Neurology🧠 Flashcards
1
Q
What is first line drug treatment for absence seizures in men?
A
Ethosuximide
2
Q
What is the first line drug treatment for focal seizures with or without secondary generalisation?
A
Lamotrigine or Levetiracitam
3
Q
What is lateral medullary syndrome?
A
Lateral medullary syndrome - PICA lesion - cerebellar signs, contralateral sensory loss & ipsilateral Horner’s.
It is also known as Wallenberg’s syndrome and occurs following occlusion of the posterior inferior cerebellar artery.
4
Q
What drug can be used to treat idiopathic intracranial hypertension?
A
Acetazolamide is a carbonic anhydrase inhibitor that is used to treat idiopathic intracranial hypertension
5
Q
What is syringomelia associated with?
A
An Arnold-Chiari malformation
6
Q
What cranial nerves are affected in vestibular schwannomas?
A
V, VII, VIII
7
Q
Red flags for headache
A
compromised immunity, caused, for example, by HIV or immunosuppressive drugs
age under 20 years and a history of malignancy
a history of malignancy known to metastasis to the brain
vomiting without other obvious cause
worsening headache with fever
sudden-onset headache reaching maximum intensity within 5 minutes - ‘thunderclap’
new-onset neurological deficit
new-onset cognitive dysfunction
change in personality
impaired level of consciousness
recent (typically within the past 3 months) head trauma
headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked), sneeze or exercise
orthostatic headache (headache that changes with posture)
symptoms suggestive of giant cell arteritis or acute narrow-angle glaucoma
a substantial change in the characteristics of their headache
8
Q
Investigations for vestibular schwannoma?
A
The first line investigations for patients with a suspected diagnosis of vestibular schwannoma are audiogram and gadolinium-enhanced MRI head scan
9
Q
What is the first line prophylactic treatment for migraines in women of childbearing age?
A
Propanolol is preferred in female patients as topiramate may be teratogenic and can reduce the effects of hormonal contraceptives
10
Q
When is a carotid artery endarterectomy recommended in patients that have had a stroke/TIA
A
If the carotid stenosis is >70%
11
Q
What prophylactic antibiotic is given to contacts of meningitis?
A
Oral ciprofloxacin
12
Q
What is the treatment of a tension headache?
A
Reassurance, analgesia, relaxation techniques
13
Q
What is the treatment of a cluster headache?
A
100%O2 for 15 minutes
Subcutaneous sumatriptan 6mg onset of attack
Prophylaxis = Verapamil 80-120mg every 8 hours
14
Q
What symptoms do you get in parietal lobe lesions?
A
- Sensory inattention
- Apraxias
- Astereognosis
- Inferior homonymous quadrantanopia
15
Q
What is Gerstmann’s Syndrome and when is it seen?
A
In lesions of the dominant parietal lobe resulting in:
Alexia, acalculia, finger agnosia and R-L disorientation
16
Q
What symptoms do you get with occipital lobe lesions?
A
- Homonymous hemianopia (with macula sparing)
- Cortical blindness
- Visual agnosia
17
Q
What symptoms do you get with temporal lobe lesions?
A
- Wernicke’s aphasia: Lesions result in word substitution
- Superior homonymous quadrantanopia
- Auditory agnosia
- Prosopagnosia (difficulty recognising faces)
18
Q
What symptoms do you get with frontal lobe lesions?
A
- Broca’s aphasia: speech is non-fluent, laboured and halting
- Disinhibition
- Preservation
- Anosmia
- Inability to generate a list
19
Q
What part of the brain does Wernickes and Korsakoff syndrome affect?
A
Medial thalamus and mamillary bodies of the hypothalamus
20
Q
What is Kluver-Bucy Syndrome?
A
Lesion of the amygdala resulting in hypersexuality, hyperorality, hyperphagia and visual agnosia.
21
Q
What is Reye’s syndrome?
A
It is a severe, progressive encephalopathy affecting children that is accompanied by fatty infiltration of the liver, kidneys and pancreas.
Associated with taking aspirin in children
22
Q
What is a lacunar infarction?
A
Occlusion of deep penetrating arteries.
It affects a small volume of subcortical white matter (therefore, does not present with cortical features)
Example of lacunar syndromes are –> Pure motor hemiparesis, ataxic hemiparesis, “clumsy hand” and dysarthria, pure/mixed hemisensory.
23
Q
What investigations would you do in a young person with a stroke?
A
Bloods –> HIV and vasculitic screen. Thrombophilia screen, homocysteine.
Cardiac investigations –> Transcranial dopplers, Transoesophageal ECHO
Vascular imaging –> CT angiography, MRI angiography
24
Q
What is the definition of a seizure?
A
Paroxysmal/unprovoked event in which changes of behaviour, sensation or cognitive processes are caused by excessive, hypersynchronous neuronal discharges.
25
How do you diagnose epilepsy?
There needs to be at least 2 or more unprovoked seizures occuring >24 hours apart
26
What investigations would you do for a vasovagal syncope?
BP lying/standing
Cardiac examination and ECG
27
What is narcolepsy?
Neurological sleep disorder characterised by chronic, excessive attacks of drowsiness during the day.
28
What gene is narcolepsy associated with?
HLA-DR2 associated with low levels of orexin (hypocretin) a protein which is responsible for controlling appetite and sleep patterns
29
How you do manage narcolepsy?
Modafinil is a daytime stimulant that is used
Sodium oxybate is used to treat cataplexy and improve sleep
30
What is the classic triad of Wernicke's encephalopathy?
Ophthalmoplegia/nystagmus, ataxia and confusion.
31
What is the aetiology of Huntington's chorea?
It is an autosomal dominant condition with full penetrance. All gene carriers will develop the disease. Presents in middle age around 35.
An abnormal huntington gene on chromosome 4 resulting in trinucleotide repeats of the CAG sequene.
32
What treatments can be used in Parkinson's disease?
L-Dopa --> Dopamine --> Dopamine receptor
Dopamine agonists act directly on the post synaptic receptors
33
What are the classic clinical features of idiopathic intracranial hypertension?.
Usually occurs in young and obese women. Includes headache and visual disturbance.
Headache is usually non-pulsatile, bilateral and worse in the morning
34
What is the first line management of idiopathic intracranial hypertension?
Weight loss.
Failing this, patients may try carbonic anhydrase inhibitors such as acetazolamide.
35
What is the management of normal pressure hydrocephalus?
Ventriculoperitoneal shunting
36
What is the normal intracranial pressure?
7-15mmHg in adult in the supine position
37
How do you calculate cerebral perfusion pressure?
CPP = mean arterial pressure - ICP
38
What is the Cushing's triad?
Sign of raised intracranial pressure
Widening pulse pressure, bradycardia, irregular breathing
39
What is the most common primary brain tumour?
Glioma (high grade more common) which is a tumour of the glial cells/
40
What are the common and uncommon causes of peripheral neuropathy?
COMMON - Diabetes, Alcohol, idiopathic
UNCOMMON - Vit B12 deficiency, toxins/chemotherapy, amiodarone, nitrous oxide, HIV
41
What is Guillain-Barré Syndrome?
Acute inflammatory demyelinating polyneuropathy
42
What is the most common type of motor neurone disease?
Amyotrophic lateral sclerosis
43
What drug can be used to prolong life in MND?
Riluzole, used mainly in ALS works by stimulating the glutamate receptors and prolongs life by about 3 months
44
What are the classifications of cerebral palsy?
Spastic (70%)
Dyskinetic
Ataxic
Mixed
45
What are the criteria for diagnosis of neurofibromatosis type 1?
There must be at least 2 of the features for a diagnosis
- Cafe-au-lait spots ( 6 or more)
- Relative with NF1
- Axillary or inguinal freckles
- Bony dysplasia such as bowing of a long bone
- Iris hamartomas
- Neurofibromas (2 or more) or 1 plexiform neurofibroma
- Glioma of optic nerve
46
What is the management of tetanus?
Prevention is better than cure (VACCINATE)
If symptomatic: Supportive - muscle relaxants/paracetamol
Immunoglobulins to mop up any toxins
47
What are some causes of Horner's Syndrome?
Pancoast tumour, stroke, carotid artery dissection
48
What is the definition of a bulbar palsy?
A LMN lesion affecting CN9 10 and 12. This causes swallowing and speech impairments.
49
What are the features of a Bell's Palsy?
Lower motor neuron facial nerve palsy with forehead AFFECTED
Patient may notice post auricular pain, altered taste, dry eyes and hyperacusis
50
What antibodies are found in myasthenia gravis?
AChR and MuSK
51
What is Lambert Eaton Myasthenic syndrome?
It is due to antibodies against voltage gated calcium channels. It is a rare condition which affects both NMJ and autonomic ganglia. 50-60% have an underlying malignancy
52
What is myelopathy?
Compression of the spinal cord resulting in UMN signs (weakness, increased reflexes, spasticity, Babinski's sign)
53
What clinical signs will you see with subarachnoid haemorrhage?
Kernig's Sign --> Unable to extend patients leg at the knee when the thigh is flexed
Brudzinski's Sign --> When the neck is flexed by doctor the patient will flex their hips and knees.
54
What drug do you give in SAH and what is it for?
Nimodipine to reduce vasospasm and therefore subsequent morbidity from cerebral ischemia
55
What vessel is commonly affected in subdural haemorrhage?
Bridging vein
56
What would the CT head of SDH look like?
Sickle/crescent shape
57
What vessel is commonly affected in extradural haemorrhage?
The middle meningeal artery
58
What is Creutzfelt-Jakob disease?
Rapidly progressive neurological condition caused by prion proteins. These proteins induce the formation of amyloid folds resulting in tightly packed beta-pleated sheets which are resistant to proteases.
59
How does a pontine haemorrhage typically present?
Commonly presents with reduced GCS, paralysis and pinpoint pupils sudden onset in nature.
60
How does syringomelia classically present?
Cape-like loss of pain and temperature sensation due to compression of the spinothalamic tract fibres decussating in the anterior white commissure of the spine.
61
What is Weber's Syndrome?
A form of midbrain stroke characterized by an ipsilateral CNIII palsy and contralateral hemiparesis
62
What are some differential diagnoses for proximal myopathy?
Acquired myopathies: Inflammatory (polymyositis, SLE, rheumatoid, sarcoid) drug-induced myopathy, toxins, endocrine (hypothyroidism, hyperthyroidism, Addison's, Cushing's) infective, hypokalaemia
Inherited myopathy: Muscular dystrophy
63
What is the inheritance pattern of Duchenne muscular dystrophy?
X- Linked recessive pattern
64
What is Myasthenia Gravis?
It is an autoimmune disease of the neuromuscular junction where antibodies bind to the acetylcholine receptor, blocking AcTH
65
What are some differential diagnoses for cervical myelopathy?
Transverse myelitis, compressive neuropathy which may be degenerative, neoplastic, infective, trauma, spinal cord stroke, B12 deficiency, syringomyelia, neoplasm, hereditary spastic paraplegia(may mimic cervical myelopathy)
66
What is a spinal cord stroke?
More rare than a cerebral stroke
- Can occur at any age
- Occur in the anterior spinal arteries
- There is typically dissociated sensory loss as dorsal columns are supplied by the posterior spinal arteries
67
What is sign of benediction and what pathology does it point to?
The index and middle fingers are held out straight despite flexion of the other fingers, due to paralysis of the flexor digitorum profundus and is indicative of a median nerve palsy.
68
What are the nerve roots of the median nerve and what does it supply?
Stems from the C6-8 and T1 nerve roots and enters the hand via the carpal tunnel and supplies 'LOAF' (lateral 2 lumbricals, opponens pollicis, abductor pollicis, flexor pollicis brevis)
69
What is polymyositis?
An inflammatory myositis with diverse causes:
- Autoimmune conditions
- Connective tissue diseases
- Drugs (e.g. statins)
- Infections (HIV, acute viral illness)
- Idiopathic (rare)
Dermatomyositis is associated with cancer especially ovary, GI, breast
70
What is Friedreich's ataxia?
Friedreich's ataxia is an autosomal recessive inherited disorder. It is the most common form of progressive ataxia among caucasian individuals.
71
What is the genetic abnormality of Friedreich's ataxia?
Genetic abnormality is at chromosome 9q13-21 (the Frataxin gene) and is usually a GAA repeat expansion.
It is usually caused by a homozygous trinucleotide repeat and the size of the expansion in the smaller of the 2 enlarged repeat sequences correlates with disease severity (patients with larger expansions will have earlier onset and more associated features)
The classic form presents before 25 years of age. There is a mild late-onset form presenting after 25 years which accounts for 14% of case.
72
What is Charcot-Marie-Tooth syndrome?
CMT is an inherited sensorimotor neuropathies. It presents before 20 years and follows a gradually progressive course.
There are two subtypes
TYPE 1 --> A demyelinating neuropathy, the most common type
TYPE 2 --> a less common axonal form
73
What is Brown-Séquard syndrome?
Brown-séquard is caused by hemisection of the spinal cord and causes :
- Unilateral lesion of the spinal cord will affect power and vibration/proprioception of the side of the lesion
- Pain and temperature sensation on the contralateral side
74
What is Tabes dorsalis?
It is a manifestation of tertiary syphilis with degeneration of the posterior columns and atrophy of the posterior nerve root.
Onset is 20-25 years after infection
75
What is Wallenberg syndrome?
Also known as lateral medullary syndrome which is usually caused by an infarct confined to the lateral medulla which produces a characteristic constellation of symptoms
76
What is the pathophysiology behind internuclear ophthalmoplegia (INO)?
It is due to interruption of the medial longitudinal fasciculus that interconnects the nuclei of cranial nerves III and VI on opposite sides.
Common causes include - MS cerebrovascular disease
77
What is the CSF sample likely to show in bacterial meningitis?
Turbid appearance, raised polymorphs, raised protein, low glucose
78
What is the CSF sample likely to show in viral meningitis?
clear appearance, raised lymphocytes, normal/raised protein, normal/low glucose
79
What is a CSF sample likely to show in encephalitis?
clear appearance, normal/raised lymphocytes, normal/raised protein, normal/low glucose
80
What is a CSF sample likely to show in TB meningitis?
turbid/clear appearance, raised lymphocytes, raised protein, low glucose
81
What is the preferred antiplatelet for secondary prevention of stroke?
Clopidogrel
82
What are early symptoms of autoimmune encephalitis?
Fever, headaches, diarrhoea and upper respiratory tract infection
83
What is autoimmune encephalitis?
A form of non-infection neuroinflammation that has become an increasingly recognized cause of acute/subacute progressive mental status change with a variety of clinical phenotypes.
84
What investigations would you do for AE?
| Autoimmune encephalitis
Full neurological examination
Blood tests:
- Low sodium is associated with LG1 encephalitis
- Antibodies: LGI1, NMDA receptor, CASPR2
MRI
Lumbar puncture (will show increased levels of lymphocytes in the cerebrospinal fluid ('lymphocytic pleocytosis'))
EEG is sensitive but not specific
85
What is the first line treatment for autoimmune encephalitis?
Steroids and IV Ig.
Second-line: if patients not responding within 2 weeks, you can give immunosuppressive agents such as Rituximab and cyclophosphamide.
86
What is the strongest risk factor for ischaemic stroke?
Hypertension
87
How does Neurogenic thoracic outlet syndrome usually present?
- Painless muscle wasting of hand muscles, with patients complaining of hand weakness e.g. grasping
- Sensory symptoms such as numbness and tingling may be present
- If autonomic nerves are involved, the patient may experience cold hands, blanching or swelling
88
How does vascular thoracic outlet syndrome usually present?
- Subclavian vein compression leads to painful diffuse arm swelling with distended veins
- Subclavian artery compression leads to painful arm claudication and in severe cases, ulceration and gangrene
89
What is thoracic outlet syndrome?
It is a disorder involving compression of brachial plexus, subclavian artery or vein at the site of the thoracic outlet. It can be neurogenic or vascular
90
What EEG change is seen in absence seizures?
3Hz spike and wave
91
What EEG finding would you get in Lennox-Gastaut syndrome
Slow spike
91
What EEG finding would you get in Lennox-Gastaut syndrome
Slow spike
92
What is the probable MRI finding in normal pressure hydrocephalus?
Ventriculomegaly without sulcal enlargement
93
What is the mechanism of action of Phenytoin?
It binds to sodium channels increasing their refractory period
94
What is Lambert-Eaton Myasthenic syndrome caused by?
An antibody directed against presynaptic voltage-gated calcium channel in the peripheral nervous system
95
What are some features of multiple system atrophy?
- Parkinsonism
- Autonomic disturbance (erectile dysfunction is often an early feature. Postural hypotension, atonic bladder
-Cerebellar signsd
96
What antibiotics are most suitable for brain abscess?
IV 3rd generation cephalosporin + metronidazole
97
What can be used for long-term prophylaxis of cluster headaches?
Verapamil
98
What medication should be avoided in myasthenia?
Beta-blockers cause a worsening of myasthenia
You should also avoid: Penicillamine, quinidine, procainamide, lithium, phenytoin, antibiotics (gentamicin, macrolides, quinolones, tetracycline)
99
What would you see if a lesion is in the cerebellar vermis?
Gait ataxia
100
What is ROSIER?
ROSIER is an acronym for 'Recognition Of Stroke In the Emergency Room'. It is the tool recommended by NICE to assess stroke symptoms in an acute setting
101
What is the first-line treatment for restless legs syndrome?
Dopamine agonists (e.g. Pramipexole or ropinirole)
102
What is Paroxysmal hemicrania?
It is defined by attacks of severe, unilateral headache, usually in the orbital, supraorbital or temporal region. These attacks are often associated with autonomic features, usually last less than 30 minutes and can occur multiple times a day
103
How do you treat paroxysmal hemicrania?
It is completely responsive to treatment with Indomethacin
104
What is the most likely surgical operation for symptomatic chronic subdural bleeds?
Burr Hole evacuation
105
What is damaged in spastic cerebral palsy?
Damage to the upper motor neurons in the periventricular white matter
106
When does autonomic dysreflexia occur?
Occurs in patients who have had a spinal cord injury at, or above T6 spinal level
107
What do infantile spasms look like clinically?
Classically characterised by repeated flexion of head/arms/trunk followed by extension of arms (Salaam attacks)
108
What does a chronic subdural haemorrhage look like on CT?
Hypodense (dark), crescentic collection around the convexity of the brain
109
How does an acute subdural haemorrhage look like on CT?
Hyperdense crescentic collection, not limited by suture lines
110
What is damaged in dyskinetic cerebral palsy?
Basal ganglia and substantia nigra
111
What is the initial management for cerebral venous sinus thrombosis?
Low molecular weight heparin
112
What antibodies are associated with neuromyelitis optica?
Aquaporin 4 antibodies
113
What is required for diagnosis of Multiple Sclerosis?
Requires demonstration of lesions disseminated in time and space
114
What is the gold standard test for diagnosing venous sinus thrombosis?
MR Venogram
115
What artery is affected in Locked-in syndrome?
Basilar artery
116
What is the most common pattern for MS?
Relapsing-remitting
117
What sign would you see on Venography in Sagittal sinus thrombosis?
'Empty delta sign'
118
What are the symptoms of progressive supranuclear palsy?
Postural instability, impairment of vertical gaze, parkinsonism, frontal lobe dysfunction
119
What is the investigation of choice for Narcolepsy?
Multiple sleep latency EEG
120
What drugs increase risk of idiopathic intracranial hypertension?
- COCP
- Steroids
- Tetracyclines
- Vitamin A
- Lithium
121
What are the guidelines for stopping anti-epileptic drugs (AED)?
Can be considered if seizure free for >2 years, with AEDs being stopped over 2-3 months
121
What is the first line treatment for neuropathic pain?
first-line treatment: amitriptyline, duloxetine, gabapentin or pregabalin
if the first-line drug treatment does not work try one of the other 3 drugs
122
What is subacute combined degeneration of spinal cord due to?
Due to Vitamin B12 deficiency
Dorsal columns + lateral corticospinal tracts are affected
123
How would a petrous temporal fracture present?
- Unilateral face palsy after head trauma
- Nasal discharge of clear fluid
124
What is the management for restless leg syndrome?
Dopamine agonists (ropinirole)
125
What are the upper motor neuron signs?
EVERYTHING GOES UP!
- Spasticity (increased muscle tone)
- Brisk reflexes
- Plantars are upturned (Babinskis sign)
- Characteristic pattern of upper limb muscle weakness
126
What are the lower motor signs?
EVERYTHING GOES DOWN
127
How long is the course of Nimodipine in SAH treatment?
A 21day course is used to prevent vasospasm as it targets the brain vasculature
128
What is the second line treatment for focal seizures?
If lamotrigine and levetiracetam are ineffective or not tolerated:
Carbamazepine, oxcarbazepine, or zonisamide as a second line monotherapy
129
What is the first line anti-epileptic for females with myoclonic seizures?
Levetiracetam
130
What is the first line anti-epileptic for females with atonic or tonic seizures?
Lamotrigine
131
In which two conditions do signs occur before symptoms?
Myelopathy and peripheral neuropathy
132
What are the long tract signs?
Also known as UMN signs
- Spastic gait
- Hypertonia
- Hyper-reflexia
- Babinski
- Clonus
- Cross-adductors
- Hoffman's sign
- Loss of fine finger movements
- Deltopectoral reflex
133
What are some lateralising signs?
- Inattention to one side
- Gaze paresis
- An upper limb drift
- Slower localising or flexion response of a limb
- Asymmetric motor response
134
What is the most common cause of hyponatraemia in neurosurgical patients?
Cerebral salt wasting (mediated by secretion of natriuretic peptides in the context of brain injury)
135
What is the commonest cause of footdrop?
L5 radiculopathy
136
What are the symptoms of spinal claudiation?
Have bilateral radiating leg pain or paraesthesia that comes on with walking. Symptoms are often relieved by leaning forward.
137
What is the commonest cause of myelopathy?
Disc-osteophyte cord compression. It is an important and preventable cause of potential loss of independence in the older population
138
What clinical testing would you get in a patient with brainstem death?
1. The pupils are fixed and dilated and do not respond to sharp changes in light intensity.
2. There is no corneal reflex
3. The oculo-vestibular reflexes are absent. No eye movements are seen during or following
the slow injection of at least 50mls of ice cold water over one minute into each external
auditory meatus in turn. Clear access to the tympanic membrane must be established by
direct inspection.
4. No motor responses within the cranial nerve distribution can be elicited by adequate
stimulation of any somatic area or vice versa, e.g. by supraorbital pressure and pressure
applied to the nail bed of a finger. Care must be taken to distinguish central response from
primitive spinally-mediated reflexes that can be ignored in this context.
5. There is no cough reflex response to bronchial stimulation by a suction catheter placed down
the trachea to the carina, or gag response to stimulation of the posterior pharynx with a
spatula.
6. There is no evidence of spontaneous respiration or respiratory effort during the apnoea test
139
What is the T2 MRI sequence?
Anything white is fat or fluid CSF=White
140
What is the T1 MRI sequence?
CSF=Black like a CT scan
This is the main sequence for pathologies in which contrast is given
