Neurology Flashcards
Deep tendon reflexes and their nerve roots?
Ankle (S1-S2)
Knee (L3-L4)
Biceps (C5-C6)
Triceps (C7-C8)
Motor (descending) pathways?
Pyramidal tracts
→ corticospinal
Extrapyramidal tracts
→ rubrospinal
→ reticulospinal
→ vestibulospinal
→ tectospinal
Function of the motor (descending) pathways?
Pyramidal = conscious movement
Extrapyramidal = unconscious movement
→ rubrospinal = flexors and extensors
→ reticulospinal = eye and respiratory muscles
→ vestibulospinal = posture and balance
→ tectospinal = reflex movements
Sensory (ascending) pathways?
DCML
Spinocerebellar tracts
Spinothalamic tracts
Function of the sensory (ascending) pathways?
DCML = proprioception, fine touch, pressure, vibration
Spinocerebellar = proprioception
Spinothalamic = pain and temperature
Types of stroke?
Ischaemic (85%)
Haemorrhagic (15%)
Features of anterior vs middle vs posterior cerebral artery stroke?
Anterior = contralateral hemiparesis and sensory loss, lower limbs > upper limbs
Middle = contralateral hemiparesis and sensory loss, lower limbs < upper limbs, contralateral homonymous hemianopia, aphasia
Posterior = contralateral homonymous hemianopia with macular sparing, visual agnosia
Oxford stroke classification assessment criteria?
- Hemiparesis +/- hemisensory loss
- Homonomyous hemianopia
- Higher cognitive dysfunction e.g. dysphasia
Oxford stroke classification features of TACI vs PACI?
TACI = all 3 features
PACI = 2 features
FAST stroke campaign?
Face = is one side droopy? can they smile?
Arms = can they raise them and keep them there?
Speech = is it slurred?
Time = call 999 if there is any of the above
Investigation for suspected stroke?
Non-contrast CT head
Acute management options for ischaemic stroke?
Thrombolysis (if < 4.5 hours)
Thrombectomy (if < 6 hours)
Aspirin 300mg daily
Long-term management of ischaemic stroke?
1st line = clopidogrel
N.B. add anti-hypertensive, statin etc. if needed
Advice for starting anticoagulants for AF post-stroke?
Only commence after haemorrhagic stroke excluded and at least 14 days has passed
Transient ischaemic attack (TIA)?
Transient neurological dysfunction without acute infarction
Symptoms typically resolve within 1 hour
Investigations for TIA?
MRI
Carotid artery doppler
Dysarthria vs dysphasia vs aphasia?
Dysarthria = weakness of muscles involved in speech
Dysphasia = partial loss of language
Aphasia = complete loss of language
Where is Broca’s vs Wernicke’s area?
Broca’s = frontal lobe
Wernicke’s = temporal
Cause of Wernicke’s aphasia and features?
Lesion of the superior temporal gyrus
→ non-sensical speech
→ remains fluent
→ comprehension/insight impaired
Cause of Broca’s aphasia and features?
Lesion of the inferior frontal gyrus
→ laboured and halting speech
→ non-fluent
→ repetition is poor
→ comprehension/insight preserved
Cause of conduction aphasia and features?
Lesion of the arcuate fasciculus (connection between Wernicke’s → Broca’s)
→ fluent speech
→ repetition is poor
→ comprehension/insight preserved
Red flags of headache?
Immunosuppressed
PMH malignancy
Sudden and severe
Age < 20
Neurological deficit
Worse on coughing, sneezing etc.
Features of a migraine?
Unilateral or bilateral throbbing pain
N&V, photophobia, phonophobia
Preceding aura e.g. visual change
Can last up to 72 hours
Acute management of a migraine?
Triptan + NSAID or paracetamol
Drug options for migraine prophylaxis?
Propanolol
Topiramate
Amitriptyline
Advice for contraception in women with migraines?
COCP absoutely contraindicated
Triptan examples, mechanism of action and side effects?
Examples = sumatriptan, zolmitriptan
Mechanism of action = 5-HT1 agonists
Side effects = tingling, heat, chest tightness
Features and management of tension headaches?
Bilateral, band-like pain
No aura or associated symptoms
May be related to stress
Management = aspirin, paracetamol or NSAID
Features and management of cluster headaches?
Sharp, stabbing pain around eye
Redness, lacrimation, eyelid swelling
Clusters usually last 4-12 weeks
Management = oxygen + triptan (acute), verapamil (prophylaxis)
Investigation for cluster headaches?
MRI with gadolinium contrast
Management of trigeminal neuralgia?
Carbamazepine
Seizure vs epilepsy?
Seizure = single episode of abnormal electrical activity with many causes e.g. fever, hypoglycaemia
Epilepsy = chronic seizure activity
Generalised vs focal seizure subtypes?
Generalised
→ tonic-clonic (grand mal)
→ myoclonic
→ absence (petit mal)
→ atonic
Focal
→ focal aware
→ focal impaired awareness
Management of focal, tonic-clonic, myoclonic, absence and atonic seizures?
Focal = lamotrigine or levetiracetam
Tonic-clonic = lamotrigine (female), sodium valproate (male)
Myoclonic = levetiracetam (female), sodium valproate (male)
Absence = ethosuximide
Atonic = lamotrigine (female), sodium valproate (male)
DVLA guidance for epilepsy?
- Must surrender licence if has a seizure
- Reapply after 6 months if one-off
- Reapply after 12 months if more than one
- Established epilepsy may qualify if at least 12 months seizure-free
- No driving if withdrawing from medication and for 6 months after last dose
Status epilepticus?
Seizure lasting > 5 minutes or ≥ 2 seizures within 5 minutes
Pre-hospital mangement of status epilepticus?
Rectal diazepam or buccal midazolam
Hospital manegement of status epilepticus?
1st line = IV lorazepam
2nd line = IV phenytoin or phenobarbital
Features and management of narcolepsy?
Hypersomnolence
Cataplexy
Sleep paralysis
Management = daytime stimulant + nighttime sodium oxybate
UMN vs LMN lesion features?
UMN = spastic paresis, hyperreflexia, hypertonia, Babinski +ve
LMN = flaccid paralysis, muscle wasting, fasiculations, hyporeflexia, hypotonia
MS subtypes?
Relapsing-remitting (~85%)
Secondary progressive
Primary progressive
Features of MS?
Fatigue
Optic neuritis
Sensory changes
Spastic weakness
Urinary incontinence
Investigations and findings for MS?
MRI
→ lesions and plaques
Lumbar puncture
→ oligoclonal bands
Acute management of MS?
Methylprednisolone for 5 days
Disease-modifying drugs for MS?
Natalizumab (1st line)
Ocrelizumab (1st line)
Fingolimod
Beta-interferon
Glatiramer acetate
Drug options for spasticity?
Baclofen
Gabapentin
Features and management of of Gullain-Barre syndrome?
Progressive (ascending) weakness of limbs
1-3 weeks post-infection
Back pain, leg pain
Reduced or absent reflexes
Mild sensory changes
Management = IV immunoglobulins (1st line), plasmapharesis (2nd line)
Lumbar puncture features of Guillain-Barre syndrome?
Raised protein with normal WCC
Features and management of MND?
Mixed UMN and LMN signs
Limb atrophy and weakness
Wasting of small hand muscles
Management = riluzole, respiratory support, nutritional support
Features and management of myasthenia gravis?
Muscle fatiguability
Diplopia
Proximal muscle weakness
Management = pyridostigimine
Investigations for myasthenia gravis?
EMG studies
Antibodies to ACh receptors
Management of a myasthenic crisis?
IV immunoglobulins
Plasmapharesis
Condition associated with myasthenia gravis?
Thymoma (~15%)
Cerebellar syndrome features?
DANISH
→ dysdiadochokinesia
→ ataxia
→ nystagmus
→ intention tremor
→ scanning dysarthria
→ hypotonia
Clonus vs myoclonus?
Clonus = rhythmic movement in response to muscle stretch e.g. testing a reflex
Myoclonus = random, jerky movements
Features and management of Parkinson’s disease?
Bradykinesia
Resting tremor (3-5 Hz)
Muscle rigidity
Loss of facial expression
Mental health problems
Management = levodopa (motor symptoms prominent), dopamine agonist or MAO-B inhibitor (fewer motor symptoms)
Parkinson’s disease vs drug-induced Parkinsonism?
Parkinson’s = progressive, unilateral, variable symptoms
Drug-induced = rapid, bilateral, rigidity and tremor rare
Features and management of essential tremor?
Postural
Worse with arms outstretched
Improves with alcohol and rest
Management = propanolol
EMG features of a myopathy vs neuropathy?
Myopathy = ↑ action potential duration and ↑ action potential amplitude
Neuropathy = ↓ action potential duration and ↓ action potential amplitude
Most common hereditary peripheral neuropathy?
Charcot-Marie-Tooth disease
Management of neuropathic pain?
1st line = amitriptyline, duloxetine, gabapentin, pregabalin
2nd line = switch to one of other 3
3rd line = pain management team referral
N.B. topical capsaicin can be used for localised pain and tramadol can be used as “rescue” medication
Features, investigation and management of degenerative cervical myelopathy?
Neck and arm pain
Loss of motor and sensory function
Urinary incontinence
Investigation = MRI cervical spine
Management = surgical decompression
Features of ulnar nerve (C8-T1) vs radial nerve (C5-T1) vs median nerve (C6-T1) lesion?
Ulnar = “claw hand,” hypothenar wasting, sensory loss over dorsal/palmar medial 1 1/2 digits
Radial = “wrist drop,” sensory loss over dorsal lateral 2 1/2 digits
Median nerve = carpal tunnel syndrome, thenar wasting, sensory loss over palmar 2 1/2 digits
Features of common peroneal nerve (L4-S2) lesion?
Foot drop
Weak extension of big toe
Sensory loss on dorsum of foot and lateral lower leg
Glasgow Coma Scale (GCS) criteria?
Motor response:
6. Obeys commands
5. Localises to pain
4. Withdraws from pain
3. Abnormal flexion to pain
2. Extending to pain
1. None
Verbal response:
5. Orientated
4. Confused
3. Words
2. Sounds
1. None
Eye opening:
4. Spontaneous
3. To speech
2. To pain
1. None
Cerebral perfusion pressure (CPP) calculation?
CPP = MAP - ICP
Normal ICP?
7-15 mmHg
Features and management of raised ICP?
Cushing’t triad (bradycardia, wide pulse pressure, irregular breathing)
Headache
Vomiting
Papilloedema
Reduced consciousness
Management = head elevation, IV mannitol, CSF drainage
Cause of communicating vs non-communicating hydrocephalus?
Communicating = increased CSF production or impaired reabsorption via arachnoid granules e.g. meningitis
Non-communicating = pathology obstructing the flow of CSF e.g. tumour
Features and management of normal pressure hydrocephalus?
Weird, wet and wobbly:
→ dementia
→ urinary incontinence
→ ataxic gait
Management = V-P shunt
Features and management of meningitis?
Headache
Fever
Neck stiffness
Photophobia
Reduced consciousness
Purpuric rash (meningococcus)
Management = IV ceftriaxone + IV amoxicillin + IV aciclovir (if viral suspected)
CSF features of bacterial vs viral meningitis?
Bacterial = cloudy, low glucose, high protein, very raised WCC
Viral = clear/cloudy, 60-80% plasma glucose, normal/high protein, raised WCC
Management of post-lumbar puncture headache?
Supportive e.g. fluids, caffeine
If > 72 hours = blood patch, epidural saline, IV caffeine
Investigation for suspected TB meningitis?
PCR
Management of a brain abscess?
Craniotomy with debridement + IV cephalosporin + IV metronidazole
Most common cause and site of encephalitis?
HSV-1
Temporal lobes
Features and management of encephalitis?
Acute headache
Meningism e.g. photophobia, seizures
Sudden behavioural change
Management = IV aciclovir + IV broad-spectrum antibiotic
UMN vs LMN facial nerve lesion?
UMN spares upper face
LMN affects all facial muscles
Features and management of Bell’s palsy?
Unilateral facial LMN weakness
Sparing of extraocular and mastication muscles
Postauricular otlagia
Management = prednisolone, eye care e.g. artificial tears
First line investigation for head trauma?
Non-contrast CT
Criteria for CT head < 1 hour?
- GCS < 13 on initial assessment
- GCS < 15 at 2 hours post-injury
- Suspected open or depressed skull fracture
- Any sign of basal skull fracture
- Post-traumatic seizure
- More than 1 episode of vomiting
- Focal neurological deficit
Criteria for CT head < 8 hours?
Those with LoC or amnesia plus:
- Age 65 years or older
- Bleeding or clotting disorders
- Anticoagulant use
- Dangerous mechanism of injury
- More than 30 minutes retrograde amnesia of events immediately before the head injury
Classification of primary brain injuries?
Focal (e.g. haematoma)
→ subdural
→ epidural
→ intracerebral
Diffuse (e.g. diffuse axonal injury)
Herniation vs coning?
Herniation = displacement of brain structures
Coning = specifically displacement of the cerebellar tonsils through the foramen magnum
CT feature of a subdural vs epidural haematoma?
Subdural = crescent shape
Epidural = biconcave/lentiform shape
CT feature of an acute vs chronic subdural haematoma?
Acute = hyperdense lesion
Chronic = hypodense lesion
Origin and management of a subdural haematoma?
Bridging veins
Management = supportive (small), decompression with burr holes (large)
Origin and management of an epidural (extradural) haematoma?
Middle meningeal artery
Management = supportive (small), craniotomy with evacuation (large)
Typical history of an epidural haematoma?
Patient with head injury loses consciousness, regains it (“lucid interval”), then loses it again
Features and management of a subarachnoid haemorrhage?
“Thunderclap” occipital headache
Photophobia, neck stiffness
N&V, seizures, coma
Management = nimodipine, aneurysm coil or clipping
Investigations for subarachnoid haemorrhage?
Non-contrast CT
CT < 6 hours and -ve = alternative diagnosis
CT > 6 hours and -ve = lumbar puncture
CSF features of subarachnoid haemorrhage?
Xanthochromia
Normal or raised LP opening pressure
Features of subacute combined degeneration of the spinal cord?
Vitamin B12 deficiency
Dorsal column disease
→ impaired sensation, parasthesia
Lateral corticospinal tract disease
→ UMN signs
Spinocerebellar disease
→ gait abnormalities
Features of Brown-Sequard syndrome?
Ipsilateral hemiplegia
Ipsilateral loss of proprioception/vibration
Contralateral loss of pain/temperature sensation
Features and management of neuroleptic malignant syndrome?
Fever
Muscle rigidity
Hypertension, tachycardia
Raised CK and WCC
Management = stop antipsychotic, IV fluids, dantrolene
