Neurology Flashcards
1
Q
What triad is seen in Horner’s syndrome?
A
Anhydrosis
Ptosis
Miosis (pupil constriction)
2
Q
Define Temporal Arteritis
A
Describes inflammatory vasculitis affecting large vessels of the scalp, neck and arms.
Most commonly affects the extracranial branches of the carotid artery.
3
Q
What is the most common risk factor for temporal arteritis?
A
Polymylagia Rheumatica (proximal weakness - may have difficulty getting out of chair)
4
Q
Give 4 clinical features of Temporal Arteritis
A
Rapid onset (<1 month)
Superficial, unilateral pounding headache
Scalp tenderness (when brushing hair)
Visual disturbance (diplopia, blurring, amaurosis fugax - transient loss of vision)
5
Q
Give 1 complication of Temporal Arteritis
A
Irreversible loss of vision in affected eye
Occurs due to carotid claudication (vasculitis can extend to 1st branch of internal carotid artery (ophthalmic artery)
6
Q
How is Temporal Arteritis managed? (2)
A
High dose glucocorticoids
No visual loss - Prednisolone
Visual loss - Methylprednisolone followed by prednisolone
7
Q
What is the most common type of headache?
A
Tension headache
8
Q
How may a tension headache present?
A
Slowly progressive
Bilateral
Tight “band like” headache.
May originate from the neck
9
Q
Give 2 triggers of tension headache
A
Stress
Dehydration
10
Q
What medications are used in the acute management of Tension Headaches? (3)
A
Aspirin, Paracetamol or NSAIDs
11
Q
What is used as prophylaxis against tension headaches?
A
Acupuncture (up to 10 sessions over 5-8 weeks)
12
Q
Describe a Cluster Headache
A
Describes excruciating, stabbing pain located unilaterally behind the eye.
13
Q
Describe the duration of Cluster Headaches
A
Occur in series (clusters) lasting for weeks/months separated by periods of remission.
Attacks tend to be brief - lasting 15-180 minutes
14
Q
Give 3 causes of Cluster Headaches
A
Smoking
Alcohol
Nocturnal sleep (late bedtime)
15
Q
Give 2 clinical features of cluster headaches
A
Unilateral peri-orbital pain (severe stabbing pain around/behind one eye)
Ptosis, Miosis, Conjunctivitis, Eyelid oedema
16
Q
Describe the acute management of cluster headaches (2)
A
100% inhaled oxygen
Subcutaneous sumatriptan
17
Q
When may sumatriptan be contraindicated?
A
Cardiac disease - IHD, Coronary Vasospasm, Angina, Hypertension
18
Q
Describe the prophylactic management of Cluster Headaches (2)
A
1st line - Verapamil
2nd line - Lithium, Topiramate, Gabapentin
19
Q
Describe migraine
A
Severe, unilateral, throbbing/pulsating headache (aggravated by movement)
20
Q
Give 3 clinical features of migraine
A
Nausea and Vomiting
Photophobia and/or Phonophobia
Aura (scintillating scotoma - waves of light/lines/spots)
21
Q
Give 1 complication of migraine
A
Hemiplegic migraine - Temporary paralysis on 1 side of the body
22
Q
Describe 2 types of migraine
A
Episodic - Occurs <15 days per month
Chronic - Occurs on at least 15 days per month for >3 months
23
Q
Give 5 triggers of migraine
A
Lack of sleep
Irregular/missed meals
Excessive caffeine intake
Lack of exercise/physical exertion
Menstruation (occurring around the time of periods)
24
Q
What is the MOA for triptans?
A
5-HT receptor agonists
25
Give 2 contraindications for triptan use
Ischemic heart disease
Cerebrovascular disease
26
Give 1 side effect of triptans
Throat and chest tightness
27
What is the 1st and 2nd line for acute management of migraine?
1st line - Oral triptan + NSAID or Oral triptan + Paracetamol.
Nasal > oral triptan in patients aged 12-17
2nd line - Metoclopramide or Prochlorperazine (+/- NSAID)
28
When should migraine prophylaxis be offered?
Give to patients experiencing 2 or more attacks per month
29
What is the 1st line prophylactic management of migraine? (3)
Propranolol or Topiramate
propranolol contraindicated in asthma
30
When should propranolol be favoured over topiramate for migraine prophylaxis?
In women of child bearing age (as topiramate is teratogenic and can reduce effectiveness of hormonal contraceptives)
31
What should be offered to women with predictable menstrual migraine?
Frovatriptan or Zlomitriptan
32
Describe trigeminal neuralgia
Sudden, excruciating, sharp, "lightning-like" unilateral facial pain occuring in the V2 (maxillary)nd V3 (mandibular) nerve branch distributions
33
What may trigeminal neuralgia be indicative of? (2)
Multiple sclerosis
Brain stem tumour
34
What is the 1st line treatment for trigeminal neuralgia?
Carbamazepine (as long as there are no red flag symptoms)
Others; Phenytoin, Gabapentin, Baclofen
35
What is the MOA of phenytoin?
Anti-convulsant (sodium channel blocker)
36
What is the MOA of gabapetin
Increases GABA concentrations in the brain
37
What is the moa for Baclofen?
Antispasmodic - GABA analogue
38
Describe idiopathic intracranial hypertension
Neurological condition caused by an increase in intracranial pressure in the absence of a tumour
39
How may idiopathic intracranial hypertension present?
Presents in young obese women
Recurrent (daily) throbbing morning headaches
Papilloedema (optic disc swelling)
40
Give 4 risk factors for idiopathic intracranial hypertension
Obesity
Female
Pregnancy
Drugs (vitamin A and COCP)
41
Why must CT/MRI be conducted before lumbar puncture in patients presenting with features of raised ICP?
To rule out tumour.
LP in the presence of a tumour can cause a sudden decrease in ICP, resulting in brain herniation.
42
How is idiopathic intracranial hypertension managed? (3)
Weight loss
Diuretics - Acetazolamide (Carbonic anhydrase inhibitor)
Repeated lumbar puncture
43
Name 2 types of stroke. Which is most common?
Ischemic (most common)
Haemorrhagic
44
Give 3 causes of ischemic stroke. Which is the most common?
Embolism (most common) - Atrial fibrillation, Infective endocarditis, MI
Atheroma (from carotid arteries)
Systemic hypoperfusion (watershed stroke - Sepsis)
45
What classification is used to classify strokes?
Oxford Stroke Classification (aka Bamford Classification)
46
What criteria are assessed in the Oxford Stroke Classification? (3)
Unilateral hemiparesis and/or hemisensory loss of the fact, arm and leg
Homonymous hemianopia
Higher cognitive dysfunction (e.g dysphasia)
47
What types of stroke are included in the Oxford Stroke Classification? (4)
Total Anterior Circulation Stroke (TACS)
Partial Anterior Circulation Stroke (PACS)
Posterior Circulation Stroke (POCS)
Lacunar Stroke (LACS)
48
Describe a Total Anterior Circulation Stroke (TACS) and state what factors must be present for diagnosis
Large cortical stroke affecting areas of the brain supplied by both the anterior and middle cerebral arteries.
All 3 must be present for diagnosis;
Hemiparesis (contralateral) and/or sensory deficit
Homonymous hemianopia (contralateral)
Higher cognitive dysfunction (i.e dysphasia)
49
Describe Partial Anterior Circulation Stroke (PACS) and state what factors must be present for diagnosis
Describes less severe form of TACS, in which only part of the anterior circulation has been compromised.
Requires only 2 of the following;
Hemiparesis (contralateral) and/or sensory deficit
Homonymous hemianopia (contralateral)
Higher cognitive dysfunction (i.e dysphasia)
50
Describe Posterior Circulation Stroke (POCS) and state what factors must be present for diagnosis
Describes damage to the area of the brain supplied by the posterior circulation (vertebrobasilar territory), particularly the brainstem and cerebellum.
One of the following must be present for diagnosis;
Cerebellar/Brainstem syndromes (ataxia, nystagmus, vertigo, cranial nerve palsy)
Loss of consciousness
Isolated contralateral homonymous hemianopia
51
What investigation is used to diagnose stroke? What does it help you identify?
Non-contrast CT head
Helps identify is stroke is ischemic or haemorrhagic
(Non contrast as contrast would appear hyperdense, just like blood)
52
What additional tests should be performed in patients <55 presenting with stroke symptoms (with no obvious cause)
Autoimmune and thrombophilia screening
Screen for;
Antinuclear antibodies (ANA)
Antiphospholipid antibodies (APL)
Anticardiolipin antibodies (ACL)
Lupus anticoagulant (LA)
Coagulation factors
ESR
Homocysteine and syphilis serology
53
Describe the acute management of stroke (2)
Oxygen (if hypoxic <92%)
Insulin and glucose
54
Describe management of ischemic stroke, once haemorrhagic stroke has been excluded.
Aspirin
Thrombolysis (alteplase) - Administered within 4.5 hours of onset of stroke symptoms
55
Give 5 contraindications for thrombolysis
Previous intracranial haemorrhage
Seizure at onset of stroke
Traumatic brain injury/stroke in last 3 months
Active bleeding/GI haemorrhage
Pregnancy
56
Describe the secondary prevention of strokes (2)
1st line - Clopidogrel
2nd line - Aspirin + Modified Release Dipyridamole (if clopidogrel contraindicated)
57
Give 1 contraindication for clopidogrel use
Active bleeding
58
What is the moa of clopidogrel
P2Y12 antagonist (inhibits activation of platelets)
59
Concurrent use of what medication can reduce the effectiveness of clopidogrel?
Proton Pump Inhibitors (PPIs - Omeprazole, Lansoprazole ect)
60
What is the MOA for Dipyridamole?
Anti-platelet - Inhibits function of phosphodiesterase and adenosine deaminase
61
How is TIA now defined?
A transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischemia without acute infarction.
Symptoms typically resolve within an hour
62
What prognostic score is used to assess TIA risk? What factors does it use?
ABCD2
Age >60
BP - >140/90
Clinical features of TIA (unilateral weakness, Speech disturbance)
Duration of symptoms
History of diabetes
63
Describe the immediate antithrombotic management of TIA
Aspirin immediately
64
What neuroimaging is recommended by NICE following TIA?
MRI - Preferred as can determine territory of ischemia
65
What is the pattern of inheritance in Huntington's disease?
Autosomal Dominant
66
Describe Huntington's disease
Autosomal dominant, slowly progressive neurodegenerative disease characterised by chorea, cognitive decline, loss of coordination and personality changes.
67
Describe the pathophysiology of Huntington's disease
Repeat expansion of CAG triplet encoding Huntingtin protein on chromosome 4.
The longer the repeat, the earlier symptoms tend to present.
68
Where in the brain is particularly affected in Huntington's disease?
Caudate and Putamen (striatum - Basal ganglia)
69
What biochemical changes occur in the striatum in Huntington's Disease? (3)
Decreased GABA
Decreased Acetyl Choline
Increased Dopamine
70
Give 5 clinical features of Huntington's disease
Positive family history
Chorea (Jerky, unwanted movements)
Dysarthria (slurred speech)/Mutism (muteness)
Loss of coordination
Personality changes/Mutism
71
What medication can be used to treat chorea in huntingtons? (2)
Sulpiride (anti-psychotic - Dopamine antagonist)
Tetrabenazine (inhibits MAO-B re-uptake, MAO-B breaks down dopamine)
72
What is given to treat nausea caused by careldopa treatment? Why?
Domperidone
As cyclazine/prochlorperazine (anti-histamines) can exacerbate Parkinson's disease
73
What medication can be used to treat bradykinesia/rigidity in Huntington's?
Carel-dopa (dopamine agonist)
74
What is the function of the Caudate and Putamen? (2)
Areas of the basal ganglia involved in;
Facilitating desired movement
Inhibiting unwanted movement
75
What trinucleotide repeat is present in abundance in Huntingtons?
CAG repeat in chromosome 4
76
Describe Parkinsons disease
Parkinson’s disease is a degenerative movement disorder (motor disease) characterized by the progressive degeneration of dopaminergic neurons in the pars compacta of the substantia nigra in the midbrain.
77
What pathological structure is seen in Parkinson' disease?
Lewy Bodies (protein deposits of synuclein) in the basal ganglia, brainstem and cortex
78
What triad of symptoms is typically seen in Parkinsons?
Bradykinesia (slow to execute movements - reduced arm swing, shuffling gait, expressionless face)
Resting tremor (pill-rolling)
Rigidity (hypertonia - lead-pipe or cogwheel)
79
Give 8 clinical features of parkinsons
TRAPPS PD
T - Tremor
R - Rigidity
A - Akinesia (slow initiation, difficulty with repetitive movement)
P - Postural instability (stooped gait, shuffling steps, reduced arm swing)
P - Postural hypotension
S - Sleep disorders 9insomndia, Excessive Daytime Sleepiness, Obstructive Sleep Apnoea)
P - Psychosis (visual hallucinations)
D - Depression/Dementia/Drug side effects
80
What are the 1st line treatments for Parkinson's disease?
Motor symptoms - Levodopa
No motor symptoms - Dopamine agonist OR levodopa OR MAO-B inhibitor
81
Diagnosis of Parkinsons is made clinically, but if there is an unclear clinical diagnosis, what tests can be performed? (4)
Dopaminergic agent trial (monitor patient's response to levodopa)
MRI
Dopamine transporter imaging (FP-CIT or beta CIT SPECT or Flurodopa PET)
Histology (post mortem, shows Lewy Bodies)
82
Name 2 dopamine agonists and give 3 side effects
Ropinirole or Pramipexole
S/E - Hallucinations, Compulsive Behaviour (gambling/hypersexuality), Drowsiness
83
Name 2 MAO-B inhibitors (monoamine Oxidase B inhibitors) and give 2 side effects
Selegiline and Rasagiline
S/E - Postural Hypotension and Atrial Fibrillation
84
Name 2 Anticholinergics and give 3 side effects
Procyclidine and Benzhexol
S/E - Dry mouth, Urinary retention and Blurred Vision
85
Describe Multiple System Atrophy
Aka Shy-Drager Syndrome
Presents similar to Parkinson's but affects the autonomic nervous system
86
Give 5 clinical features of Multiple System Atrophy
Parkinsons symptoms (Bradykinesia, Tremor, Rigidity)
Ataxia (loss of coordination - Unsteady walking)
Postural hypotension
Urinary incontinence (atonic bladder - unable to spontaneously urinate)
Rectal incontinence
87
Do patients with Multiple System Atrophy respond to levodopa?
No. Poor response to levodopa
88
How does Progressive Supranuclear Palsy present? (4)
Presents similar to Parkinsons but with additional features affecting the eyes;
Slow eye movements
Impairment of vertical gaze (may have difficulty reading or walking down stairs)
Frontal lobe dysfunction (alterations to mood/behaviour)
No tremor
89
Define Alzheimers
Alzheimer’s disease is the most common type of dementia characterised by the degeneration of the cerebral cortex with cortical atrophy
90
Describe the pathophysiology of Alzheimer's disease
Accumulation of;
Abnormal extracellular beta amyloid plaques
and
Intracellular neurofibrillary tangles of tau protein
91
Where in the brain does Alzheimer's first present?
Hippocampus
92
Early onset Alzheimer's is associated with mutations in what genes? (3)
Amyloid precursor protein (chromosome 21)
Presenilin 1 (most common cause of early onset)
Presenilin 2
93
Give 5 clinical features of Alzheimer's disease
Decreased visuo-spatial skill (i.e using a map)
Decreased executive function
Nominal dysphasia (unable to name objects)
Apraxia (impaired ability to carry out motor tasks)
Agnosia (failure to recognise objects)
94
What would be seen on a CT of a patient with Alzheimer's disease
Increased sulci depth (due to atrophy)
95
What are the 1st and 2nd line pharmaceutical treatments for Alzheimers?
1st line - Acetylcholinesterase inhibitors (Rivastigmine, Donepezil, Galantamine)
2nd line - Memantine (NMDA receptor antagonist)
96
Give 1 contraindication and 1 side effect of Donepezil
Contraindication - Bradycardia
Side effect - Insomnia
97
How is Status Epilepticus managed in a pre-hospital setting? (2
PR diazepam
or
Buccal Midazolam
98
What immediate non-medical management should be conducted in status epilepticus? (4)
ABC
Airway adjunct
Oxygen
Check blood glucose
99
Define status epilepticus
A single seizure lasting >5 minutes
Or
>=2 seizures within a 5 minute period without the person returning to normal between them
100
What are the 2 most important causes of status epilepticus to rule out first?
Hypoxia and Hypoglycemia
101
Describe the hospital management of status epilepticus (1st line and 2nd line)
1st line - IV lorazepam (may be repeated once after 10-20 minutes)
2nd line - Phenytoin or Phenobarbital infusion
102
When starting a phenytoin infusion, what investigation should also be performed?
Cardiac monitoring (as phenytoin has pro-arrythmogenic effects)
103
If there is no response to 1st and 2nd line treatments in Status Epilepticus within 45 minutes of onset, what is the next stage of management?
General anaesthesia
104
How may Bells palsy present? (4)
Acute onset, unilateral facial weakness (with NO forehead sparing - LMN palsy)
ear pain (may precede paralysis)
Hyperacusis
Altered taste and dry eyes/mouth
105
How is Bells' palsy managed? (1)
Oral Prednisolone (10 days)
106
Define Multiple Sclerosis (pathologically)
MS is a chronic autoimmune disease of the CNS, characterised by T cell (CD4+) mediated inflammation and demyelination
107
What cell type drives MS?
T-cell (CD4+)
108
What cell type is targeted in MS?
Oligodendrocytes (CNS)
109
What cell type drives the PNS?
Schwann cells
110
How is MS defined clinically?
Defined as two episodes of neurological dysfunction that are separated by in time and space.
I.e patient must exhibit symptoms of MS in two separate CNS areas (brain, spinal cord, optic nerves) at two different times
111
A mutation in what is linked to MS?
HLA-DR2
112
Give 2 environmental factors that are linked to developing MS
Epstein Barr Virus (EBV)
Vitamin D Deficiency
113
What are the 4 patterns of MS? Which is most common?
Relapsing-Remitting MS (80%)
Secondary progressive MS
Primary progressive MS
Progressive Relapsing MS
114
Describe relapsing remitting MS
Characterised by acute attacks followed by episodes of remission
Some remyelination occurs but is often inefficient, resulting in some residual disability post attack
115
Describe secondary progressive MS
65% of relapsing remitting patients go on to develop secondary progressive MS within 15 years of diagnosis
Characterised by a constant immune attack causing a steady progression of disability
116
Describe progressive MS
More common in elderly
Characterised by a constant immune attack on myelin resulting in a steady progression of disability from the start.
117
Describe progressive relapsing MS
Characterised by constant immune attack on myelin with superimposed acute episodes of exaggerated immune attack.
Patients tend to deteriorate and develop significant symptoms much quicker.
118
Give 4 sensory symptoms of MS
Dysaesthesia (peculiar sensory phenomena - odd patches of wetness/burning)
Paraesthesia (pins and needles)
Trigeminal neuralgia (severe facial pain)
Uhthoff's phenomenon (symptoms worsen with heat)
119
Give 4 motor symptoms of MS
Unilateral optic neuritis (blurring/graying of vision in one eye, may have pain moving eye)
Urinary frequency/bowel dysfunction (increases UTI risk)
Spastic weakness
Lhermitte's sign (sudden sensation of electric shocks down spine after neck flexion)
120
Describe Uhthoff's Phenomenon and Lhermitte's sign
Both features of MS
Uhthoff's phenomenon - Symptoms worsen with heat.
Lhermitte's sign - Sudden sensation of electric shocks down spine after neck flexion.
121
What condition is often mistaken for MS. How is it differentially diagnosed?
Devic's syndrome (aka neuromyelitis optica)
Characterised by immune attacks on the optic nerves and spinal cord.
DDx from MS achieved through presence of NMO antibody.
122
Describe a neurological history/exam for MS
History of transient motor, cerebellar, sensory, gait or visual dysfunction lasting over 48 hours and NOT accompanied by fever.
Symptoms often asymmetrical
Fundoscopy to view optic disc
123
What may be seen in a Lumbar Puncture in a patient with MS? (1)
CSF containing IgG oligoclonal bands (suggests inflammation of CNS)
124
What is the gold standard diagnostic test for identifying demyelinating lesions in MS?
MRI with contrast
125
What may be seen on an MRI of a patient with MS? (2)
Periventricular lesions (white matter near cerebral ventricles)
Multiple scattered plaques
126
How is an acute relapse of MS managed?
High dose steroids (IV methylprednisolone) given for 5 days.
127
Give 2 indications for use of disease-modifying drugs in MS patients
Relapsing remitting disease + 2 relapses in past 2 years + able to walk 100m unaided
Secondary progressive disease + 2 relapses in past 2 years + able to walk 10m (aided or unaided)
128
Name 3 disease modifying drugs used in MS treatment (give their MOA)
Dimethyl Fumarate (enhances Nrf2 pathway)
Alemtuzumab (CD52 MAB - targets and destroys T cells)
Natalizumab (Inhibits VLA-4 receptors to allow immune cells to cross BBB)
129
What drugs can be used to manage spasticity (stiff/tight muscles) in MS? (2)
Baclofen
Gabapentin
130
What drug can be used to manage tremor in MS?
Botulinum toxin
131
What can be used to manage fatigue in MS? (2)
Amantadine
CBT therapy
132
Give 1 side effect of Alemtuzumab (MS management)
Can increase risk of infection and triggering autoimmune disease
133
Define Guillain Barre Syndrome. What is it typically triggered by?
Describes an acute inflammatory peripheral neuropathy (PNS)
Triggered by infection
134
What cell type is affected (attacked) in GBS?
Schwann cells (PNS)
135
What are the most common triggers of GBS? (4)
Campylobacter Jejuni (most common)
CMV
EBV
Mycoplasma pneumoniae
136
Give 3 ways GBS can be differentiated from MND
Absent deep tendon reflexes (knee, bicep, triceps, patellar ect)
Increased CSF protein
Sensory features (Dysesthesia) (not seen in MND)
137
What triad of symptoms is classically seen in GBS
Ophthalmoplegia
Areflexia
Ataxia
138
Give 5 clinical features of GBS
Global symmetrical weakness of proximal and distal limbs (follows ascending pattern - starts in legs)
Respiratory distress (dyspnoea on exertion/SoB)
Back/leg pain (in early stages)
Dysphasia
Absent tendon reflexes
139
Give 2 diagnostic tests for GBS (and results)
Nerve conduction studies (showing decreased motor nerve conduction velocities)
Lumbar puncture (shows elevated CSF protein)
140
How is GBS managed?
Plasmapheresis (plasma exchange) + Intravenous Immunoglobulin (IgG)
141
Name 1 variant of GBS and it's associated symptoms
Miller Fisher Syndrome
Associated with;
Opthalmoplegia
Areflexia
Ataxia
Usually presents with descending paralysis (rather than ascending seen in GBS)
142
What antibodies are seen in Miller Fisher syndrome? (variant of GBS)
Anti-GQ1b antibodies
143
Name 2 pyramidal tracts
Corticobulbar tract
Corticospinal tract
144
What is the function of the pyramidal tracts? What are they composed of?
Innervate skeletal muscle, facilitating voluntary movements
Composed of upper motor neurones that innervate lower motor neurones at the anterior horn of the spinal cord.
145
What is the function of extrapyramidal tracts? What are they composed of?
Function to coordinate muscle movement by indirectly activating or inhibiting groups of lower motor neurones, through interneurones
Do not directly innervate lower motor neurones.
Usually innervate multiple muscles that share the same function (i.e flexion, extension ect)
146
What cranial nerves are found at the terminus of the corticobulbar tracts? (4)
V - Trigeminal (pons)
VII - Facial (pons)
XI - Accessory (medulla)
XII - Hypoglossal (medulla)
147
What extrapyramidal tract facilitates posture?
Pontine (medial) Reticulospinal Tract
148
What extrapyramidal tract controls walking movements and breathing?
Medullary (lateral) Reticulospinal tract
149
What extrapyramidal tract is involved in coordinating balance?
Lateral vestibulospinal tract
150
What extrapyramidal tract is involved in coordinating the speed of movement?
Rubrospinal Tract
151
What extrapyramidal tract relays information regarding proprioception, stretch, vibration and fine touch?
DCML
152
How does the DCML detect touch? (3)
Through use of mechanoreceptors in the skin.
Meissner's corpuscles and Merkel's disks - Fine touch
Pacinian Corpuscles - Vibration
Ruffini Corpuscles - Stretch
153
Where does the DCML decussate?
Brainstem
154
Where does the spinothalamic tract decussate?
Spinal cord (before reaching the brainstem)
155
What does the spinalthalamic tract sense?
Pain and Temperature (lateral)
Crude touch (Anterior)
156
Describe a lower motor neurone
Describes a neurone which connects an UMN to skeletal muscle
157
Where do LMNs typically lie?
Within the ventral horn of the spinal cord
158
What motor neurones are responsible for coordinating muscle contraction? How is this achieved?
Alpha motor neurones (LMNs)
Achieved through the myostatic stretch reflex.
159
What is the myostatic stretch reflex?
Describes a reflex in which a muscle contracts when passively stretched (i.e patellar tendon tap)
160
How is Brown-Sequard Syndrome characterised?
Characterised by damage (lesion) to the spinal cord, resulting in;
Ispilateral loss of; Proprioception, motor and fine touch (DCML + Corticospinal)
Contralateral loss of; Pain and Temperature (Spinothalamic)
161
Define upper motor neurone
Describes a neurone whose cell body originates in the cerebral cortex (or brainstem) and terminates within the brainstem or spinal cord
162
Give 5 signs/symptoms of an Upper Motor Neurone Lesion
Hypertonia (too much muscle tone)
Hyper-reflexia (brisk reflexes and twitching)
Spasticity (Clasp Knife Pnenomenon - rigidity)
Positive Babinski Reflex
Minimal muscle atrophy
163
Give 5 signs/symptoms of Lower Motor Neurone Lesions
Muscle atrophy
Hyporeflexia (absent tendon reflexes)
Hypotonia
Flaccid muscle weakness or paralysis
Fasciculations (muscle twitch)
164
Describe motor neurone disease
Describes a cluster of neurodegenerative diseases characterised by progressive degeneration of motor neurones, cranial nerve nuclei and anterior horn cells
165
Name 4 types of MND
Amyotrophic Lateral Sclerosis (ALS) (most common)
Progressive Bulbar Palsy (PBP)
Progressive Muscular Atrophy (PMA)
Primary Lateral Sclerosis (PLS)
166
How can MND be differentiated from other diseases affecting the nervous system?
MND has no sensory loss or sphincter disturbance (distinguishing from MS and polyneuropathies)
Also never affects eye movements (distinguishing from myasthenia)
167
What gene mutation is associated with MND
SOD1 gene mutation
168
What drugs can be used to manage drooling in MND?
Propantheline (anti-cholinergic)
Amitriptyline (tricyclic antidepressant)
169
What motor neurones are affected in ALS?
Upper and Lower Motor Neurones
170
What disease is ALS closely linked to?
Frontotemporal dementia
171
What motor neurones are affected in PBP?
Lower Motor Neurones Only
172
What cranial nerves are affected in PBP?
Glossopharyngeal (9)
Vagus (10)
Accessory (11)
Hypoglossal (12)
173
Give 5 clinical features of PBP
Dysphagia (difficulty swallowing)
Dysarthria (difficulty speaking)
Flaccid fasciculating tongue
Nasal regurgitation
Choking (due to paralysis of glottis)
174
What motor neurones are affected in PMA?
Lower Motor Neurones Only (anterior horn cell lesions)
175
What motor neurones are affected in PLS? How is it characterised?
Upper motor neurones only.
Characterised by loss of Betz Cells (pyramidal cells in motor cortex)
176
Describe Bells' Palsy
Describes an acute, unilateral, lower motor neurone facial nerve paralysis
177
What virus is linked to Bells' palsy?
Herpes Simplex Virus
178
What motor neurone is affected in Bells' palsy?
Lower Motor Neurone (of facial nerve)
179
How does Bells' palsy typically present? (3)
Unilateral facial paralysis with NO forehead sparing
Inability to close eye
Hyperacusis (due to paralysis of stapedius muscle)
180
How is Bells' palsy managed? (2)
Oral prednisolone within 72 hours of onset
Eye care (artificial tears) - To prevent exposure keratopathy
181
What is the prognosis for Bells' palsy?
Most people make a full recovery after 3-4 months
182
Describe the long term pharmacological treatment of ischemic stroke
Clopidogrel + Atorvastatin
If clopidogrel is contraindicated, offer;
Aspirin + Dipyridamole
183
NICE recommend thrombectomy for stroke patients who; (3)
Last known to be well up to 24 hours previously
Who have acute ischaemic stroke and confirmed occlusion of the proximal posterior circulation (demonstrated on CTA or MRA)
If there is potential to salvage brain tissue shown by CT perfusion or MRI (showing limited infarct core volume)
184
Define Wernicke's encephalopathy
Describes a neuropsychiatric disorder caused by thiamine deficiency, most commonly seen in alcoholics.
Is acute and reversible
185
Wernicke's encephalopathy is characterised by a deficiency in what?
Thiamine (vitamin B1)
186
Give 4 causes of Wernicke's encephalopathy
Alcoholics (most common)
Persistent vomiting (i.e hyperemesis gravidarum)
Stomach cancer
Dietary deficiency
187
What classic triad is seen in Wernicke's encephalopathy?
Opthalmoplegia/nystagmus
Ataxia (Gait)
Confusion (altered GCS)
188
How is Wernicke's encephalopathy managed? (3)
Immediate IV thiamine/vitamin B1 (must be given before IV glucose infusion as can worsen symptoms)
Long term oral replacement of vitamin B1, B6, B12 and folic acid
Abstinence from alcohol
189
What investigation result would be seen in Wernicke's encephalopathy?
Decreased red cell transketolase (indicates thiamine deficiency)
190
Define Korsakoff syndrome
Describes a condition occuring in patients with persistent thiamine deficiency (due to chronic alcohol use)
Chronic and irreversible
191
Give 5 clinical features of Korsakoff Syndrome (5)
Similar to Wernicke's encephalopathy;
Opthalmoplegia/nystagmus, Ataxia (Gait) and Confusion (altered GCS)
With;
Anterograde and Retrograde amnesia
Confabulation (producing fabricated memories)
Personality changes (apathy, decrease executive function ect)
Disorientation/Hallucinations
192
What nerve innervates the skin on the palmar aspect of the hand?
Median nerve
193
What nerve innervates the nail bed of the index finger?
Median nerve
194
What nerve innervates the skin overlying the medial aspect of the hand?
Ulnar nerve
195
From which vertebrae does the Brachial Plexus originate?
Anterior rami of C5-T1
196
Give 4 causes of brain abscesses
Sepsis extending from middle ear or sinuses (i.e sinusitis)
Trauma
Surgery to scalp
Embolic events from endocarditis
197
Give 4 clinical features of brain abscess
Headache
Fever
Focal neurology (i.e CN III, VI palsy)
Raised ICP (nausea, papilloedema, vomiting, seizures)
198
How are brain abscesses managed? (2)
IV cephalosporin (ceftriaxone) + Metronidazole
Intracranial pressure management - Dexamethasone
199
Give 4 symptoms of uncal herniation
Recent onset of loss of consciousness
New onset horizontal diplopia
CNIII palsy (unequal pupil size - anisocoria)
Cheyne-Stokes respiration
200
What is the 1st line drug treatment for generalised tonic clonic seizures in males and females?
Males; Sodium Valporate
Females; Lamotrigine or levetriacetam
201
Define epilepsy
Describes a recurrent tendency of spontaneous, intermittent, abnormal electrical activity in part of the brain, manifesting as seizures.
Convulsions are the motor signs of electrical discharges.
202
What are the 1st and 2nd line treatments for focal seizures?
1st line - Lamotrigine or levetriacetam
2nd line - Carbamazepine, oxycarbazepine or zonisamide
203
Define seizure
Defined as a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain.
204
Give 8 causes of seizures
VITAMINS;
V - Vascular (ischaemic/haemorrhagic stroke)
I - Infection (meningitis, encephalitis, abscess)
T - Trauma or toxins
A - Autoimmune (CNS vasculitis or lupus)
M - Metabolic (hyponatraemia, hypocalcemia, hypoglycemia)
I - Idiopathic (epilepsy)
N - Neoplasm
S - Syncope/Psychogenic seizures
205
What are the 1st and 2nd line treatments for absence seizures?
1st line - Ethosuximide
2nd line;
Males - Sodium Valoprate
Females - Lamotragine or levetriacetam
206
What drug can exacerbate absence seizures?
Carbamazepine
207
What is the 1st line treatment for myoclonic seizures in males and females?
Males - Sodium valporate
Females - levetriacetam
208
What is the 1st line treatment for males and females with tonic/atonic seizures?
Males - Sodium valoprate
Females - lamotrigine
209
Define focal seizures
Most common type of seizure
Characterised by abnormal neural activity localised to one area of the cerebral hemisphere
210
What symptoms are seen in a focal seizure located to the temporal lobe? (5)
Automatisms - Lip smacking, chewing
Deja vu/Jamais vu
Delisions
Tastes +smells
Abdominal rising/nausea/vomiting
211
What symptoms would be seen in a focal seizure localised to the frontal lobe? (motor cortex) (3)
Motor features;
Arrest
Jacksonian March (twitching)
Todd's palsy (post-ictal weakness of limbs)
212
What symptoms would be seen in a focal seizure localised to the parietal lobe?
Sensory disturbances (tingling, numbness ect)
213
Describe myoclonic seizures
Sudden jerk of limb, face or trunk
214
Describe atonic seizures
Sudden loss of muscle tone (causing patient to fall to the ground)
215
216
How should a patient with a seizure be managed?
Specialist referral and investigation in <2 weeks
217
What is the MOA for ethosuzimide
Blocks T-type calcium channels in thalamic neurones
218
What is the MOA for lamotrigine. Give 3 side effects
Inhibits voltage gated sodium channels and inhibits glutamate release
S/E - Skin rash, Diplopia, Blurred vision
219
Give 4 side effects of Sodium Valoprate
Increased appetite
Liver failure
Oedema
Ataxia
220
What effect do phenytoin and carbamazepine have on the COCP? why?
Reduce it's effectiveness
As are enzyme inducers
221
What is the MOA for phenytoin and give 3 side effects.
Inhibits voltage gated sodium channels
S/E - Gingival hypertrophy, Hirsutism, Cerebellar symptoms (ataxia, nystagmus, dysarthria)
222
Define febrile seizures
Describes seizures accompanied by fever in infants aged 6 months to 6 years old
223
Name 2 types of febrile seizure
Simple febrile seizure
Complex febrile seizure
224
How are simple febrile seizures defined? (3)
Generalized (tonic clonic - involving both cerebral hemispheres)
Lasts <15 minutes
Doesn't occur again in 24 hours
225
How are complex febrile seizures defined? (3)
Focal seizures (limited to one side of the body/limb)
Lasts >15 minutes
Recurrence in 24 hours
226
What virus has a high association with febrile seizures?
Human Herpes Virus 6 (HHV-6)
(Associated with Roseola Infantum in children - Fever first, Rash later)
227
Define status epilepticus (2)
A single seizure
228
What medication should be avoided in patients with Lewy Body Dementia? (2)
Risperidone
Haloperidol (neuroleptics)
229
What is the 1st line treatment for cognitive impairment and behavioural symptoms in Lewy Body Dementia?
Donepezil (acetyl cholinesterase inhibitor)
230
What is the 1st line treatment for motor symptoms in Lewy Body Dementia?
Carbidopa/Levodopa
231
What is used to treat REM sleep disturbances in Lewy Body Dementia?
Clonazepam
232
What is the preferred antidepressant to treat depression in Lewy Body dementia?
Sertraline (SSRI)`
233
What drugs are associated with increased mortality in dementia patients?
Antipsychotics (i.e olanzapine)
234
Give 5 risk factors associated with a worse prognosis in MS
Older
Male
Motor signs at onset
Early relapses
Many MRI lesions
235
What laboratory results would you expect to see in Wilson's disease? (3)
Low Serum Copper
Low Serum Caeruloplasmin
High Urinary Copper
236
Wilson's disease occurs due to a defect in what?
Defective ATP9B protein.
Results in impaired copper metabolism resulting in copper build up in tissues.
237
How may encephalitis present? (4)
Absence of neck stiffness
High fever
Altered mental status
Seizures
238
What is the most common cause of encephalitis?
Herpes simplex virus
239
How is encephalitis treated?
IV acyclovir
240
Name 4 drugs that are contraindicated in myasthenia gravis (exacerbate symptoms)
Beta blockers (Propranolol)
Calcium channel blockers (Verapamil)
Lithium
Antibiotics (Ciprofloxacin)
241
Define lateral medullary syndrome
Syndrome caused by lesion in the posterior inferior cerebellar artery
242
Lateral medullary syndrome is characterised by a lesion in which artery?
Posterior inferior cerebellar artery
243
What symptoms would be seen in lateral medullary syndrome? (4)
Cerebellar signs (ataxia, nystagmus)
Ispilateral facial numbness
Horner's syndrome (ptosis, miosis, anhidrosis)
Contralateral sensory loss
(if damage is on the right, the right side is affected)
244
How is Cerebral Perfusion Pressure Calculated?
CPP = Mean arterial pressure (MAP) - Intracranial Pressure (IP)
245
Describe Cushing reflex
Describes a response to increased intracranial pressure that results in hypertension and bradycardia.
May be seen in extradural haemorrhages (injury, loss of consciousness, lucid interval)
246
Give 4 clinical signs of of Cushing's reflex
Widening pulse pressure
Bradycardia
Hypertension
Irregular breathing (sign of impending brian herniation)
247
How may Meniere's disease present?
Recurrent episodes of;
Vertigo, tinnitus and hearing loss (sensorineural)
Aural fullness/pressure
Episodes lasting minutes to hours
248
How are acute attacks of Meniere's disease managed?
Buccal or IM Prochlorperazine
249
What neurological condition are vegans more susceptible to? Why?
Sub-acute combined degeneration of the cord
Occurs due to vitamin B12 deficiency
250
How may subacute combined degeneration of the cord present?
Positive Romberg's sign (balance problems in the shower)
Brisk knee jerk and up-going plantars
Absent ankle jerks
251
What is seen on CT for extradural haemorrhage?
Biconcave disk/lens shaped bleed
252
What is seen on CT for subdural haemorrhage?
Crescent shaped haemorrhage
253
How may Ramsey Hunt Syndrome present?
Auricular pain (first feature)
Facial Nerve Palsy
Vesicular Rash around ear
Vertigo/tinnitus
254
What pathogen causes Ramsey Hunt Syndrome?
Herpes Zoster (reactivation of varicella zoster)
255
Where does Varicella Zoster reactivate in Ramsey Hunt Syndrome?
Geniculate ganglion of CN VII
256
Describe the management of Ramsey Hunt Syndrome
Oral aciclovir and corticosteroids
257
What is the most common cause of subarachnoid haemorrhage?
Ruptured berry aneurysms
258
Where are the most common sites for berry aneurysms to form?
Junctions of;
Posterior communicating artery and internal carotid
Anterior cerebral artery and anterior communicating artery
Bifurcation of middle cerebral artery
259
Name 3 diseases that predispose to berry aneurysms
Polycystic kidney disease
Ehlers Danlos syndrome
Coarctation of the aorta
260
Give 5 clinical features of subarachnoid haemorrhage
Sudden onset Thunder-clap headache
Vomiting
Collapse
Photophobia
Depressed/loss of consciousness
261
Give 5 risk factors for subarachnoid haemorrhages
Smoking
Hypertension
Mycotic aneurysms
Diseases that predispose to berry aneurysms (Polycystic kidney disease, Ehlers-Danlos syndrome, Coarctation of the aorta)
History of previous subarachnoid haemorrhages
262
What 2 clinical signs are likely to be positive in subarachnoid haemorrhage?
Positive Kernig's sign (Pain felt on leg extension)
Positive Brudzinski's sign (involuntary hip/knee flexion on neck flexion)
Both indicate meningeal irritation
263
What tests are used to diagnose subarachnoid haemorrhage? (1st and 2nd line)
1st line - Non-contrast CT head
2nd line - Lumbar puncture (if CT is negative but symptoms suggest SAH - shows xanthochromic CSF)
264
What pupil changes may be seen in subarachnoid haemorrhages?
Fixed dilated pupil
III nerve palsy due to rupture of posterior communicating artery aneurysm.
265
What is used to identify ruptured aneurysms in patients with confirmed SAH?
CT angiography
266
What surgical technique is used to treat SAH?
Endovascular coiling
267
What medical treatment may be used in the acute management of subarachnoid haemorrhage?
Calcium channel blocker - Nimodipine (reduce vasospasm)
268
Give 3 complications of subarachnoid haemorrhage
Rebleeding
Cerebran ischemia
Hyponatremia
269
Describe subdural haematoma
Describes collection of blood between the dura and arachnoid meningeal layers
Bleeding occurs from bridging veins between cortex and venous sinuses.
270
Give 5 symptoms of subdural haematoma
Fluctuating level of consciousness
Nausea/vomiting (due to increased ICP)
Headache
Gradual physical/intellectual slowing
Unsteadiness
271
How is subdural haematoma diagnosed?
Non - Contrast CT showing crescent shaped collection of blood
272
Describe extradural haematoma
Commonly occurs perforation of middle meningeal artery.
Describes collection of blood between the bone and the dura.
273
Give 3 symptoms of extradural haemorrhage
Lucid interval (may last hours/days)
Decreasing level of consciousness
Nausea and vomiting
274
How is extradural haematoma diagnosed?
Non-contrast CT - Lens Shaped Haematoma
275
What may be used to lower ICP in extradural haemorrhage?
Mammitol
276
What does a positive Romberg's test suggest?
Sensory ataxia
277
Give 3 symptoms of encephalitis
Altered mental status
High fever, tachycardia, tachypnoea
New onset seizures
278
Where in the brain does encephalitis commonly affect?
Temporal lobe
279
What investigation results are likely seen in encephalitis?
Raised CRP and lymphocytes (raised in viral infection)
LP - Raised lymphocytes and CSF protein
280
What is the most common cause of encephalitis?
Herpes Simplex Virus 1
281
How is encephalitis treated?
IV Ceftriaxone + Oral Acicloviry
282
Give 3 side effects of acyclovir
Generalised fatigue/malaise
GI disturbance
Photosensitivity and urticarial rash
283
Describe the driving law (car) for epilepsy
One off seizure - Inform DVLA and don't drive for 6 months
>1 seizure - Inform DVLA and don't drive for 1 year
Seizure following change in epileptic medication - Reapply to drive if seizure was >6 months ago or if back on previous medication for 6 months
284
Describe the driving law (HGV) for epilepsy
One off seizure - Inform DVLA and don't drive for 5 years (unless haven't taken medications for 5 years)
>1 seizure - Inform DVLA and don't drive for 10 years.
285
Describe MRC grading for power
Grade 0 - No muscle involvement
Grade 1 - Trace of contraction
Grade 2 - Movement at the joint with gravity eliminated
Grade 3 - Movement against gravity, but not against added resistance
Grade 4 - Movement against external resistance with reduced strength
Grade 5 - Normal strength
286
Describe essential tremor
Describes autosomal dominant condition, usually affecting both upper limbs
287
Give 3 features of essential tremor
Postural tremor - Worse if arms are outstretched
Symptoms improve with alcohol and rest
Most common cause of titubation (head tremor)
288
How is essential tremor managed?
Propranolol
Primidone (barbituate) sometimes used
289
What is used in the management of chemotherapy-related nausea?
Ondansetron (5-HT3 receptor antagonist) + Dexamethasone
290
What is a common cause of third nerve palsy?
Posterior communicating artery aneurysm
291
What clinical findings would likely be seen in a patient with cavernous sinus thrombosis?
Third nerve palsy
Ptosis
Dilated Pupil (unable to constrict)
Down and out position of eye.
Pupil is dilated as CNIII carries efferent fibres controlling light reflex
292
Give 1 risk factor for cavernous sinus thrombosis
Anti-phospholipid syndrome
293
How may Horner's syndrome present?
Ptosis
Pupil constriction
Intact light reflex
294
What are the 1st and 2nd line treatments for focal seizures?
1st - Lamotrigine or carbamazepine
2nd - Levetriacetam
295
What are the 1st and 2nd line treatments for generalized tonic clonic seizures?
1st - Sodium valporate (males)
2nd - Lamotrigine (women of child bearing age)
296
What are the 1st and 2nd line treatments for absence seizures?
1st line - Ethosuximide (women) or sodium valoprate (males)
2nd line - Lamotrigine
297
What are the 1st line treatments for myoclonic seizures in males and females?
1st line - Sodium valporate (males)
1st line - Levetriacetam (females)
298
What anti-epileptic should be avoided in myoclonic seizures? and why?
Carbamazepine
Can worse seizures
299
What is the 1st line treatment for tonic/atonic seizures?
1st line - Sodium valporate or lamotrigine
300
What scale is used to measure disability or dependence in activities of daily living in stroke patients?
Barthel index
301
What scale categorises patients into levels of frailty according to function?
Rockwood frailty score
302
Define myasthenia gravis
Describes an autoimmune disorder resulting in insufficient functioning of acetyl choline receptors.
Occurs due to generation of Acetyl Choline Receptor antibodies.
303
How may myasthenia gravis present? (5)
Key feature - Muscle fatigability - Muscles become progressively weaker during periods of activity and slowly improve with rest.
Other features;
Extra ocular muscle weakness; diplopia
Proximal muscle weakness; face, neck, limb girdle
Ptosis
Dysphagia
304
Myasthenia gravis is commonly associated with what? (3)
Thymomas (15%) - May present on anterior mediastinum
Thymic hyperplasia (50-70%)
Autoimmune disorders - pernicious anaemia, SLE, RA ect
305
What is the 1st line for myasthenia gravis?
Pyridostigmine (acetylcholinesterase inhibitor)
Later add - Prednisolone
306
Define myasthenic crisis
Describes an acute, life threatening exacerbation of myasthenic symptoms, leading to respiratory failure
307
How is myasthenic crisis managed? (3)
Plasmapheresis
IV Immunoglobulin G
Early endotracheal intubation
308
What cranial nerves are commonly affected in vestibular schwannomas?
V, VII, VIII (cerebellopontine junction)
309
What is the classical presentation of vestibular schwannoma? (4)
Vertigo
Sensorineural hearing loss
Tinnitus
Absent corneal reflex (ophthalmic branch of trigeminal nerve)
310
Describe the mechanism of adjusting ventilation in the management of patients with raised ICP
Controlled hyperventilation
Hyperventilation > reduces Co2 > Vasoconstriction of cerebral arteries > Reduced ICP
311
How may a patient with a craniopharyngioma present? (2)
Lower bitemporal hemianopia
Diabetes insipidus (Polydipsia/Polyuria)
312
How can Weber's test be interpreted? (3)
Normal - Sound heard equally in both ears
Sensorineural hearing loss - Sound is louder on the side of the intact ear
Conductive hearing loss - Sound is louder on the side of the affected ear
313
How can Rinne's test be interpreted? (3)
Normal - Air conduction > bone conduction (positive)
Conductive hearing loss - Bone conduction > air conduction (negative)
Sensorineural hearing loss - Air conduction > bone conduction (positive)
314
What are the 3 modalities of GCS?
Motor response
Verbal Response
Eye opening
315
Describe the motor response modality of GCS (6)
6. Obeys commands
5. Localises to pain
4. Withdraws from pain
3. Abnormal flexion to pain (decorticate posture)
2. Extending to pain
1. None
316
Describe the verbal response modality of GCS (5)
5. Orientated
4. Confused
3. Words
2. Sounds
1. None
317
Describe the eye opening modality of GCS (4)
4. Spontaneous
3. To speech
2. To pain
1. None
318
What respiratory management should take place in a patient with a GCS <8?
Insert Cuffed Endotracheal Tube
319
What triad of symptoms is typically seen in Normal Pressure Hydrocephalus?
Urinary incontinence
Dementia and bradyphrenia (slow thinking)
Gait abnormalities (ataxia)
320
What is thought to be the cause of normal pressure hydrocephalus
Occurs secondary to reduced CSF absorption at the arachnoid villi.
May be secondary to head injury, subarachnoid haemorrhage or meningitis.
321
What may be seen on MRI in a patient with Normal Pressure Hydrocephalus?
Ventriculomegaly (enlarged cerebral ventricles)
322
How is normal pressure hydrocephalus managed?
Ventriculoperitoneal shunting
323
How are medication overuse headaches managed?
Abruptly stop - Simple analgesics and Triptans
Gradually stop - Opioids (codeine)
324
Define neurofibromatosis
Describes an autosomal dominant condition characterised by the formation of tumours on nerve tissue
325
What are the 3 main types of neurofibromatosis?
NF-1
NF-2
Schwannomatosis
326
Give 4 clinical features of neurofibromatosis 1
Multiple fibromas - Soft, painless nodules under the skin
Cafe au lait spots
Lisch nodules (pigmented iris haematomas)
Seizures
327
Give 2 clinical features of neurofibromatosis 2
Bilateral vestibular schwannomas
Early onset cataracts (usually bilateral)
328
Describe tuberous sclerosis
Describes an autosomal dominant condition characterised by the generation of non-cancerous tumours in different parts of the body.
329
Give 4 pathogmonic cutaneous features of tuberous sclerosis
'Ash lead spots'
Rough patches over lumbar spine (Shagreen patches)
Adenoma sebaceum (angiofibromas - butterfly distribution over nose)
Subungual fibromatoma (fibromata beneath nails)
330
Give 3 extra-cutaneous features of tuberous sclerosis
Epilepsy
Retinal haemorrhage
Developmental delay
331
Define glaucoma
Describes an optic neuropathy due to raised intraocular pressure
332
Give 3 factors predisposing people to acute angle closure glaucoma (AACG)
Hypermetropia (long-sightedness)
Pupillary dilatation
Lens growth associated with age
333
Give 5 clinical features of Acute Angle Closure Glaucoma
Severe pain - Ocular or Headache
Decreased Visual Acuity
Red eye
Haloes around lights
Semi-dilated non-reacting pupil
334
How is acute angle closure glaucoma managed (acute)? (3)
Urgent referral to opthalmologist
Combination of eye drops;
Pilocarpine (parasympathomimetic)
Timolol (beta blocker)
Apraclonidine (alpha 2 agonist)
IV acetazolamide (reduces aqueous secretions)
335
What is the definitive treatment for acute angle closure glaucoma?
Laser peripheral iridotomy
336
How does pilocarpine alleviate symptoms of acute angle closure glaucoma?
Causes contraction of ciliary muscle > opening the trabecular meshwork > increased outflow of aqueous humour
337
What is the protocol regarding driving for a patient whom experienced a TIA?
Can start driving if symptom free for 1 month - No need to inform DVLA
338
What type of visual field defect is seen in pituitary adenoma?
Bitemporal Superior Quadrantanopia (as pituitary adenoma presses on optic chiasm from below)
339
What type of visual field defect is seen in craniopharyngioma?
Bilateral inferior quadrantanopia (as craniopharyngioma presses on optic chiasm from above)
340
Craniopharyngioma is derived from a remnant of what?
Rathke's pouch
341
What condition is associated with bilateral vestibular schwannomas?
Neurofibromatosis 2
342
What is the most common primary brain tumour in adults?
Glioblastoma
343
How may a glioblastoma appear on imaging?
Solid tumour with central necrosis
Has a rim that enhances on contrast
344
What is the 2nd most common brain tumour in adults?
Meningioma
345
Where do meningiomas arise? Where are they typically located?
From the arachnoid cap cells of the meninges, typically located next to the dura
Typically located at the flax cerebri
346
How may a pontine haemorrhage (stroke) present? (3)
Reduced GCS
Paralysis (quadriplegia)
Bilateral pin point pupils
347
How should a patient taking warfarin/doac presenting with TIA be managed? Why?
Immediate referral to emergency department for imaging
(to exclude haemorrhage - increased risk in bleeding disorders/on blood thinners)
348
What is the gold standard investigation for Intracranial Venous thrombosis?
MRI venography
349
Where do intracranial venous thromboses commonly occur?
Sagittal sinus
350
How is intracranial thrombosis managed?
Acute - LMWH
Chronic - Warfarin
351
How may sagittal sinus thrombosis present? (2)
Seizures and hemiplegia
Empty delta sign on venography
352
Give 4 common features of non-epileptic attacks
Arms flexing and extending (may have pelvic thrusting)
Eyes are usually closed (eyes are open in epilepsy)
Prolonged seizure (>30 minutes)
Symptoms wax and wane
353
How is postural hypotension defined? How is the test done?
Systolic drop of >20mm when going from sitting to standing.
Patient should lie or sit still for 5 minutes before taking their baseline measurement.
Then get them to stand and measure their BP at 1 min and 3 min.
354
What is the 1st line treatment of peridcarditis?
NSAIDs
2nd line - Colchicine (for recurrent or continued symptoms beyone 14 days)
355
Give 3 common features of PE on CXR
Fleischner sign (dilated central pulmonary vessel)
Westermark sign (collapse of vasculature distal to PE)
Hampton's hump (Wedge shaped infarct)
356
Give 2 ECG features of PE
Sinus tachycardia
ST depression
357
What is the MOA of caffeine?
Blocks adenosine receptors
358
What is the MOA of methotrexate?
Competitively inhibits dihydrofolate reductase
359
Define Transient Ischaemic Attack (TIA)
Aka Mini Strokes
Defined as a brief, transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal infarction, without acute ischaemia.
360
Give 4 causes of TIAs
Atherothromboembolism from the internal carotid artery (main cause)
Cardioembolism (post MI, or AF, or prosthetic valves)
Hyperviscosity (polycythemia, sickle cell, myeloma)
Vasculitis (rare)
361
Give 4 symptoms/signs of TIA. Do symptoms resolve?
TIA patients tend to have complete resolution of symptoms within an hour.
Amaurosis fungax (unilateral progressive vision loss - like a curtain descending)
Unilateral weakness or sensory loss
Ataxia, vertigo or loss of balance
Aphasia or dysarthria
362
Give 6 investigations useful in excluding other diagnoses in TIA patients
Serum glucose (exclude hypoglycaemia)
FBC (exclude anaemia/infection)
Prothrombin time, INR, PTT (exclude coagulopathy)
Fasting lipid profile (exclude hyperlipidaemia/atherosclerotic risk)
ECG (investigate AF or other arrhythmias)
Doppler +/- Angiography
363
What risk assessment is used to estimate risk of stroke after TIA?
ABCD2
364
Describe the immediate management of TIA
Immediate antithrombotic therapy:
Give Aspirin 300mg immediately.
365
In TIA management, when should aspirin not be given? (3)
If;
The patient has a bleeding disorder or is taking an anticoagulant (needs admission for imaging to exclude haemorrhage)
The patient is already taking low dose aspirin regularly (continue the current dose of aspirin until reviewed by a specialist)
Aspirin is contraindicated (discuss management with a specialist team)
366
What is the preferred diagnostic imaging test for TIA? What carotid imaging test should also be performed?
MRI is preferred imaging to determine the territory of ischaemia.
Carotid doppler should be conducted in all patients (unless not a candidate for carotid endartectomy)
367
Describe the secondary prevention for TIA
Antiplatelet and lipid modification therapy to follow on from initial aspirin therapy;
1st line - Clopidogrel + atorvastatin (20-80mg)
2nd line - Aspirin + dipyridamole + atorvastatin (if clopidogrel not tolerated)
368
In TIA patients, when is carotid artery endarterectomy recommended?
Recommended if patient has suffered stroke or TIA in the carotid territory and is not severely disabled.
Should only be considered if;
Carotid stenosis >70% according to European or >50% according to North American
369
From what layer of brain tissue does a lumbar puncture extract CSF?
Sub arachnoid
370
Where does the dura mater receive it's blood and nerve supply?
Blood supply = middle meningeal artery/internal jugular veins
Nerve supply = Trigeminal Nerve
371
Why should phenytoin and carbamazepine be avoided in patients taking the oral contraceptive pill?
They are enzyme induces so reduce the effectiveness of the oral contraceptive pill.
372
Define meningitis
Describes an inflammation of the meninges, usually due to infection. (meninges are the lining of the brain and spinal cord)
373
Name 5 common causes of bacterial meningitis
Neisseria meningitidis (most common)
Streptococcus pneumoniae (most common in adults)
Haemophilus influenzae
Group B streptococcus (GBS)
Listeral monocytogenes
374
What 2 pathogens commonly cause meningitis in neonates?
Group B streptococcus (GBS) (as HBS can colonise the vagina)
Listeria monocytogenes
375
Define meningococcal meningitis and meningococcal septicaemia.
Meningococcal meningitis - When the bacteria infects the meninges and the CSF
Meningococcal septicaemia - When the bacteria infects the bloodstream.
376
What rash is commonly seen in meningococcal septicaemia?
Non-blanching rash
377
What are the 3 most common causes of viral meningitis?
Enteroviruses (coxsackievirus)
Herpes simplex virus (HSV)
Varicella zoster virus (VZV)
378
What diagnostic test is performed to diagnose viral meningitis?
Viral PCR testing on CSF sample
379
What is used to treat HSV and VZV (viral meningitis)?
Aciclovir
380
Give 6 typical symptoms of meningitis
Fever
Neck stiffness
Vomiting
Headache
Photophobia
Altered consciousness/Seizures
381
How may meningitis present in babies/neonates?
Non-specific symptoms;
Hypotonia
Poor feeding
Lethargy
Hypothermia
Bulging fontanelle
382
When do NICE recommend performing a lumbar puncture on a child with suspected sepsis? (2)
Children who are;
Under 1 month, presenting with fever
1-3 months and are unwell or have a low or high white blood cell count
383
When performing a lumbar puncture, which vertebrae is the needle inserted?
L3/L4 or L4/L5 vertebral space
384
What tests are performed on a sample of CSF when investigating meningitis?
Bacterial Culture
Viral PCR
Cell Count
Protein levels
Glucose levels
385
What may CSF test results show in a patient with bacterial meningitis? (5)
Appearance - Cloudy
Protein - High (bacteria release proteins)
Glucose - Low (bacteria eat glucose)
White Cell Count - High (neutrophils)
Culture - Shows Bacteria
386
What may CSF test results show in a patient with viral meningitis? (5)
Appearance - Clear
Protein - Mildly raised/normal
Glucose - Normal (viruses don't eat glucose)
White cell count - High (lymphocytes)
Culture - Shows viruses
387
Is bacterial meningitis a medical emergency?
Yes. Should be treated immediately.
388
A child presenting with suspected meningitis and a non-blanching rash should be given what immediately?
Benzylpenicillin (IM or IV)
Under 1 = 300mg
1-9 years = 600mg
Over 10 = 1200mg
389
What antibiotics are given to babies with suspected meningitis?
Under 3 months - Cefotaxime + Amoxicillin (to cover listeria)
Above 3 months - Ceftriaxone
390
If there is a risk of penicillin-resistant pneumococcal infection (e.g recent foreign travel/prolonged antibiotic exposure), what should be added? (treatment of bacterial meningitis)
Vancomycin
391
What medication is used to reduce the frequency and severity of hearing loss and neurological complications in patients with bacterial meningitis?
Steroids (Dexamethasone)
392
Is bacterial meningitis and menigococcal infection an notifiable disease?
Yes. Both should be notified to the UK Health Security Agency
393
When is the exposure risk highest for people in close contact with an individual with a meningococcal infection?
Risk is highest within 7 days before onset of illness.
Risk decreases 7 days after the diagnosis.
394
What is given as post-exposure prophylaxis for meningococcal infection?
Single dose of Ciprofloxacin (preferred) or rifampicin
395
Give 5 complications of meningitis
Hearing loss (key complication)
Seizures and epilepsy
Cognitive impairment and learning disability
Memory loss
Focal neuological deficits (limb weakness or spasticity)
396
In what circumstances should a lumbar puncture be delayed? (4)
Signs of severe sepsis or a rapidly evolving rash
Severe respiratory/cardiac compromise
Significant bleeding
Signs of raised ICP (focal neuro deficits, papilloedema, continuous/uncontrolled seizures, GCS <12)
397
How should patients with signs of raised ICP be managed? (6)
Get critical care input
Secure airway + high flow oxygen
IV access > take bloods and blood cultures
IV dexamethasone
IV antibiotics (ceftriaxone/cefotaxime)
Arrange neuroimaging
398
If a lumbar puncture is performed for suspected meningitis, what should it be tested for? (5)
glucose, protein, microscopy and culture
lactate
meningococcal and pneumococcal PCR
enteroviral, herpes simplex and varicella-zoster PCR
consider TB investigations
399
Bacterial meningitis - What is the initial empirical therapy for child aged <3 months?
IV cefotaxime + amoxicillin (or ampicillin)
400
Bacterial meningitis - What is the initial empirical therapy for aged 3 months - 50 years?
IV cefotaxime (or ceftriaxone)
401
Bacterial meningitis - What is the initial empirical therapy for patients aged >50?
IV cefotaxime (or ceftriaxone) + amoxicillin (or ampicillin)
402
Bacterial meningitis - What is the treatment for meningococcal meningitis?
IV benzylpenicillin or cefotaxime (or ceftriaxone)
403
Bacterial meningitis - What is the treatment for pneumococcal meningitis?
IV cefotaxime (or ceftriaxone)
404
Bacterial meningitis - What is the treatment for meningitis caused by haemophilus influenzae?
Intravenous cefotaxime (or ceftriaxone)
405
Bacterial Meningitis - What is the treatment for meningitis caused by Listera?
IV amoxicillin (or ampicillin) + Gentamicin
406
