neurology Flashcards

1
Q

first line for muscle spasticity in MS

A

baclofen and gabapentin

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2
Q

how to treat a brain abscess

A

IV 3rd-generation cephalosporin (ceftriaxone) + metronidazole

(+ intercranial pressure mx (dexamethasone) )

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3
Q

what does it show on CT scan w brain abscess

A

ring enhancing lesion

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4
Q

what would you find on a head CT for Alzheimer’s

A

atrophy of cortex + hippocampus

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5
Q

what would you find on a head CT for frontotemporal dementia (pick’s disease)

A

atrophy of the frontal + temporal lobes
knife-blade appearance

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6
Q

what do you find on a head CT for SAH

A

Hyper-attenuating area in the basilar cistern (Circle of Willis)

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7
Q

most common cancers than spread to the brain

A

lung (most common)
breast
bowel
skin (namely melanoma)
kidney

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8
Q

tx for cerebral oedema in context of malignancy

A

dexamethasone

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9
Q

tx increased icp

A

mannitol

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10
Q

what happens if you give folate to someone who is b12 deficient

A

it can precipitate subacute combined degeneration of the cord

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11
Q

features of subacute combined degeneration of the cord

A

dorsal column involvement
- distal tingling/burning/sensory loss is symmetrical and tends to affect the legs more than the arms
- impaired proprioception and vibration sense

lateral corticospinal tract involvement
- muscle weakness, hyperreflexia, and spasticity
- upper motor neuron signs typically develop in the legs first
- brisk knee reflexes
- absent ankle jerks
- extensor plantars

spinocerebellar tract involvement
- sensory ataxia → gait abnormalities
- positive Romberg’s sign

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12
Q

most common site of berry aneurysm

A

anterior communicating artery

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13
Q

what condition is assoc w berry aneurysms

A

AD PKD

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14
Q

presentation of normal pressure hydrocephalus

A

dementia
gait abnormalities
urinary incompetence

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15
Q

neuro-imaging in normal pressure hydrocephalus

A

ventriculomegaly in the absence of sulcal enlargement

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16
Q

tx normal pressure hydrocephalus

A

ventriciuloperitoneal shunting

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17
Q

what is the barthel index

A

scale that measures disability/dependence in ADLs in stroke px

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18
Q

what is the most common cause of brain mets

A

lung tumours

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19
Q

SEs of levodopa

A

on-off effect
cardiac arrhythmias
N&V
psychosis
reddish discol of urine
dyskinesias

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20
Q

parkinson’s presentation

A

cogwheel rigidity
bradykinesia
- small writing
- shuffling gait
- can’t initiate movement/turn
tremor
- asymmetric, AT REST, improves w voluntary activity
mask-like facies
postural instability

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21
Q

describe parkinson’s tremor

A

resting
pin-rolling
4-6 Hz
improves w voluntary movement, worsens when distracted
No change with alcohol
Asymmetrical

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22
Q

what is levodopa usually combined w + why

A

peripheral decarboxylase inhibitors e.g. carbidopa
stops levodopa being broken down in the body before it gets the chance to enter the brain

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23
Q

what is dystonia

A

This is where excessive muscle contraction leads to abnormal postures or exaggerated movements.

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24
Q

what is chorea

A

These are abnormal involuntary movements that can be jerking and random.

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25
what is athetosis
These are involuntary twisting or writhing movements usually in the fingers, hands or feet.
26
what is syringomyelia
cape-like loss of pain + temp sensation due to a collection of cerebrospinal fluid within the spinal cord
27
what is brown-sequard
damage to lateral 1/2 of the spinal cord ipsilateral loss of proprioception + vibration (dorsal column decussates at medulla after leaving spinal cord) contralateral loss of pain + temp (spinothalamic tract decussates asap)
28
sx optic neuritis
unilateral decrease in visual acuity over hours or days poor discrimination of colours, 'red desaturation' pain worse on eye movement relative afferent pupillary defect (respond diff to light) central scotoma (blind spot) think ms?!
29
3rd nerve palsy
ptosis dilated pupil looking down + out
30
encephalitis sx
fever headache altered mental status
31
viral encephalitis tx
IV aciclovir
32
bacterial encephalitis tx
IV ceftriaxone
33
what is Ramsay Hunt syndrome
infection of facial nerve by HZV
34
presentation of Ramsay Hunt syndrome
ipsilateral LMN facial palsy (forehead not spared) ear pain hearing loss vertigo vesicular rash in outer ear
35
what is bell's palsy
LMN facial nerve lesion
36
presentation of bell's palsy
ipsilateral facial paralysis (forehead not spared) post-auricular pain altered taste dry eyes hyperacusis (reduced tolerance to sound)
37
tx bell's palsy
oral prednisolone 10 days if no improvement after 3 wks, refer urgently to ENT eye drops
38
presentation of acoustic neuroma (vestibular schwannoma)
vertigo hearing loss tinnitus absent corneal reflex fullness in ear facial nerve palsy if big
39
ix acoustic neuroma (vestibular schwannoma)
MRI of cerebellopontine angle audiometry
40
mx acoustic neuroma (vestibular schwannoma)
urgent ENT referral
41
what is acoustic neuroma (vestibular schwannoma) assoc w
neurofibromatosis type 2 (AD)
42
what is charcot-marie-tooth
most common hereditary sensory + motor peripheral neuropathy
43
charcot-marie-tooth presentation
Patients can present with lower motor neurone signs in all limbs and reduced sensation (more pronounced distally). motor loss distal muscular weakness + atrophy hyporeflexia hx of freq sprained ankles foot drop high arched feet - pes cavus hammer toes stork leg deformity
44
what is chronic inflammatory demyelinating polyneuropathy
chronic version of GBS progressive weakness + impaired sensory func in legs + arms
45
tx of chronic inflammatory demyelinating polyneuropathy
corticosteroids
46
what is degenerative cervical myelopathy + presentation
spinal cord compression in neck loss of fine motor func in upper limbs, pain, numbness Hoffman's sign 50% of patients were initially incorrectly diagnosed and sometimes treated for carpal tunnel syndrome
47
dx degenerative cervical myelopathy
MRI cervical spine = disc degeneration + ligament hypertrophy cord signal change
48
what is autonomic dysreflexia
syndrome that occurs in px w spinal cord injury at/> T6. sympathetic reflex caused by trigger
49
what commonly triggers autonomic dysreflexia
faecal impaction or urinary retention px cld: - bed bound/immobile - meds (opioids) - anal fissure - Hirschsprungs - dementia - spinal trauma
50
sx of autonomic dysreflexia
extreme HTN flushing + sweating above lesion level agitation
51
where does the spinal cord end
L1-2 - splits to cauda equina
52
what does the dorsal column do
ascending tract carries sensory info to the brain fine touch vibration sense proprioception
53
where does the dorsal column decussate
after leaving the spinal cord at medulla therefore stays in same lane for ages therefore if damaged problems are on ipsilateral side
54
what does the spinothalamic tract do
ascending tract carries sensory info to brain pain + temperature
55
where does the spinothalamic tract decussate
as soon as in spinal cord so ascends contralaterally therefore crosses lanes immediately therefore if damaged problems on opposite side (2 segments below injury)
56
what is the corticospinal tract
descending pyramidal tract sending motor signals to muscles voluntary muscle control immediately changes lanes + travels contralaterally
57
what is the corticobulbular tract
descending pyramidal tract voluntary muscle control of the face, head + neck
58
what are upper motor neurons
originate in cerebral cortex + travel down to brainstem or spinal cord
59
what are lower motor neurons
begin in spinal cord + innervate muscles + glands throughout the body
60
what are signs of upper motor neuron lesions
increased tone - spasticity - clonus? increased reflexes positive babinski sign positive hoffman sign upper limb has weak extensor muscles lower limb has weak flexor (bend) muscles pyramidal drift
61
what are signs of lower motor neuron lesions
decreased tone - flaccid decreased reflexes/none fasciculations muscle wasting - bulbar = speech + swallow - resp - diaphragm higher up - hand - foot drop
62
what do extrapyramidal tracts do
involuntary control i.e. tone + balance
63
what are manifestations of extrapyramidal injury
parkinsonism - rigidity - bradykinesia - tremors - postural deficits chorea athetosis dystonia
64
initial dementia blood screen
FBC U&Es LFTs Ca glucose ESR/CRP TFTs vitamin B12 folate levels
65
what is wernicke's encephalopathy + how does it present
thiamine (v B1) deficiency (in alcoholics) ophthalmoplegia ataxia confusion
66
wernicke's encephalopathy tx
thaimine replacement -> pabrinex
67
what do you get if you don't treat wernicke's encephalopathy + how does it present
Korsakoff syndrome antero + retrograde amnesia confabulation (false mems)
68
presentation of multiple system atrophy
parkinsonism autonomic disturbance - erectile dysfunction: often an early feature - postural hypotension - atonic bladder cerebellar signs
69
Posterior inferior cerebellar artery stroke (PICA) (lateral medullary syndrome) (Wallenberg syndrome)
Ipsilateral: facial pain and temperature loss Contralateral: limb/torso pain and temperature loss Ataxia Nystagmus sudden vomiting/vertigo to differentiate from ANTERIOR.... POSTERIOR has no deafness or facial paralysis
70
Anterior inferior cerebellar artery stroke (AICA) (lateral pontine syndrome)
Ipsilateral: facial paralysis and deafness, facial pain + temp loss contralateral: body pain + temp loss pin point pupils to differentiate from POSTERIOR.... ANTERIOR has deafness and facial paralysis as well as the ipsilateral face sx + contralateral body sx
71
what does a basilar artery stroke cause
locked in syndrome
72
what does a retinal/ophthalmic artery stroke cause
Amaurosis fugax
73
Anterior cerebral artery stroke
Contralateral hemiparesis and sensory loss Lower extremity more affected (ants have legs) logical thinking/personality
74
Middle cerebral artery stroke
Contralateral hemiparesis and sensory loss Upper extremity more affected Contralateral homonymous hemianopia Aphasia Most common
75
Posterior cerebral artery stroke
Contralateral homonymous hemianopia with macular sparing Visual agnosia (can't rec faces)
76
Weber's syndrome
Ipsilateral CN III palsy (down + out) Contralateral weakness of upper and lower extremity (branches of the posterior cerebral artery that supply the midbrain)
77
what do total anterior circulation infarcts have to have
involves middle and anterior cerebral arteries all 3 of the criteria are present: 1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg 2. homonymous hemianopia 3. higher cognitive dysfunction e.g. dysphasia
78
what do partial anterior circulation infarcts have to have
involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery 2 of the criteria are present: 1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg 2. homonymous hemianopia 3. higher cognitive dysfunction e.g. dysphasia
79
what do lacunar infarcts have to have
presents with 1 of the following: 1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three. 2. pure sensory stroke. 3. ataxic hemiparesis
80
ix TIA
MRI brain w diffusion-weighted imaging only do to exclude other dx all patients should have an urgent carotid doppler unless they are not a candidate for carotid endarterectomy (to check as a source of emboli)
81
immediate tx TIA
aspirin 300mg
82
what to do if px has had more than 1 TIA or has a suspected cardioembolic source or severe carotid stenosis
discuss the need for admission or observation urgently with a stroke specialist
83
what to do if If the patient has had a suspected TIA in the last 7 days
arrange urgent assessment (within 24 hours) by a specialist stroke physician
84
what to do if the patient has had a suspected TIA which occurred more than a week previously
refer for specialist assessment as soon as possible within 7 days
85
driving + TIAs
Advise the person not to drive until they have been seen by a specialist. Can start driving if sx free after 1 month
86
2ndary prev after TIA
antiplatelet therapy after initial aspirin - clopidogrel high-intensity statin
87
when to do a carotid artery endarterectomy in TIA
carotid stenosis > 70% + sx
88
tx ischaemic stroke
aspirin 300 mg < 4.5 hrs of onset = thombolysis w alteplase AND thrombectomy 4.5 - 6 hrs of onset = thrombectomy or thrombectomy after 6 hrs if there is the potential to salvage brain tissue, as shown by imaging (but not usually after 24 hrs)
89
features of acute subdural haemorrhage
4-7 wks following high impact trauma fluctuating conc + sx come on gradually crescent shaped hyperdense
90
features of chronic subdural haemorrhage
wks/months confusion decreased conc neuro def more likely elderly + alcoholic as brain atrophy or in shaken baby syndrome hypodense crescent shaped slow bleeding
91
what ruptures in subdural haemorrhage
bridging veins
92
tx acute subdural haemorrhage
decompressive craniotomy
93
tx chronic subdural haemorrhage
burr hole evacuation
94
features of extradural haemorrhage
sudden onset soon after injury following brief lucid interval headache compression of CN III - fixed + dilated pupil lemon shaped (biconvex)
95
what ruptures in extradural haemorrhage
middle meningeal artery
96
tx extradural haemorrhage
burr holes craniotomy ligation of bleeding artery
97
ix SAH
CT = acute blood (hyperdense/bright on CT) is typically distributed in the basal cisterns, sulci and in severe cases the ventricular system. if done within 6 hrs of sx onset + normal, no LP needed - consider an alt dx if CT is done 6+ hrs after sx onset + normal -> LP (at least 12 hrs after sx) = xanthochromia (RBC breakdown) + normal/raised opening pressure -> refer to neurosurgery
98
ix is to identify a causative pathology of SAH
CT intracranial angiogram (to identify a vascular lesion)
99
mx SAH
coil/clip IV nimidopine 21 days to prevent vasospasm
100
what signs do you get in GBS
LMN
101
features of temporal lobe seizure
Hallucinations Epigastric rising/Emotional Automatisms (lip smacking) Deja Vu/Dysphasia post ictal
102
features of a frontal lobe seizure
Head/leg movements, posturing Post ictal Todd's palsy (weakness) Jacksonian march (clonic movements travelling proximally)
103
what is an atonic seizure
suddenly fall to the ground due to sudden loss of muscle tone confused after
104
EEG on absence seizure
3Hz spike + wave
105
what is status epilepticus
seizure > 5 mins / > 2 in 5 mins not returning to normal
106
drug tx for male generalised tonic clonic epilepsy
sodium valproate
107
drug tx for female generalised tonic clonic epilepsy
lamotrogine/levetiracetam
108
drug tx for males in myoclonic epilepsy
sodium valproate
109
drug tx for focal seizures in epilepsy
1 = lamotrogine/levetiracetam 2 = carbamazepine
110
drug tx for females in myoclonic epilepsy
levetiracetam
111
tx status epilepticus
ABC - airway adjunct - oxygen - check blood glucose Pre-hosp = PR diazepam / buccal midazolam Hosp = IV lorazepam. Repeat after 5-10 mins Ongoing = phenytoin Anaesthesia
112
what are infantile spasms (West syndrome)
rare disorder starting in infancy at around 6 months of age brief spasms of sudden uncontrolled movements including flexion of the head, trunk, limbs, and extension of the arms (Salaam attack) poor prognosis usually secondary to serious neurological abnormality (e.g. tuberous sclerosis, encephalitis, birth asphyxia) or may be idiopathic
113
EEG of infantile spasms
Hypsarrhythmia
114
drug tx absence seizures
ethosuximide
115
drug tx for female tonic / atonic seizures in epilepsy
lamotrigine
116
drug tx for male tonic / atonic seizures in epilepsy
sodium valproate
117
features of MG
Autoimmune autoantibodies at post-synaptic membrane = AChR. These prevent ACh from being able to stim the receptor + trigger muscle contractions Assoc w thymomas (CT to exc) -> dry cough, breathlessness Muscle fatiguability - extraocular - proximal - ptosis - dysphagia
118
ix in MG
Acetylcholine receptor (ACh-R) antibodies (85% of patients) Muscle-specific kinase (MuSK) antibodies (10% of patients) LRP4 (low-density lipoprotein receptor-related protein 4) antibodies (less than 5%) EMG (nerve conduction studies) CT Edrophonium Test
119
MG tx
anticholinesterase inhibitors = PYRIDOSTIGMINE Prednisolone Thymectomy
120
tx for myasthenic crisis
plasmapheresis IV immunoglobulin
121
what can make sx of MG worse
BBs gentamicin is CI
122
features of Lambert Eaton syndrome
AI antibodies against VG calcium channels in pre-synaptic membrane so ACh cannot be exocytosed assoc w small cell lung cancer proximal muscle weakness espesh in lower limbs strength increases w effort autonomic features
123
tx Lambert Eaton syndrome
Amifampridine
124
features of GBS
progressive, symmetrical weakness of all the limbs - classically ascending - reduced or absent reflexes hx viral infection e.g. gastroenteritis
125
ix GBS
LP - rise in protein with a normal WBCS (albuminocytologic dissociation) - found in 66% nerve condution studies - decreased motor nerve conduction velocity (due to demyelination) - prolonged distal motor latency - increased F wave latency
126
what is GBS
an immune-mediated demyelination of the peripheral nervous system often triggered by an infection (classically Campylobacter jejuni)
127
most common causative organism of viral encephalitis
herpes simplex virus 1
128
CSF in viral encephalitis
high lymphocytes high protein
129
EEG in viral encephalitis
lateralised periodic discharges at 2 Hz
130
causes of bacterial meningitis
NEISSERIA MENINGITIDIS Streptococcus pneumoniae (pneumococcus) Haemophilus influenzae Group B streptococcus (GBS) (particularly in neonates as GBS may colonise the vagina) Listeria monocytogenes (particularly in neonates)
131
causes of viral meningitis
Enteroviruses (e.g., coxsackievirus) Herpes simplex virus (HSV) Varicella zoster virus (VZV)m
132
meningitis presentation
Fever Neck stiffness Vomiting Headache Photophobia Altered consciousness Seizures meningococcal septicaemia (when it has entered the blood) = non-blanching rash.
133
special to look for meningeal irritation
Kernig’s test Brudzinski’s test
134
LP for bacterial meningitis
cloudy high protein low glucose (relative to serum) high neutrophils (polymorphs)
135
LP for viral meningitis
clear mildly raised/normal protein normal glucose high lymphocytes
136
features of benign essential tremor
fine tremor 6-12 Hz symmetrical more prominent w voluntary movement worse when tired, stressed or after caffeine improved by alcohol absent during sleep
137
mx benign essential tremor
just to improve sx: propranolol primidone (a barbiturate anti-epileptic medication)
138
what is MS
chronic + progressive AI condition involving demyelination in the CNS (oligodendrocytes) (multiple sites) T cell mediated type 4 hypersensitivity reaction begins early adulthood, more common in F
139
typical presentations of MS
LOSS NB - Lhermitte’s sign - electric shock runs down back + radiates to limbs on neck flexion - Optic neuritis – impaired vision + eye pain - Spasticity + other pyramidal signs - Sensory symptoms + signs - ataxia - Nystagmus, double vision + vertigo - Bladder + sexual dysfunction Exacerbated by heat – showers, hot weather, saunas (Uhthoff’s phenomenon)
140
types of MS
relapsing + remitting (80%) - onset over days recovery over weeks - periods of gd health in betweeen secondary progressive - gradually worsening sx + fewer remissions - evolves from relapsing + remitting primary progressive - gradually worsening disability WITHOUT relapses or remissions
141
diagnosis of MS
TWO+ attacks affecting DIFFERENT PARTS of CNS; that is 2 CNS lesions disseminated in time + space
142
ix in MS
MRI brain + spinal cord * 95% have periventricular lesions * Over 90% show discrete white matter abnormalities * Multiple scattered plaques are usually seen - with contrast - active lesions will take up contrast + appear white in colour = Dawson fingers: often seen on FLAIR images - hyperintense lesions penpendicular to the corpus callosum LP * oligoclonal IgG bands in CSF
143
tx for acute relapse MS
High-dose steroids (e.g. oral or IV methylprednisolone) may be given for 5 days to shorten duration of relapse
144
First line drug for reducing the risk of relapse in MS
natalizumab IV - a recombinant monoclonal antibody
145
drug for fatigue in MS
amantadine (once other probs - anaemia, thyroid, depression - have been excluded)
146
tx for bladder incompetence in MS
get US first to assess bladder emptying if significant residual volume → intermittent self-catheterisation if no significant residual volume → anticholinergics may improve urinary frequency
147
tx for oscillopsia in MS
gabapentin
148
inheritance of huntington's disease
AD
149
what is huntingtons disease (+what is its genetics)
genetic condition that causes progressive neurological dysfunction. trinucleotide repeat (CAG) disorder involving a genetic mutation in the HTT gene on chromosome 4, which codes for the huntingtin (HTT) protein.
150
examples of trinucleotide repeat disorders
Huntington's disease Fragile X syndrome Spinocerebellar ataxia Myotonic dystrophy Friedrich ataxia
151
what is genetic anticipation
a feature of trinucleotide repeat disorders where successive generations have more repeats in the gene, resulting in: Earlier age of onset Increased severity of disease
152
Huntington's disease presentation
insidious, progressive worsening of symptoms. It typically begins with cognitive, psychiatric or mood problems, followed by the development of movement disorders: Chorea (involuntary, random, irregular and abnormal body movements) Dystonia (abnormal muscle tone, leading to abnormal postures) Rigidity (increased resistance to the passive movement of a joint) Eye movement disorders Dysarthria (speech difficulties) Dysphagia (swallowing difficulties)
153
dx huntington's disease
genetic testing
154
med for chorea sx in huntington's
Tetrabenazine
155
prognosis huntington's
Life expectance is around 10-20 years after the onset of symptoms. As the disease progresses, patients become more frail and susceptible to illness (e.g., infections, weight loss, falls and pressure ulcers). Death is often due to aspiration pneumonia. Suicide is also a common cause of death.
156
what is motor neurone disease
progressive degeneration of both the upper + lower motor neurones sensory neurones are spared
157
classic features of MND
asymmetric limb weakness is the most common presentation of ALS (usually upper limbs first) the mixture of lower motor neuron and upper motor neuron signs wasting of the small hand muscles/tibialis anterior is common fasciculations the absence of sensory signs/symptoms vague sensory symptoms may occur early in the disease (e.g. limb pain) but 'never' sensory signs rarely presents before 40 yrs does NOT affect - external occular muscles - no cerebellar signs - abdo reflexes preserved
158
types of MND
Amyotrophic lateral sclerosis (ALS) - most common - LMN + UMN Progressive bulbar palsy - tongue , worst prog Progressive muscular atrophy - LMN Primary lateral sclerosis - UMN
159
pattern of signs in ALS
LMN signs in the arms and UMN signs in the legs Asymmetric limb weakness
160
MND dx
clinical exclude done by specialist
161
what drug can slow progression of MND + how does it work
Riluzole - prevents stim of glutamate receptors - used mainly in ALS - prolongs life by about 3 months
162
other tx MND
Respiratory care non-invasive ventilation (usually BIPAP) is used at night Nutrition percutaneous gastrostomy tube (PEG) is the preferred way to support nutrition and has been associated with prolonged survival
163
causes of peripheral neuropathy
ABCDE: A – Alcohol B – B12 deficiency C – Cancer (e.g., myeloma) and Chronic kidney disease D – Diabetes and Drugs (e.g., isoniazid, amiodarone, leflunomide and cisplatin) E – Every vasculitis
164
charcot-marie-tooth inheritance
AD
165
what is neurofibromatosis
genetic condition that causes neuromas to develop throughout the nervous system benign tumours but cause neuro + structural probs
166
Neurofibromatosis Type 1 Gene
found on chromosome 17 codes for neurofibromin (a tumour suppressor protein) Mutations in this gene are inherited in an autosomal dominant pattern.
167
diagnostic criteria for neurofibromatosis type 1
“CRABBING” mnemonic: C – Café-au-lait spots (more than 15mm diameter is significant in adults) R – Relative with NF1 A – Axillary or inguinal freckling BB – Bony dysplasia, such as Bowing of a long bone or sphenoid wing dysplasia I – Iris hamartomas (Lisch nodules), which are yellow-brown spots on the iris N – Neurofibromas G – Glioma of the optic pathway
168
what is a neurofibroma + when are they significant
Skin-coloured, raised nodules or papules with a smooth, regular surface. Two or more are significant. A plexiform neurofibroma is a larger, irregular, complex neurofibroma containing multiple cell types. A single plexiform neurofibroma is significant.
169
complications of neurofibromatosis
Migraines Epilepsy Renal artery stenosis, causing hypertension Learning disability Behavioural problems (e.g., ADHD) Scoliosis of the spine Vision loss (secondary to optic nerve gliomas) Malignant peripheral nerve sheath tumours Gastrointestinal stromal tumour (a type of sarcoma) Brain tumours Spinal cord tumours with associated neurology (e.g., paraplegia) Increased risk of cancer (e.g., breast cancer and leukaemia)
170
Neurofibromatosis Type 2 genetics
The gene is found on chromosome 22 It codes for merlin (a tumour suppressor protein important in Schwann cells). Mutations in this gene lead to schwannomas Inheritance is also autosomal dominant. Assoc w acoustic neuromas
171
what is tuberous sclerosis
autosomal dominant genetic condition leads to development of harmartomas (benign tissue growths) commonly affect: Skin Brain Lungs Heart Kidneys Eyes
172
Tuberous sclerosis is caused by mutations in either:
TSC1 gene on chromosome 9, which codes for hamartin TSC2 gene on chromosome 16, which codes for tuberin Hamartin and tuberin interact with each other to control the size and growth of cells. Abnormalities in one of these proteins lead to abnormal cell size and growth.
173
Tuberous sclerosis skin features
Ash leaf spots (depigmented areas of skin shaped like an ash leaf) Shagreen patches (thickened, dimpled, pigmented patches of skin) Angiofibromas (small skin-coloured or pigmented papules that occur over the nose and cheeks) Ungual fibromas (circular painless lumps that slowly grow from the nail bed and displace the nail) Cafe-au-lait spots (light brown “coffee and milk” coloured flat pigmented lesions on the skin) Poliosis (an isolated patch of white hair on the head, eyebrows, eyelashes or beard)
174
Tuberous sclerosis neuro features
Epilepsy Learning disability Brain tumours
175
systemic features tuberous sclerosis
Rhabdomyomas in the heart Angiomyolipoma in the kidneys Lymphangioleiomyomatosis in the lungs Subependymal giant cell astrocytoma in the brain Retinal hamartomas in the eyes
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headache red flags
Fever, photophobia or neck stiffness (meningitis, encephalitis or brain abscess) New neurological symptoms (haemorrhage or tumours) Visual disturbance (giant cell arteritis, glaucoma or tumours) Sudden-onset occipital headache (subarachnoid haemorrhage) Worse on coughing or straining (raised intracranial pressure) Postural, worse on standing, lying or bending over (raised intracranial pressure) Vomiting (raised intracranial pressure or carbon monoxide poisoning) History of trauma (intracranial haemorrhage) History of cancer (brain metastasis) Pregnancy (pre-eclampsia)
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why to do fundoscopy in headaches
to check for papilloedema - suggests raised ICP
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first-line for chronic or frequent tension headaches
Amitriptyline
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Tension headaches may be associated with:
Stress Depression Alcohol Skipping meals Dehydration
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mx tension headaches
Reassurance Simple analgesia (e.g., ibuprofen or paracetamol)
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first line abx for sinusitis that has lasted > 10 days
phenoxymethylpenicillin
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why do you get hormonal headaches + how do they present
low oestrogen unilateral, pulsatile headache associated with nausea They may occur: - Two days before and the first three days of the menstrual period - In the perimenopausal period - Early pregnancy (headaches in the second half of pregnancy should prompt investigations for pre-eclampsia)
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tx hormonal headaches
Triptans and NSAIDs (e.g., mefenamic acid)
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what is trigeminal neuralgia
intense facial pain in the distribution of the trigeminal nerve, which has three branches: Ophthalmic (V1) Maxillary (V2) Mandibular (V3) Can affect any combo of branches
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presentation trigeminal neuralgia
>90% are unilateral pain comes on suddenly + can last seconds to hrs an electricity-like, shooting, stabbing or burning pain may be triggered by touch, taking, eating, shaving or cold Attacks may worsen over time. more common in px w MS
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first line tx trigeminal neuralgia
carbamazepine
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4 types of migraine
Migraine without aura Migraine with aura Silent migraine (migraine with aura but without a headache) Hemiplegic migraine
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stages of migraine
Premonitory or prodromal stage (can begin several days before the headache) Aura (lasting up to 60 minutes) Headache stage (lasts 4 to 72 hours) Resolution stage (the headache may fade away or be relieved abruptly by vomiting or sleeping) Postdromal or recovery phase
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sx migraine
Usually unilateral Moderate-severe intensity Pounding or throbbing in nature Photophobia (discomfort with lights) Phonophobia (discomfort with loud noises) Osmophobia (discomfort with strong smells) Aura (visual changes) Nausea and vomiting
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what is aura + its sx
Can affect vision, sensation or language. Visual symptoms are the most common: Sparks in the vision Blurred vision Lines across the vision Loss of visual fields (e.g., scotoma) Sensation changes may include tingling or numbness. Language symptoms include dysphasia (difficulty speaking).
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what is a hemiplegic migraine
rare subtype of migraine with aura that is hemiplegia / ataxia / impaired consciousness
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inheritance of familial hemiplegic migraine
AD
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migraine triggers
Stress Bright lights Strong smells Certain foods (e.g., chocolate, cheese and caffeine) Dehydration Menstruation Disrupted sleep Trauma
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medical mx for acute migraine attack
NSAIDs (e.g., ibuprofen or naproxen) Paracetamol Triptans (e.g., sumatriptan) - taken as soon as it starts to halt the attack, do not take again in same migraine if does not work Antiemetics if vomiting occurs (e.g., metoclopramide or prochlorperazine)
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CI for triptans
risks associated with vasoconstriction, for example, hypertension, coronary artery disease or previous stroke, TIA or myocardial infarction
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migraine prophylaxis
headache diary to identify triggers Propranolol (CI asthma) Topiramate (teratogenic and very effective contraception is needed) Amitriptyline
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tx for menstrual migraines
Prophylactic triptans (e.g., frovatriptan or zolmitriptan) Sx tend to occur two days before until three days after the start of menstruation
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sx cluster headaches
Severely painful headache - unilateral - centred around the eye Red, swollen and watering eye Pupil constriction (miosis) Eyelid drooping (ptosis) Nasal discharge Facial sweating Comes in clusters of attacks lasting 15mins-3hrs
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who typically gets cluster headaches
A typical patient is a 30-50 year old male smoker. They may have triggers, such as alcohol, strong smells or exercise.
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acute mx cluster headaches
Triptans (e.g., subcutaneous or intranasal sumatriptan) High-flow 100% oxygen (may be kept at home)
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cluster headache prophylaxis
Verapamil
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RFs Alzheimer's
age FHx - 5% of cases are inherited as an AD trait apoprotein E allele E4 - encodes a cholesterol transport protein Caucasian ethnicity Down's syndrome
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medical mx mild-moderate Alzheimer's
Acetylcholinesterase inhibitors - donepezil - galantamine - rivastigmine
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medical mx severe Alzheimer's / when 1st line not worked/CI
memantine - an NMDA receptor antagonist
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blood screen when ix dementia
FBC U&E LFTs calcium glucose ESR/CRP TFTs vitamin B12 and folate levels
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characteristic feature Lewy body dementia
alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas
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presentation of Lewy body dementia
progressive cognitive impairment - BEFORE parkinsonism, but usually both features occur within a year of each other (in Parkinson's disease, motor sx typically present at least one year before cognitive symptoms) - cognition may be FLUCTUATING, in contrast to other forms of dementia - early impairments in attention and executive function rather than just memory loss parkinsonism visual hallucinations (other features such as delusions and non-visual hallucinations may also be seen)
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mx Lewy body dementia
same as Alzheimer's avoid neuroleptics
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what is vascular dementia
a group of syndromes of cognitive impairment caused by different mechanisms causing ischaemia or haemorrhage secondary to cerebrovascular disease
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subtypes of vascular dementia
Stroke-related VD – multi-infarct or single-infarct dementia Subcortical VD – caused by small vessel disease Mixed dementia – the presence of both VD and Alzheimer’s disease
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RFs vascular dementia
History of stroke or TIA AF HTN Diabetes Hyperlipidaemia Smoking Obesity Coronary heart disease A family history of stroke or cardiovascular
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presentation vascular dementia
Several months or several years of a history of a sudden or stepwise deterioration of cognitive function. Sx and the speed of progression vary: Focal neurological abnormalities e.g. visual disturbance, sensory or motor symptoms The difficulty with attention and concentration Seizures Memory disturbance Gait disturbance Speech disturbance Emotional disturbance
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dx vascular dementia
Presence of cognitive decline that interferes with activities of daily living, not due to secondary effects of the cerebrovascular event + Cerebrovascular disease + A relationship between the above two disorders inferred by: - the onset of dementia within three months following a recognised stroke - an abrupt deterioration in cognitive functions - fluctuating, stepwise progression of cognitive deficits
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types of frontotemporal lobar dementias
Frontotemporal dementia (Pick's disease) Progressive non fluent aphasia (chronic progressive aphasia, CPA) Semantic dementia
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Common features of frontotemporal lobar dementias
Onset before 65 Insidious onset Relatively preserved memory and visuospatial skills Personality change and social conduct problems
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features of pick's disease
personality change impaired social conduct hyperorality (putting things in mouth) disinhibition increased appetite perseveration behaviours (get stuck on idea)
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microscopic changes in pick's disease
Pick bodies - spherical aggregations of tau protein (silver-staining) Gliosis Neurofibrillary tangles Senile plaques
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Progressive non fluent aphasia (chronic progressive aphasia, CPA)
non-fluent speech short utterances that are agrammatic comprehension is relatively preserved.
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Semantic dementia
fluent progressive aphasia speech is fluent but empty and conveys little meaning memory is better for recent rather than remote events (unlike alzheimer's)
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what spinal tract does neurosyphilis affect and what does that cause
dorsal columns -> Loss of proprioception and vibration sensation (posterior cord syndrome)
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presentation of anterior cord syndrome
acute onset loss of pain + temp sensation loss of movement bilaterally Autonomic dysfunction: abnormal blood pressure Bladder dysfunction: Urinary incontinence
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what is anterior cord syndrome
A clinical syndrome due to damage to the anterior two-thirds of the spinal cord. Damage to: 1. Lateral corticospinal tracts 2. Lateral spinothalamic tracts
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causes of anterior cord syndrome
ischaemia of the anterior spinal artery: Thromboembolism Trauma Hypotension Aortic disease Other pathology: Disc herniation Tumour Trauma Epidural collection
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features of Intracranial venous sinus thrombosis
headache (may be sudden or gradual onset) nausea & vomiting reduced consciousness
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GS ix for Intracranial venous sinus thrombosis
MRI VENOGRAPHY CT venography is an alternative non-contrast CT head is normal in around 70% of patients D-dimer levels may be elevated
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Mx Intracranial venous sinus thrombosis
anticoagulation - typically with low molecular weight heparin acutely - warfarin is still generally used for longer term anticoagulation
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tx degenerative cervical myelopathy
decompressive surgery
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sign of potentially salvageable tissue on CT
limited infarct core
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what does the facial nerve supply
'face, ear, taste, tear' face: muscles of facial expression ear: nerve to stapedius taste: supplies anterior two-thirds of tongue tear: parasympathetic fibres to lacrimal glands, also salivary glands
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what is erb's palsy a result of
injury to the C5/C6 nerves in the brachial plexus during birth associated with shoulder dystocia, traumatic or instrumental delivery and large birth weight
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what does erb's palsy lead to
weakness of shoulder abduction and external rotation, arm flexion and finger extension. This leads to the affected arm having a “waiters tip” appearance: Internally rotated shoulder Extended elbow Flexed wrist facing backwards (pronated) Lack of movement in the affected arm
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Pontine haemorrhage
reduced GCS, paralysis (tetraparesis ) and bilateral pin point pupils may have facial droop
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Idiopathic intracranial hypertension RFs
obesity female sex pregnancy drugs: COCP, steroids, tetracyclines, retinoids (isotretinoin, tretinoin) / vitamin A, lithium
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Idiopathic intracranial hypertension features
headache blurred vision papilloedema (usually present) enlarged blind spot sixth nerve palsy may be present
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Idiopathic intracranial hypertension tx
weight loss carbonic anhydrase inhibitors e.g. acetazolamide topiramate is also used, and has the added benefit of causing weight loss in most patients repeated lumbar puncture may be used as a temporary measure but is not suitable for longer-term management surgery: optic nerve sheath decompression and fenestration lumboperitoneal or ventriculoperitoneal shunt to reduce ICP
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which are of the brain does herpes simplex encephalitis affect
temporal lobes
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which antiemetic to prescribe in parkinsons
Domperidone
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what to do if not tolerating clopidogrel after stroke
aspirin and modified release dipyramidole
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where is the lesion for broca's (expressive) aphasia
inferior frontal gyrus
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where is the lesion for wernicke's (receptive) aphasia
superior temporal gyrus
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prev of vasospasm after SAH
nimodipine