Neurology Flashcards
1
Q
Define stroke
A
Cerebrovascular accident caused by ischaemia, infarction of intracranial haemorrhage
2
Q
Define transient ischaemic attack
A
Symptoms of a stroke that resolve within 24 hours. Transient neurological dysfunction secondary to ischaemia without infarction
3
Q
History of a stroke
A
Sudden onset neurological symptoms
Weakness of limbs, face
Dysphasia
Visual loss
Sensory loss
4
Q
Risk factors for a stroke
A
Cardiovascular disease- angina, MI, PVD
Previous stroke or TIA
AF
Carotid artery disease
Hypertension
Diabetes
Smoking
Vasculitis
Thrombophilia
COCP
5
Q
Management of stroke
A
CT head within 1 hour
Aspirin 300mg
Thrombolysis within 4.5 hours
Thrombectomy - 24 hours
6
Q
Management of TIA
A
Aspirin 300mg
Secondary prevention
7
Q
Risk factors for intracranial bleeds
A
Head injury
Hypertension
Aneurysms
Ischaemic stroke
Brain tumours
Anticoagulants
8
Q
What is assessed in GCS
A
Eyes, verbal and motor response
9
Q
GCS scores eyes
A
Eyes - AVPU
Spontaneous - 4
Speech - 3
Pain - 2
None - 1
10
Q
GCS scores verbal
A
Orientated - 5
Confused conversation - 4
Inappropriate words - 3
Incomprehensible sounds - 2
None - 1
11
Q
GCS scores motor
A
Obeys commands - 6
Localises to pain - 5
Normal flexion - 4
Abnormal flexion - 3
Extends - 2
None - 1
12
Q
Define a sub dural haemorrhage
A
Haemorrhage occuring between the dura mater and arachnoid mater.
13
Q
What shape is a subdural haemorrhage on a CT
A
Crescent shaped
14
Q
Where does bleeding happen in subdural haemorrhage
A
Caused by rupture of the bridging veins in the outer most meningeal layer
15
Q
Define extradural haemorrhage
A
Bleed occuring between the skull and the dura mater
16
Q
What shape is an extra dural haemorrhage on CT
A
Bi-convex, lemon, lentiform
17
Q
Where does bleeding happen in an extra dural haemorrhage
A
Most commonly the middle meningeal artery - in the temporo-parietal region
18
Q
Classic presentation of extradural haemorrhage
A
Traumatic head injury followed by period of improved neurological symptoms which rapidly decline over hours.
19
Q
Define intracerebral haemorrhage
A
Bleeding within brain tissue
20
Q
Define subarachnoid haemorrhage
A
Bleeding between the arachnoid mater and the pia mater
21
Q
Classical presentation of subarachnoid haemorrhage
A
Sudden onset occipital headache during strenuous activity - thunderclap headache
Neck stiffness
Photophobia
Vision changes
Neurological symptoms
22
Q
Risk factors for subarachnoid haemorrhage
A
Hypertension
Smoking
Excessive alcohol
Cocaine
FH
Black, femal, 45-70
Sickle cell anaemia, connective tissues disorders (marfans, Ehlers-Danlos), neurofibromatosis, ADPKD
23
Q
Investigations in subarachnoid haemorrhage
A
CT head!
Lumbar puncture if negative
Angiography - locate source of bleed
24
Q
What is seen on lumbar puncture in subarachnoid
A
Red cells - traumatic lumbar puncture?
Xanthochromia - yellow colour caused by bilirubin
25
Management of subarachnoid haemorrhage
Surgery
Coiling
Clipping
Nimodipine - prevent vasospasm.
Lumbar puncture or shunt - hydrocephalus
Mange complications - seizures
26
Define multiple sclerosis
A chronic progressive condition that involves demyelination of the myelinated neurones in the central nervous system - caused by an inflammatory process involving the activation of immune cells against myelin
Demyelinating polyneuropathy disseminated in time and space.
27
Causes of MS
Multiple genes
SBV
Low vitamin D
Smoking
Obesity
28
Possible presentations of MS
Optic neuritis - most common, monocular vision loss.
Abnormal eye movements
Focal weakness - Bells, Horners, limb paralysis, incontinence
Focal sensory symptoms - trigeminal neuralgia, numbness, paraesthesia, lhermittes sign
Ataxia - sensory or cerebella.
29
Define sensory ataxia
Loss of proprioception causing ataxia
Results in a positive romberg's test -
30
Define cerebellar ataxia
Results from the problems with the cerebellum causing issue with coordination
31
Define clinically isolated syndrome
Describes the first episode of neurological symptoms which cannot be classed as MS as is not disseminated in time and space
32
What are the main patterns seen in MS
Relapsing-remitting
Secondary progressive
Primary progressive
33
Define relapsing-remitting MS
Most common pattern
Episodes of disease a neurological symptoms followed by recover.
These occur in different areas and episodes
34
Define secondary progressive MS
Where there was relapsing-remitting disease at first but there is a progressive worsening of symptoms with incomplete remission. Symptoms become more and more permanent
35
Define primary progressive MS
There is worsening of disease and symptoms from the point of diagnosis without initial relapses and remissions
36
Investigations in MS
Largely clinical
MRI
Lumbar puncture
37
What is seen on lumbar puncture in MS
Oligoclonal bands
38
Define optic neuritis
Inflammation of the optic nerve
39
Features of optic neuritis
Unilateral reduced vision developing over hours to days
Central scotoma - blind spot
Pain on eye movement
Impaired colour vision
Relative afferent pupillary defect
40
Management of MS
Disease modification - induce long term remission
Treat relapses - methylprednisolone 500mg for 5 days
Symptomatic treatment
Exercise
Neuropathic pain management
Depression
Urge incontinence - oxybutynin
Spasticity - baclofen, physiotherapy
41
Define Parkinson's disease
A condition where there is a progressive reduction of dopamine in the basal ganglia of the brain leading to disorder of movement
42
What is the classic triad of parkinsions diseas
Resting tremor
Bradykinesia
Rigidity
43
Classic presentation of parkinsons
Stooped posture
Facial masking
Forward tilt
Reduced arm swing
Shuffling gait
Unilateral tremmor - pill rolling
Rigidity - cogwheel
Bradykinesia - slower and smaller, shuffling, hand writing, dificulty turning, hypomimia
Depression
Sleep disturbance
Loss of sense of smell
Postural instability
Cognitive impairment and memory problems
44
Distinguish parkinson's from benign essential tremor
Parkinson's
Asymmetrical, 4-6 hz, resting, improves with intentional movement, other parkinson's features, No change with alcohol
Benign essential
Symmetrical, 5-8 hz, intention, improves with rest, no parkinson's feature, improves with alcohol
45
Define multiple system atrophy
Rare condition where the neurones of multiple systems degenerate. Affects the basal ganglia causing parkinson's as well as other areas leading to autonomic and cerebellar dysfunction.
46
Define dementia with lewy bodies
Type of dementia associated with parkinsonism. Causing progressive cognitive decline as well as hallucinations, delusions, sleep disorders and fluctuating consciousness.
47
Examples of parkinson's plus syndromes
Progressive supranuclear palsy
Corticobasal degeneration
Multiple system atrophy
Dementia with lewy bodies
48
Management of parkinson's disease
Levodopa - co-benyldopa, co-careldopa (can cause dyskinesias, excessive motor activity)
COMT inhibitors - entacapone.
Dompamine agonists - bromocryptine, pergolide, cabergolin (Cause pulmonary fibrosis)
MOABs - selegiline, rasgiline
49
Define benign essential tremmor
Common condition associated with old age - characterised by a fine tremor affecting all the voluntary muscles
50
Features of benign essential tremor
Fine tremor
Symmetrical
More prominent or voluntary movement
Worse when tired, stressed or after caffeine
Improved with alcohol
Absent in sleep
51
Management of benign essential tremor
Propranolol
Primidone
52
Define epilepsy
The umbrella term for a condition where there is a tendency to have seizures.
53
Define seizure
Transient episodes of abnormal electrical activity
54
Investigations in epilepsy
EEG
MRI
ECG
55
Examples of types of seizure
Generalised tonic clonic
Focal seizures
Absence seizures
Atonic seizure
Myoclonic seizure
Infantile spasms
56
Define generalised tonic-clonic seizures
Loss of consciousness with tonic movements - muscles tensing - followed by clonic movement - muscles jerking.
Associated with tongue biting, incontinence, groaning, irregular breathing
Post seizure there is a prolonged post-ictal period of confusion, drowsiness, irritable, and depressed.
57
Management of generalised tonic-clonic seizures
1st - sodium valproate
2nd - lamotrigine or carbamazepine
58
Define focal seizures
Start in the temporal loves and affect hearing, speech, memory and emotions
Present with hallucinations, memory flashbacks, deja vu, doing strange things on autopilot
59
Management of focal seizures
Reverse of generalised tonic clonic
1st - carbamazepine or lamotrigine
2nd - sodium valproate or levetiracetam
60
Define absence seizures
Typically seen in children, patient becomes black, stares into space then abruptly returns to normal. They will be unaware of their surroundings and wont respond. Typically last 10-20 seconds.
61
Management of absence seizures
Sodium valproate
Ehosuximide
62
Define atonic seizures
Also known as drop attackes. Characterised by brief lapses in muscle tone for short periods of time, without loss of consciousness
63
Management of atonic seizures
1st - sodium valproate
2nd - lamotrigine
64
Define myoclonic seizures
Sudden brief muscle contractions, normally remaining awake. Occur in vaious form of epilepsy but mainlt in children
65
Management of myoclonic seizures
1st - sodium valproate
2nd - lamotrigine, levetiracetam or topiramate
66
Define infantile spasms
Also known as west syndrome
Clusters of full body spasms in infants - very poor prognosis!
67
Management of infantile spasms
Prednisolone
Vigabatrin
68
Side effects of sodium valproate
Teratogenic
Liver damage and hepatitis
Hair loss
Tremor
69
Side effects of carbamazepine
Agranulocytosis
Aplastic anaemia
Induces P450
70
Side effects of phenytoin
Folate and vit D deficiency
Megaloplastic anaemia
Osteomalacia
71
Side effects of ethosuximide
Night terrors
Rashes
72
Side effects of lamotrigine
Stevens-Johnson syndrome - life threatening skin rashes
Leukopenia
73
Define status epilepticus
Seizures lasting more than 5 minutes or more than 3 in one hour
74
Management of status epilepticus
ABCDE
Community - buccal midazolam, rectal diazepam
IV lorazepam 4 mg repeated after 10 minutes
IV phenobarbital or phenytoin
75
Define neuropathic pain
Pain caused by abnormal functioning of the sensory nerves delivering abnormal painful signals to the brain.
76
Common causes of neuropathic pain
Post herpetic - shingles
Nerver damage in surgery
MS
Diabetic neuralgia - feet
Trigeminal neuralgia
Complex regional pain syndrome
77
Features of neuropathic pain
Burning
Tingling
Pins and needles
Electric shocks
Loss of sensation to touch the affected area
78
Management of neuropathic pain
Amitriptyline
Duloxetine
Gabapentin
Pregabalin
Tramadol
Capsaicin
Physiotherapy
Psychological
Trigeminal - carbamazepine
79
Define facial nerve palsy
Isolated dysfunction of the facial nerve - typically presenting with unilateral facial weakness.
80
Branches of the facial nerve
Temporal
Zygomatic
Buccal
Marginal mandibular
Cervical
81
Function of the facial nerve
Motor - facial expression, stapedius, posterior digastric, stylohyoid and platysm.
Sensory - taste to anterior 2/3 of tongue
Parasympathetic - submandibular, sublingual salivary glans and lacrimal gland.
82
What is presentation of an upper motor nuerone facial nerve palsy
Forehead sparing unilateral facial weakness.
83
What is the presentation of a lower motor neurone facial nerve palsy
Unilateral facial weakness with no forehead sparing.
84
Causes of upper motor neurone facial nerve palsy
Cerebrovascular accidents
Tumours
Bilateral - motor neurone disease, pseudobulbar palsies
85
Define Bell's palsy
Idiopathic lower motor neurone facial nerve palsy
86
Management of Bells palsy
Prednisolone
87
Define Ramsay-Hunt syndrome
A lower motor neurone facial nerve palsy caused by varicella zoster virus
Normally present with a painful, tender vesicular rash in the ear canal pinna or arround ear.
88
Management of Ramsay-Hunt syndrome
Prednisolone
Aciclovir
89
Causes of lower motor neurone facial nerve palsy
Infection - otitis media, malignant otitis media, HIV, lyme's disease
Systemic disease - diabetes, sarcoidosis, leukaemia, MS, GBS
Tumours - acoustic neuroma, parotid tumours, cholesteatomas
Trauma - direct nerver, damage in surgery, base of skull fracture.
90
Define brain tumours
Abnormal growths within the brain.
91
Classic presentation of brain tumours
Focal neurological symptoms
Raised intracranial pressure.
92
Features of raised intracranial pressure
Headache - constant, nocturnal, worse on waking, coughing, straining, bending forwards.
Altered mental state
Visual field defect
Seizure
Third and sixth nerve palsies
Papilloedema
93
Define papiloedema
Swelling of the optic disc caused by raised intracranial pressure.
94
Fundoscopic changes in papilloedema
Blurring of the optic disc margin
Elevated optic disc - vessels curve across it
Loss of venous pulsation
Engorged retinal veins
Haemorrhages
Around optic disc
Paton's lnes - creases in retina around optic disc.
95
What is the triad of raised intracranial pressure
Cushing's triad
Brady cardia
Irregular respiration
Widened pulse pressure
96
Common types of brain tumours
Seconday metastases
Gliomas
Meningiomas
Pituitary tumours
Acoustic neuroma - vestibular schwannoma
97
What cancer commonly metastasis to the brain
Lung
Breast
Renal cell carcinoma
Melanoma
98
Define glioma
Tumour of the glial cells in the brain or spinal cord.
Astrocytoma - glioblastoma multiforme
Oligodendroglioma
Ependymoma
99
Define meningioma
Tumour frowing from cells of the meninges in the brain and spinal cord.
Usually benign but often space occupying
100
Management of brain tumours
Palliative
Chemo
Radio
Surgery
101
Define huntington's Chorea
Is a autosomal dominant genetic condition that causes a progressive deterioration in the nervous system. This is a trinucleotide repeat disorder that involves a mutation on the HTT gene on chromosome 4
102
Define anticipation
A feature of trinucleotide repeat disordfers where successive generations have more repeat genes resulting in earlier age onset and increased severity
103
Presentation of Hungtington's chorea
Cognitive, psychiatric or mood problems
Chorea - involuntary, abnormal movement
Eye movement disorders
Speech difficulties
Swallowing difficulties
104
Investigations in Huntington;s chorea
Genetic testing!
105
Management of Huntington's choresa
Cannot slow or stop the diseasae
SALT
Genetic counselling
Advanced directives
End of life care
Symptomatic relief
Movement - antipsychotics, Benzos, dopamine depleting agents
106
Prognosis of Huntington's Chorea
15-20 years after the onset of symptoms.
107
Define myasthenia gravis
An autoimmune condition that causes muscle weakness that gets progressively worse with activity and improves with rest.
Antibodies against acetylcholine receptors prevent excitation at neuromuscular junctions stopping contraction.
These antibodies also activate the complement system leading to damage of post synaptic membrane
108
Presentation of mysasthenia gravis
Weakness that gets worse with muscle use and improves with rest.
Typically better in the morning and worse at night. Most commonly affecting proximal muscles
Extraocular muscle weakness causing double vision
Eyelid weakness causing ptosis
Weakness in facial movements
Difficulty with swallowing
Fatigue when chewing
Slurred speech
Progressive weakness
109
How to elicit fatiguability on examination
Repeated blinking - ptosis
Prolonged upward gaze - diplopia
Repeated abduction of arm - unilateral weakness
110
What autoantibodies are present in myasthenia gravis
Acetylcholine receptor antibodies
Muscle specific kinase
LRP4 antibodies
111
Management of myasthenia gravis
Reversible acetylcholinesterase inhibitors - pyridostigmine or neostigmine
Immunosuppression - pred, azathioprine
Thymectomy
Rituximab
Exulizumab
112
Define myasthenic crisis
Life threatening worsening of symptoms often triggered by another illness. LEads to respiratory failure - requiring bipap or intubation
113
Management of myasthenic crisis
IV Ig and plasma exchange
114
Define Lambert-Eaton myasthenic syndrome
Progressive muscle weakness with increased use, typically occuring in patients with small-cell lung cancer
Results from auto immune attack on voltage-gated sodium channels.
115
Presentation of Lambert-Eaton syndrome
Insidious onset of proximal muscle weakness.
Intraocular muscle weakness
Reduce tendon reflexes
116
Management of Lambert-Eaton syndrome
Diagnose and mange underlying condition (malignancy)
Amifampridine
Immunosuppression
IV Ig
Plasmapheresis
117
Define Charcot-Marie tooth disease
An inherited disease that affects the peripheral motor and sensory nerves. Various types of autosomal dominant genetics which cause dysfunction of the myelin or the axons
118
Clinical features of Charcot-Marrie-Tooth disease
High foot arches
Distal muscle wasting - inverted champagne bottle legs
Weakness in the lower legs - loss of ankle dorsiflecion
Weakness in the hands
Reduced tendon reflexes
Reduced muscle tone
Peripheral sensory loss
119
Causes of peripheral neuropathy
ABCDE
Alcohol
B12 deficiency
Cancer and CKD
Diaeteds and Drugs- amiodarone, isoniazid, cisplatin
Every vasculitis
120
Management of Charcot-Marie-Tooth disease
Cannot prevent progression
Physio
OT
Podiatrists
Orthopaedic surgeons
121
Define Guillian Barre syndrome
An acute paralytic polyneuropathy that affects the peripheral nervous system.
Causes acute symmetrical ascending weakness and can also cause sensory symptoms.
Often triggered by infection.
122
Presentation of guillian barre
Symmetrical ascending weakness
Reduced reflexes
Peripheral loss of sensation or neuropathic pain
May progress to the cranial nerves causing facial weakness
123
Criteria fro diagnosis of GBS
Brighton criteria
Supported by investigations
Nerve conduction studies
Lumbar puncture - raised protein no cells or glucose
124
Management of GBS
IV Ig
Plasma exchange
Supportive care
VTE prophylaxis
Close monitoring of respiratory function
125
Define neurofibromatosis
Genetic condition that causes benign nerve tumours to develop throughout the nervous system.
Type 1 is more common than type 2
126
Classical features of neurofibromatosis type 1
CRABBING - at least 2 of 7
Cafe-au-lait spots 6 or more
Relative with NF1
Axillary or inguinal freckles
BB - Bony dysplasia such as Bowing of long bone or spenoid wing dysplasia
Iris hamartomas - yellow, brown spots on iris
Neurofibromas - 2 or more
Glioma
127
Investigations in neurofibromatosis
Clinical criteria
Genetic testing
Xray - bone lesions
CT/MRI -
128
Management of neurofibromatosis type 1
Manage and monitor symptoms and complications
129
Complications of neurofibromatosis
Migraines
Epilepsy
Renal artery stenosis and HTN
Learning and behavioural poblems
Scoliosis
Vision loss
Malignant peripheral nerve sheath tumours
Gastrointestinal stromal tumour
Brain tumour
Spinal cord tumour
Increased risk of cancer
Leukaemia
130
What is neurofibromatosis most associated with
Acoustic neuromas! - bilateral
131
Define tuberous sclerosis
a genetic condition that causes features in multiple systems
Caharacteristic feature is the deveelopment of hamartoma - benign neoplastic growths of the tissue they originate in. They commonly affect the skin, brain, lungs, heart. kidneys and eys
132
Signs of tubersou sclerosis in skin
Ash leaf spots
Shagreen patches - thckened dimpled pigmented patches
Angiofibromas - small coloured pigmented papules that occur over the nose and cheeks
Subungual fibromata - fibromas under the nail bed
Cafe-au-lait spots
Pliosis - isolated patch of white hair on the head, eyebrows, eyelashes or beard.
133
Common features of tuberous sclerosis
Epilepsy
Learning disabilit and development delay
Rhabdomyomas in the heart
Gliomas
PCKD
Lympangioleiomyomatosis
Rentinal hamartomas
134
Managment of tuberous sclerosis
Suppportive and monitoring of complications
135
Red flags for headaches
Raised intracranial pressure or haemorrhage
Fever, photophobia or neck stiffness
Dizziness - stroke
Visual disturbance
Sudden onset occipital
Worse on coughing or straining
Postural, worse on standing lying or bending
Waking from sleep
vomiting
Trauma
Pregnancy
136
Define tension headaches
Mild ache across the forehead in a band like pattern - muscle aches
137
Causes of tension type headache
Stress
Depression
Alcohol
Skipping meals
Dehydration
138
Management of tension type headaches
Reassurance
BAsic analgesia
Relaxation
Hydration!
139
What can causes a secondary tension headache
Underlying condition - infection, obstructive sleep apnoea or pre-eclampsia
Alcohol
Head injury
Carbonmonoxide poisioning
140
Define sinusitis
Headache associated with inflammation of the sinuses - facial pain behin nose forehead and eyes
Normally resolves - irrigation can help
141
Define analgesic headache
A headache caused by medication overuse - non-specific tension type feature with excessive use of analgesia
142
Define trigeminal neuralgia
Intense facial pain tha comes on suddenly in the distribution of the trigeminal nerma
143
Management of trigeminal neuralgia
Carbamazepine
144
Define migraines
A complex neurological condition that causes headaches and other associated symptoms
145
Typical patterns of migraines
Migraine without aura
Migraine with aura
Silent migraine - no headache
Hemiplegic migraine
146
Typical headache in migraine
Moderate to severe intensity
Pounding or throbbing in nature
Unilateral - mostly
Photophobia
Phonophobia
Maybe aura
Nausea and vommiting
147
Define aura in migraine
Term usedto describe visual changes
Sparks
Blurring
Lines across vision
Loss of different visual fields
148
Define hemiplegic migraine
Stroke mimic
Typical migraine symptoms
Sudden or gradual onset
Hemiplegia
Ataxia
149
Potential triggers of migraine
Stress
Bight lights
Strong smells
Certain food - chocolate, cheese, caffeine
Dehydration
Menstruation
Abnormal sleep patterns
Trauma
150
Typical stages of migraine
Prodromal
Aura
Headache
Resolution
Postdromal
151
Acute management of migraine
Paracetamol
Triptans - sumatriptan
NSAIDs
Antiemetics
152
Migraine prophylaxis
PRopanolol
Topiramate
Amitriptyline
Acupuncture
153
Define cluster headaches
Severe unbearable unilateral headaches usually around the eye.
Occur in clusters - 3-4 a day for weeks than a long gap maybe a years
154
Presentation of cluster headaches
Red swollen watering eye
Pupil constriction
Ptosis
Nasal discharge
Facial sweating
155
Acute management of cluster headaches
Triptans
High flow oxygen!!
156
Prophylaxis of cluster headaches
Verapamil
Lithium
Prednisolone
