Neurology Flashcards
What are the types of seizure?
*Generalised tonic-clonic: muscle tensing and jerking
*focal: hearing/speech/memory/emotions affected
*Absence: blank, stare into space
*Atonic: lapses in tone
*Myoclonic seizure: sudden brief muscle contraction
What is status epilepticus?
Seizure lasting > 5 minutes or >3 seizures in one hour, medical emergency
What is the management of status epilepticus?
*ABCDE
*high conc oxygen
*Test blood glucose
*IV lorazepam 4mg, repeat after 10 minutes
*After 2 doses of lorazepam if seizure continues, give IV phenytoin or phenobarbital
What are the acute causes of status epilepticus?
*Hypoxia
*Stroke
*Metabolic abnormalities
*Alcohol intoxication/withdrawal
*Poor anticonvulsant therapy adherence
What is the definition of epilepsy?
The tendency to have recurrent unprovoked seizures
What investigations should you carry out in suspected epilepsy?
*EEG
*MRI brain
*ECG
What is the management of generalised tonic clonic seizures?
Sodium valporate first line
What is the management of focal seizures?
Carbamazepine or lamotrigine
What is the management of absence seizures?
Sodium valporate
What is the management of atonic seizures?
Sodium valporate
What is the presentation of a stroke?
*Sudden weakness of limbs
*Sudden facial weakness
*Sudden onset dysphasia
*Sudden onset visual or sensory loss
What are the risk factors for ischaemic stroke?
*Cardiovascular disease
*Previous stroke/TIA
*Hypertension
*Smoking
*Vasculitis
*Thrombophilia
*Combined contraceptive pill
What investigations should you carry out in suspected stroke?
*Not contrast CT (diffusion weighted MRI is gold standard)
*Serum glucose
*Serum electrolytes, UEs, FBC
*Cardiac enzymes
*ECG
*Prothrombin time and PTT
What is the management of ischaemic stroke?
*Admit to hyperacute stroke unit within 4 hours
*Swallow function assessment
*If <4.5 hours of onset, IV alteplase
*If >4.5 hours, consider mechanical thombectomy
*Start aspirin within 24 hours 300mg OD
*Atorvastatin after 48 hours
Wernicke’s aphasia
Receptive, impaired comprehension, can speak fluently but sentences may not make any sense
Broca’s aphasia
Expressive aphasia, can understand but cannot speak properly
TACS
Total anterior circulation
*All 3 of:
- Unilateral weakness
- Homonymous hemianopia
- Higher cerebral dysfunction
PACS
Partial anterior circulation
Two of:
- Unilateral weakness
- Homonymous hemianopia
- Higher cerebral dysfunction
POCS
Posterior circulation
One of:
- CN palsy and contralateral motor deficit
- bilateral motor/sensory deficit
- isolated homonymous hemianopia
- cerebellar dysfunciton
- conjugate eye movement disorder
LACS
Lacunar
One of:
- pure motor
- pure sensory
- sensori-motor
- ataxic hemiparesis
What is a TIA?
Transient neurological dysfunction secondary to ischaemia without infarction. Symptoms resolve within 24 hours
What is the management of TIA?
*300mg PO OD aspirin, once confirmed, switch to 75mg PO OD clopidogrel
*Atorvastatin
*If AF: anticoagulate
Tension headache
*Associated with stress/depression/alcohol/skipping meals/dehydration
*Mild ache, band like pattern around the head
What is the management of tension headaches?
Analgesia, reassurance, relaxation techniques
Migraine
*At least 5 attacks, lasting 4-72 hours
*Unilateral, pulsating, moderate to severe pain, worsened by routine physical activity
*Causes nausea/vomiting and/or photo/phonophobia
*Preceded by prodrome and aura, followed by postdrome
What is the prevention of migraine?
*Avoidance of triggers
*If 4-5 attacks a month, prophlaxis:
- propranolol
- topiramate
- amitryptiline
- candesartan
- flunarazine
*≥15 headaches a month with 8+ being migraines and failed on 3 prophylactics, consider onabotulism toxin A
Acute treatment of migraine
Sumatriptan or aspirin 900mg or ibuprofen
Cluster headaches
*Severe/very severe unilateral orbital, supraorbital and/or temporal pain
*Last 15-180 minutes
*One every other day up to 8 a day
*Also associated with one of:
- lacrimal injection
- nasal congestion or rhinorrhea
- forehead/ facial sweating/flushing
- eyelid oedema
- sensation of fullness in the ears
- miosis/ptosis
What is the management of cluster headaches?
100% oxygen, subcutaneous triptan
Trigeminal neuralgia
*unilateral, electric shock like pains
*Abrupt onset and termination
*Limited to the distribution of the trigeminal divisions
*Pain evoked by light touch
Thunderclap headache
*Sudden onset severe, occipital headache
*Associated nausea, meningism, seizure
Investigations thunderclap headache
Non contrast head CT within 12 hours, if negative after 12 hours from headache onset, lumbar puncture
Why do you have to wait 12 hours from onset to do a lumbar puncture in thunderclap headache?
To allow for xanthochromia to develop
What are the causes of thunderclap headache?
*Subarachnoid haemorrhage
*Intracerebral haemorrhage
*Arterial dissection
*Cerebral venous sinus thrombosis
*Ischaemic stroke
*Bacterial meningitis
Presentation of raised pressure headache
*Worse on lying down, improved on standing
*Worse in the morning
*Worse on valsalva (coughing, laughing)
*Worse on exertion
*Transient visual obscurations with changes in posture
*Persistent nausea and vomiting
*Papilloedema/optic disc swelling
*Impaired visual acuity, reduced fields, poor colour vision
*III or VI nerve palsy
*Focal neurological signs
What are the causes of raised intracranial pressure?
*Idiopathic intracranial hypertension
*Trauma
*Infection: meningitis
*Hydrocephalus
*Tumour
What is MS?
Demyelinating central nervous system condition clincially defined by 2 episodes of neurological dysfunction (brain, spinal cord, optic nerve) that are separated in space and time
What is the presentation of MS?
*Visual disturbance in one eye, painful movement of eye, loss of colour discrimination (particularly red)
*Peculiar sensory phenomena: wetness/burning sensation
*Ataxia: sensory or cerebellar
What is Lhermitte’s sign?
Electric shock sensation down the spine into the limbs when flexing the neck due to disease in the dorsal column of the spinal cord
What investigations should you carry out in suspected MS?
*MRI brain and spinal cord
*FBC and metabolic panel, VIt B12 and TSH to exclude other pathologies
*Lumbar puncture - oligoclonal bands
*visual evoked potentials
What are the patterns of disease in MS?
*Relapsing-remitting
*Primary progressive (has never been relapsing remitting)
*Secondary progressive (was once relapsing-remitting)
What is the management of an MS relaspe?
*Methylprednisolone:
- 500mg orally for 5 days
- 1g IV for 3 days
*Give PPI for gastro protection
What is the presentation of Parkinsons?
*Bradykinesia
*Rigidity
*Resting tremor
*Postural instability
*Fatigue
*Depression, anxiety
*Constipation
*Dementia
*Speech difficulties (hypophonia and dysarthria)
What are the exclusion criteria for parkinson’s?
*Cerebellar signs
*Limited to the lower limbs for >3 years
*Vertical gaze palsy
*No response to L-Dopa
*Normal FP-CIT scan
What are the drug options for parkinsons?
*L-Dopa: sinemet (Levodopa and carbidopa)
*Dopamine agonist: ropinerole, rotigotine, pramipexole
*MAO-B inhibitor
*COMT inhibitor
MAO-B inhibitor
Selegiline, rasagiline
COMT inhibitor
Entracapone, opicapone
What are the side effects of L-Dopa
*nausea
*Vomiting
*Postural instability
*Confusion
*hallucination
What are the side effects of dopamine agonists?
*Daytime somnolence
*Impulse control disorders
*nausea, vomiting, postural hypotension
What are the complications of advanced parkinsons?
*Motor complications
*Change in posture
*Increased falls
*L-Dopa induced dyskinesia
*Poor balance
*Swallowing and speech difficulties
*Dementia, hallucinations, psychosis
What are the treatment options for advanced parkinson’s?
*Apomorphine pen injection
*Intrajejunal duodopa infusion
*Deep brain stimulation
What are the other causes of parkinsonism?
*Drug induced
*PSP: progressive supranuclear palsy
*MSA- multi systems atrophy
*Vascular Parkinsonism
*Lewy body dementia
*Corticobasal degeneration
What drugs can causes parkinsonism?
*Lithium
*Antipsychotics
*CCB
*Metoclopramide
What are the signs of MSA?
*Poor response to l-dopa
*Autonomic dysfunction
*Speech difficulties
What are the signs of PSP?
*Vertical gaze palsy
*Postural instability
What are the signs of vascular parkinsonism?
*Lower extremities
*Symmetrical
What is cervical spondylosis?
Osteoarthritis of the spine including the spontaneous degeneration of the disc or facet joints
What is the presentation of cervical spondylosis?
*Spontaneous onset of neck pain
*Cervical muscle pain and spasm
*Headaches/occipital pain
*Weakness or numbness
*Radiating arm pain
*Reflex changed (reduced in radiculopathy, increased in myelopathy)
What investigation should be carried out in suspected cervical spondylosis?
Cervical MRI (order if pain remains after 4-6 weeks)
What is the management of cervical spondylosis?
*Axial neck pain: physio, NSAIDs, muscle relaxant if spasm
*Cervical spondylitiic radiculopathy: NSAIDs, physio, consider prednisolone
*Degenerative cervical myelopathy: consider surgical decompression
What is myasthenia gravis?
Autoimmune condition of the post synaptic membrane at the neuromuscular junction in skeletal muscle. Circulation of antibodies against the nicotinic acetylcholine membrane
What is the presentation of myasthenia gravis?
- muscle strength fatiguability
- ptosis due to eyelid weakness
- diplopia due to extraocular muscle weakness
- slurred speech
- problems with swallowing and chewing
Investigation for myasthenia gravis
- serum acetylcholine receptor antibody analysis
- muscle specific tyrosine kinase
- edrophonium test
Management of myasthenia gravis
Pyridostigmine or neostigmine
What are the types of MND?
- amytrophic lateral sclerosis
- progressive bulbar palsy
- progressive muscular atrophy
- primary lateral sclerosis
What is the presentation of MND?
- LMN lesion: muscle wasting, reduced tone, reduced reflexes
- UMN lesion: increased tone/spasticity, brisk reflexes, upgoing plantar response
There will be an absence of sensory or cerebellar signs
Investigation for MND
- Clinical diagnosis
- Can perform MRI and nerve conduction studies to exclude other diagnoses
Amyotrophic lateral sclerosis
- most common
- UMN in lower limbs
- LMN in upper limbs
Progressive bulbar pasly
- affects muscles responsible for talking and swallowing
- poor prognosis
Progressive muscular atrophy
LMN only
Primary lateral sclerosis
UMN only
What are the causes of a predominantly motor peripheral neuropathy?
- Guillain barre
- Lead poisoning
- Diptheria
- Charcot Marie Tooth
What are the causes of a predominantly sensory peripheral neuropathy
- diabetes
- vitamin B12 deficiency
- alcohol
- uraemia, chronic kidney disease
- amyloidosis
What is Guillain barre syndrome?
- acute inflammatory demyelinating neuropathy
- post infectious autoimmune aetiology (e.g. campylobacter, CMV, EBV)
- progressive weakness over days
- flaccid, quadraparesis with areflexia
Treatment of guillain barre
IV immunoglobulin or apheresis
What is secondary progressive MS?
Relapsing remitting patients who have deteriorated and have developed neurological signs and symptoms between relapses
Management of an acute relapse of MS
High dose steroids (oral or IV methylprednisolone)
Drug options for reducing risk of relapse in MS
- natalizumab IV
- ocrelizumab
Fatigue in MS
Amantadine
Spasticity in MS
baclofen and gabapentin
Bladder dysfunction in MS
- get an ultrasound to assess bladder emptying
- if significant residual volume then intermittent self catheterisation
- if no significant residual volume then anticholinergics
Visual evoked response
Delayed but well preserved waveform
Where is the lesion in wernickes
Superior temporal gyrus
What supplies wernickes area?
inferior division of the left MCA
Where is brocas area
Inferior frontal gyrus
What supplies brocas area?
Superior division of the left MCA
What is conduction aphasia
Speech is fluent but repetition is poor, they are aware of the errors they are making
Area affected in conduction aphasia
Arcuate fasiculus
Global aphasia
All 3 areas: superior temporal gyrus and inferior frontal gyrus and arcuate fasiculus
Severe expressive and receptive aphasia
Causes of aphasia resulting in non fluent speech
- Brocas: comprehension intact
- Global: comprehension impaired
Causes of aphasia with fluent speech
- comprehension impaired: wernickes
- comprehension relatively intact: conduction aphasia
Cerebellar vermis lesion
Gait ataxia
Spinal cord level autonomic dysrefelxia
At or above T6
Autonomic dysreflexia
- spinal cord injury at or above T6
- afferent signals triggered by faecal impaction or urinary retention
- sympathetic spinal reflex
- parasympathetic prevented by cord lesion
- extreme hypertension, sweating above the level of the cord, agitation
Management of autonomic dysreflexia
Removal or control of the stimulus and treatment of life threatening hypertension and/or bradycardia
Origin of brachial plexus
anterior rami C5 to T1
Presentation of brain abscess
- headache
- fever
- focal neurology
- raised ICP: nausea, papilloedema, seizure
Management of brain abscess
- surgery: craniotomy and debridement
- IV metronidazole and 3rd gen cephalosporin
- intracranial pressure management
Which tumours most commonly spread to the brain?
- lung (most common)
- breast
- bowel
- skin (melanoma)
- kidney
What is the most commonly primary brain tumour?
Glioblastoma multiforme
Location vestibular schwannoma
- benign tumour
- 8th cranial nerve
- often seen in cerebellopontine angle
Most common primary brain tumour in children
- Pilocytic astrocytoma
Brown sequard syndrome
- caused by lateral hemisection of the spinal cord
- ipsilateral weakness below the lesion
- ipsilateral loss of proprioception and vibration sensation
- contralateral loss of pain and temperature sensation
Adverse effects of carbamazepine
- P450 inducer
- dizziness and ataxia
- drowsiness
- headache
- visual disturbance
- steven johnson syndrome
- leucopenia and agranulocytosis
- hyponatraemia secondary to syndrome of inappropriate ADH secretion
Why may someone see a return of seizures when starting carbamazepine?
Exhibits autoinduction
What is in the cavernous sinus?
In the lateral wall:
- oculomotor nerve
- trochlear nerve
- ophthalmic nerve
- maxillary nerve
In the sinus
- internal carotid artery
- sympathetic plexus
- abducen nerve
Symptoms of cerebellar disease
- Dysdiadochokinesia, dysmetria (past pointing)
- Ataxia
- Nystagmus
- intention tremor
- slurred staccato speech, scanning dysarthria
- hypotonia
Causes of cerebellar disease
- Freidreichs ataxia
- cerebellar haemangioma
- stroke
- alcohol
- MS
- hypothyroidism
- drugs: phenytoin, lead poisoning
- paraneoplastic
Features of charcot marie tooth disease
- foot drop
- high arched foot (pes cavus)
- hammer toes
- distal muscle weakness
- distal muscle atrophy
- hyporeflexia
- stork leg deformity
How long does a cluster headache typically last?
15 minutes to 2 hours
gold standard imaging cluster headaches
MRI with gadolinium contrast
Prophylaxis of cluster headaches
Verapamil
Common peroneal nerve lesion
- foot drop
- weakness of foot dorsiflexion and eversion
- weak extensor hallucis longus
- sensory loss over the dorsum of the foot and lower lateral part of the leg
- wasting of the anterior tibial and peroneal muscles
Which drugs can cause a peripheral myopathy?
- amiodarone
- isoniazid
- vincristine
- nitrofuratoin
- metronidazole
driving after first seizure
6 months no seizure if no structural abnormalities of epileptiform waveform otherwise 12 months
Stroke/TIA driving
one month off if no residual neurological deficit
neuropathy EMG
Increased action potential duration and amplitude
Myopathy EMG
Decreased action potential duration and amplitude
Management of encephalitis
Intravenous aciclovir
What virus is responsible for most encephalitis?
HSV
Features of an essential tremor
- postural : worse if arm is outstretched
- improved by alcohol and rest
Management of essential tremor
Propranolol
What is the most common cause of foot drop?
Common peroneal nerve lesion
Foot drop with weak hip abduction
L5 radiculopathy
What classically triggers guillain barre?
Campylobacter jejuni
Features of guillain barre
- initially leg/back weakness
- ascending symmetrical weakness
- reflexes reduced or absent
- may have mild sensory symptoms
- may be a history of gastroenteritis
Features of lambert eaton syndrome
- Repeated muscle contractions lead to increased muscle strength
- limb girdle weakness
- hyporeflexia
- autonomic symptoms
What muscle heads does the median nerve pass through?
The two heads of pronator teres
Median nerve motor supply of hand
- lateral 2 lumbricals
- opponens pollicis
- abductor pollicis brevis
- flexor pollicis brevis
Damage to median nerve at wrist
- carpal tunnel syndrome
- paralysis and wasting of the thenar eminence and opponens pollicis
- sensory loss to the palmar aspect of the lateral (radial) 2 1/2 fingers
Damage to the median nerve at the elbow
- unable to pronate the forearm
- weak wrist flexion
- ulnar deviation of the wrist
- carpal tunnel syndrome
Damage to the anterior interosseous nerve
- loss of pronation of the forearm
- weakness of the long flexors of the thumb and index finger
What is the anterior interosseous nerve a branch of?
Median nerve
Features of neuroleptic malignant syndrome
- pyrexia
- muscle rigidity
- autonomic lability: hypertension, tachycardia, tachypnoea
- agitated delerium with confusion
- raised creatine kinase
Bloods neuroleptic malignant syndrome
- raised creatine kinase
- AKI
- leukocytosis
Factors suggestive of pseudo seizure
- pelvic thrusting
- family member with epilepsy
- female
- crying agter seizure
- doesnt occur when alone
- gradual onset
Damage to radial nerve
- wrist drop
- sesory loss to the dorsal aspect of the 1st and 2nd metacarpals
- paralysis to triceps (loss of elbow extension)
Ankle reflex
S1/S2
Knee REflex
L3/4
Biceps reflex
C5/6
Triceps reflex
C7/8
Absolute contraindications to thrombolysis
- previous ICH
- seizure at onset of stroke
- intracranial neoplasm
- suspected SAH
- stroke or traumatic brain injury in last 3 months
- lumbar puncture in past 7 days
- GI haemorrhage in past 3 weeks
- active bleed
- pregnancy
- oesophageal varices
- uncontrolled hypertension >200/120
What drug can result in subacute combined degeneration of he spinal cord?
Nitrous oxide
Features of subacute combined degeneration of the spinal cord
Dorsal column:
- distal tingling or burning symmetrically
- impaired proprioception and vibration sense
Lateral corticospinal tract involement
- muscle weakness,hyperreflexia, spasticity
- UMN signs
- brisk knee relex
- absent ankle jerks
- extensor plantars
Spinocerebellar tract
- sensory ataxia leading to gait abnormality
- positive rombergs sign
Motor supply of ulnar nerve
- medial two lumbricals
- adductor pollicis
- interossei
- hypothenar muscles: abductor digiti minimi, flexor digiti minimi
- flexor carpi ulnaris
Sensory of ulnar nerve
- medial 1 1/2 fingers
Damage to the ulnar nerve at the wrist
- claw hand
- wasting and paralysis of teh intrinsic hand muscles
- wasting and paralysis of the hypothenar muscles
- sensory loss to the medial 1 1/2 fingers
Damage to the ulnar nerve at the elbow
- clawing is more severe than wrist lesion
- radial deviation of the wrist
- wasting and paralysis of teh intrinsic hand muscles
- wasting and paralysis of the hypothenar muscles
- sensory loss to the medial 1 1/2 fingers
Features of vestibular schwannoma
- vertigo (CN VIII)
- hearing loss
- tinnitus (CN VIII)
- absent corneal reflex (cranial nerve V)
- facial palsy if CNVII affected
What are bilateral vestibular schwannomas seen in
neurofibromatosis type 2
investigation vestibular schwannoma
MRI cerbellopontine angle
