Neurology Flashcards
what is a transient ischemic attack
sudden onset focal neurological deficit - temporary
what are the two types of transient ischemic attack
Internal carotid artery (anterior)- 90%
Vertebral (posterior) - 10%
what are causes of transient ischemic attack
Carotid thrombo-emboli
- thrombosis
- Emboli (AF)
what is the CHA2DS2 - VASc score
A way of assessing stroke risk from AF in AF patients
what are risk factors for transient ischemic attack
same as ischemic heart disease
- smoking
- diabetes T2
- hypertension
- Atrial fibrillation
- obesity/hypercholesterolemia
- VSD
what are the symptoms of anterior cerebral artery syndrome (transient ischemic attack)
weak numb contralateral leg
what are the symptoms of middle cerebral artery syndrome (transient ischemic attack)
weak numb contralateral side of body, face drooping w/forehead spared, dysphasia (temporal)
what is amaurosis fugax
this is when there is occlusion or reduced blood flow to the retina through the ophthalmic/retinal/ciliary artery
- sign that stroke is impending
what are the signs of a posterior coronary artery attack
vision loss
what is seen with occipital artery attack
contralateral homonymous hemianopia with macular sparing
what is seen in vertebral artery attack (transient ischemic attack)
cerebellar syndrome: DANISH
brainstem infarct
cranial nerve lesions 3-12
when can you differentiate between a stroke and a transient ischemic attack
after the recovery
how do you tell the difference between a transient ischemic attack and a stroke
TIA: resolve within minutes usually and always <24 hours with no infarct
Stroke: last 24 hours with infarct
how do you diagnose transient ischemic attack
clinically made
FAST scoring system = face, arms, speech, time
ABCD2 - age (>60), BP (>140/90). Clinical sx, duration, DMT2
how do you treat a transient ischemic attack
Acutely = 300mg of aspirin
prophylaxis long term = clopidogrel 75mg + atorvastatin 80mg
what is a stroke
a focal neurological defect lasting 24 hours with infarction
what are the two types of stroke
ischemic and haemorrhagic
what are the features of an ischemic stroke
mc - 85%
caused by carotid-thrombo-emboli
what are the features of haemorrhagic stroke
15% of strokes
caused by ruptured blood vessel
what can cause a haemorrhagic stroke
trauma
hypertension
berry aneurysm rupture
where are haemorrhagic strokes more common
intraendural
subarachnoid
what a specific sign of a stroke
the pronator drift
what is the pronator drift and what does it show
ask the patient to lift their arms to the ceiling and the arm affected will pronate and the palm faces down
- sign of a stroke
what are risk factors for stroke
hypertension
smoking
obesity
type 2 diabetes
atrial fibrillation
transient ischemic attack
hypercoagulability
what are symptoms of a stroke
focal neurology - like TIA
haemorrhagic strokes show an increase in intracranial pressure
what are lacunar strokes
they are a very common types of ischemic stroke of lenticulostriate arteries (support deep brain structures) which causes ischemia in the basial ganglia, internal capsule, thalamus and pons
what kind of stroke do you suspect is a patient is on oral anticoagulants
haemorrhagic stroke until proven otherwise
how do you diagnose stroke
NCCT head
ischemic - mostly normal
haemorrhagic - hyperdense blood
how do you treat ischemic stroke
- if it presents within 4.5 hours use a thrombolytic (alteplase IV)
- aspirin 300mg for two weeks
- lifelong clopidogrel 75mg
how do you treat a haemorrhagic stroke
neurosurgery referral
IV mannitol for increased intracranial pressure
what is the prophylaxis for both ischemic and haemorrhagic stroke
atorvastatin
ramipril
what spaces can haemorrhages occur within
- subarachnoid
- subdural
- extradural
what can cause a subarachnoid haemorrhage
berry aneurysm in the circle of willis rupturing
trauma
what can cause subdural haemorrhage
bringing vein rupture
what can cause extradural haemorrhage
middle meningeal artery trauma
what are the most common arteries subarachnoid haemorrhage occurs in
anterior communicating
anterior cerebral junction
what are the risk factors of a subarachnoid haemorrhage
hypertension
polycystic kidney disease
trauma
increased age
family history
male
what are symptoms of a subarachnoid haemorrhage
occipital thunderclap headache
suddenly onset
may have sentinel headache - throbbing pain which preceded berry aneurysm rupture
very severe
meningism - kernig and brudzinski signs
low GCS (consciousness)
Fixed dilated pupils
Non specific signs of raised intracranial pressure
what is the Kernig sign
Cant extent the leg properly when the knee is flexed
what is the Brudzinski sign
when neck elevated, knees automatically flex
what is the Glasgow coma scale
coma score out of 15
eyes - 4, Verbal - 5, motor - 6
15 = normal
8 = comatose
3 = unresponsive
what are differential diagnosis for subarachnoid haemorrhage
meningitis
migrane
how do you diagnose subarachnoid haemorrhage
diagnostic = CT head (expect a star shape)
+ve CT angiogram
-ve Lumbar puncture
what is the first line treatment for subarachnoid haemorrhage
neurosurgery: endovascular coiling
also give Nimodipine
why do you give Nimodipine in subarachnoid haemorrhage
because it reduced vasospasm and blood pressure
- its a calcium channel blocker
what is a subdural haemorrhage
rupture of a bridging vein due to shearing
- deceleration injuries and abused children
what are risk factors of subdural haemorrhage
trauma
child abuse
cortical atrophy - dementia
what are symptoms of subdural haemorrhage
gradual onset with latent period
bleeding is small: accumulation and autolysis of blood (symptoms after days/weeks/months)
signs of intracranial pressure
what are the signs of increased cranial pressure
Cushings triad:
bradycardia
increased pulse pressure
irregular breathing
plus fluctuating GCS and papillodema
how do you diagnose subdural haemorrhage
NCCT head - banana or crescent shaped haematoma not confused to suture tines, midline shift
what do
a. acute
b. subacute
c. chronic
subdural haemorrhage look like on a CT
a. hyper dense (bright)
b. isodense
c. hypodense - darker than the brain
how do you treat subdural haemorrhage
Burr hole and craniotomy
IV mannitol to decrease intracranial pressure
what is an extradural haemorrhage
caused by trauma to the middle meningeal artery, due to damage to the lateral pterygoid bone
when is extradural haemorrhage more common
in young adults - 20-30
as you age there is a decreased risk as the dura becomes more firmly adhered to the skull
what are the risk factors of extradural haemorrhage
head trauma
what are the symptoms of extradural haemorrhage
after the initial event there is a lucid interval and then there will be a rapid deterioration due to an increased cranial pressure
why is there a delayed increased inter cranial pressure in extradural haemorrhage
because of old blood clots, these clots become haemolysed and takes up water and will therefore increase the volume in the skull
what symptoms are seen in extradural haemorrhage
decreased GCS score - comatose and confusion
Increased intracranial pressure signs
death from respiratory arrest
why do you have respiratory arrest in extradural haemorrhage
tonsillar hemiation and coning of brain causes a compressed respiration centre
how do you diagnose extradural haemorrhage
NCCT the head
- lens shaped hyperdense bleed confined to suture lines
- midline shift
what is the treatment for extradural haemorrhage
urgent surgery
mannitol IV to reduce inter cranial pressure
what are primary causes of headaches
migrane
cluster
tension
drug overdose
what are secondary causes for headaches
due to an underlying condition
GCA
infection
SAH
trauma
cerebrovascular disease
eye, ear, sinus pathology
what is a migraine
it is recurrent episodes of throbbing headache plus or minus aura
often with vision changes
what is the most common cause of recurrent headache
migraine
In who is migraine most common
in women under 40
what are triggers of migraine
chocolate
hangovers
orgasms
cheese
bral contraceptives
lie ins
alcohol
tumult
exercise
how does a migraine come on
prodrome - days before attack see mood changes
Aura - part of the attack, minutes before headache
Throbbing headache lasting 4-72 hours
what are symptoms of a migraine
2 or more of
- unilateral pain
- throbbing
- motion sickness
- mod-severely intense
plus one of
- nausea and vomiting
- photophobia
how do you diagnose migraine
clinical
- unless other pathology is suspected
how do you treat migraine
Acute: oral triptan or aspirin (900mg)
Prophylaxis: propranolol or TCA (2nd line)
what is a cluster headache
a unilateral periorbital pain with autonomic features
10-15 minutes
what is the most disabling primary headache
cluster headaches
what are risk factors for cluster headaches
male
smoking
genetics - autodom link?
what are symptoms of cluster headaches
crescendo unilateral periorbital excruciating pain (may affect temples too)
autonomic features
- face flushing
- conjunctival injection and lacrimation
- ptosis
- miosis
- rhinorrhoea
how do you diagnose cluster headaches
clinically
5 or more similar attacks confirm diagnosis
how do you treat cluster headaches
acute = Triptans - sumatriptan
Prophylaxis = Verapamil (CCB)
what are tension headaches
bilateral generalised headache which can radiate to the neck
what is the most common type of primary headache
tension headache
what is the trigger for tension headaches
stress
what are symptoms of tension headache
rubber band tight around the head
bilateral pain
feel it in the trapezius too
mold-moderate severity
no motion sickness, photophobia or aura
how do you diagnose tension headaches
clinically from the history
how do you treat tension headaches
simple analgesia
- aspirin
- paracetamol
what is primary trigeminal neuralgia
unilateral pain in one or more trigeminal branches
what are risk factors for trigeminal neuralgia
MS (20X more likely)
increased age
female
what is trigeminal neuralgia triggered by
eating
shaving
talking
brushing teeth
what are symptoms of trigeminal neuralgia
electric shock pain (seconds to minutes)
in V1/2/3
how do you diagnose trigeminal neuralgia
clinical
three or more attacks with symptoms
what is the treatment for trigeminal neuralgia
carbamazepine - anticonvulsant
what is giant cell arteritis
it is large vessel vasculitis
how does giant cell arteritis normally present
50 y/old caucasian woman presents with unilateral tender scalp, intermittent jay claudication
- worst case is amaurosis fugax which is transient vision loss in one eye
how do you diagnose giant cell arteritis
temporal artery biopsy - large region as you can get skip lesions
increased ESR and CRP
normocytic normochromic anaemia of chronic disease
what is seen on a temporal artery biopsy in giant cell arteritis
granulomatous non caseating inflammation of the intima and media with skip lesions
how do you treat giant cell ateritis
corticosteroids = prednisolone
if there is any sign of vision changes then give high dose IV methylprednisolone quickly
what are causes of seizures
VITAMIN DE
vascular
Infection
trauma
autoimmune - SLE
metabolic - hypocalcaemia
Idiopathic - epilepsy
neoplasms
dementia +drugs (cocaine)
eclampsia
what is epilepsy
idiopathic cause of seizures with two or more episodes more than 24 hours apart
what are risk factors for epilepsy
familial inherited
dementia
what is the pathophysiology behind seizures
the normal balance between GABA (-) and glutamate (+) shifts towards glutamate therefore making it more excitatory
how long do epileptic seizures usually last for
about 2 minutes
what are the phases of a epileptic fit
prodrome
aura
ictal event - seizure
postictal period
what happens in the prodrome stage of a fit
this is changes in someones mood days before the event
what happens in the aura stage of a fit
minutes before the fit
Deja vu ad automatisms (lip smacking/rapid blinking)
- not always present
what happens in the postictal period of a fit
headache
confusion and decreased GCS score
TODD’S paralysis - temporary paralysis and muscle weakness of the motor cortex is affected
dysphagia
amnesia
sore throat - in epileptic seizures
what are different classifications of epileptic seizures
generalised - tonic clonic and absence
focal - simple and complex focal
what is a Tonic Clonic generalised seizure
GRANDMAL
- no aura
- tonic phase - rigidity, fall to floor
- clonic phase - jerking of limbs
ungazing open eyes, incontinence, tongue bitten
what is an absence generalised seizure
Often in childhood
characterised by moments of staring blankly into space
lasts seconds to minutes
3HZ spike on ECG
what does tonic mean
when someone is rigid
what does myoclonic mean
when someone is jerking limbs
what does atonic mean
when someone is suddenly floppy (limbs and muscles)
what generally happens during general seizures
all the cortex and deep brain structures bilaterally are affected
- always have a loss of consciousness
what are general features of focal seizures
confined to one region of the brain
- temporal may progress to secondary generalised
what is a simple focal seizure
where there is no basal ganglia or thalamic involvement
what is a complex focal seizure
where there is basal ganglia and thalamic involvement
what are features of a simple focal seizure
there is no loss of consciousness
patient is awake and aware
uncontrollable muscle jerking
what are features of a complex focal seizure
loss of consciousness
patient is unaware
postictal period positive
what symptoms would you get with a temporal focal seizure
AURA
dysphagia
post ictal period
what symptoms would you get with a frontal focal seizure
Jacksonian march
todd’s palsy
what symptoms would you get with a parietal seizure
paresthesia
what symptoms would you get with an occipital seizure
vision changes
how do you diagnose seizures
Must have had over 2 24 hours apart to consider epilepsy
CT head and MRI
ECG
Bloods
what do you need to examine on head CT and MRI in seizure diagnosis
hippocampus
check for bleeds
check for tumours
what is seen on an ECG in an absence seizure
3 HZ wave
how do you treat seizures
sodium valproate to all
who cant have sodium valproate for seizures
females in childbearing age as its teratogenic
what is given instead of sodium valproate in pregnancy for seizures
lamotrigine
what is a complication of seizures
status epilepticus = epileptic seizures without a break back to back OR
seizures lasting longer than 5 minutes
how do you treat status epilepticus
Benzodiazepines: lorazepam 4mg IV
if its not working then Lorazepam again and then phenytoin
what is parkinsons
when there is a loss of dopaminergic neurons from the substantia nigra pars compacta
what are risk factors for developing parkinsons
family history
increased age
smoking seems to be protective ?
what is the pathophysiology of parkinsons
normally to initiate movement the nigrostriatal pathway signals to the striatum to stop firing to substantia nigra and therefore stops movement inhibition
in Parkinson’s there is degeneration of the substantia nigra so that its harder to initiate movement
what are symptoms of parkinsons’s
cardinal Sx = bradycardia, resting tremor, rigidity, postural instability
anosmia seen early
constipation
shuffling gait
pill rolling thumb
cogwheel/lead pipe forearm
typically asymmetrical
How do you diagnose parkinsons
clinical
bradykinesia and more than one other cardinal sign
how do you treat parkinsons
LDOPA and a decarboxylase inhibitor
what is the problem that can occur with LDOPA
the body becomes resistant to it and the effects can wear off and therefore you dont want to give LDOPA too early
what are some differential diagnosis for parkinsons
lewy body dementia
parkinsons Sx then dementia = perkinsons dementia
Parkinsons Sx after dementia = lewy body dementia
what is dementia
a neurodegenerative disorder with a reduced in cognition (memory, judgement, language) over time
what is the most common type of dementia
alzheimers
what is alzheimers disease
it is when you have B amyloid plaques and tau neurofibrillary tangles in the cerebral cortex
- increases cortical scarring
- brain atrophy
- decreased Ach
what are risk factors for Alzheimers
Down’s syndrome (inevitable)
ApoE4 allele in familial alzheimers
what are symptoms of alzheimers
agnosia - cant recognise things
apraxia - cant do basic motor skills
aphasia - cant talk as well as normal
what is vascular dementia
it is due to cerebrovascular damage such as a stroke or trauma
history of TIA/stroke, UMN signs and general decrease in cognition
what is Lewy body dementia
it is when alpha synuclein and ubiquitin aggregates in the cortex (lewy bodies)
what are symptoms of lewy body dementia
cognitive decline
parkinsonism
what is frontotemporal dementia
it is when there is frontotemporal atrophy causing speech, language, thinking and memory problems
how do you diagnose dementia
mini mental state exam (out of 30)
over 25 is normal
18-25 is impaired
<17 is severely impaired
Brain MRI will show atrophy
what is the treatment for dementia
conservative
social stimulation
exercise
for alzheimers - achase i (donepazil)
for vascular - antihypertensives (ramipril)
what is huntingtons chorea
it is an autosomal dominant disease with full penetrance
there is a lack of GABA and an excessive nigrostriatal pathway
what is huntingtons disease due to
due to trinucleotide expansions repeats - more repeats the earlier it presents
what are the ranges for trinucleotide repeats in huntingtons
<35 repeats - no huntingtons
35-55 - huntingtons
60+ - severe huntingtons
what are symptoms of Huntingtons chorea
Chorea - excessive limb jerking
dementia
psychiatric issues
depression
how do you treat huntingtons
extensive counselling - inevitable Sx
dopamine antagonists for chorea
tetrabenazine
what is multiple sclerosis
T4 hypersensitivity against myelin basic protein of oligodendrocytes causing demyelination of the CNS neurons
what are risk factors for multiple sclerosis
females
20-40
autoimmune disease
family history
EBV
what are types of multiple sclerosis
Relapsing remitting - incomplete recovery
Primary progressive - gradual deterioration
secondary progressive - relapsing-remitting
what is the first presentation of multiple sclerosis
blurred vision
- due to optic nerve damage
what are the symptoms of multiple sclerosis
paresthesia
blurred vision
Uthoff’s phenomenon (exacerbated in heat)
what are signs of multiple sclerosis
optic neuritis - inflamed optic nerve
internuclear ophthalmoplegia - lateral gaze impaired
brainstem signs
sensory signs
UMN signs
Lhermitte phenomenon
charcot neurological triad
what is the Charcot neurological triad
dysarthria
nystagmus
intention tremor
what is Lhermitte phenomenon
electric shock sensation with neck on flexion
how do you diagnose multiple sclerosis
the McDonald criteria = 2 or more attacks disseminated in time and space
MRI brainstem and cord
delayed conduction speeds
LP may show digoclonal igG bands
how do you treat multiple sclerosis
Acutely (episodes) = IV methylprednisolone
Prophylaxis = b interferon (DMARD; biologic)
what is motor neuron disease
neurodegenerative disease causing lower and upper motor neuron signs
what is the main motor neuron tract affected in motor neuron disease
the corticospinal tract
what is the corticospinal tract
it has an upper motor neuron from the precentral gyrus which has
- No decussation (anterior 10%)
- decussation (lateral 90%)
what are symptoms of upper motor neuron lesions
hypertonia: rigidity + spasticity
hyperreflexia
no fasciculation
Babinski positive
power:
arms - flexors more than extensors
legs - extensors more than flexors
what are symptoms of a lower motor neuron lesion
hypotonia - flaccid and muscle wasting
hyporeflexia
fasciculations
Babinski -ve
generally low power
what is an UMN lesion
lesion from the pre-central gyrus to the anterior spinal cord
- everything goes UP
what is a LMN lesion
Lesion from the anterior spinal cord to the muscles innervated
everything goes DOWN
what happens if you see mixed upper and lower motor neuron signs
then it is motor neuron disease
what is organisation of movement
- idea of movement - association cortexes, pre-motor cortex
- Activation of UMNs in motor cortex
- Impulse via corticospinal tract
- modulation by cerebellum and basal ganglia
- movement and somatosensory information
what are risk factors for motor neuron disease
male
family history
SOD-1 mutation
increased age
in what diseases are eye muscles affected
MS
Myasthenia gravis
in what diseases is sensory function and sphincters affected
MS
polyneuropathies
what is amyotrophic lateral sclerosis
a neurodegenerative disease that results in the progressive loss of motor neurons that control voluntary muscles
what is the most common motor neuron disease
ALS
what can ALS progress to
Bulbar palsy
what is progressive bulbar palsy
it is where cranial nerves 9-12 are damaged
- worse prognosis and can increase the chance of respiratory failure
what are different kinds of motor neuron disease
Amyotrophic lateral sclerosis
progressive muscular atrophy - LMN only
Primary lateral sclerosis - UMNs only
progressive bulbar palsy
what are symptoms of motor neuron disease
mixed upper and lower motor neuron signs
- no eye, sensory, cerebellar or parkinson signs
how do you diagnose motor neuron disease
mainly clinical - from mixed picture
ECG shown fibrillation potentials
(due to muscle degeneration with LMN)
how do you treat motor neuron disease
MDT management
Riluzole - antiglutaminergic
Supportive - physiotherapy and breathing support if necessary
what is a complication of motor neuron disease
respiratory failure
aspiration pneumonia
swallowing failure
what is meningitis
an infection of the meninges of the brain
- notifiable to PHE
what are the viral causes of meningitis
Enteroviruses - coxsackie
HSV-2
V2V
what are bacterial causes of meningitis
mainly S.pneumonae
N.meningitidis
what are risk factors for meningitis
extremes of age
immunocompromised
crowded environment
non-vaccinated
what bacteria is the most common in meningitis of 0-3 months
group B alpha haemolytic strep (S.agalectiae)
listeria
E.coli
S.pneumoniae
what is the most common bacteria in meningitis of 3m-6yrs
Strep. Pneumonae
N. meningitidis
H. influenzae
what is the most common bacteria in meningitis 6-60yrs
S. pneuminae
N. meningitidis
what is the most common bacteria in meningitis 60+yrs
S. pneuminae
N. meningitidis
Listeria
what is N. meningitidis
Gram negative diplococcus
vaccine available: men B+C
10% mortality
what is seen in N.meningitidis meningitis
non blanching purpuric rash
10% mortality
can cause meningococcal septicemia
what is S. pneumoniae
gram positive diplococcus in chains
what is mortality rate of meningitis caused by S. pneumoniae
25% mortality
why is group B strep most common cause of neonatal meningitis
because it colonises the maternal vagina
what type of bacteria is Group B strep
Gram positive coccus in chains
what type of bacteria is listeria monocytogenes
gram positive bacilli
what meningitis does listeria monocytogenes cause
affects the extremes of age and maternal (pregnant ladies)
what are symptoms of meningitis
meningism: headache, neck stiffness, photophobia
what are signs of meningitis
Kernig - cant extend knee when hip is flexed (without pain)
Brudzinksi - when neck is flexed, knees and hips automatically flex
how do you diagnose meningitis
Lumbar puncture and CSF analysis
- sample taken form L3/4
when is a lumbar puncture contraindicated in meningitis
in increased intercranial pressure
what will be seen in a lumbar puncture in bacterial meningitis
increased opening pressure
cloudy yellow in appearance
increased WBC - neutrophilia
increased Ig/L
decreased glucose (less than 50% serum level)
what will be seen in a lumbar puncture in viral meningitis
equal opening pressure
clear normal appearance
increased WBC - lymphocytosis
equal protein (<Ig/L)
glucose is higher than 60% serum level
what is seen in a lumbar puncture in fungal/TB meningitis
increased opening pressure
cloudy and fibrous appearance
increased WBC - lymphocytosis
increased protein - !g/L
reduced glucose = <50% serum level
how do you treat bacterial meningitis
In hospital
Ceftriaxone/cefotaxime (3rd gen cephalosporin)
Steroids - dexamethasone
amoxicillin covers listeria
what is the treatment for viral menintigis
Nothing if enterovirus
Acyclovir if HSV or V2V
what is important to do when you have a meningitis diagnosis
contact tracing - prophylaxis to contacts with 7 days of more prolonged exposure proceeding the symptoms - i.e live in the same house
- give a one off dose of ciprofloxacin
what are complications of meningitis
Meningococcal septicemia (DIC)
Waterhouse Friedrichsen syndrome - adrenal insufficiency caused by intradrenal haemorrhage as a result of meningococcal DIC
in a GP if someone presents with a non blanching rash and suspected meningococcal septicemia what do you do
IM BENZYLPENELICCIN and an immediate hospital referral
what is encephalitis
viral infection of the brain parenchyma
what are most cases of encephalitis caused by
95% of cases are caused by HSV-1
what are other causes of encephalitis other than HSV-1
CMV
EBV
HBV
Toxoplasmosis
HIV
what are risk factors for encephalitis
immunocompromised
extremes of age
what are symptoms of encephalitis
fever
headache
encephalopathy
focal neurology (temporal lobe MC affected)
how do you diagnose encephalitis
CSF may show Viremia (increased lymphocytes)
MRI of the head - unilateral usually temporal encephalitis
Non specific ECG firing of 2Hz periodically
how do you treat encephalitis
Acyclovir
what are examples of primary brain tumours
Astrocytoma (90%)
oligodendrocytoma
Meningioma
Schwannoma
What types of cancer metastasis cause brain cancer
Non-small cell lung cancer (MC)
small cell lung cancer
Breast cancer
Melanoma
renal cell carcinoma
gastric cancer
what are the grades of astrocytoma’s
graded 1-4 by WHO
1 = benign
4 = glioblastoma (very bad prognosis)
what are symptoms of primary brain tumours
increased intercranial pressure
Cushings triad
Papilloedema
CN6 palsy
Focal neurology
Epileptic seizures
Lethargy
Weight loss
what is Cushings triad of symptoms in primary brain tumours
Increased pulse pressure
bradycardia
irregular breathing
how do you diagnose primary brain tumours
MRI the head - locate the tumour
Biopsy the tumour - grade
NO LUMBAR PUNCTURE (due to increased intercranial pressure it can cause a massive CI)
how do you treat primary brain tumour
Surgery - remove tumour if possible and reduce intercranial pressure
Chemotherapy - before/during/after surgery
Steroids, dexamethasone, may help
what is Hemiplegia
Paralysis on one side of the body
- caused by a brain lesion
what is Paraplegia
paralysis of both legs
- caused by a cord lesion
what level does the spinal cord run between
C1 - L1/2
what is found past L3 of the spine
the conus medullaris and the cauda equina
What type of tract is the DCML
it is an ascending tract
what is the pathway of the DCML
From the dorsal root to the medulla and then decussates
what is the DCML tract used for
sensing fine touch
two point discrimination
proprioception
Is DCML a sensory or motor nerve
A sensory nerve
what type of tract is the spinothalamic tract
Ascending tract
sensory
what is the pathway the spinothalamic tract takes
Decussates 1-2 spinal levels above where it enters and then ascends to the medulla
what does the spinothalamic tract detect
pain
temperature
what type of tract is the corticospinal tract
A descending tract
Motor
What is the pathway taken by the corticospinal tract
UMN which then decussates at the medulla
then has its ventral roots down
what happens when you have a spinal cord lesion
you have ipsilateral sensory signs remaining
you have contralateral motor signs remaining
what is the L3/4 reflex
the knee jerk reflex
what is the L5 reflex
the big toe jerk reflex
what is the S1 reflex
ankle jerk reflex
what are causes of spinal cord compressions
Vertebral body neoplasms
spinal pathology - disc prolapse/herniation
metastasis from what can develop into vertebral body neoplasms
breast
lung
renal cell carcinoma
melanoma
what is Brown sequard syndrome
Incomplete spinal cord injury leading to:
ipsilateral motor weakness
ipsilateral DCML dysfunction
Contralateral spinothalamic dysfunction
what are symptoms of spinal cord compression
Progressive leg weakness with UMN signs
- contralateral hyperreflexia
- Babinski +ve
- spasticity
sensory loss below the lesion
sphincter involvement is uncommon (v. bad sign)
how do you diagnose spinal cord compression
MRI spinal cord ASAP - can risk permanent damage if not
Chest X ray if malignancy is suspected
what is the treatment for spinal cord compression
Neurosurgery
- laminectomy
- microdisectomy
what causes cauda equina syndrome
lumbar herniation - L4/5 or L5/S1
what is cauda equina syndrome
Compression below the conus medullaris - emergency
what are symptoms of cauda equina syndrome
Leg weakness with lower motor neuron signs
- ipsilateral hypotonia
- fasciculations
- hyporeflexia
Saddle anaesthesia
Bladder/bowel dysfunction
Sphincter involvement common
how do you treat cauda equina syndrome
Neurosurgery ASAP
- microdiscectomy
- spinal fixation
how do you diagnose cauda equina syndrome
MRI cord
test nerve roots
test reflexes
what are mechanisms of peripheral neuropathy
demyelination
axonal damage
nerve compression
vasavenosum infarction
Wallerian degeneration - nerve cut and dies
what are causes of peripheral neuropathy
Demyelination
Diabetes mellitus T2
Surgery
pathology - infection, endocrine. RA
what is mononeuropathy
Single nerve damage
what is mononeuritis multiplex
when there is several individual nerves damaged
what is polyneuropathy
diffuse and often symmetrical pathology
what are causes of mononeuritis multiplex
WARDS PLC
Wegeners
AIDs/amyloidosis
RA
DMT2
Sarcoidosis
Polyarteriosis nordosa
Leprosy
Carcinomas
what nerve roots are affected in carpal tunnel syndrome
C6-T1
what is carpal tunnel syndrome
when there is pressure on the median nerve passing through the carpal tunnel
what are risk factors/causes of carpal tunnel syndrome
female more likely than male
Hypothyroidism
Acromegaly
Pregnancy
Rheumatoid arthritis
Obesity
what are symptoms of carpal tunnel syndrome
Gradual onset
- weakness of grip and aching hand/forearm
- paresthesia of the hand
- wasting of the thenar eminence
how do you diagnose carpal tunnel syndrome
Phalen test
Tinel test
EMG if tests are uncertain
what is the Phalen test
flex the wrist for one minute and if they have carpel tunnel they will have paresthesia and pain at the wrist
what is the Tinel test
Tapping of the wrist causes tingling
how do you treat carpel tunnel syndrome
Wrist splint at night
steroid injection
last resort = surgical decompression
what nerve roots are affected in radial palsy
C5-T1
How does radial palsy present
Wrist drop
how do you treat radial nerve palsy
Splint and simple analgesia
what nerve roots are affected in ulnar nerve palsy
C8-T1
how does ulnar nerve palsy present
classic claw hand - 4th and 5th fingers claw up
what is sciatica
it is a L5/S1 lesion due to
SPINAL: IV disc herniation/prolapse
NON SPINAL: Piriformis syndrome, tumours, pregnancy
what are symptoms of sciatica
pain from buttock down the lateral leg to pinky toe
weak plantarflexion and absent ankle jerk
how do you diagnose sciatica
Exam: cant do straight leg raise without pain
MRI the cord to confirm
how do you treat sciatica
Analgesia and physiotherapy
Neurosurgery
how do you treat ulnar nerve palsy
Splints and simple analgesia
how does polyneuropathy present
Glove and stocking distribution
mostly peripheries are affected
What are causes of polyneuropathy
Motor - guillian barre
sensory - diabetic neuropathy
vasculitis
malignancy
B-12 deficiency
rheumatoid arthritis
how do you treat polyneuropathy
analgesia and treat the underlying cause
how do you diagnose polyneuropathy
Find the underlying cause
- bloods
- serology
- ESR/CRP
what are common causes of cranial nerve lesions
Trauma
MS
tumours
what occurs in cranial nerve 3 lesions
ptosis
down and out eye
fixed dilated pupil
LEW nuclei dysfunction
What happens in cranial nerve 4 lesions
Diplopia when looking down
- this is rare and always due to trauma
What happens in cranial nerve 6 lesion
Adducted eye
a sign of increased intercranial pressure
What happens in cranial nerve 5 lesion
Jaw deviates towards the affected side
loss of corneal reflex
trigeminal neuralgia including sensory/motor jaw pain in V1/2/3
what happens in cranial nerve 7 lesion
facial droop with no forehead sparing
Bells palsy
Parotid inflammation
what happens in cranial nerve 8 lesion
hearing loss
loss of balance
skull changes
compression
middle ear disease
what happens in cranial nerve 9+10 lesions
Impaired gag reflex
issues with swallowing, respiration and vocal issues
- jugular foramen lesions
what happens in cranial nerve 11 lesion
cant shrug shoulders
cant turn head against resistance
what happens in cranial nerve 12 lesions
tongue deviation towards the side of the lesion
what is myasthenia gravis
AN autoimmune response against the neuromuscular junction post synaptic receptors
- Nicotinic Ach R
- MusK
TYPE 2 HYPERSENSITIVITY
what are common causes of myasthenia gravis in
a. men
b. women
a. thymoma - thymus tumour (60y/old)
b. autoimmune disease (40y/old)
what is the pathophysiology of myasthenia gravis
85% Anti Ach-R: bind to post synaptic receptor and inhibit it competitively. Active complement causes NMJ destruction. More binding with exertion
15% Anti MuSK: this helps to synthesise AchR so you have reduced receptor expression
what are symptoms of myasthenia gravis
Weak eye muscles - diplopia
Ptosis
Myasthenic snarl
Jaw fatiguability
swallowing difficulty
speech fatiguability
what is the progression of myasthenia gravis symptoms like?
it is worse later on and with excursion
it starts at the head and neck and moves to the lower body
it is better with rest
What is a differential diagnosis for myasthenia gravis
Lumbar Eaton syndrome
What is lambert Eaton syndrome
Auto antibodies against presynaptic calcium channels
What are symptoms of lambert Eaton syndrome
Similar to MG but they start at the extremities and them move to the head and neck
There is also autonomic involvement
How do you treat lambert Eaton syndrome
Prednisone (steroids)
Immunosuppression
How do you diagnose MG
Serology anti AchR and anti MusK
Tension/edrotropium test
What is the Edrotropium test
It is where you administer edrotropium which is a rapidly acting Ach ase inhibitor. If positive then there is an increase in muscle power for a few seconds
How do you treat Myasthenia gravis
1st line is Ach ase inhibitor (neostigmine/pyrdostigmine)
2nd line immunosuppression (steroid)
What is a complication of myasthenia gravis
A myasthenic crisis
Acute symptom worsening with a severe respiratory weakness
How do you treat a myasthenic crisis
Plasma exchange and IV ig
What is Guillian Barr syndrome
Post infection there is a demyelination response against the peripheral nervous system myelinating oligodendrocytes
Who is Guillian Barr syndrome most common in
Males 15-30 and 50-70
What are causes of Guillian Barr syndrome
C.jejuni
CMV
EBV
H2V
What is the pathophysiology of guillain Barr syndrome
Disease of mimicking
Organism antigens against those on the schwaan cells resulting in antibodies made against the schwaan cells causing demyelination and acute polyneuropathy
What are symptoms of guillian Barr syndrome
Post infection you present with
Ascending symmetrical muscle weakness
Loss of deep tendon reflexes
Autonomic involvement in 50%
Respiratory failure in about 35%
How do you diagnose Guillian Barr syndrome
Nerve conduction studies
Lumbar puncture- raised protein and normal WBC (inflammation no infection)
How do you treat Guillian Barr syndrome
IVIg for 5 days plus plasma exchange
If FVC is less than 0.8 then consider intubation
What is wernikes encephalopathy
Reversible acute emergency due to a severe B1 (thiamine) deficiency
What are causes of Werinkes encephalopathy
Mostly high Alcohol
What are symptoms of Wernickes encephalopathy
Ataxia
Confusion
Opthalmoplegia
How do you diagnose Wernickes encephalopathy
Clinically recognised supported with microcytic anaemia and deranged LFTs
How do you treat Wernickes encephalopathy
Parentral pabrinex for 5 days acutely
Oral thymine prophylactically
What is a complication of wernickes encephalopathy
Korsakoff syndrome
what is Korsakoff syndrome
when wernickes is left too long without treatment leading to severe thiamine deficiency. Same symptoms with as disproportionate increase in memory loss
= irreversible damage
what is Duchenne muscular dystrophy
X linked recessive mutated dystrophin gene
what is the pathophysiology of Duchenne muscular dystrophy
the muscle is replaced with adipose tissue
what gender is duchenne muscular dystrophy found in
Boys exclusively
what are symptoms of Duchenne muscular dystrophy
difficulty getting up from lying down - Gowers sign
skeletal deformities
scoliosis
hyperlordosis
how do you diagnose Duchenne muscular dystrophy
prenatal tests
DNA genetic tests
How do you treat Duchenne muscular dystrophy
purely supportive treatment
what is Charcot marie tooth
an inherited sensory and motor PNS polyneuropathy caused by an autonomic dominant mutation of PUP22 gene (chromosome 17)
what are symptoms of Charcot marie tooth
foot drop - peroneal palsy
stork legs - v.thin calves
hammer toes - curled up
Pes planus - flat feet
Pes cavus - high arched feet
reduced DTRs
how do you diagnose Charcot marie tooth
Nerve biopsy
nerve conduction study
genetic testing
how do you treat Charcot Marie tooth
supportive treatment
orthotics
physiotherapy
what is tetanus
Tetanus is an infection caused by bacteria called Clostridium tetani. When these bacteria enter the body, they produce a toxin that causes painful muscle contractions.
what bacteria causes tetanus
clostridium tetani
what type of bacteria is clostridium tetani
gram positive bacilli
what is the pathophysiology of tetanus
tetanospasmin toxin is produced by the clostridium tetani bacteria, and causes involuntary muscle spasms by targeting VAMP, which is necessary for the release of neurotransmitter from nerve endings
how do you treat tetanus
PRIMARY - vaccinate
what is herpes zoster
chicken pox or shingles
what percentage of under 16s have varicella zoster virus
90% !!!
what does reactivation of varicella zoster virus cause
Shingles
- peripheral nerves attacked via the dorsal root
what is the symptoms of shingles
painful rash confined to a dermatome
how do you treat shingles
oral acyclovir (antiviral)
what is Prion/creutzveld-jakub disease
‘mad cow disease’
Prion diseases are transmissible, untreatable, and fatal brain diseases of mammals
what is the pathophysiology of prions disease
the idiopathic misfold proteus is deposited in the cerebrum and cerebellum causing severe cerebellar dysfunction
can you treat prions disease
no there is no treatment
What is a transient ischaemic attack
Acute loss of cerebral or ocular function with symptoms lasting less than 24 hours due to an arteriothromboembolism from an artery
How long does a transient ischemic attack last for
Between 5-15 minutes
What presentation do you get with a transient ischemic attack in the carotid artery
Amaurosis fugax
Aphasia
Hemiparesis
Hemisensory loss
Hemianopia
What presentation do you get with a transient ischemic attack in the vertebrobulbar artery
Diplopia
Vomiting
Choking
Vertigo
Ataxia
Hemisensory loss
How does an ischemic anterior carotid artery stroke present
Contralateral weakness and sensory loss of lower limb
Incontinence
Drowsiness
Thinking and personality changes
Truncal ataxia
How does an ischemic middle cerebral artery stroke present
Contralateral motor weakness and sensory loss
hemiparesis
Speach changes
Facial dropping
how does a posterior carotid artery ischemic stroke present
perception
homonymous hemianopia
what is seen in a vertebrobasilar artery ischemic attack
coordination and balance problems
what is seen in lateral medullary syndrome
sudden vomiting and vertigo
ipsilateral Horners syndrome - reduced sweating, facial numbness, dysarthria, limb ataxia, dysphagia
How does a brainstem infarction present
Quadriplegia
facial paralysis and numbness
gaze and vision problems
coma
locked in syndrome
altered consciousness
vertigo
vomiting
what is an extradural haematoma
it is a bleed between the skull and the dura mater-usually die to a fracture of the skull affecting the middle meningeal artery
what skull fracture do you suspect if there is a lemon shaped lesion on a CT
Temporal or parietal bone fracture
what must you not give in the cause of an extradural haematoma
Aspirin
what is a subarachnoid haemorrhage
it is bleeding between the arachnoid mater and the pia mater
what is seen on a CT when a patient has a subarachnoid haematoma
a star shapes lesion on CT
what is a subdural haematoma
it is bleeding between the dura mater and arachnoid mater
what is seen on CT when someone has suffered from a subdural haematoma
a banana shaped lesion on CT - clot turs from white to grey over time
what investigation is done to diagnose a subdural haematoma
midline shift of the brain
what risk factors increase chances of epilepsy
family history
premature babies - abnormal cerebral blood vessels
drugs - cocaine
what is the diagnosis criteria for epilepsy
need to have 2 unprovoked seizures occurring over 24 hours apart
need to have one unprovoked seizure and probability of future seizures
epileptic syndrome diagnosis
when is dysphagia present in epilepsy
after a temporal love seizure
what is a primary generalised seizure
involves the whole cortex
bilateral and symmetrical motor manifestations
loss of consciousness and awareness
what is an atonic seizure
it is loss of muscle tone - floppy
what is seen in temporal lobe focal seizure
speech comprehension, memory and emotion are affected
anxiety
lip smacking - automatisms
what is seen in a frontal lobe focal seizure
motor disturbances
Jacksonian march 0 up and down the motor homunculus
Postical Todds palsy
What is seen in a parietal lobe focal seizure
sensation changes
occipital - spots, flashes, lines
what medication is given in myoclonic seizures
Levetiracetam or topiramate
what medication is given in absence seizures
ethosuximide
what is given in partial seizures
Lamotrigine or carbamazepine
what are features of non epileptic seizures
Metabolic disturbances
longer
dont occur in sleep
no incontinence or tongue biting
pre-ictal anxiety signs
no muscle pain
what medication is given in parkinsons if the patient is young and biologically fit
- DA agonist
- MOA-B inhibitor
- L-DOPA
what is given in parkinsons if the patient is biologically frail with comorbidities
- L-DOPA
- MOA-B inhibitor
what is the pathophysiology behind huntingtons
there is less GABA causing less regulation of dopamine to the striatum. This causes an increase in dopamine levels resulting in excessive thalamic stimulation and subsequent increased movement (chorea)
what is the treatment for Huntingtons
Benzodiazepines or valproic acid for chorea
SSRI for depression
Haloperidol or risperidone for psychosis
what is a differential diagnosis for Huntingtons
Sydenham’s chorea - rheumatic fever
how do you treat alzheimers
can use cholinesterase inhibitors to help slow progression
what sort of decline is seen in vascular dementia
a stepwise deterioration
how do you manage vascular dementia
manage predisposing factors
How do you manage lewy body dementia
cholinesterase inhibitors
what are symptoms of lewy body dementia
disinhibition
personality change
early memory preservation
progressive aphasia
what are other diseases can cause dementia
infection
chronic haematoma
SLE
sarcoidosis
neoplasia
hypothyroid
hypoadrenalism
hypercalcaemia
hydrocephalus
what are symptoms of frontotemoral (picks) dementia
disinhibition
personality change
early memory preservation
progressive aphasia
what are secondary causes for headache
giant cell/temporal arteritis
sentinel headache
thunderclap headache
trauma
medication overdose
trigeminal neuralgia
systemic infection
meningitis or encephalitis
what are red flags in headaches
worst headache ever
epilepsy
onset is over 50
severe and rapid onset
abnormal pattern of migraine
how does a migraine clinically present
unliteral pain
motion sensitivity
throbbing pain
moderate to severe intensity
nausea and vomiting
photophobia and phonophobia
what can be given as prophylaxis for migraine
beta blockers
acupuncture
TCAs - amitriptyline
Anticonvulsant - topiramate
what are causes of tension headache
missed meals
conflict
stress
clenched jaw
overexertion
fatigue
depression
bad posture
hunger
noise
what are differential diagnosis for tension headache
migraine
cluster headaches
GCA
drug induced headache - worsens with analgesia
how long can a cluster headache last for
15-160 minutes
what is the definition of motor neurone disease
a group of neurodegenerative disorders that are characterized by the selective loss of neurons in the motor cortex, the cranial nerve nuclei and the anterior horn cells. there is no effect on sensory neurones
it is a progressive and ultimately fatal condition
What is ALS
type of motor neurone disease where you see loss of neurons in the motor cortex and the anterior horn
What are features of ALS
Have LMN and UMN signs
Positive babinski response
Asymmetric
Corticobulbar signs indicate a worse prognosis
what type of motor neurone disease is the most common
ALS
what gene is associated with ALS
SOD1 gene
what is progressive bulbar palsy
a type of motor neurone disease affecting cranial nerves 9-12
what are features of progressive bulbar palsy
UMN and LMN
Dysphagia and chewing difficulties
Flaccid tongue
Speech is hoarse, quiet and nasal
normal or absent jaw jerk
What motor neurone disease has the worse prognosis
Progressive bulbar palsy
what is progressive muscular atrophy
A motor neurone disease where the Anterior horn cells are affected
what are features of progressive muscular atrophy
Only the lower motor neurone is affected, distal muscles are affected first then the proximal ones
what is primary lateral sclerosis
a rare neuromuscular disease with slowly progressive weakness in voluntary muscle movement. PLS affects the upper motor neurons (also called corticospinal neurons) in the arms, legs, and face
what fungi can cause meningitis
Cryptococcus
Candida - immunocompromised patients
what bacteria can cause meningococcal septicaemia
Neisseria meningitidis
What would the glass test show in someone with meningitis
blanching or non blanching rash
what empirical therapy would you give for meningitis before you know whats causing it
IV benzylpenicillin
what medication would you give to a patient with meningitis if they had a penicillin allergy
Chloramphenicol
what are differential diagnosis for meningitis
SAH
migraine
Encephalitis
Flu
what are the clinical presentations of Guillian-Barr syndrome
Breathing problems
Back pain
Sensory disturbance
Sweating
Urinary retention
what is syncope
it is the event of temporarily loosing consciousness due to disruption of blood flow to the brain, often leading to a fall.
what can cause primary syncope
Dehydration
Missed meals
Extended standing in a warm environment
A vasovagal response to a stimuli such as a sudden surprise
What are secondary causes of syncope
Hypoglycaemia
dehydration
anaemia
infection
anaphylaxis
arrhythmias
valvular heart disease
hypertrophic obstructive cardiomyopathy
what are signs of syncope
Hot or clammy symptoms
sweaty
heavy
dizzy or lightheaded
vision going blurry or dark
headache
what investigations are done for syncope
Full history and examination
ECG - arrhythmias or long QT
24 hour EGC
Echocardiogram
Bloods - FBC, U+E and blood glucose
what are the three broad pathologies that can lead to ischaemic stroke
primary vascular pathologies
cardiac pathologies
haematological pathologies
what are signs and symptoms of an ischaemic stroke
Vision loss/vision field deficit
Muscle weakness
Aphasia
Ataxia
Sensory loss
Headache
Diplopia (double vision)
Dysarthria (slurred words)
Gaze paresis (can’t move eyes in same direction)
Arrhythmias, murmurs, pulmonary oedema
what are possible complications of ischaemic stroke
DVT
haemorrhagic transformation of an ischaemic stroke
depression
aspiration pneumonia
what are signs and symptoms of a haemorrhagic stroke
Unilateral weakness
Sensory loss (numbness)
Dysphasia
Dysarthria
Visual disturbance
Photophobia
Headache
Ataxia
Vertigo
N+V
Decreased level of
consciousness/coma
Confusion
Gaze paresis
what drugs can be given to manage a haemorrhagic stroke
Manitol
what is the pathophysiology behinds a transient ischaemic attack
combination of
- degree of obstruction
- area and function of tissue supplied
- length of time obstruction occurs over
- ability of collateral vessel to provide supplemental perfusion
where do the majority of subarachnoid haemorrhages occur
anterior communicating/anterior cerebral artery junction
Distal internal carotid artery/posterior communicating artery junction
middle cerebral artery bifurcation
what are differential diagnosis for subarachnoid haemorrhage
Non-aneurysmal perimesencephalic SAH
Aortic dissection
Cerebral and cervical arteriovenous malformation
Dural arteriovenous fistulae
Vasculitis
Saccular aneurysms of spinal
arteries
Cardiac myxoma
Septic (mycotic) aneurysm
Pituitary apoplexy
Cocaine abuse
Anticoagulants
Sickle cell disease
what are complications of subdural haemorrhage
Neurological defects
coma
stroke
epilepsy
what is the presentation of extradural haemorrhages
Drowsiness
Pupil asymmetry (IIIrd cranial nerve compression)
Impaired consciousness
Headache (severe)
Vomiting
Seizures
Confusion
Hemiparesis
Upgoing plantars
Coma
what triggers can push neurones past the seizure threshold
sleep withdrawal
alcohol intake or withdrawal
drug misuse
physical or mental exhaustion
flickering lights
infection or metabolic disturbance
what are tonic symptoms of epilepsy
Rigidity
Epileptic cry
Tongue biting
Incontinence
Hypoxia/cyanosis (no breathing during this phase)
what are clonic seizure symptoms
Convulsions/limb jerking
Eye rolling
Tachycardia
No breathing/random or uncontrolled breaths
what is the pathophysiology of parkinsons disease
Progressive loss of dopaminergic neurones in the basal ganglia
- mostly substantia nigra
what are differential diagnosis for parkinsons disease
Alzheimer’s
Multi-infarct dementia
Repeated head injuries
VODKA signs:
Vascular events (stroke/MI)
Orthostatic hypotension with atonic bladder
Dementia with vertical gaze paralysis
Kayser-Fleisher rings
Apraxic gait
what can cause drug overuse headache
Analgesics - aspirin
Combination pain killers -caffeine and aspirin
Migraine medications
Opiates
what are risk factors for drug overuse headaches
History of chronic headaches
frequent use of headache medications
what are symptoms of drug overdose headache
Chronic headache occurring > 15 days a month
Develops/worsens with frequent use of any drug treatment for pain in people with tension headache/migraine
Resolves with withdrawal of symptomatic treatment
how do you manage drug overdose headache
analgesia withdrawal
no more than 6 days a month on analgesia
log acting anti inflammatories can ease headaches
antiemetics can help withdrawal
what is the pathophysiology of multiple sclerosis
Demyelination due to CD4 attacking oligodendrocytes, and macrophages digest the myelin sheathe
what is the progression of multiple sclerosis
relapse -remission disease
relapse - inflammation and damage to myelin
remission - inflammation subsides and some remyelination of damaged areas
what are differential diagnosis of multiple sclerosis
Migraine
Cerebral neoplasms
Nutritional deficiencies (B12 and copper)
Infections (syphillis/HIV)
MND
Psychiatric disease/functional
Vascular causes
Other progressive diseases
MRI lesions (sarcoidosis, SLE, Bechet’s syndrome)
what are complications of multiple sclerosis
UTI
Osteopenia and osteoperosis
depression
visual impairment
erectile dysfunction
cognitive impairment
impaired motility
what is the pathophysiology behind motor neurone disease
there is oxidative neuronal damage with internal cell damage leading to apoptosis, as well as prolonged caspase activity, promoting apoptosis
what are causes of parasitic meningitis
P. Falciparum
what are complications of meningitis
hearing loss
epilepsy
memory loss and concentration problems
coordination problems
learning difficulties
vision loss
loss of limbs
bone and joint problems
kidney problems
what is the pathophysiology of encephalitis
there is an intracranial infection causing an inflammatory response in the
- cortex
- white mater
- basal ganglia
- brain stem
what medication can be given to treat high intracranial pressure
dexamethasone
what are possible complications of encephalitis
death
hypothalamic and autonomic dysfunction
ischaemic stroke
neurological sequelae
seizures
cerebral haemorrhage
cerebral vasculitis
hydrocephalus
post viral chronic fatiuge syndrome
what are three types of gliomas
astrocytoma
oligodendroglioma
ependymoma
what are acoustic neuromas
Schwann cell tumour of the auditory nerve that innervates the inner ear
what is the classic triad seen in acoustic neuromas
hearing loss
tinitus
balance problems
what are risk factors for primary brain tumours
affluent groups
ionising radiation
vinyl chloride
immunosuppression
family history - genetics
what are possible complication of primary brain tumours
Hydrocephalus
Midline shift and herniations through the foramen magnum
what are signs and symptoms of giant cell arteritis
Rare under 50
Generalised headaches
Scalp tenderness
Claudication of jaw
Painless temporary or permanent visual loss
Generalised malaise
Fever
Tiredness
Superficial temporal artery tenderness, thickening or nodularity
Absent temporal artery pulse
Abnormal fundoscopy
Associated with polymyalgia rheumatica symptoms
what are causes of spinal cord compression
degenerative disc lesions
degenerative vertebral lesions
TB
Epidural abscess
vertebral neoplasm
epidural haemorrhage
Paget’s disease
what are possible complications of spinal cord compression
pressure ulcers
cardiovascular dysfunction
heterotopic ossification
deep vein thrombosis
UTI
PE
MRSA infection
what are possible complications for cauda equina syndrome
permanent leg weakness
sexual dysfunction
urinary dysfunction
chronic pain
DVT
on what level is the common peroneal nerve
L4-S1
where does the common peroneal nerve originate
sciatic nerve, just above the knee
ow can the common peroneal nerve be damaged
trauma
sitting crossed legged
what are signs of common peroneal nerve lesions
foot drop
weak ankle dorsiflexion
sensory loss over the dorsum of foot
on what level is the median nerve
C6-T1
on what level is the ulnar nerve
C7-T1
on what level is the radial nerve
C5-T1
what are the signs of a lesion in the brachial plexus
pain
weakness
variable distribution
on what level is the phrenic nerve
c3-5
what is the lateral cutaneous nerve of the thigh
L2-3
on what level is the sciatic nerve
L4-S3
where does the tibial nerve originate
L4-S3
what does a lesion of the tibial nerve lead to
inability to
stand on tiptoes
invert the foot
flex the toe
sensory loss over the sole
what are differential diagnosis for myasthenia gravis
Lambert-eaton myasthenic syndrome
what are differential diagnosis for myasthenia gravis
Lambert-eaton myasthenic syndrome
botulism
penicillamine induced myasthenia gravis
primary mypoathies
what are complications of myasthenia gravis
respiratory failure
impaired swallowing
acute aspiration
secondary pneumonia
what causes peripheral neuropathy
DAVID
diabetes
alcoholism
vitamin deficiency - B12
infective/inherited - Guillaine-barre/charcot-marie-tooth
drugs - isoniazid
what are signs of peripheral neuropathy
Numbness/tingling in feet and hands
Burning/stabbing/shooting pain in affected areas
Loss of balance/co-ordination
Muscle weakness (especially in feet)
How do you assess depression in clinic
The PHQ-9 is the depression tool used by patients, which scores each of the nine DSM-IV criteria as “0” (not at all) to “3” (nearly every day). It has been validated for use in primary care.
what are different treatments for depression
Selective serotonin reuptake inhibitors
Serotonin-noradrenaline reuptake inhibitors
TCAs
MAOIs
what is the mode of action of SSRIS
this stop the reuptake of serotonin from the synaptic cleft
what are examples of SSRIs
SERTRALINE, CITALOPRAM, DAPOXETINE, PAROZETINE
what are side effects of SSRIs
They can cause nausea, anorexia, insomnia, loss of libido, failure to orgasm, serotonin syndrome where you have too much serotonin which causes tremor hyperthermia and cardiovascular collapse
CONTRAINDICATED WITH NDAIDS
what is the mode of action of SNRIs
they bloc re-uptake of noradrenaline and serotonin from the synaptic cleft
what are examples of SNRIs
DULOXETINE AND VENLAFAXINE
what are side effects of SNRIs
these can cause nausea, dry mouth, dizziness, headache, excessive sweating
what is the mode of action of TCAs
they block re-uptake of amines by nerve terminals and cause them to be in the synapse longer
- act as a competitive antagonist
what are examples of TCAs
AMYTRYPTILINE, CLOMPRIMINE, IMIPRAMINE, DOSULEPIN
what are side effects of TCAs
their side effects are sedation, confusion, dry mouth, blurred vision, constipation, urinary retention, postural hypertension
what is the mode of action of MAOIs
they inhibit the breakdown of monoamines in the synaptic cleft
What are some examples of MAOIs
PHENELZINE, ISOCARBOXAZID, SELEGILINE
what are side effects of MAOIs
side effects are dry mouth, nausea, diarrhoea, constipation, headache, drowsiness, insomnia, dizziness and lightheadedness
