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Neurology Flashcards

1
Q

What is myasthenia gravis?

A

Autoimmune condition that causes muscle weakness that gets progressively worse with activity and improves with rest

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2
Q

Describe the epidemiology of myasthenia gravis

A
  • More commonly affects females under 40 or males over 60
  • Association between thymoma and myasthenia gravis (10-20% of patients with myasthenia gravis have a thymoma, 20-40% of patients with a thymoma develop myasthenia gravis)
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3
Q

What are 2 causes of myasthenia gravis?

A
  1. Acetylcholine receptor (ACh-R) antibodies (85%)
  2. Muscle-specific kinase (MuSK) antibodies and low-density lipoprotein receptor-related protein 4 (LRP4) antibodies (15%)
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4
Q

Describe the pathophysiology of myasthenia gravis (due to ACh-R antibodies)?

A
  • Antibodies bind to postsynaptic neuromuscular junction receptors
  • This blocks the receptor and prevents acetylcholine from being able to stimulate the receptor and trigger muscle contraction
  • During muscle activity, receptors become increasingly blocked up which causes less effective stimulation of muscle with increased activity
  • = more muscle weakness the more muscles are used
    Antibodies also activate the complement system within the neuromuscular junction which leads to damage to cells at the postsynaptic membrane
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5
Q

Describe the pathophysiology of myasthenia gravis (due to MuSK and LRP4 antibodies)?

A
  • Important proteins for creation and organisation of acetylcholine receptors
  • Destruction causes inadequate acetylcholine receptors
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6
Q

What is the characteristic feature of myasthenia gravis?

A

Weakness that gets worse with muscle use and improves with rest

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7
Q

What are 7 symptoms of myasthenia gravis?

A
  1. Diplopia
  2. Ptosis
  3. Weakness in facial movements
  4. Difficulty with swallowing
  5. Fatigue in jaw when chewing
  6. Slurred speech
  7. Progressive weakness with repetitive movements
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8
Q

What are 5 investigations for patients with myasthenia gravis?

A
  1. Check fatiguability in muscles
  2. Check for a thymectomy scar or CT/MRI of thymus gland
  3. Test forced vital capacity (FVC)
  4. Antibodies
  5. Edrophonium test
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9
Q

What are 3 ways of checking fatiguability in muscles?

A
  1. Repeated blinking will exacerbate ptosis
  2. Prolonged upward gazing with exacerbate diplopia
  3. Repeated abduction of one arm 20 times will result in unilateral weakness when comparing both sides
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10
Q

Which 3 antibodies should you test for in myasthenia gravis?

A
  1. Acetylcholine receptor antibodies (85%)
  2. Muscle-specific kinase antibodies (10%)
  3. Low-density lipoprotein receptor-related protein antibodies (<5%)
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11
Q

What is the edrophonium test?

A
  • Patient given IV dose of edrophonium chloride
  • Acetylcholinesterase enzymes break down acetylcholine in neuromuscular junctions
  • Edrophonium blocks enzymes to stop the breakdown of acetylcholine
  • Level of acetylcholine increases
  • Briefly and temporarily relieves weakness in patients with myasthenia gravis
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12
Q

What is the treatment for myasthenia gravis?

A
  • Reversible acetylcholinesterase inhibitors e.g. pyridostigmine, neostigmine
  • Immunosuppression e.g. prednisolone, azathioprine
  • Thymectomy
  • Monoclonal antibodies e.g. rituximab, eculizumab
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13
Q

What type of drugs are pyridostigmine and neostigmine and how do they work?

A

Reversible acetylcholinesterase inhibitors - increase the amount of acetylcholine in the neuromuscular junction and improve symptoms

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14
Q

What is rituximab and how does it work?

A

Monoclonal antibody - targets B cells and reduces the production of antibodies

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15
Q

What is eculizumab and how does it work?

A

Monoclonal antibody - targets complement protein C5 to reduce inflammation

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16
Q

What is the main complication of myasthenia gravis?

A

Myasthenia crisis

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17
Q

What does a myasthenia crisis cause?

A
  • Acute worsening of symptoms (often triggered by another illness e.g. respiratory tract infection)
  • Can lead to respiratory failure
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18
Q

How is a myasthenia crisis treated?

A
  • Non-invasive ventilation with BiPAP or full intubation and ventilation
  • Immunomodulatory therapies e.g. IV immunoglobulins and plasma exchange
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19
Q

What is Parkinson’s disease?

A

Progressive reduction of dopamine in the basal ganglia leading to disorders of movement

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20
Q

Describe the epidemiology of Parkinson’s disease

A
  • Most common in older men
  • 2nd most common neurodegenerative disorder
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21
Q

What are 3 risk factors for Parkinson’s disease?

A
  1. Age
  2. Male
  3. Pesticide exposure
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22
Q

Describe the pathophysiology of Parkinson’s disease

A
  • Basal ganglia are a group of structure responsible for coordinating habitual movements
  • Substantia nigra pars compacta is a part of the basal ganglia that produces dopamine which is essential for the correct functioning of the basal ganglia
  • Parkinson’s = gradual fall in the production of dopamine (impaired nigrostriatal pathway)
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23
Q

What is the classic triad for Parkinson’s disease?

A
  1. Resting unilateral tremor
  2. ‘Cogwheel’ rigidity
  3. Bradykinesia
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24
Q

How does a Parkinson’s tremor differ from a benign essential tremor?

A
  • Asymmetrical
  • 4-6 Hz frequency
  • ‘Pill rolling’ tremor
  • Improves on voluntary movement
  • Worsened if patient is distracted
  • No change with alcohol
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25
How does bradykinesia present in Parkinson's patients?
- Handwriting gets smaller - Can only take small steps when walking - Difficulty initiating movement - Difficulty turning around when standing - Reduced facial movements/expressions (hypomimia)
26
What are 5 other clinical presentations of Parkinson's disease?
1. Depression 2. Sleep disturbance and insomnia 3. Loss of sense of smell (anosmia) 4. Postural instability 5. Cognitive impairment and memory problems
27
What is the treatment for Parkinson's disease?
- Synthetic dopamine (levodopa) - COMT inhibitors (entacapone) - Dopamine agonists (bromocriptine, pergolide, cabergoline) - Monoamine oxidase-B inhibitors (selegiline, rasagiline)
28
What is synthetic dopamine often combined with when treating Parkinson's disease?
Peripheral decarboxylase inhibitors e.g. carbidopa, benserazide (stop levodopa being broken down in the body before it can reach the brain) - Co-beneldopa - Co-careldopa
29
What do COMT inhibitors do and give an example?
- Inhibit catechol-o-methyltransferase (enzyme that metabolises catecholamine neurotransmitters in the body and brain) - Extends the effective duration of levodopa - E.g. Entacapone
30
What do dopamine agonists do and give 3 examples?
Mimic dopamine in the basal ganglia and stimulate dopamine receptors 1. Bromocriptine 2. Pergolide 3. Cabergoline
31
What do monoamine oxidase-B inhibitors do and give 2 examples?
Inhibit monoamine oxidase-B (enzyme that breaks down dopamine) 1. Selegiline 2. Rasagiline
32
What are 3 side effects of excess levodopa (excess dopamine)?
Dyskinesias: 1. Dystonia (abnormal posture or exaggerated movements) 2. Chorea (abnormal involuntary jerking movements) 3. Athetosis (involuntary twisting/writhing movements)
33
What is a side effect of dopamine agonists?
Pulmonary fibrosis
34
What is Huntington's disease?
Autosomal dominant genetic condition that causes a progressive deterioration in the nervous system
35
Which gene in affected in Huntington's disease?
- Autosomal dominant condition - Increase of CAG repeats on the Huntington (HTT) gene on chromosome 4
36
Describe the epidemiology of Huntington's disease
Symptoms begin around age 30-50
37
Describe the pathophysiology of Huntington's disease
- Caudate nucleus atrophies - Inhibitory neurones in the corpus striatum degenerate - Lack of GABA and excessive nigrostriatal pathway activation
38
Explain the genetics of Huntington's disease
- Trinucleotide repeat disorder that involves a genetic mutation in the HTT gene on chromosome 4 - Anticipation = successive generations have more repeats in the gene resulting in earlier age of onset and increased severity of disease
39
What are 4 clinical presentations of Huntington's disease?
1. Chorea (involuntary, abnormal movements) 2. Eye movement disorders 3. Dysarthria (speech difficulties) 4. Dysphagia
40
What are 2 investigations for patients with Huntington's disease?
1. Genetic test for faulty gene (HTT gene) 2. MRI/CT (loss of striatal volume)
41
What is the treatment for Huntington's disease?
No treatment Symptomatic relief: - Antipsychotics e.g. olanzapine - Benzodiazepines e.g. diazepam - Dopamine-depleting agents e.g. tetrabenazine - Antidepressants
42
What is the life expectancy of patients with Huntington's disease?
15-20 years after the onset of symptoms
43
What are the 2 most common causes of death in patients with Huntington's disease?
1. Respiratory disease e.g. pneumonia 2. Suicide
44
What is Guillain-Barre syndrome?
An acute paralytic polyneuropathy that affects the peripheral nervous system, usually triggered by infection
45
Describe the epidemiology of Guillain-Barre syndrome
Associated with campylobacter jejuni, cytomegalovirus and Epstein-Barr virus
46
Describe the pathophysiology of Guillain-Barre syndrome
Molecular mimicry: - B cells create antibodies against pathogen's antigens - These antibodies also match proteins on nerve cells - Proteins on the myelin sheath of motor nerve cells or nerve axons are targeted (Schwann cells)
47
What are 8 clinical presentations of Guillain-Barre syndrome?
1. Symmetrical ascending weakness (starts at feet and moves up) 2. Reduced reflexes 3. Peripheral loss of sensation 4. Neuropathic pain 5. Facial nerve weakness 6. Breathing problems 7. Urinary retention 8. Sweating
48
What are 2 investigations for patients with Guillain-Barre syndrome?
1. Nerve conduction studies = reduced signal through nerves 2. Lumbar puncture for CSF = raised protein with normal cell count and glucose
49
What is the treatment for Guillain-Barre syndrome?
- IV immunoglobulins - Immunosuppression - Plasma exchange (alternative to IV Ig) - Supportive care - VTE prophylaxis
50
What 2 complications of Guillain-Barre syndrome?
1. Respiratory failure 2. Locked in syndrome
51
What is multiple sclerosis (MS)?
Chronic inflammation of the CNS causing demyelination of myelinated neurones
52
Describe the epidemiology of MS
- More common in females - Typically presents in young adults under 50 years
53
What are 5 causes/associations of MS?
1. Genetics (multiple genes) 2. Epstein-Barr virus 3. Low vitamin D 4. Smoking 5. Obesity
54
Describe the pathophysiology of MS
- Typically only affects the CNS (oligodendrocytes) - Inflammation and infiltration of immune cells causes damage to the myelin - Lesions vary in location over time
55
What are 5 clinical presentations of MS?
1. Optic neuritis (demyelination of optic nerve) 2. Eye movement abnormalities (due to lesions in abducens nerve) 3. Focal weakness 4. Focal sensory symptoms 5. Ataxia (problems with coordinated movement)
56
Describe the presentation of optic neuritis in patients with MS
- Unilateral reduced vision - Central scotoma (enlarged blind spot) - Pain on eye movement - Impaired coloured vision - Relative afferent pupillary defect
57
Describe eye movement abnormalities in patients with MS
- Diplopia - Internuclear ophthalmoplegia (unilateral lesions - problems with muscles around the eye) - Conjugate lateral gaze disorder (eye don't move together to look laterally)
58
Describe focal weakness in patients with MS
- Bells palsy (sudden weakness in muscles on one side of face) - Horners syndrome (ptosis, miosis, anhidrosis) - Limb paralysis - Incontinence
59
Describe focal sensory symptoms in patients with MS
- Trigeminal neuralgia - Numbness - Paraesthesia (pins and needles) - Lhermitte's sign (electric shock sensation)
60
Describe ataxia in patients with MS
- Sensory ataxia (loss of proprioceptive sense) - Cerebellar ataxia (problems with cerebellum coordinating movement)
61
What are the 4 disease patterns of MS?
1. Clinically isolated syndrome 2. Relapsing-remitting 3. Secondary progressive 4. Primary progressive
62
What is clinically isolated syndrome in MS?
- First episode of demyelination and neurological signs and symptoms - Cannot diagnose with MS (as some patients may never have another episode or develop MS)
63
What is relapsing-remitting in MS?
- Episodes of disease and neurological symptoms followed by recovery - Can be further classified as active/not active, progressing/not progressing
64
What is secondary progressive in MS?
- Relapsing-remitting disease at first but now progressive worsening of symptoms with incomplete remissions - Can be further classified as active/not active, progressing/not progressing
65
What is primary progressive in MS?
Worsening of disease and neurological symptoms without initial relapse and remission
66
What does active/not active, progressing/not progressing mean in MS?
Active = new symptoms/lesions developing Not active = no new symptoms/lesions developing Progressing = overall worsening of disabilities/disease over time Not progressing = no worsening of disabilities/disease over time
67
What are 4 investigations for patients with MS?
1. Exclude other causes for symptoms 2. Symptoms must be progressive over a period of 1 year = diagnosis 3. MRI for lesions 4. Lumbar puncture for CSF = oligoclonal bands
68
What is the diagnostic criteria for MS?
McDonald's criteria: - Dissemination in time (damage that happened at more than 1 point in time) - Disseminated in space (damage in at least 2 regions of the brain/spinal cord)
69
What is the treatment for MS?
- Disease modifying drugs and biological therapy (interleukins, inflammatory cytokines, immune cells) - Steroids e.g. methylprednisolone (for relapse) - Steroids for optic neuritis - Symptomatic releief
70
What symptomatic relief is given for MS?
- Neuropathic pain relief e.g. amitriptyline, gabapentin - Antidepressants - Anticholinergic medication for urge incontinence e.g. tolterodine, oxybutynin - Medication for spasticity e.g. baclofen, gabapentin
71
What is a side effect of anticholinergic medication?
Can worsen cognitive impairment
72
What is meningitis?
Inflammation in the meninges
73
What are 4 causes of bacterial meningitis?
1. Neonates = group B strep (s. agalactiae) 2. Children <2 = strep pneumoniae 3. Up to 50 years = neisseria meningitis (meningococcus), strep pneumoniae 4. >50 = strep pneumoniae, listeria meningitis
74
What are 2 causes of viral meningitis?
1. Enterovirus 2. HSV (herpes simplex virus)
75
What are 2 causes of fungal meningitis?
1. Cryptococcus 2. Candida
76
What are 6 risk factors for meningitis?
1. Student 2. Travel 3. Immunocompromised 4. Pregnancy 5. Extremes of ages 6. Unvaccinated
77
What is characteristic symptom of meningococcal septicaemia?
Non-blanching rash - indicates the infection has caused disseminated intravascular coagulopathy (DIC) and subcutaneous haemorrhage
78
What are 7 clinical presentations of meningitis?
1. Fever 2. Neck stiffness 3. Vomiting 4. Headache 5. Photophobia 6. Altered consciousness 7. Seizures
79
What are 5 non-specific clinical presentations of meningitis (often in neonates/babies)?
1. Hypotonia 2. Poor feeding 3. Lethargy 4. Hypothermia 5. Bulging fontanelle
80
What are 5 investigations for patients with meningitis?
1. Lumbar puncture for CSF 2. Blood culture 3. Bloods (meningococcal PCR) 4. Kernig's test 5. Brudzinski's test
81
What in the CSF do we look at when investigating meningitis?
- Bacterial culture - Viral PCR - Cell count - Protein - Glucose
82
Describe the differences in CSF with bacterial and viral meningitis
- Bacterial = cloudy, viral = clear - Bacterial = high protein, viral = mildly raised/normal - Bacterial = low glucose, viral = normal glucose - High WCC (bacterial = neutrophils, viral = lymphocytes) - Culture (bacterial = bacteria, viral = negative)
83
What is Kernig's test?
- Patient lies on back, flexing one hip and knee to 90 degrees and then slowly straightening the knee whilst keeping the hip flexed at 90 degrees - Meningitis = spinal pain or resistance to movement
84
What is Brudzinski's test?
- Patient lies on back - Lift their head and neck off the bed and flex their chin to their chest - Positive = patient involuntarily flexes hip and knees
85
What is the treatment for bacterial meningitis?
- Meningitis and non-blanching rash = IM/IV benzylpenicillin - Cefotaxime plus amoxicillin (under 3 months) - Ceftriaxone - Vancomycin - Steroids (dexamethasone)
86
What other treatment is given for meningitis?
Post exposure prophylaxis = ciprofloxacin
87
What is the treatment for viral meningitis?
Aciclovir
88
What are 7 complications of meningitis?
1. Hearing loss 2. Seizures and epilepsy 3. Cognitive impairment and learning disability 4. Memory loss 5. Cerebral palsy 6. Limb weakness 7. Spasticity
89
What is encephalitis?
Inflammation of the brain
90
What is the most common cause of encephalitis?
Herpes simplex type 1 (HSV-1) from cold sores (95%)
91
What are 5 other causes of encephalitis?
1. Herpes simplex type 2 (HSV-2) from genital herpes (neonates) 2. Varicella zoster virus (VZV) associated with chickenpox 3. Cytomegalovirus (CMV) associated with immunodeficiency 4. Epstein-Barr virus (EBV) associated with infectious mononucleosis, enterovirus, adenovirus and influenza virus 5. Viruses from vaccinations (polio, mumps, rubella, measles)
92
What are 2 risk factors for encephalitis?
1. Extremes of ages 2. Immunocompromised
93
What are 8 clinical presentations of encephalitis?
1. Fever 2. Headache 3. Encephalopathy 4. Altered consciousness 5. Altered cognition 6. Unusual behaviour 7. Acute onset of focal neurological symptoms 8. Acute onset of focal seizures
94
What are 4 investigations for patients with encephalitis?
1. Lumbar puncture for CSF (viral PCR testing, CSF may show uraemia) 2. CT/MRI (unilateral temporal encephalitis) 3. Swabs 4. HIV testing
95
What is the treatment for encephalitis?
- Aciclovir (for HSV and VZV) - Ganciclovir (for CMV)
96
What are 9 complications of encephalitis?
1. Lasting fatigue and prolonged recovery 2. Change in personality or mood 3. Changes to memory and cognition 4. Learning disability 5. Chronic pain 6. Movement disorders 7. Sensory disturbance 8. Seizures 9. Hormonal imbalance
97
What is dementia?
Irreversible, progressive decline and impairment of more than one aspect of higher brain function (concentration, memory, language, personality, emotion) without impairment of consciousness
98
Describe the epidemiology of Alzheimer's disease
- Most common type of dementia - Most common neurodegenerative disorder - Commonly affects patients over 65 - More common in females
99
What are 5 risk factors for Alzheimer's disease?
1. Down's syndrome 2. ApoE E4 allele homozygosity 3. Reduced cognitive activity 4. Depression/loneliness 5. Increasing age
100
Describe the pathophysiology of Alzheimer's disease
- Extra-cellular deposition of beta-amyloid plaques - Tau-containing intracellular neurofibrillary tangles - Accumulation leads to damaged synapses and atrophy - Tends to progress steadily over time
101
What are 5 clinical presentations of Alzheimer's disease?
1. Memory - episodic and semantic 2. Language - difficulty understanding or finding words 3. Attention and concentration issues 4. Psychiatric changes e.g. withdrawal, delusions 5. Disorientation e.g. time and surroundings
102
What are 4 investigations for patients with Alzheimer's disease?
1. MMSE (mini mental state examination) 2. Bloods - TFTs, B12 3. Memory clinical assessment 4. MRI
103
What is the treatment for Alzheimer's disease?
- No cure - Supportive therapy - Symptomatic management (acetylcholinesterase (AChE) inhibitors e.g. galantamine, donepazil, rivastigmine)
104
Describe the epidemiology of frontotemporal dementia
- More common dementia in patients under 65 - 5% of dementias
105
What is a risk factor for frontotemporal dementia?
Family history
106
Describe the pathophysiology of frontotemporal dementia
- Atrophy of frontal and temporal lobes - Loss of neurons but no plaque formation - Tau protein +ve or TDP-43 +VE inclusions - Onset tends to be insidious and progressive
107
What are the 3 main symptoms of frontotemporal dementia?
1. Behavioural issues 2. Progressive aphasia 3. Semantic dementia
108
What are 3 behavioural issues that present in frontotemporal dementia?
1. Loss of inhibition/empathy 2. Compulsive behaviours 3. Difficulty planning
109
What are 2 progressive aphasia presentations in frontotemporal dementia?
1. Slow, difficulty speech 2. Grammatical errors
110
What are 3 semantic dementia presentations in frontotemporal dementia?
1. Loss of vocabulary 2. Problems understanding 3. Inability to recognise objects or familiar faces
111
What are 4 investigations for patients with frontotemporal dementia?
1. Bloods - B12, TFTs, U&Es 2. FBC and LFTs (for suspected encephalopathy) 3. MMSE (mini mental state examination) 4. MRI (frontal/temporal atrophy)
112
What is the treatment for frontotemporal dementia?
- No cure - Supportive therapy - SSRIs - Levdopa/carbidopa (if Parkinson's symptoms present) - Stop exacerbating drugs
113
Describe the epidemiology of Lewy Body dementia
- Most commonly affects patients over 50 - More common in males - Most commonly associated with Parkinson's
114
Describe the pathophysiology of Lewy Body dementia
- Eosinophilic intracytoplasmic neuronal inclusion bodies (Lewy bodies) in the brainstem and neocortex - Substantia nigra depigmentation and amyloid deposits - Rapidly progressive
115
What are 7 clinical presentations of Lewy Body dementia?
1. Loss of cognitive function 2. Spatial awareness difficulties 3. Visual hallucinations 4. Problems multitasking 5. Sleep disorders and restless leg syndrome 6. Memory loss 7. Parkinson-like symptoms (tremor, rigidity, change in gait)
116
What are 5 investigations for patients with Lewy Body dementia?
1. MMSE (mini mental state examination) 2. Bloods - B12, TFTs, U&Es 3. MRI 4. MSU (mid stream specimen of urine - to check for urine infection) 5. SPECT/PET scan (low dopamine transported uptake in basal ganglia)
117
How is Lewy Body dementia diagnosed?
Presence of dementia with 2 of: - Fluctuating attention and concentration - Recurrent well-formed visual hallucinations - Spontaneous Parkinsonism ^ if only 1, diagnosis can be made with SPECT/PET scan
118
What is the treatment for Lewy Body dementia?
- Supportive therapy - Cholinesterase inhibitors e.g. rivastigmine (to help with cognitive decline) - Avoid use of neuroleptic drugs e.g. haloperidol (can produce severe sensitivity reactions)
119
What is the average prognosis of Lewy Body dementia?
Death most commonly in the first 7 years post-diagnosis
120
Describe the epidemiology of vascular dementia
- 2nd most common type of dementia - More common in males
121
What is the cause of vascular dementia?
Multiple small cerebrovascular infarcts
122
What are 7 risk factors for vascular dementia?
1. Previous stroke/TIA 2. Hypertension 3. Smoking 4. Type 1 diabetes mellitus 5. Hyperlipidaemia 6. Obesity 7. Hypercholesterolaemia
123
Describe the pathophysiology of vascular dementia
- Most commonly affects white matter of both cerebral hemispheres, grey nuclei, thalamus, striatum - Progresses in a sudden stepwise fashion (period of stability, acute decline progression, period of stability)
124
What are 4 clinical presentations of vascular dementia?
1. Cognitive impairment 2. Mood disturbances and mood disorders 3. Visual disturbances 4. UMN signs
125
What are 5 mood disturbances and mood disorders in vascular dementia?
1. Psychosis 2. Delusions 3. Hallucinations 4. Paranoia 5. Depression
126
What are 3 UMN signs in vascular dementia?
1. Muscle weakness 2. Overactive reflexes 3. Clonus (involuntary and rhythmic muscle contractions)
127
What are 3 investigations for patients with vascular dementia?
1. MRI (infarcts) 2. Patient history (e.g. for previous strokes) 3. Cognitive impairment screen (orientation, attention, language, visuospatial functions, motor control)
128
What is the treatment for vascular dementia?
- Manage predisposing factors - Supportive therapy - Symptom control with antidepressants (SSRIs) or anti-psychotics
129
What are the primary headaches?
Migraine, tension, cluster
130
What is a migraine?
Recurrent, throbbing headache often preceded by an aura and associated with nausea, vomiting and visual change
131
Describe the epidemiology of migraines
- Most common cause of episodic headaches - 3 x more common in females - 90% have an onset before 40 years
132
What are the triggers for migraines?
CHOCOLATE C - chocolate H - hangovers O - orgasms C - cheese O - oral contraceptives L - lie-ins A - alcohol T - tumult (loud noises) E - exercise
133
What are 3 risk factors for migraines?
1. Genetics/family history 2. Female 3. Age (adolescence)
134
Describe a theory for the pathophysiology of migraines
Irritation of trigeminal nuclei within the brainstem due to changes to arterial blood flow
135
What are 4 symptoms of migraines?
1. Unilateral, throbbing-type pain (moderate to severe intensity) 2. Nausea/vomiting 3. Motion sensitivity 4. Photophobia/phonophobia
136
What are 3 prodrome symptoms of migraines?
1. Yawning 2. Cravings 3. Mood/sleep changes
137
What is aura?
- Precedes migraine attacks - Visual disturbances e.g. lines, dots, zig zags - Somatosensory disturbances e.g. paraesthesia, pins and needles
138
What are 2 investigations for patients with migraines?
1. CT/MRI 2. Lumbar puncture
139
How are migraines diagnosed?
At least 2 of: - Unilateral pain (4-72 hours) - Throbbing-type pain - Moderate to severe intensity - Motion sensitivity Plus at least 1 of: - Nausea/vomiting - Photophobia/phonophobia
140
What is the treatment for migraines?
- Triptans e.g. sumatriptan - NSAIDs e.g. naproxen - Anti-emetics e.g. prochlorperazine - Avoid opioids and ergotamine
141
What is used to prevent migraines?
- Beta blockers e.g. propranolol - TCAs e.g. amitriptyline - Anti-convulsants e.g. topiramate
142
What is a tension headache?
Mild to moderate pain that is often described as feeling like a tight band around the head
143
Describe the epidemiology of tension headaches
Most common chronic daily and recurrent headache
144
What are 9 triggers of tension headaches?
1. Stress 2. Sleep deprivation 3. Bad posture 4. Hunger 5. Eyestrain 6. Anxiety/depression 7. Noise 8. Dehydration 9. Alcohol
145
What is the difference between episodic and chronic tension headaches?
Episodic <15 days/month Chronic >15 days/month (for at least 3 months)
146
Describe the pathophysiology of tension headaches
- Muscle ache in the frontalis, temporalis and occipitalis muscles - Come on and resolve gradually
147
What is the main symptom of tension headaches?
'Pressure behind eyes' - no aura, vomiting or sensitivity to head movement
148
What is the treatment for tension headaches?
- Avoidance of triggers and stress relief - Basic analgesia (aspirin, paracetamol, ibuprofen - avoid opioids) - Relaxation techniques - Hot towels to local area
149
What is a cluster headache?
Excruciating attacks of pain in one side of the head, often felt around the eye
150
Describe the epidemiology of cluster headaches
- 4 x more common in males - Much rarer than migraines - Typically affects adults in 20s-40s
151
What are 4 risk factors for cluster headaches?
1. Male 2. Genetics (autosomal dominant gene has a link) 3. Smoker 4. Alcohol
152
How long do cluster headaches last?
Episodic headaches, lasting from 7 days up to 1 year with pain-free periods in between that last ~4 weeks
153
How do cluster headaches present?
- Rapid onset of excruciating pain, classically around the eye (or temples or forehead) - Pain is strictly unilateral and localised to one area - Pain rises to a crescendo over a few minutes and lasts for 15-160 minutes, once or twice a day, usually around the same time of day
154
What are 5 ipsilateral autonomic features of cluster headaches?
1. Watery and bloodshot eyes 2. Facial flushing 3. Rhinorrhoea (runny nose) 4. Miosis 5. Ptosis
155
What is the treatment for acute cluster headaches?
- Analgesics unhelpful - 15L 100% O2 for 15 mins via non-rebreather mask - Triptans e.g. sumatriptan
156
What is used to prevent cluster headaches?
- Verapamil (CCB - 1st line) - Prednisolone - Reduced alcohol consumption and stop smoking
157
What is trigeminal neuralgia?
Type of secondary headache causing sudden, severe facial pain
158
Describe the epidemiology of trigeminal neuralgia
Around 5-10% of people with multiple sclerosis have trigeminal neuralgia
159
What are 4 triggers for trigeminal neuralgia?
1. Cold weather 2. Spicy food 3. Caffeine 4. Citrus fruits
160
Describe a theory for the pathophysiology of trigeminal neuralgia
Compression of the trigeminal nerve and its branches (ophthalmic, maxillary, mandibular)
161
How does trigeminal neuralgia present?
- Intense facial pain that comes on spontaneously and lasts anywhere between a few second to hours - Often described an electricity-like shooting pain - Attacks often worsen over time - 90% unilateral, 10% bilateral
162
What is the treatment for trigeminal neuralgia?
- Carbamazepine - Surgery to decompress or intentionally damage trigeminal nerve
163
What is amaurosis fugax?
Temporary blockage of artery to retina resulting in loss of vision in one or both eyes
164
When does amaurosis fugax happen?
Can happen as a result of strokes
165
What is epilepsy?
The recurrent tendency to spontaneous, intermittent, abnormal electrical activity in part of the brain, manifesting in seizures
166
Describe the epidemiology of epilepsy
Onset is most common in the extremes of ages e.g. <20 or >60
167
What are 6 causes of epilepsy?
1. 2/3 idiopathic, often familial 2. Cortical scarring e.g. trauma, cerebrovascular disease, infection 3. Tumours/space-occupying lesions 4. Strokes 5. Alzheimer's 6. Alcohol withdrawal
168
What are 4 risk factors for epilepsy?
1. Family history 2. Premature babies 3. Abnormal cerebral blood vessels 4. Drugs e.g. cocaine
169
Describe the pathophysiology of epilepsy
- Seizures/convulsions are motor signs of abnormal electrical discharges - Epileptic seizures are convulsions that result directly from epileptic syndromes
170
Describe 6 ways in which non epileptic seizures differ from epileptic seizures
1. Occur in abnormal metabolic circumstances e.g. low Na+, hypoxia 2. Longer than epileptic seizures 3. Do not occur in sleep 4. No incontinence or tongue biting 5. Pre-ictal anxiety signs 6. No muscle pain
171
What are the 3 components of a seizure?
1. Prodrome 2. Aura 3. Post-ictal
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What is the prodrome component of a seizure?
- Precedes seizures by hours to days - Weird feeling (mood, behavioural changes)
173
What is the aura component of a seizure?
- Patient is aware and precedes other manifestations - Strange feelings in gut - Deja vu - Strange smells - Flashing lights - Can occur before a partial seizure
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What is the post-ictal component of a seizure?
- After seizure - Headache - Confusion - Myalgia - Sore tongue (often bitten) - Temporary weakness after focal seizure in motor cortex = post-ictal Todd's palsy - Dysphasia after temporal lobe seizure
175
What is the diagnosis criteria for epilepsy?
One of: - At least 2 unprovoked seizures occurring more than 24 hours apart - 1 unprovoked seizure and a probability of future seizures (>60% risk in 10 years) - Diagnosis of an epileptic syndrome
176
What are 4 investigations for patients with epilepsy?
1. Electroencephalogram (EEG) 2. MRI (find structural problems e.g. tumours, space-occupying lesions that may be associated with seizures) 3. ECG (to exclude heart problems) 4. Bloods (to exclude metabolic disturbances)
177
What are 7 medication options for epilepsy/seizures?
1. Sodium valproate 2. Carbamazepine 3. Lamotrigine 4. Ethosuximide 5. Phenytoin 6. Levetiracetam 7. Topiramate
178
Females of child-bearing potential experiencing seizures should not be given what medication?
Sodium valproate, carbamazepine
179
What are the 2 broad types of seizures?
1. Primary generalised seizures 2. Partial focal seizures
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What are primary generalised seizures?
Abnormal electrical activity in both hemispheres of the brain
181
Describe primary generalised seizures
- 40% of seizures - Whole cortex affected - Bilateral and symmetrical motor manifestations - Loss of consciousness and awareness
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What are 6 types of primary generalised seizures?
1. Tonic 2. Clonic 3. Tonic clonic 4. Myoclonic 5. Atonic 6. Absence
183
What are 6 clinical presentations of tonic clonic seizures?
1. Loss of consciousness 2. Tonic (muscle tensing) and clonic (muscle jerking) episodes (tonic usually comes before clonic) 3. Tongue biting 4. Incontinence 5. Groaning 6. Irregular breathing
184
Describe the post-ictal period of a tonic clonic seizure
Patient is confused, drowsy and feels irritable or depressed
185
What is the treatment for tonic clonic seizures?
- Sodium valproate (first line) - Lamotrigine or carbamazepine (second line)
186
What are 2 clinical presentations of myoclonic seizures?
1. Sudden brief muscle contractions (sudden 'jump') 2. Patient is usually awake during the episode
187
Who do myoclonic seizures most commonly occur in?
Children as part of juvenile myoclonic epilepsy
188
What is the treatment for myoclonic epilepsy?
- Sodium valproate (first line) - Lamotrigine, levetiracetam or topiramate
189
What are 4 clinical presentations of atonic seizures?
1. Brief lapses in muscle tone 2. Sudden loss of muscle strength 3. Part/all of the body becomes limp (a.k.a 'drop attacks') 4. Usually last <3 minutes
190
Who do atonic seizures most commonly occur in?
- Typically begin in childhood - May be indicative of Lennox-Gastaut syndrome
191
What is the treatment for atonic seizures?
- Sodium valproate (first line) - Lamotrigine (second line)
192
What are 4 clinical presentations of absence seizures?
1. Patient become blank and stares into space 2. Abruptly returns to normal 3. Patient is unaware of their surroundings and won't respond during the episode 4. Typically only last 10-20 seconds
193
Who do absence seizures most commonly occur in?
- Children - >90% of patients stop having absence seizures as they get older
194
What is the treatment for absence seizures?
Sodium valproate or ethosuximide
195
Describe partial focal seizures
- 60% (most common type of seizure experience by people with epilepsy) - Starts in one side of the brain and usually only affects one side of the body
196
Describe single lobe features of partial focal seizures
- Underlying structural disease - Limited to a lobe - Progresses to become generalised seizures
197
Describe simple partial seizures
- Does not affected consciousness/memory - No post-ictal signs - Motor, sensory, autonomic, psychic signs
198
Describe complex partial seizures
- Memory affected before, during and after - Usually affects temporal lobe - Post-ictal confusion common in temporal lobe seizures
199
What are 5 clinical presentations of seizures affecting the temporal lobes?
1. Hallucinations 2. Memory flashbacks 3. Deja vu 4. Anxiety 5. Automatisms e.g. lip smacking
200
What do seizures affecting the temporal lobes affect?
Hearing, speech, memory and emotions
201
What is the treatment for seizures affecting the temporal lobes?
- Lamotrigine or carbamazepine (first line) - Sodium valproate or levetiracetam (second line)
202
How do seizures affecting the frontal lobes present?
- Motor disturbances - Jacksonian march (abnormal movement/sensation starting in a small area and then 'marching'/spreading to a larger part of the body - Patients do not lose awareness - Post-ictal Todd's palsy
203
What do seizures affecting the parietal lobes affect?
Sensation
204
What do seizures affecting the occipital lobes affect?
Vision (visual phenomena e.g. spots, lines, flashes)
205
What is sciatica?
Pain that travels along the path of the sciatic nerve (L4-S3)
206
What are 9 causes of spinal cord compression?
1. Osteoarthritis 2. Trauma 3. Tumours 4. Central disc protrusion 5. Prolapsed disc (L4-L5 and L5-S1 most common) 6. Epidural haematoma 7. Infection 8. Cervical spondylitic myelopathy 9. Scoliosis
207
What are 3 causes of sciatica?
1. Herniated disc 2. Spondylolisthesis 3. Spinal stenosis
208
What is spondylolisthesis?
Anterior displacement of a vertebra out of line with the one below
209
Describe the pathophysiology of spinal cord compression
- Pressure on the spinal cord causes nerves in the spinal cord to swell and slow down/block blood supply - Nerves are unable to function normally
210
What does the sciatic nerve do?
- Supplies sensation to the lateral lower leg and the foot - Supplies motor function to the posterior thigh, lower leg and foot
211
Where does the sciatic nerve divide?
At the knee into the tibial and common peroneal nerves
212
What are 3 red flag presentations in spinal cord compression?
1. Loss of bladder/bowel function 2. UMN in lower limbs e.g. clonus, hyperreflexia 3. LMN signs in upper limbs e.g. atrophy
213
What are 4 clinical presentations of spinal cord compression?
1. Pain and stiffness in the neck, back or lower back 2. Paraplegia 3. Paraesthesia 4. Changes to tendon reflexes
214
What are 5 clinical presentations of sciatica?
1. Unilateral 'shooting'/'electric' pain from the buttock radiating to the back of the thigh to below the knee or feet 2. Paraesthesia 3. Numbness 4. Motor weakness 5. Affected reflexes
215
What is bilateral sciatica an indication of?
Cauda equina syndrome
216
What are 5 investigations for patients with spinal cord compression/sciatica?
1. History (SOCRATES for pain, any trauma etc.) 2. X-ray/CT whole spine 3. MRI (if suspected cauda equina) 4. Haemoglobin - to monitor blood loss 5. Check renal function
217
What is a specific investigation for sciatica?
Sciatic stretch test
218
Describe the sciatic stretch test
- Patient lies on their back with leg straight - Examiner lifts one leg from the ankle with the knee extended until the limit of hip flexion is reached - Examiner dorsiflexes the patient's ankle - Sciatica-type pain in the buttock/posterior thigh indicates sciatic nerve root irritation - Symptoms improve with flexing the knee
219
What is the treatment for spinal cord compression/sciatica?
- Dexamethasone until treatment plan confirmed - Catheterisation - Analgesia - Surgical decompression - Chemotherapy if indicated
220
What are 3 complications of spinal cord compression/sciatica?
1. Cauda equina syndrome 2. Chronic pain 3. Paralysis
221
What is cauda equina syndrome?
Compression of the nerve roots of the cauda equina at the bottom of the spine
222
What are 5 causes of cauda equina syndrome?
1. Herniated disc (most common) 2. Tumours 3. Spondylolisthesis 4. Abscess (infection) 5. Trauma
223
What does the cauda equina do?
- Supplies sensation to the lower limbs, perineum, bladder and rectum - Supplies motor innervation to the lower limbs and the anal and urethral sphincters - Supplies parasympathetic innervation of the bladder and rectum
224
What are 8 clinical presentations of cauda equina syndrome?
1. Saddle anaesthesia (loss of sensation in the perineum) 2. Loss of sensation in bladder and rectum 3. Urinary retention or incontinence 4. Faecal incontinence 5. Bilateral sciatica 6. Bilateral or severe motor weakness in legs 7. Reduced anal tone 8. LMN signs (reduced tone and reflexes)
225
What is the investigation for cauda equina syndrome?
MRI
226
What is the treatment for cauda equina syndrome?
Neurosurgical emergency: - Immediate hospital admission - Emergency MRI - Emergency lumbar decompression surgery - Anti inflammatory agents - Antibiotics if infection present - Chemotherapy if indicated
227
What is a complication of cauda equina syndrome?
Permanent neurological dysfunction
228
What is an ischaemic stroke?
Occlusion of blood vessels to/in the brain due to a clot
229
What are 4 causes of ischaemic strokes/transient ischaemic attacks?
1. Thromboemboli 2. Hypoviscosity 3. Hypoperfusion 4. Vasculitis
230
What are 9 risk factors for ischaemic/haemorrhagic strokes or transient ischaemic attacks?
Same as CVD risk factors: 1. Age 2. Male 3. HTN 4. Smoking 5. Diabetes 6. Recent/past TIA 7. Hyperlipidaemia 8. Heart disease (IHD, valve disease) 9. AF
231
Describe the pathophysiology of ischaemic strokes
- Clot occludes a blood vessel - Causes ischaemia and infarction to certain areas of the brain
232
What is a cerebral infarct?
- Occlusion of large blood vessel to cerebrum e.g. internal carotid artery, middle cerebral artery - More common
233
What is a lacunar infarct?
- Occlusion of smaller blood vessels - Affects smaller areas and produces more specific symptoms - e.g. internal capsule, basal ganglia, thalamus, pons - Rarer and often asymptomatic
234
What are 4 clinical presentations of ischaemic/haemorrhagic strokes and transient ischaemic attacks?
1. Sudden weakness of limbs and face 2. Dysphasia 3. Vision and unilateral, asymmetrical, contralateral sensory loss 4. Nausea and vomiting
235
What are 2 investigations for patients having ischaemic/haemorrhagic strokes?
1. CT (first line) 2. Diffusion-weighted MRI
236
Why is a CT necessary for identifying strokes?
- Distinguishes ischaemic from haemorrhagic - Shows site of infarct - Identifies conditions mimicking a stroke
237
Why is a diffusion-weight MRI good for identifying strokes?
- More sensitive - CTs may be negative in the first few hours after infarct - Indicated if diagnosis is uncertain
238
What is the immediate treatment for ischaemic strokes?
- Exclude haemorrhagic stroke - Aspirin 300mg
239
What is the treatment for ischaemic strokes?
- Antiplatelet therapy e.g. aspirin and clopidogrel - Anticoagulation e.g. warfarin - Thrombolysis - Mechanical thrombectomy (endovascular removal of thrombus)
240
Describe thrombolysis
- Break up clots - Must happen within 4.5 hours of symptom onset - IV alteplase - Can cause lots of bleeding (lots of contraindications)
241
What is a haemorrhagic stroke?
Reduced blood flow due to intracranial bleeding
242
Describe the pathophysiology of haemorrhagic strokes
- Rupture of blood vessel within the brain - Causes bleeding into brain tissues - Pooling blood increases ICP - Leads to ischaemia and infarction
243
What is the treatment for haemorrhagic strokes?
- Neurosurgery referral (evacuate blood) - IV mannitol for raised ICP - Stop anticoagulants immediately
244
What is a transient ischaemic attack?
Sudden onset transient neurological dysfunction secondary to ischaemic without infarction
245
Describe the pathophysiology of transient ischaemic attacks
- Reduced blood flow to brain tissue - Never any infarction therefore no lasting damage
246
What is a crescendo TIA?
- 2 or more TIAs in one week - High risk factor for stroke
247
How do symptoms of transient ischaemic attacks differ from ischaemic/haemorrhagic strokes?
- Temporary - Sometimes precede a stroke - Always last <24 hours without infarction (typically resolve within 10 minutes)
248
What are the investigations for patients having transient ischaemic attacks?
- CT - Diffusion-weighted MRI - Can only be differentiated from a stroke until after recovery
249
What is the treatment for TIAs?
- Acute = aspirin - Long term prophylaxis = clopidogrel and atorvastatin
250
What is an intracerebral haemorrhage?
Bleeding within brain tissue
251
What are 3 causes of intracerebral haemorrhages?
1. Can occur spontaneously 2. As a result of bleeding into an ischaemic infarct or tumour 3. Aneurysm
252
Describe the pathophysiology of intracerebral haemorrhages
- Rupture of blood vessel within the brain - Causes bleeding into brain tissues - Leads to ischaemia and infarction - Pooling blood increases ICP
253
How do intracerebral haemorrhages present?
Similarly to ischaemic strokes - Sudden weakness of limbs and face - Dysphasia - Vision and unilateral, asymmetrical, contralateral sensory loss - Nausea and vomiting
254
What is the treatment for intracerebral haemorrhages?
- Neurosurgery referral - IV mannitol for raised ICP - Stop anticoagulants immediately
255
What is a complication of intracerebral/subarachnoid haemorrhages?
Haemorrhagic stroke
256
What is a subarachnoid haemorrhage?
Bleeding into the subarachnoid space (in between pia and subarachnoid meningeal layers)
257
What is the most common cause of subarachnoid haemorrhages?
Ruptured cerebral aneurysm
258
Describe the pathophysiology of subarachnoid haemorrhages
- Bleeding into subarachnoid space - Blood will accumulate and cause raised ICP - Increased ICP may push on structures and cause ischaemia and infarction
259
What is the main symptom of subarachnoid haemorrhages?
'Thunderclap' headache
260
What is the treatment for subarachnoid haemorrhages?
- Neurosurgery referral - IV mannitol for raised ICP - Stop anticoagulants immediately
261
What is an extradural/epidural haemorrhage?
Bleeding into extradural space (between the skull and dura) due to ruptured middle meningeal artery
262
Describe the epidemiology of extradural/epidural haemorrhages
- More common in males - More common in young people
263
What is the most common cause of extradural/epidural haemorrhages?
Ruptured middle meningeal artery due to fractured temporal bone (associated with traumatic head injury)
264
Describe the pathophysiology of extradural/epidural haemorrhages
- Bleeding into extradural space - Blood will accumulate and cause raised ICP - Increased ICP may push on structures and cause ischaemic and infarction
265
What are 3 signs of extradural/epidural haemorrhages?
1. Raised ICP 2. Ipsilateral pupil dilation 3. Seizures
266
What are 5 symptoms of extradural/epidural haemorrhages?
1. Increasingly severe headaches 2. Rapidly declining consciousness level 3. Vomiting 4. Hemiparesis (weakness on one side of the body) 5. Deep and irregular breathing
267
Describe extradural/epidural haemorrhages' lucid interval
- Hours - Initial drowsiness/unconsciousness, then recovery - Then rapid deterioration later on
268
What are 2 investigations for patients with extradural/epidural haemorrhages?
1. CT 2. X-ray of skull (fracture lines might be seen)
269
What does a CT look like in patients with extradural/epidural haemorrhages?
- Appears bi-convex (lemon-shaped) - Unilateral - Shows midline shift - Limited by cranial strictures
270
What is the treatment for extradural/epidural haemorrhages?
- Neurosurgery = clot evacuation, ligation of bleeding vessel - IV mannitol for raised ICP - Stop anticoagulants immediately
271
What can extradural/epidural/subdural haemorrhages lead to?
Haemorrhagic stroke (rare)
272
What is a subdural haemorrhage?
Bleeding into subdural space (between dura and arachnoid mater) due to ruptured bridging vein
273
Describe the epidemiology of subdural haemorrhages
More common in babies or people with brain atrophy (dementia, elderly, alcoholics) as their veins are more susceptible to rupture
274
What are 5 risk factors for subdural haemorrhages?
1. People on anticoagulants Accident-prone people: 2. Dementia 3. Elderly 4. Alcoholics 5. Epileptics
275
What is the most common cause of subdural haemorrhages?
Ruptured bridging veins out outer meningeal layers (run from cortex to venous sinuses - associated with traumatic head injury)
276
Describe the pathophysiology of subdural haemorrhages
- Bleeding from bridging veins into subdural space - Forms a haematoma (solid swelling of clotted blood) - Bleeding stops - Weeks/months later the haematoma will start to autolyse - This causes a large increase in oncotic and osmotic pressure - Water moves in and the haematoma enlarges - Blood will accumulate and cause raised ICP - Increased ICP may push on structures and cause ischaemic and infarction
277
What are 5 signs of subdural haemorrhages?
1. Raised ICP 2. Seizures Local neurological signs: 3. Unequal pupils 4. Hemiparesis 5. Occur later (often >1 month after injury)
278
What are 7 symptoms of subdural haemorrhages?
1. Fluctuating levels of consciousness 2. Drowsiness 3. Headache 4. Confusion 5. Insidious physical and intellectual slowing 6. Personality change 7. Unsteadiness
279
Describe subdural haemorrhages' latent interval
- Weeks to months - Initial drowsiness/unconsciousness, then recovery - Then rapid deterioration later on
280
What is the investigation for patients with subdural haemorrhages?
CT
281
What does a CT look like in patients with subdural haemorrhages?
- Haematoma - Appears crescent-shaped (banana-shaped) - Unilateral - Midline structures shifted away from side of clot - Not limited by cranial strictures
282
What is the treatment for subdural haemorrhages?
- Neurosurgery = clot evacuation to remove haematoma, craniotomy, Burr hole washout - IV mannitol for raised ICP - Stop anticoagulants immediately
283
What are 4 causes of cranial nerve lesions?
1. Trauma 2. Tumours 3. Meningitis 4. MS
284
What is CN I and what will a lesion there cause?
- Olfactory - Reduced taste and smell - Can still smell ammonia (as it stimulates pain fibres carried in the trigeminal nerve)
285
What is CN II and what will a lesion there cause?
- Optic - Visual field defects (unilateral visual loss)
286
What is CN III and what will a lesion there cause?
- Oculomotor - Ptosis (dropping eyelids) - Down and out eye - Fixed dilated pupil
287
What is CN IV and what will a lesion there cause?
- Trochlear - Diplopia (double vision) looking down
288
What is CN V and what will a lesion there cause?
- Trigeminal - Jaw deviates towards affected side - Loss of corneal reflex - Trigeminal neuralgia
289
What is CN VI and what will a lesion there cause?
- Abducens - Adducted eye - Sign of raised ICP
290
What is CN VII and what will a lesion there cause?
- Facial nerve - Facial drop with no forehead sparing - Due to Bell's palsy, parotid inflammation
291
What is CN VIII and what will a lesion there cause?
- Vestibulocochlear - Hearing loss - Loss of balance - Due to skull changes, compression
292
What is CN IX and what will a lesion there cause?
- Glossopharyngeal - Impaired gag reflex - Swallowing, respiratory and vocal issues - Due to jugular foramen lesion
293
What is CN X and what will a lesion there cause?
- Vagus - Impaired gag reflex - Swallowing, respiratory and vocal issues - Due to jugular foramen lesion
294
What is CN XI and what will a lesion there cause?
- Spinal accessory - Inability to shrug shoulders or turn head
295
What is CN XII and what will a lesion there cause?
- Hypoglossal - Tongue deviation towards side of lesion
296
Where do CNs III-XII arise from?
The brainstem
297
What is motor neurone disease?
A group of progressive neurodegenerative disorders characterised by loss of neurones in the motor cortex, cranial nerve nuclei and anterior horn cells
298
Describe the epidemiology of motor neurone disease
- 5-10% of cases are inherited - Most commonly presents in late middle aged (60) men
299
What are 4 motor neurone diseases?
1. Amyotrophic lateral sclerosis (ALS - most common - 80%) 2. Progressive bulbar palsy (second most common) 3. Progressive muscular atrophy 4. Primary lateral sclerosis
300
What are 4 risk factors for motor neurone disease?
1. Genetics (family history) 2. Smoking 3. Exposure to heavy metals 4. Pesticides
301
Describe the general pathophysiology of motor neurone disease
- Progressive degeneration of both upper and lower motor neurones - Does not affect sensory neurones
302
Describe the pathophysiology of amyotrophic lateral sclerosis (ALS)
- Loss of neurons in the motor cortex and anterior horn - Affects both UMN and LMN - Asymmetric
303
Describe the pathophysiology of progressive bulbar palsy
- Affects cranial nerves 9-12 - Affects both UMN and LMN
304
Describe the pathophysiology of progressive muscular atrophy
- Affected anterior horn cells - Only affects LMN
305
Describe the pathophysiology of primary lateral sclerosis
Only affects UMN
306
What are upper motor neuron lesions?
Any damage to motor neurons that reside above the nuclei of cranial nerves or the anterior horn cells of the spinal cord
307
What are lower motor neuron lesions?
Damage anywhere from the anterior horn of the spinal cord, peripheral nerve, neuromuscular junction or muscle
308
What are 4 signs of lower motor neurone lesions/disease?
1. Muscle wasting 2. Hypotonia (reduced tone) 3. Fasciculations (twitches in muscles) 4. Reduced reflexes
309
What are 3 signs of upper motor neurone lesions/disease?
1. Hypertonia (increased tone or spasticity) 2. Brisk reflexes (hyperreflexia) 3. Clonus (involuntary muscle contractions)
310
What are 5 symptoms of motor neurone disease?
1. Insidious, progressive weakness of muscles affecting limbs, trunk and face 2. Weakness often first noticed in upper limbs 3. Increased fatigue when exercising 4. Clumsiness (dropping things or tripping over) 5. Dysarthria (slurred speech)
311
What are 5 clinical presentations of progressive bulbar palsy?
1. Dysphagia 2. Chewing difficulties 3. Flaccid tongue 4. Speech is hoarse, quiet and nasal 5. Normal/absent jaw jerk (LMN)
312
How does progressive muscular atrophy present?
Distal muscles affected first then proximal
313
How does primary lateral sclerosis present?
Progressive tetraparesis (muscle weakness in all 4 limbs)
314
How is motor neurone disease diagnosed?
- Clinical presentation - Excluding other conditions that can cause motor neurone symptoms
315
What is the treatment for motor neurone disease?
- No effective treatment - Non-invasive ventilation (NIV) (supports breathing at night to improve survival and quality of life) - End of life care - ALS = riluzole (slows progression of disease and extends survival by a few months)
316
Which motor neurone disease has the worst prognosis?
Progressive bulbar palsy
317
What is Lambert Eaton Syndrome?
Condition in which the immune system attacks the neuromuscular junctions a.k.a Lambert Eaton myasthenic syndrome
318
Describe the epidemiology of Lambert Eaton Syndrome
Typically occurs in patients with small cell lung cancer
319
Describe the pathophysiology of Lambert Eaton Syndrome
- Antibodies against voltage-gated calcium channels produced in small cell lung cancer cells - The antibodies also target and damage voltage-gated calcium channels in the presynaptic terminals of neuromuscular junctions - Damage to neuromuscular junctions causes less acetylcholine to be released into synapses meaning muscle contractions cannot be as easily stimulated
320
Which condition is Lambert Eaton Syndrome similar to?
Myasthenia gravis
321
How does Lambert Eaton Syndrome differ from myasthenia gravis?
Symptoms tend to be more insidious and less pronounced
322
Which muscles are most notably affected in Lambert Eaton Syndrome?
Proximal muscles - most common is proximal leg muscle weakness
323
What are 9 clinical presentations of Lambert Eaton Syndrome?
1. Diplopia 2. Ptosis 3. Blurred vision 4. Dysphagia 5. Slurred speech 6. Dry mouth 7. Impotence 8. Dizziness 9. Reduced tendon reflexes
324
What is a notable finding in patients with Lambert Eaton Syndrome?
- Reduced tendon reflexes - Reflexes become temporarily normal for short periods following periods of strong muscle contraction - Post-tetanic potentiation
325
What are 4 investigations for patients with Lambert Eaton Syndrome?
1. Nerve conduction studies 2. Low-frequency repetitive nerve stimulation 3. Anti-P/Q voltage gated calcium channel serology 4. Chest CT
326
What is the treatment for Lambert Eaton Syndrome?
- Amifampridine - Immunosuppressants e.g. prednisolone, azathioprine - IV immunoglobulins - Plasmapheresis
327
How does amifampridine work?
- Allows more ACh to be released into neuromuscular junction synapses - Blocks voltage-gated potassium channels in presynaptic cells - This prolongs the depolarisation of cell membranes and assist calcium channels in carrying out their action
328
What is syncope (a.k.a fainting, vasovagal episodes)?
Temporary loss of consciousness due to a disruption of blood flow to the brain
329
Describe the epidemiology of syncope
Common in children, particularly teenage girls
330
What are 4 causes of primary syncope?
1. Dehydration 2. Missed meals 3. Extended standing in a warm environment 4. Vasovagal response to stimuli e.g. sudden surprise, pain, sign of blood
331
What are 8 secondary causes of syncope?
1. Hypoglycaemia 2. Dehydration 3. Anaemia 4. Infection 5. Anaphylaxis 6. Arrhythmias 7. Valvular heart disease 8. Hypertrophic obstructive cardiomyopathy
332
Describe the pathophysiology of syncope
- Failure of the autonomic nervous system to regulate blood flow to the brain - When the vagus nerve receives a strong stimulus (e.g. emotional event, painful sensation, change in temperature), the parasympathetic nervous system is stimulated - Blood vessels dilate, causing blood pressure in the cerebral circulation to drop - This leads to hypoperfusion of brain tissue and the patient loses consciousness
333
Describe prodrome in syncope
- Feeling prior to fainting - Hot and clammy - Sweaty - Heavy - Dizzy/lightheaded - Blurred/dark vision - Headache
334
Describe collateral history of syncope
- Sudden loss of consciousness and falling to the ground - Unconscious on the ground for a few seconds to a minute - May be some twitching, shaking or convulsion activity
335
What are 2 other clinical presentations of syncope?
- Groggy feeling afterwards - Incontinence
336
What are 5 investigations for patients experiencing syncope?
1. History 2. Examination 3. ECG (arrhythmias) 4. Echocardiogram 5. Bloods (FBC, electrolytes, glucose - anaemia, arrhythmias, seizures, diabetes)
337
When discussing syncope, what are 5 important things to gain from taking a history?
1. Distinguish a syncopal episode from a seizure 2. Triggers 3. Syncope after exercise is more likely to be secondary to an underlying trigger 4. Associated cardiac/neurological symptoms 5. Family history
338
When discussing syncope, what are 4 important things to check when doing an examination?
1. Any physical injuries as result 2. Concurrent illnesses 3. Neurological/cardiac examination 4. Lying and standing blood pressure
339
What is the treatment for syncope?
- Avoid dehydration/missing meals/standing still for long periods - Sit or lie down and have some water/eat something when experiencing prodromal symptoms
340
What is carpal tunnel syndrome?
Compression of the median nerve in the carpal tunnel, causing pain and numbness
341
Describe the epidemiology of carpal tunnel syndrome
- More common in late 50s and late 70s - More common in pregnant women
342
What are 3 causes of carpal tunnel syndrome?
1. Idiopathic 2. Swelling of contents (e.g. swelling of tendon sheaths due to repetitive strain) 3. Narrowing of tunnel
343
What are 7 risk factors for carpal tunnel syndrome?
1. Repetitive strain 2. Obesity 3. Perimenopause 4. Rheumatoid arthritis 5. Diabetes 6. Acromegaly 7. Hypothyroidism
344
Describe the pathophysiology of carpal tunnel syndrome
- Compression of the contents of the carpal tunnel - median nerve and flexor tendons - Median nerve supplies sensation to the thumb, index finger, middle finger and half of the ring finger
345
Which fingers does carpal tunnel syndrome affect?
Thumb, index finger, middle finger and lateral half of ring finger (index and middle fingers often affected first)
346
What are 4 sensory symptoms of carpal tunnel syndrome?
1. Paraesthesia (pins and needles) 2. Pain, can reach the shoulder 3. Numbness 4. Burning sensation
347
What are 4 motor symptoms of carpal tunnel syndrome?
1. Weakness of grip strength 2. Weakness of thumb movements 3. Difficulty with fine movements involving the thumb 4. Muscle atrophy of the thenar muscles
348
How are symptoms of carpal tunnel syndrome distributed?
- Symptoms come and go - Typically worse at night
349
What are 5 investigations for patients with carpal tunnel syndrome?
1. Phalen's test 2. Tinel's test 3. Carpal tunnel questionnaire 4. Nerve conduction studies 5. USS/MRI if other damage suspected
350
Describe Phalen's test
- For carpal tunnel syndrome - Fully flex the wrist - Positive = position triggers sensory symptoms of carpal tunnel syndrome
351
Describe Tinel's test
- For carpal tunnel syndrome - Tap the wrist at the location where the median nerve travels through the carpal tunnel - Positive = position triggers sensory symptoms of carpal tunnel syndrome
352
What are nerve conduction studies?
- E.g. for carpal tunnel syndrome - Small electrical current applied to the median nerve on one side of the carpal tunnel - Electrodes over the median nerve on the other side record the electrical current that reaches them - Demonstrates how well signals are passing through the carpal tunnel along the median nerve
353
What is the treatment for carpal tunnel syndrome?
- 1/4 cases are self-limiting within 1 year - Pregnancy cases usually resolve post-partum - Rest the wrist and avoid gripping/squeezing actions - Splint - Steroid injections - Surgery (flexor retinaculum cut to release pressure on the median nerve)
354
What is 'wrist drop'?
Deformity of a radial nerve palsy
355
What are 7 causes of 'wrist drop'?
1. Fractures of proximal humerus, shaft of humerus or radius 2. Stab wounds to antecubital fossa, forearm or wrist (includes blood tests and cannulation) 3. Pressure of crutches on armpits ('crutch palsy') 4. Falling asleep with arm hanging over back of a chair ('Saturday night palsy') 5. Somebody else falling asleep with their head on the patient's arm ('honeymoon palsy') 6. Excessively tight plaster casts, wristbands or handcuffs 7. Prolonged tourniquet use on the arm
356
What does the radial nerve supply sensation to?
- Posterior arm and forearm - Lateral 2/3 of dorsum of hand - Proximal dorsal aspect of lateral 3 1/2 fingers (thumb, index, middle and half of ring finger)
357
What does the radial nerve supply motor sensation to?
- Triceps - Posterior forearm
358
What are 4 symptoms of 'wrist drop'?
1. Numbness of skin over affected areas 2. Weak elbow extension 3. Weak wrist 4. Absent triceps and supinator reflexes
359
What is the investigation for 'wrist drop'?
- Flex elbow, pronate forearm and ask patient to extend wrist/fingers - Positive = patient will be unable to perform this manoeuvre
360
What is the treatment for 'wrist drop'?
- Analgesia (NSAIDs) - Physical therapy - Splint or cast - Transcutaneous electrical nerve stimulation (TENS) - Surgery
361
What is 'claw hand'?
Deformity of an ulnar nerve palsy
362
What are 4 causes of 'claw hand'?
1. Supracondylar fracture of the humerus 2. Fractures or soft tissue injuries to medial epicondyle of humerus 3. Stab wounds to forearm or wrist (includes blood test and cannulation) 4. Compression either at the cubital tunnel in the elbow or at Guyon's canal in the wrist
363
What does the ulnar nerve supply sensation to?
- Skin over hypothenar eminence - Medial 1/3 palm of hand - Palmar aspect of the medial 1 1/2 fingers - Medial 1/3 dorsum of hand - Dorsal aspect of medial 1/2 fingers
364
What does the ulnar nerve supply motor sensation to?
- Anterior forearm - Intrinsic muscles of the hand
365
What are 6 symptoms of 'claw hand'?
1. Numbness over hypothenar eminence and ulnar distribution of hand 2. Weak wrist and adduction 3. Weak flexion of ring and little finger DIPJs 4. Weak MCPJ flexion and IPJ extension of ring and little fingers 5. Loss of finger abduction and adduction 6. Loss of opposition of little finger
366
What is the investigation for 'claw hand'?
- Extend IPJs of ring and little fingers - Positive = patient unable to do this
367
What is the treatment for 'claw hand'?
- Analgesia (NSAIDs) - Physical therapy - Splint or cast - Transcutaneous electrical nerve stimulation - Surgery
368
What is 'foot drop'?
Damage to the common peroneal/fibular nerve making it difficult to lift the front part of the foot, result in dragging of the toes
369
What are 6 causes of 'foot drop'?
1. Injury 2. Lower back damage 3. Tumour 4. Hip replacement 5. Cauda equina syndrome 6. Multiple sclerosis
370
What does the common peroneal/fibular nerve supply sensation to?
Skin of the lateral leg and dorsum of foot
371
What does the common peroneal/fibular nerve supply motor sensation to?
- Short head of biceps femoris - Muscles in lateral and anterior compartments of leg
372
What are 3 symptoms of 'foot drop'?
1. One foot dragging across the floor when walking 2. Tripping 3. Numbness/weakness in the same side (symptoms are unilateral)
373
What are 2 investigations for patients with 'foot drop'?
1. Imaging (X-ray/USS/CT/MRI) to find underlying cause 2. Nerve conduction studies to find underlying cause
374
What is the treatment for 'foot drop'?
- Can be permanent or temporary - Brace/splint - Physiotherapy - Specialised shoes to prevent foot drop when walking) - Nerve stimulation - Surgery
375
What is peripheral neuropathy?
Damage to the peripheral nervous system
376
What is mononeuropathy multiplex?
A type of peripheral neuropathy in which there is damage to at least two different areas of the peripheral nervous system
377
What are 5 causes of peripheral neuropathy?
DAVID D - diabetes mellitus A - alcoholism V - vitamin B12 deficiency I - infective/inherited (Guillian-Barre/Charcot-Marie-Tooth) D - drugs
378
What are 4 causes of mononeuropathy multiplex?
1. Diabetes 2. Rheumatoid arthritis 3. Lupus 4. Diseases affecting the blood vessels
379
What are the 6 main pathophysiology mechanisms of peripheral neuropathy?
1. Demyelination (schwann cell damage e.g. Guillian-Barre syndrome) 2. Axonal degeneration (axons die but conduction speed remains normal) 3. Wallerian degeneration (fibre degeneration when the fibre is cut or crushed - axon and myelin degenerate) 4. Compression (e.g. carpal tunnel syndrome) 5. Infarction (e.g. Churg-Strauss syndrome, diabetes) 6. Infiltration (e.g. leprosy. sarcoidosis)
380
What are 5 symptoms of peripheral neuropathy?
1. Burning pain 2. Tingling 3. Numbness 4. Pain 5. Partial paralysis
381
What is an investigation for peripheral neuropathy?
Nerve conduction studies
382
What is the treatment for mononeuropathy multiplex?
- Maintain healthy weight and diet - Smoking cessation
383
What is a complication of peripheral neuropathy?
Paralysis
384
What is Brown-Sequard syndrome?
Neurological condition that results from a hemisection to the spinal cord
385
What is the most common cause of Brown-Sequard syndrome?
Penetrating trauma
386
Describe the pathophysiology of Brown-Sequard syndrome
- Hemisection of spinal cord - Crossing of fibres in the spinothalamic tract (causes some ipsilateral and contralateral symptoms) - Most cases seen in the cervical and thoracic region
387
What are 4 clinical presentations of Brown-Sequard syndrome?
1. Ipsilateral loss of position, light touch and vibration sensation at the level of the lesion 2. Contralateral loss of pain and temperature below the lesion 3. Sphincter disturbances 4. Ipsilateral spastic paraparesis (muscle weakness with spasms)
388
What are 3 investigations for patients with Brown-Sequard syndrome?
1. Plain radiographs for penetrating or blunt trauma 2. MRI to determine extent of injury 3. Neurological examination to establish level of injury
389
What is the treatment for Brown-Sequard syndrome?
- Spine immobilisation - Steroids to decrease swelling - Physical therapy - Occupational therapy - Surgery
390
What is Charcot-Marie-Tooth syndrome?
Inherited disease that affects the peripheral motor and sensory nerves
391
Describe the epidemiology of Charcot-Marie-Tooth syndrome
- Most common inherited neuromuscular disorder - CMT1 = onset by 10 years - CMT2 = onset between 10-20 years - CMT3 = infantile onset, usually by 2 years - CMTX = more severe in males
392
What are 5 causes of Charcot-Marie-Tooth syndrome?
ABCDE: A - alcohol B - B12 deficiency C - cancer/CKD D - diabetes/drugs E - every vasculitis
393
Describe the pathophysiology of Charcot-Marie-Tooth syndrome
- CMT1 = production of abnormal, unstable myelin - CMT2 = primarily an axonal disorder - CMT3 = characterised by marked segmental demyelination - CMTX = demyelinating neuropathy - Majority of types are mutations inherited in an autosomal dominant pattern
394
How does Charcot-Marie-Tooth 1 syndrome present?
- Muscle weakness starting in feet and working up ('inverted champagne bottle') - Sensory loss in the same pattern as weakness - Foot drop and spinal deformities
395
How does Charcot-Marie-Tooth 2 syndrome present?
Weakness and wasting pattern same as CMT1
396
How does Charcot-Marie-Tooth 3 syndrome present?
Hypertonia (floppy baby syndrome)
397
How does Charcot-Marie-Tooth X syndrome present?
Similar presentation as CMT1
398
What are 6 investigations for patients with Charcot-Marie-Tooth syndrome?
1. Bloods (FBC, TFTs, LFTs, B12, folate) 2. CSF examination 3. MRI brain and spinal cord 4. Genetic studies 5. Nerve conduction studies 6. Nerve biopsy
399
What is the treatment for Charcot-Marie-Tooth syndrome?
- No treatment to prevent progression Supportive management: - Surgical correction (if spinal deformity) - Analgesia - Avoid neurotoxic drugs e.g. vincristine (can exacerbate condition)
400
What is Duchenne muscular dystrophy?
Inherited disorder characterised by progressive muscle wasting and weakness
401
Describe the epidemiology of Duchenne muscular dystrophy
- X-linked recessive condition = more common in males - Usually presents in early childhood, before 3
402
Describe the pathophysiology of Duchenne muscular dystrophy
- Mutation on DMD gene - Lack of dystrophin (molecule that strengthens muscle fibres and protects from injury) - = damage to sarcolemma and cell death
403
What are 6 clinical presentations of Duchenne muscular dystrophy?
1. Progressive proximal muscular dystrophy which characteristics pseudohypertrophy of calves 2. Fatigue 3. Inability to run/hop/jump 4. Recurrent falls 5. Speech delay 6. Major milestones delayed
404
What are 5 investigations for patients with Duchenne muscular dystrophy?
1. Serum creatine kinase = very high 2. Genetic analysis 3. Muscle biopsy with assay for dystrophin protein 4. Muscle strength test 5. Gait assessment
405
What is the treatment for Duchenne muscular dystrophy?
- Immunisations - Physiotherapy - Vitamin D and bisphosphonates - Corticosteroids - Mobility help - Nutritional care
406
What are 6 complications of Duchenne muscular dystrophy?
1. Joint contractures 2. Respiratory failure (most common cause of death) 3. Cardiomyopathies and heart failure 4. Gastric dilation 5. Learning difficulties 6. Constipation, osteoporosis, hypertension
407
What is the prognosis for patients with Duchenne muscular dystrophy?
Poor: - Wheelchair by 12 - Death by 30
408
What are 4 types of primary brain tumours?
1. Glioma (tumour of glial cells - astrocytoma, oligodendroglioma, ependymoma) 2. Meningioma (tumour from cells of meninges - usually benign) 3. Schwannoma (tumour of Schwann cells) 4. Acoustic neuroma (tumour of Schwann cells surrounding auditory nerve)
409
What is the most common type of primary brain tumour?
Astrocytoma
410
What is the main sign of primary brain tumours?
Raised ICP
411
What are 3 symptoms of primary brain tumours?
Small ones tend to be asymptomatic Symptoms of raised ICP: - Headache that is constant, nocturnal, worse on waking and worse on coughing/straining/bending forward - Vomiting - Visual field defects
412
What are 3 symptoms of acoustic neuromas?
Usually unilateral 1. Hearing loss 2. Tinnitus 3. Balance problems
413
What is an investigation for patients with primary brain tumours?
Fundoscopy will show papilloedema (swelling of the optic disc due to raised ICP) - Blurring of optic disc margin - Elevated optic disc - Engorged retinal veins
414
What is the treatment for primary brain tumours?
- Palliative care - Chemotherapy - Radiotherapy - Surgery
415
What brain tumours are more common?
Secondary
416
What are the most common cancers that metastasise to the brain?
- Lung (non-small cell more common than small cell) - Breast - Renal cell carcinoma - Melanoma
417
What is depression?
Disorder causing persistent feelings of low mood, low energy and reduced interest
418
What is a cause of depression?
Not necessarily always a cause but often triggered by life events e.g. losing a loved one
419
What are 12 clinical presentations of depression?
1. Low mood 2. Low energy 3. Anhedonia (lack of pleasure in activities) 4. Anxiety/worry 5. Clinginess 6. Irritability 7. Avoiding social situations 8. Hopelessness about the future 9. Poor sleep 10. Poor appetitie/over eating 11. Poor concentration 12. Physical symptoms e.g. abdominal pain
420
What are 6 important things to note when taking a history for depression?
1. Potential triggers 2. Home environment 3. Relationships with family/friends 4. Bullying 5. Drugs and alcohol 6. History/thoughts of self-harm/suicide
421
What is the treatment for mild depression?
Advice about healthy habits e.g. healthy diet, exercise and avoiding alcohol/cannabis
422
What is the treatment for moderate to severe depression?
- Psychological therapy e.g. CBT - Fluoxetine (first line) - Sertraline and citalopram (second line)
423
When may admission be required in patients with depression?
If there is a risk of: - Self-harm - Suicide - Self-neglect - Immediate safeguarding issue

Phase 2a (29 decks)

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