice for a ischaemic stroke, and how soon after onset of symptoms must this be administered?
Alteplase
Within 4.5hrs (Ideally within 3hrs)
What treatment would be used 24 hours after initial management of an ischaemic stroke?
Aspirin 300mg for 2 weeks
(Necessary to rule out haemorrhagic transformation of stroke with CT)
What are the symptoms and signs of optic neuritis?
Changes in vision
Pain in the eyes
Slow light reflex
Relative Afferent Pupillary Defect
What pathology is most likely to cause bitemporal hemianopia?
Pituitary Adenoma
(Upper visual fields will be affected more - due to compression below the optic chiasm)
What is Guillain-Barre Syndrome?
An immune-mediated demyelination of the peripheral nervous system, often triggered due to infection (Campylobacter jejuni, EBV, CMV, Mycoplasma)
What would Guillain-Barre Syndrome present with?
- Ascending, progressive, symmetrical flaccid weakness, starting in legs/arms
- Neuropathic pain
- Reduced or absent reflexes
- Paraesthesia and sensory loss beginning in lower extremities
- Autonomic symptoms - reduced sweating, reduced heat tolerance, paralytic ileus
What does a bitemporal hemianopia involve?
- Loss of vision in the outer half of both left and right visual field
What would a homonymous hemianopia involve?
Visual field loss on both left or right sides from the vertical midline of both eyes
What does Romberg’s Test show?
Sensory ataxia
Positive test implicates loss of proprioception
What are the features of cerebellar disease?
DANISH:
Dysdiadochokinesia
Ataxic gait
Nystagmus
Intention tremor
Slurred Speech
Hypotonia
What is the treatment for Temporal arteritis?
High-dose glucocorticoid therapy:
Prednisolone
What are the clinical features of GCA?
- New-onset temporal headache
- Temporal artery abnormality
- Visual disturbances
- Scalp tenderness
- Jaw claudication
- Fever, fatigue, anorexia, weight loss, depression
What can be the complications of GCA?
- Loss of vision
- Aneurysms, dissections and stenotic lesions of aorta and major branches
- CNS disease
- Steroid related complications
What would be the relevant investigations for GCA?
Temporal Artery Biopsy
- CRP elevated
- Normocytic normochromic anaemia and thrombocytosis
- LFTs - Alkaline phosphatase elevated
Colour duplex ultrasonography
Which nerve is responsible for the corneal reflex
CN V - Trigeminal - sensory
CN VII - Facial - Motor
What are the symptoms of Bell’s Palsy?
- Abrupt onset of ipsilateral facial weakness
- Peri-aural pain/numbness
- Decreased taste
- sound hypersensitivity
What nerve palsy causes bell’s palsy?
Facial nerve
What is the treatment for Bell’s Palsy?
Prednisolone within 72 hours
Advise regarding eye care
What is the Bamford classification for POCS (Posterior circulation) Stroke?
ANY OF:
1. Cerebellar or brainstem syndromes
2. Loss of consciousness
3. Isolated homonymous hemianopia
What is the Bamford classification for TACS (Total Anterior Circulation) Stroke?
ALL 3 OF:
1. Unilateral weakness (and/or sensory deficit) of face, arm, leg
2. Homonymous hemianopia
3. Higher cerebral dysfunction (Dysphasia, visuospatial disorder)
What is the Bamford classification for PACS (Partial Anterior) Stroke?
ANY 2 OF:
1. Unilateral weakness (and/or sensory deficit)
2. Homonymous hemianopia
3. Higher cerebral dysfunction (dysphasia, visuospatial disorder)
What is the Bamford classification for LACS (Lacunar) Stroke?
ANY OF:
1. Unilateral weakness (/sensory deficit) of face and arm, arm and leg or all three
2. Pure sensory stroke
3. Ataxic hemiparesis
What is normal pressure hydrocephalus?
Enlarged lateral and third ventricles, with CSF opening pressure remaining within normal range
What is the clinical presentation of hydrocephalus?
- Urinary incontinence
- Deterioration in cognition
- Gait disturbances
What is the radiological finding of an extradural haemorrhage?
Bi-convex hyperdensity in the extradural space
What are the most common types of dementia in order?
- Alzheimer’s
- Vascular
- Lewy body dementia
- Frontotemporal
What are the risk factors for vascular dementia?
Hypertension
Smoking
Diabetes Mellitus
Hyperlipidaemia
Obesity
Hypercholesterolaemia
What is the pathophysiology of vascular dementia?
Most commonly small cerebrovascular infarcts, small vessel disease and single cerebrovascular accidents
Most commonly affects white matter of cerebral hemispheres, grey nuclei, thalamus and striatum
What are the symptoms of Brown-Séquard syndrome?
- Contralateral loss of pain and temperature
- Ipsilateral loss of sensation to light touch, vibration sense and proprioception
- Ipsilateral UMN weakness below the lesion
What is the main cause of optic neuritis?
Multiple Sclerosis
Where do cranial nerves 9, 10 and 11 exit?
The lateral medulla
If the uvula is deviated to the right, which side of the brainstem is the lesion on, and which nerve is this affecting?
The left side (Contralateral to lesion)
Cranial Nerve X - Vagus
After an unprovoked, isolated seizure, what should the driving advice for a patient be?
Do not drive for 6 months and inform DVLA
What is the triad of symptoms in Parkinson’s Disease?
- Cogwheel rigidity
- Bradykinesia
- Resting Tremor
What lesion would cause “clasp-knife” phenomenon?
An UMN
What is progressive supranuclear palsy?
A Parkinson’s Plus syndrome, consisting of:
- Failure of vertical gaze
- Symmetrical extrapyramidal features
- Frequent falls
- Lack of response to levodopa
What is encephalitis?
Inflammation of the brain, commonly caused by viral infection
What causes encephalitis?
- Viral - acute viral encephalitis, post-infectious encephalitis (autoimmune process)
- Herpes Simplex Encephalitis most frequent cause
- Bacterial - tuberculosis, mycoplasma, listeria, Lyme disease
- Fungal
What are the symptoms of encephalitis?
- Flu-like illness or headache
- Followed by rapid development of altered consciousness - confusion, drowsiness, seizures, coma
- Symptoms of increased intracranial pressure - headache, nausea, convulsions, mental confusion
- Photophobia, sensory changes and neck stiffness
How is encephalitis diagnosed?
- CSF
- Lymphocytosis with normal CSF/plasma glucose ratio
- CSF proteins high
- CSF PCR test for HSV - FBC and film
- Leukocytosis
How would encephalitis be treated?
- Urgent admission
- Parenteral Abx for possibility of meningitis - IV or IM benzylpenicillin
- Treatment with acyclovir by IV infusion
What is the treatment for Guillain Barre Syndrome?
Plasma Exchange
Intravenous Immunoglobulins
Supportive therapy
DVT Prophylaxis
Pain relief
Admission to ICU
What investigations are used to diagnose Guillain Barre Syndrome?
Nerve Conduction studies
Lumbar puncture - elevated CSF protein
Spirometry
What is Lambert Eaton Myasthenic Syndrome?
Autoimmune disease of NMJ, characterised by impaired presynaptic release of ACh
What causes Lambert-Eaton Syndrome?
Small cell lung cancer
What are the symptoms of Lambert-Eaton Syndrome?
Weakness in the proximal muscles of lower limb, affecting gait, better on exertion
Increase of symptom severity with atmospheric temperature
What causes Horner’s Syndrome?
Disruption of sympathetic nerves supplying the eye
What investigations may be relevant to Horner’s Syndrome?
CXR may show apical carcinoma of the lung
CT/MRI useful in case of cerebrovascular accident
CT angiography may demonstrate dissection of carotid artery
Apraclonidine - dilates pupil affected by Horner’s Syndrome
What is Vernet’s disease?
Paralysis of cranial nerves IX, X and XI
What marker would be an indication of LEMS (Lambert-Eaton Syndrome)?
Antibodies to voltage-gated calcium channels
What antibodies would be found in Myasthenia Gravis (MG)?
Acetylcholine (ACh)
What are the symptoms of frontotemporal dementia?
Prominent personality and behavioural changes
Memory impairment
- Loss of awareness, disinhibition, impulsivity, social withdrawal, stereotyped or preservative behaviour and speech output changes
What is the biological treatment for Parkinson’s disease?
No one universal first-line drug:
MAO-BIs - selegiline, rasagiline
Oral or transdermal dopamine agonist - pramipexole, ropinirole
Levodopa (Co-careldopa, co-beneldopa) - most effective symptomatic drug
Amantadine
What is donepezil used in?
Alzheimer’s disease
- ACh inhibitor
What is the key characteristic feature needed to diagnose multiple sclerosis?
More than one nerve lesion disseminated in time and space
What are the risk factors of multiple sclerosis?
Multiple genes
Epstein–Barr virus (EBV)
Low vitamin D
Smoking
Obesity