Neurology Flashcards
Differentiate carpal tunnely syndrome from pronatory syndrome
Palmar cutaneous branch. Splits off before carpal tunnel and goes above flexor retinaculum
In CTS, lateral pal spared
In pronator syndrome, lateral palm involved
Rapidly progressive dementia associate with myoclonus
CJD
Adies pupil
Loss of parasympathetic consrictors of pupil
Different from CN III lesion where opthalmoplegia occur
Management of IIH
1st line weight loss
2nd - medical (acezetolamide, topiramate)
3rd - surgery
CSF changes in Alzheimer’s
Earliest signs of pre-clinical Alzheimer’s disease
Early - Low CSF AB peptide 42
Next - High CSF Tau
High PET amyloid tracer retention
Imaging changes for Alzheimers
- MRI
- MRI - hippocampal atrophy
Which primary headache type can you use botulinum toxin in?
Chronic migraine (16-30 days of headache per month)
Use 2nd line
Most common ongoing outcome of Wernicke’s
Amnestic memory loss i.e Korsakoff’s syndrome
DDx of bilateral temporal lobe MRI changes
Infection
Inflammation - Limbic encephalitis (paraneoplastic or autoimmune)
Rx of serotonin syndrome
Cyproheptadine
Rx of NMS
Bromocriptine
Signs and Rx of malignant hyperthermia
Fever, hypcarbia, rigidity after volatile induction anaesthetic
Rx - dantrolene (direct muscle relaxant)
Which side of brain are speech centres?
Usually L - Left dominance
Another name for essential tremor
Benign familial tremor
Management of psychosis in Parkinson’s
Withdraw Parkinson’s meds in order of least effective (anticholinergics first)
Rx - quetiapine, clozapine
Treatment of CVST
LWMH/heparin
Aim for therapeutic anticoagulation for 3-6 months
Main risk factors for CVST
Pregnancy/puepuerium
COCP use
Malignancy
Treatment of eclampsia - features of hypermagnesiaemia
Loss of deep tendon refexes –> hypermagnesaemia
Episodic vertigo/ataxia
Interstitial keratitis
Oscilopsia (sensation of unstable vision
Cogan syndrome
Treat with pred and DMARDs - MTX
Hemiballismus. Lesion where?
Subthalamic nucleus
Components of basal ganglia
Striatum - caudata/putamen
Globus pallidus
Subthalamic nucleus
Substantia nigra - pars compact (Da) and parts reticulata (GABA)
Trauma, neck pain, headache, horner’s syndrome
Carotid artery dissection
Rhomberg test -positive and negative results intepretation
Positive - ataxia due to sensory loss (proprioception)
Negative - ataxia due to cerebellar cause
Endolymphatic hydrops
Menierre disease
Rinne and Weber
Rinne - tunin fork on mastoid and next to ear. Normal is air > bone
Weber - if Rinne abnormal, can distinguish conductive vs sensironeural. cOnductive localises bad ear, sensironeural localises good ear
Parkinsonism
Postural instability/frequent falls
PSP
Parkinsonism
Asymmetric
Alien limb phenomenon
Athetosis, chorea
Corticobasal degeneration
Parkinsonism
Predominant autonomic symptoms
MSA
Features of prodromal PD
RBD
Hyposmia
Anxiety
Significance of RBD
50% will develop synucleopathy - iPD, MSA
GBA1 gene
- heterozygous - increased risk?
- homozygous - increased risk?
Heterozygous - 10% Parkinsons’
Homozygous - Gaucher disease
A/e of ergot Da agonists (hence not used)
Valvulopathy
Raynaud’s
Erythromelalgia
Pulmonary fibrosis
Retroperitoneal fibrosis
COM-T - what is it and benefit of blocking
Degrades dopamine
Entacapone blocks COM-T, so reduces rate of breakdown of Da (and therefore L-dopa), potentiating effect (increasing half-life. Good for wearing off periods
Treatment of REM sleep behaviour disorder
Clonazepam
Risk of starting Da agonists
Impulse control disorders
- Pathological gambling
- Hypersexuality
- Compulsive shopping, bing eating
Repetitive sterotype movements in patient with Parkinson’s on treatment
Name?
Cause?
Punding
Feature of dopamine dysregulation syndrome, due to Da agonists
Management of off periods
Add entacapone
Add amandatadine
Add Da agonist
Increase L-dopa dose or frequency
Which Parkinson medication has anticholinergic activity
Amantadine
Gene for Wilson’s
ATP7B
- homozygote - confirms diagnosis
- heterozygote - confirms, most patients are compound heterozygotes
Neurological manifestations in Wilson’s in terms of frequency
Dysarthria - most common
Dystonia
Tremor
Parkinsonism
Diagnostic approach to Wilson’s
Caeroplasmin low, 24 urinary copper excretion high, Kayser fleischer rings confirm diagnosis
Any one of above not present - obtain liver biopsy or ATP7B gene testing to confirm
Oral disease modifying therapy for MS
Fingolimod
Teriflunomide
Dimethyl fumarate
MoA fingolimod
Decreases ability of lymphocytes to enter CNS by preventing lymphocytes leaving lymphatic tissue
A/E of fingolimod
Bradycardia and heart block
Overwhelming hsv
Downregulates spingosine 1 phosphate receptor subtypes
MoA of teriflunomide
Inhibits pyrimidine synthesis
NMOSD
- Name
- Cell involved
Neuromyelitis optica spectrum disorder
Astrocytes
APQ4 antibody
NMOSD
NMOSD mimicker:
- Classic clinical presentations
Bilateral/rapidly sequential optic neuritis
Tranverse myelitis (often > 3 segments)
Area postrema syndrome -Intractabile hiccups, nausea
NMOSD diagnosis
Clinical features (3)
APQ4 antibody
MOGAD disease presentation
ADEM in children
- Confusion
- Demyelination - weaness, numbness, bladder/bowel changes
MOGAD Ab
Myelin oligodendrocyte gylcoprotein associated Ab (MOGAD)
MS in pregnancy
Can use GIN
- glatiramer, inteferon, nataluzimab.
Aim for quiscient disease. Pregnancy is protective for MS relapse so can w/h altogether
Oftatumumab
Anti-CD20 for MS
Dominant lobe
- Side
- Symptoms
Left usually (for R hand people)
Aphasia - Broca’s and Wernicke’s
Non-dominant lobe
- Side
- Symptoms
R usually
Neglect, homonomous heminopia
Gerstman syndrome
- Location
Inferior angular gyrus parietal lobe dominant side
L PCA syndrome
- Normal
- Gerstmand
Normal - Alexia (reading issue), but no agraphia
Gerstman - Agraphia, (issue with writing), acaculia, Agnosia, L-R disorientation
L vs R PCA syndrome
- Similar
- Different
Both can have homonomous heminopia with macular sparing
L - Alexia without agraphia, Gerstman
R - more likely to have neglect
Blind but denies blindness
- Name?
- Cause
Anton syndrome
Bilateral PCA artery
Decreased conscious state
Gaze palsy
Dilated pupils
Top of the basilar stroke
Locked in syndrome - site of lesion?
Pons infarction - proximal basilar artery
Basilar artery
- Proximal pathology
- Distal pathology
Proximal = pons/medullar junction. Get bulbar dysfunction, locked in syndrome, herald weakness
Distal = midbrain pons. Get LoC and gaze palsies. (“top of basilar)
Most common residual effect of Wernicke’s encephalopathy
Amneistic memory loss - Korsakoff syndrome, memory loss can persist in 80% of patients after recocery
Preventative stroke therapy for non-cardioembolic stroke
- Acute stroke NIHSS > 5
- TIA or NIHSS < 5 stroke
- Low ris TIA
Acute stroke NIHS > 5 or low risk TIA - aspirin
High RISK TIA or small stroke NIHSS < 5 - DAPT 21 days, clopi monotherapy
Pyrodoxine deficiency
- Deficiency causes?
- Common cause
Required for GABA synthesis
Deficiency can cause seizures, peripheral neuropathy
Common cause isoniazid use - Give concomittant B6
1st line for generalised seizures
Valproate
If child-bearing - lamotrigine
First line for focal seizures
CBZ
First line for absence seizures (generalised)
Ethosuximide
ANti-epileptics acting on GABA
PTV B to GABA
Phenobarbitol
Tigabine
Vigabitrin
BZD
Ca Channel anti-epileptics
Ca Channels - Ethosuximide
Alpha 2 delta subunit - pregabalin, gabapentin
Synaptic vesicle 2A
leviteracetam
NMDA receptor antagonist
Perampanel
A/E leviteracetam
Psychiatric - mood, irritability, suicidality
A/E of perampenl
Weight gain
Hostility
Antiepileptic causing weight loss
Topiramte
Options for pregnant women epilepsy
Lamotrigine, leviteracetam
Phenytoin decreased absoprtion with?
Enteral feeds
Anti-epileptic most likely to cause weight gain
Valproate
Seizures with CTB showing calcified cysts
Neurcysterocosis
- Calcified cysts - late stage, AED only
- Non-calcified cysts - albendazole and praziquantel
4 principles of MG therapy
Symptomatic - acetylcholinesterase inhibitor (pyridostigmine)
Immunomdulator therapy
Thymemectomy
Rescue for crisis - IVIG, PLEX
MusK Ab positive MG - Rx?
Rituximab
Indications for thymemectomy
MG + thymoma
MG + ACHr Ab positive + inadequate response to immunotherapy
Pathophys of LEMS
VGc Ab
EMG difference of LEMS and MG
LEMS - repeat high frequency stimulation causes high amplitude
MG - low amplitude with repeated stimulation
Management of LEMS
3.4 DAP (diaminopyrmidine) - K channel blocker
Severe shouder pain, with subsequent weaness/wasting around shoulder girlde
Brachial neuritis
Often post inefction/vaccination
Pain, numbness, weakness in arm on raising arm above head or repeated exertion
- ?cause
- Common aetiology
Neurogenic thoracic outlet syndrome - compression of NV bundle between 1st rib and clavicle.
Common cause - cervical rib
Deep tendon reflex - where is sensory receptor
Muscle spindle - stretch receptor in muscle that is stimulated with stretching of tendon
Pre-ganglionic autonomic nerve fibre type
B
Post-ganglionic autonomic nerve fibre type
C
Nerve fibre for warm temperature
C - opposite of cold
Nerve fibres for motor, proprioception/vibration
Aa - large fibre,large myelin
- Motor, vibration/proprioception
Ad fibres?
Small, minimally myelinated
- Cold temperature, pain
What are positive sensory symptoms?
- more common in acquired or hereditary
Prickling, paresthesias
More common in acquired peripheral neuropathy
CIDP
- Ab’s indicating nodal/paranodopathy
- Rx?
Neurofascin AB’s
Contactin 1
Both IgG4
Treat with rituximab
Charcot Marie tooth inheritance and gene
Autosomal dominant
Type 1 is PMP22
Sensory and Motor symptoms
Foot deformities - Pes planus (flat), pes cavus (high arch)
Foot drop, pseudohypertrophy calves
Charcot Marie Tooth
= Herediatry and Sensory Motor neuropathy
Episodes of isolated peripheral nerve palsy. Usually nerves susceptible to compression
- Cause?
- Genetics
Hereditary neuropathy with liability to pressure palsy (HNLPP)
Allele of PMP22 (Charcot Marie Tooth form)
Sensory symptoms
- Worsen with closing eyes (sensory ataxia)
- Associatd with pseudoathetoid movements (moving fingers like playing piano)
Cause?
Location of lesion
Paraneoplastic sensory neuropathy
Involving DRG
Sensory symptoms
- Worsen with closing eyes (sensory ataxia)
- Associatd with pseudoathetoid movements (moving fingers like playing piano)
Cause?
Location of lesion
Paraneoplastic sensory neuropathy
Involving DRG
Sensory symptoms, usually level
Motor symptoms - paraparesis
Autonomic symptoms - bladder, bowel dysfunction
Acute or Subacute
Transverse myelitis
Need MRI-spine to exclude compressive cause
Corticospinal tract which part of internal capsule?
Posterior limb
Where do following pathways decussate?
- Corticospinal
- DCMLN
- ST
Corticospinal (pyramid) - medulla
DCMLN - medulla
ST - 1-2 levels above spinal cord exit
Differentiate central cord syndrome and anterior cord
Simalarities
Anterior cord - has autonomic dysfunction, and preference of upper and lower limb weakness
Central Cord - rarely autonomic dysfunction. UL >LL for weakness. Hyperreflexia below lesion early
Both have preserveation of vibration/proprioception (dorsal columns)
Brown Sequard
- Patter of neurological loss - ipsilateral and contralteral?
Ipsilateral motor and vibration/proprioception
Contralteral pain/temperature (ST decussates 1-2 levels above)
Posterior cord features
Intermittent Shooting pains
Tabes Dorsalis - Neurosyphilis
LMN findings at spinal level only, no sensory
- type of disease
- cause
Anterior horn cell disease
Cause - Polio
Complete spinal cord lesion
Spasticity and paresis below level of lesion
Loss of all sensory modalities
Loss of autonomic function - bowel, bladder, erectile dysfunction
(similar to transverse myelitis)
Radial nerve palsies features
- Arm
- deep forearm (below elbow)
- Superficial forearm
Arm = spiral groove. Sensory loss and wrist drop
Splits below elbow:
- Posterior interosseus (deep forearm) - weakness extensors of hand, wrist spared a extensor carpi radialis get inmrvaton at elbow
Superficial radial - sensory only, no motor weakness
Weakness of extensors of hands
No sensory changes
Posterior interosseus palsy
- Fracture/dislocation radius
- Entrapment arcade of Frohse
Loss of sensation dorsum of hand, no wrist extensor weakness
Superficial radial nerve injury
- laceration to forearm
Median nerve injury at elbow (pronator teres syndrome) vs in forearm (AIN palsy)
Elbow - supracondylar fracture. = loss of LOAF muscles, forearm pronation, finger extension, Sensory deficit lateral 3 1/2 digits
AIN - can’t pinch finger/thumb together. No senssory loss.
Carpal Tunnel vs laceration above palmar branch division
Carpal tunnel - sensory thenareminence spare
Above palmar branch division (wrist) - involves thenar eminence
Ulnar paradox
Ulnar lesion at elbow - long flexors also affected, so claw is more mild (DIP’s can’t flex due to loss of FDP)
Ulnar at wrist - long flexors preserved, so more pronounced DIP flexion from FDP
Cranial nerve 3 palsy
- Pupillary sparing (normal miosis (parasympathetics)
Diabetic mononeuritis multiplex
Function of trochlear nerve
SO
- Downward movement when adducted
- Intorsion when abducted
Isolated CN VI palsy - what case to be mindful of?
Elevated ICP - can be false localising sign
Structures cerebellopontine angle
CN V, VI, VII, VIII
CN V in more extensive lesions
Cranial nerves cavernous sinus
III, IV, V1, V2, VI and sympathetics
Cranial nerves foramen magnum
CN 9,10,11,12
Pons gaze centres
- sequence
Contralateral Eye field –> PPRF –> 6 –> crossover via MLF to 3 –> eye
Can’t recognise faces
Propasognosia
R PCA
Apraxia
- What is it
- Which hemisphere
Difficulty performing tasks that require some complex planning - e.g constructional, dressing aprexia
Non-dominant
Operculum - consists of
Frontal, temporal and parietal lobe junction
Covers the insula
Prompting to get out of bed, eat:
- Sign?
- Cause?
Abulia
Frontal cortical stroke (ACA)
Pyramidal weakness
Extensors UL
Flexors LL
Think back of body
What detects and initaites deep tendon reflex
Muscle spindles
Treatment options for essential tremor
Propanolol
Primidone (antiseizure medication metabolised to phenobarbitol, beware CYP interactions
Ab for Miller Fisher syndrome
GQ1b
GQ1B syndromes - simialr features
Variants and separating features
Opthalmoplegia, Ataxia
MFS - areflexia
Bickerstaff encephalitis - encephalopathy
Pharyngeal/cervical - bulbar dysfunction
When to treated GQ1b syndromes
Lower limb weakness
Bulbar or respiratory involvement
Rapid onset vertigo
Nausea/vomitting
Gait instability but can still ambulate
Vestibular neuritis
Midline cerebellar features
Think middle
- Truncal ataxia - swaying of head/trunk when sitting
- Titubation - involuntary nodding of head/neck/trunk
- Gait ataxia with tendency to fall
Hemipshere cerebellar features
Think peripheral
- Dysdiadochonesis
- Dysmetria UL
- Intention tremor
- Limb ataxia
Diagnostic approach to GBS
Typical symptoms?
- LP –> high protein, normal WCC –> confirms diagnosis
Atypical symptoms or non-diagnostic LP –> NCS/EMG
Cause of lateral medulalry syndrome
Vertebral artery infarct
Cause of medial medullary syndrome
Vertebral artery or basilar artery infarct
Headache, vomitting, cerebellar signs
Decreased LoC
Stupor
Which vessel?
PICA
causing cerebellar infarction and mass effect
PML treatment for natazilumab
Stop natazilumab
Steroids if develop IRIS after withdrawal
Hummingbird sign MRI
PSP
A/E of amantadine
antichoinergic like activity
Moa of triptan release
Inhibits CRGP release (associated with migraine)
Type 1 muscle fibres
Slow, aerobic, fatigue resistance
High mitochondria, capillaries, myoglobin (for O2)
Low gylcogen
Type 2 muscle fibres - features
Fast
High glyocgen –> anaerobic
Dissemination in space for MS
2 MRI lesions
Dissemination in time for MS
MRI
- new lesion
- x2 lesions, one enhancing other note
- Further clinical attack
- Oligoclonal bands
Inferior qunadrantopia only
Occiptal lobe - cuneus
Important mimicker for meningitis involving VZV
Herpes opthalmicus - V1 (opthalmic branch of trigeminal)
Which radiculopathy are reflexes usually preserved?
L5
Most others have hyporeflexia
Anti-psychotic with highest risk of seizure
Clozapine
Findings that a NCS can demonstrate
Axonal degeneration
Demyelination
Conduction block
