Neurology Flashcards
Crescent shaped haemorrhage - what is it, Px and cause?
Subdural haemorrhage
Caused by rupture of bridging veins
Presents with gradually increasing confusion
lemon shaped haemorrhage - what is it, Px and cause?
Extradural haemorrhage
Trauma to pterion, rupture of the middle meningeal artery
Px = trauma, lucid period, rapid decline
thunderclap headache after strenuous activity. what is it, cause and special Mx
subarachnoid haemorrhage.
aneurysm rupture
endovascular coiling
recognising stroke in ED tool
ROSIER
5 points for haemmorhagic stroke Mx
- non contrast CT head
- BP control to <140mmHG (IV labetalol)
- reverse anticoagulation
- refer to neurosurgery
- if aneurysm = endovascular coiling
reversing warfarin
vitamin K & prothrombin complex concentrate
reversing dabigatran
idaracizumab
factor Xa reversal
prothrombin complex concentrate
how to differentiate ischaemic and haemorrhagic stroke on CT
ischaemic = hypodense
haem = hyperdense
gold standard diagnosis for ischaemic stroke
Diffusion weighted MRI
management of ischaemic stroke
thrombolysis (alteplase) within 4.5hrs
if presents after 4.5hrs: mechanical thrombectomy
long term management of ischaemic stroke
aspirin and clopidogrel
atorvastatin to prevent recurrence
contraindications to thrombolysis
intracranial/GI bleed
major surgery in the last 2 weeks
INR >1.7
horners syndrome
ptosis, miosis, anhidrosis
Wallenberg syndrome (lateral medullary)
what vessel is occluded
ipsilateral: ataxia, nystagmus, face numbness, horners
contralateral: body numbness
PICA occlusion
Lateral pontine
similar to wallenberg
ipsilateral hearing loss
AICA occlusion
Locked in syndrome
which artery is occluded
tetraplegia, preserved consciousness and vertical gaze
basilar artery occlusion
pathophysiology of MS
inflammatory demyelination of CNS neurones causing destruction go oligodendrocytes
two main types of MS
relapse-remitting (occurs in phases with improvement)
Primary progressive (gradual deterioration)
presentation of MS
optic neuritis = painful eye movements, red desats, loss of central vision
Internuclear ophthalmoplegia (nystagmus during horizontal vision)
parasthesia
cerebellar ataxia
what does MRI show in MS?
paraventricular plaques
methylprednisolone is the management of …
acute attacks of MS
two drug classes used for RRMS
disease modifying = interferon-beta/fingolimod
symptoms reducing e.g. amantadine for fatigue
cause of guillain barre
infective gastroenteritis (campylobacter jejuni, CMV, epstein barr virus)
pathophis of guillain barre
demyelination of PNS
symmetrical ascending weakness of the limbs
reduced reflexes
parasthesia
Px of guillain barre
medical management for guillain barre
IV immunoglobulin
plasmapheresis
differentiating between guillain barre and miller fisher
Miller-fisher starts proximally, Guillain barre starts distally
muscle weakness condition linked to thymoma
myasthenia gravis
presentation of myasthenia gravis
eye drooping, double vision
weak facial muscles, jaw
trouble swallowing, slurred speech
what is pyridostigmine?
acetylcholinesterase inhibitor
Mx for myasthenia gravis
similar symptoms to myasthenia gravis but has small cell lung cancer
Lambert eaton syndrome
Mx of lambert eaton syndrome
amifampridine
allows more ACh into synapse
Px of ramsay hunt syndrome
unilateral facial nerve palsy
hearing loss
herpetic rash in ear canal
Mx of ramsay hunt syndrome
Aciclovir
Prednisolone
Mx of tonic clonic seizure
lamotrigine (if female of reproductive age)
sodium valproate
Mx of absence seizures
ethosuximide
Mx of focal seizures
lamotrigine
Mx flowchart for status epilepticus
- rectal diazepam / IV lorazepam if you have IV access
- sodium valoproate
- general anaesthesia
triad of huntingtons disease
autosomal dominant inheritance
choreoathetosis
dementia
MRI in huntingtons
atrophy of caudate nucleus and putamen
MRI in alzheimers
widespread cerebral atrophy
Px of charcot-marie-tooth syndrome
high foot arch
distal muscle wasting (reverse champagne bottle legs)
reduced muscle tone
peripheral neuropathy
features of Brown-Sequard syndrome
damage to a hemisection of the spinal cord
Results in:
ipsilateral: loss of proprioception, paralysis, hyperreflexia
contralateral: loss of pain and temperature sensation
loss of pain/temp sensation and motor function below the lesion
what is this???
anterior cord syndrome
loss of proprioception below the lesion
what is this?
posterior cord syndrome
bladder/bowel dysfunction
lower back+leg pain
lower limb motor deficit
loss of perianal sensation and tone
what is this and what is the main cause?
Cauda equina syndrome
Massive herniated disc
multiple system atrophy
parkinsonism + autonomic dysfunction e.g. postural hypotension; incontinence; impotence
corticobasal degeneration
Parkinsonism + spontaneous limb movements / akinesia
progressive supranuclear palsy
Parkinsonism + impaired vertical gaze
lewy body dementia
Parkinsonism + hallucinations
what is a positive Romberg’s sign and what does it show?
eyes closed, can’t stand still
shows that there is sensory ataxia due to a dysfunctional dorsal column - can’t detect proprioception
Cushings Triad
signs of raised ICP
1. bradycardia
2. hypertension
3. irregular breathing
wernicke’s encephalopathy triad, why does this happen
- confusion
- ataxia
- ophthalmoplegia
this happens due to thiamine deficiency in alcohol overuse
cluster headache: px and mx
unilateral eye pain, bloodshot eye, vomiting, rhinorrhoea
Mx =
High flow oxygen
sumatriptan
cluster headache: px and mx
unilateral eye pain, bloodshot eye, vomiting, rhinorrhoea
Mx = sumatriptan
Proph = verapamil
tension headache
band around the head, non-pulsatile
Mx = pain relief
migraine
Mx
Px: photophobia, nausea, aura
Mx = sumatriptan
Proph = propanolol
headache associated with obese women, stooping and in the mornings
What to rule out
idiopathic intracranial headache
Rule out venous sinus thrombosis
sharp stabbing pain on the side of head when eating/talking
Trigeminal Neuralgia
Mx = carbamazepine
vascular decompression
giant cell arteritis triad
- headache
- jaw claudication
- temporary loss of vision
management of giant cell arteritis
prednisolone
meningitis px
fever, neck stiffness, headache, photophobia, non-blanching rash
bacterial meningitis CSF
low glucose, high protein, high WBC
viral meningitis/encephalitis CSF
normal glucose, high protein
Mx of meningitis
in GP = IM benzylpenicillin
in hospital = IV ceftriaxone/aciclovir
Px of encephalitis (diff. it from meningitis)
fever, headache, bizarre behaviour, confusion, seizures
Mx of encephalitis
IV acyclovir and ceftriaxone
alcohol withdrawal stages
- tremor, anxiety, palpitations
- hallucinations
- delirium tremens: ataxia, seizures, confusion
Mx of alcohol withdrawal
chlordiazepoxide + pabrinex (contains thiamine, prevents wernickes encephalopathy)
Px of opioid toxicity
drowsiness, respiratory distress, constricted pupils
Mx of opioid toxicity
naloxone
tongue fasciculations, dribbling, trouble swallowing
bulbar palsy due to lower motor neurone lesion in CN 9, 10, 12
UMN lesion vs LMN lesion
site, muscle tone, fasciculations, reflexes
UMN : cerebrum, brainstem etc. LMN: anterior horn cell, nerve roots
UMN: spasticity, LMN: hypotonia
LMN: fasciculations present
UMN: hyperreflexia
acute onset confusion, fluctuation, inattention
delirium
seizure like movements, pelvic thrusting, back arching
pseudoseizure
focal seizure - temporal lobe
lip smacking, deja vu, hallucinations, olfactory sensations
focal seizure - frontal lobe
motor: paralysis, eye movements to the side
twitching
Stiffening
focal seizure - parietal lobe
tingling
Vertigo
Parasthesia
focal seizure - occipital lobe
spots and lines in the visual field
Scotoma
Amaurosis
managing acute raised ICP
hyperventilation, elevate the head of bed, mannitol, induce hypothermia
normal pressure hydrocephalus Px and Mx
urinary incontinence, abnormal gait, dementia
Mx: ventriclo-peritoneal shunt
suspected TIA Mx
aspirin 300mg loading dose, TIA clinic
confirmed TIA Mx
clopidogrel
atorvastatin
difference between stroke and bells palsy
bells palsy is a lower motor neurone lesion - forehead is affected
stroke - forehead sparing
where is lumbar puncture done
L3/4 towards the subarachnoid space
crushing to the axillary region causes damage to what nerve? effect?
radial nerve
loss of sensation to dorsal thumb and index finger
dementia classification according to MMSE
<10 severe
10-20 moderate
21-26 mild
suspected SAH but CT head is clear
next MX
lumbar puncture
check for xanthochromia
thiamin is vitamin ….
b1
lesion in parietal lobe causes what visual defect
homonymous inferior quadrantinopia
lesion in temporal lobe causes what visual defect
homonymous superior quadrantinopia
triad of parkinsons
rigidity
resting tremor
bradykinesia
pathophysiology of vasovagal syncope
a trigger causes increased cardiac contractility.
vagal firing causes reduced cardiac contractility + reduced vascular tone.
reduced preload and venous return
mean arterial blood pressure drops to below the level of cerebral auto regulation
reduced cerebral perfusion
transient loss of consciousness
CN VII UMN vs LMN palsy Px
UMN: forehead sparing, facial drooping, slurred speech
LMN = bells palsy. forehead is affected, drooping eyelids and face
upper motor neurone features
weakness
spasticity
hyperreflexia
lower motor neurone features
fasciculations
atrophy
hypotonia
rapid cognitive decline and myoclonic jerks
suspect what, Ix
suspect sporadic creutzfeld jakob disease
Ix electroencephalogram
Korsakoffs syndrome
cause
Px
B1 (thiamine) deficiency due to chronic alcoholism
anterograde amnesia
confusion
confabulations
what is beriberi
epidemiology
cause
risk factors
two types
severe form of thiamine (B1) deficiency
rare in West, found in sub saharan africa
Rx: chronic alcoholism, diet consisting of white rice, chronic diarrhoea, long term diuretic use
Wet: cardiovascular system (fast heart rate, swelling)
dry: nervous system (numbness, muscle wasting, confusion)
what Ix is done in MND
electromyography confirms denervation
4 features of MND
degenerative disease
affects both UMN and LMN
no eye involvement
no sensory or sphincter disturbance
most common type of MND and PX
amyotrophic lateral sclerosis
UMN and LMN signs
hyperreflexia, spasticity
fasciculations, atrophy
Bulbar palsy cause and Px
disease of CN 9-12
quiet nasal speech, weak jaw, flaccid tongue
pseudo bulbar palsy cause and Px
bilateral lesions above mid pons
spastic tongue, brisk jaw reflect
progressive muscular atrophy presents with mainly …. signs
LMN
primary lateral sclerosis presents with mainly …. signs
UMN
what drug improves life expectancy in MND
riluzole
what is used to manage muscle spasms in MND
baclofen
what nerve is responsible for sensory component of the gag reflex
glossopharyngeal
what nerve is responsible for the motor component of the gag reflex
vagus
what proteins are present in alzheimers x 2
tau
amyloid precursor protein
what proteins are present in frontotemporal dementia x 3
TARDP-43
Tau protein
Pick bodies (ballooned neuronal cells)
what protein is present in lewy body dementia + parkinsons
alpha synuclein
what is a coma
tate of impaired consciousness in which the patient is not rousable despite external stimuli
what is a persistent vegetative state
state in which individuals have lost cognitive neurological function and awareness of the environment
but retain non-cognitive function and a preserved sleep– wake cycle.
oculocephalic reflex
on rotating head to left/right, the eyes will m maintain their position by conjugating movement in the opposite direction
“dolls eye reflex”
oculovestibular reflex
injecting cold water into the ear causes the eyes to look towards the irrigated side
decerebrate posturing
what does it show
elbows extended
wrists and fingers flexed
knee extended
plantar flexion
shows upper brainstem lesion
decorticate posturing
arms flexed at elbow and wrist
knee and ankle extendeed
shows diencephalon lesion (thalamus, hypothalamus, cerebellum)
duchenne’s muscular dystrophy
cause
pathophis
PX
x linked recessive
absence of dystrophin
proximal muscle weakness that spreads
cardiomyopathy
“Gower’s” sign to. get up
Becker’s muscular dystrophy
cause
pathophis
PX
x linked recessive
altered dystrophin
muscle cramps,
cardiomyopathy symptoms are worse
occlusion of what vessel causes global aphasia
left middle cerebral artery
wernickes encephalopathy
ophthalmoplegia, ataxia, and confusion
entacapone moa and indication
COMT inhibitor
prevents elinimation of L-dopa
parkinsons
selegiline moa and indication
MAOI
reduces metabolism of dopamine in the brain
parkinsons
1st line management of parkinsons
L dopa + carbidopa
numbness
hypo and hyperreflexia
weakness of limbs
ataxia
what is it and what is it assoc. with
subacute combined degeneration of the cord
assoc with b12 defieincy / pernicious anaemia
5 types of gait
cerebellar
sensory ataxia
hemiparetic
spastic
parkinsonian
Cerebellar ataxia gait
Px and causes
Walk unsteadily (as if they’re drunk), then compensate for this by adopting a wide stepping gait/broad based
Nystagmus
e.g. MS, alcoholic cerebellar degeneration
sensory ataxia gait
px, cause
Wide-based, high stepping gait
Positive rombergs test
e.g. MS, vitamin b12, tabes dorsalis (tertiary syphilis)
hemiparetic gait
px, cause
Flexion+internal rotation of the upper limb & extension of the lower limb
Foot is dragged in a semi-circle shape, sometimes scrapes the floor
e.g. focal brain lesions (stroke/tumour)
diplegic / spastic gait
px, cause
Scissoring gait
Legs move slowly and stiffly
e.g. MS, MND, Subacute combined degeneration of the cord
parkinsonian gait
px
Shuffling, stooped
Turning occurs as multiple stiff steps
blown pupil is caused by what CN defect
ipsilateral oculomotor palsy
Mx of amaurosis fugax
aspirin
Bells palsy Px
unilateral facial droop
loss of lacrimation
hyperacusis
Syringomyelia
who is affected
Px
a fluid-filled cavity that typically lies within the cervical or thoracic spinal cord
Young patients are usually affected.
loss of pain and temperature sensation, with preservation of light touch and vibration (due to the syrinx’s compression of the anterolateral pathway)
what is chiari malformation
structural defect in the cerebellum. One of the cerebella tonsils will be displaced downwards through the foramen magnum (basically a herniation)
symptoms of chiari malformation
headaches
associated with valsalva manoeuvre/straining
Lhermitte’s sign: electrical shock like pain that runs down back and into limbs
Paralysis in a clockwise fashion (RA, RL, LL, LA)
can develop into syringomyelia
Dx of synringomyelia
MRI
cluster headache prophylaxis
verapamil
headache that is worse on standing up but relieved when lying down
caused by…
idiopathic intracranial hypotension
dural leak somewhere
treatment of idiopathic intracranial hypotension
fluids, caffeine
blood patch: patients own blood is injected into the epidural space to prevent dural leak
differential for cluster headache
differences
paroxysmal hemicrania
PH has more attacks, continuous pain, absolute response to indomethacin
differentiating between amaurosis fugal and CRAO
CRAO is not transient
amaurosis fugal is transient, and like a curtain falling
subacute combined degeneration of the cord causes what column abnormalities
dorsal column
functional B12 deficiency is caused by
nitrous oxide recreational use
miller fisher presentation
ataxia
areflexia
ophthalmoplegia !!!!!
autonomic dysreflexia
what and happens when
autonomic dysfunction e.g. urianry retention, bradycardia, hypertension
within 1 year of spinal cord injury
differentiating between wernickes encephalopathy and korsakoffs syndrome
korsakoffs has confabulation and antero/retrograde amnesia
choosing between mannitol and dexamethasone
mannitol is better for raised icp caused by trauma
dex is better for neoplasms causing raised icp
most common long term complication of meningitis
sensorineural hearing loss
imaging for suspected TIA
diffusion weighted MRI
loss of taste where in bells palsy
anterior 2/3rd of the tongue
if pt is on DOAC/warfarin and has symptoms of a TIA…
refer to ED for urgent non-contrast CT head
they might be having a haemorrhagic TIA
what is used as prophylaxis for ppl in contact with meningitis patients
ciprofloxacin or rifampicin
role of lumbar puncture in SAH
if a CT head is done >6hrs after the onset of headache, do an LP to check for xanthochromia
when will xanthochromia appear
12 hours after onset
antibiotics for meningitis in young adults + adults >50
ceftriaxone
ceftriaxone + amoxicillin
4 drugs that can worsen myasthenia gravis
betablockers
lithium
phenytoin
ABx e.g. gentamicin, doxycycline, clarithryomicin
What causes Progressive multifocal leukoencephalopathy
Polyomavirus JC
Mx of myasthenia crisis
Supportive care
IV Ig
Plasmapheresis
speech non-fluent, comprehension normal, repetition impaired
impairment in what area
brocas aphasia
left inferior frontal gyrus
fluent aphasia characterized by fluent speech that lacks meaning and poor comprehension.
impairment in what area
wernickes area
right superior temporal gyrus
‘antsy’ legs, a creeping sensation, and relief with movement
what is it and what MX
restless legs syndrome
Mx: ropinirole
speech fluent, but repetition poor. Comprehension is relatively intact
what is it
conduction aphasia
1st line Ix for vestibular schwanoma
Audio gram, gadolinium enhanced MRI
Where is the damage in conduction aphasia
Arcuate fasciculus
What imaging can be used to diagnose MS
Contrast MRI
Fall or limb weakness after laughing or excitement
Cataplexy
GCS under what value requires intubation
8
best feeding option in MND option struggling to chew and swallow
PEG
Px of juvenile myoclonic epilepsy
intermittent seizures in teenage girls
often following sleep deprivation
these will progress to tonic clonic seizures if untreated
amaurosis fugal is caused by block of what artery
retinal or opthalmic
posterior cerebral artery stroke Px
contralateral homonymous hemianopia
with macular sparing
visual agnosia
middle cerebral artery stroke Px
contralateral homonymous hemianopia
sensory loss and weakness on contralateral limbs, arms > legs
anterior cerebral artery stroke Px
contralateral homonymous hemianopia
sensory loss and weakness on contralateral limbs,
legs > arms
