neurology Flashcards
best investigation for VZV?
viral PCR - can quickly detect DNA
list the causes of tension headaches
depression, lack of sleep, missed meals, stress
- NOT dehydration
what is the treatment for Guillian-Barre syndrome?
- IV immunoglobulins - contains antibodies which help prevent harmful antibodies damage your nerves
- plasma exchange
- supportive care
what medication is given to control chorea?
risperidone is a dopamine receptor antagonist that helps manage aggression and chorea, it is in the antipsychotic drug class
give 4 signs of upper motor neurone disease
babinski reflex, increased muscle tone, muscle weakness, overactive reflexes
give 4 signs of lower motor neurone disease
fasciculations, decreased muscle tone, muscle weakness, underactive reflexes
list 4 causative organisms of meningitis
- listeria monocytogenes,
- neisseria meningitis,
- strep agalactiae,
- strep pneumonia - most common
1st line treatment for a migraine?
NSAIDs!
an extradural haemorrhage is caused by a rupture of what artery?
middle meningeal artery
a subarachnoid haemorrhage is caused by a rupture of what?
berry aneurysm not following a head injury
will a subdural haemorrhage have a lucid period?
no
what does a subdural haemorrhage look like on a CT?
crescent shaped
what does a extradural haemorrhage look like on a CT?
lemon shaped
what is the first line investigation of meningitis?
blood cultures
what would bacterial cause of meningitis show on CSF?
cloudy appearance, increased neutrophils, increased protein levels, decreased glucose
prophylaxis for meningitis?
oral ciprofloxacin
What is the medical term for a feeling of a curtain coming down on eyes?
amaurosis fugax
what would temporal arteritis show on biopsy?
multinucleated giant cells
what danger is possible after sudden stop in taking prednisolone?
adrenal crisis
typical history of giant cell arteritis?
unilateral headache, tiredness in jaw on eating, pain in scalp, weight loss
typical presentation of a cluster headache?
severe unilateral, present around orbits, blood shot eye and ptosis on affected side
5 features on examination of a cluster headache?
- blood shot eye on affected side
- ptosis
- rhinorrhoea
- lid swelling
- lactrimation
- miosis
- sweating
what is the acute treatment of a cluster headache?
100% O2 and SC sumatriptan
what is the long term prophylaxis of cluster headaches?
CCB e.g. verapamil
define encephalitis
inflammation of the brain usually caused by viral infection
What is the most common infective cause of encephalitis in immunocompetent patients?
herpes simplex virus
What would be the diagnostic investigation in a patient with encephalitis?
LP with CSF viral PCR testing
What would be the route and treatment provided for encephalitis?
IV acyclovir
What would your immediate medical management be of a migraine?
combination therapy with an oral triptan (sumatriptan) and an NSAID, or an oral triptan and paracetamol
What are 2 risk factors for developing Alzheimer’s disease?
family history, depression, loneliness, reduced mental and physical activity, Down’s syndrome
You examine a patient’s CSF, do some bloodwork and an MRI. You see hallmark features of Alzheimer’s. What would you be expecting to see?
cortical atrophy, extracellular deposition of beta amyloid plaques, tau neurofibrillary tangles, damaged synapses
what medication is given to Alzheimer’s patients?
acetylcholinesterase
state some symptoms of PD
- bradykinesia, rigidity, resting tremor
- dementia, disordered sleep, depression, urinary frequency and constipation
treatment for PD?
levodopa, dopamine agonists, COMT/MAO-B inhibitor
what is the main cause of GBS?
campylobacter jejuni infection
What 4 clinical features would you expect to see with GBS?
motor weakness, paraesthesia, respiratory and autonomic involvement
how is a diagnosis of GBS made?
LP with raised CSF proteins
no sensation in genital area -> What is this phenomenon known as?
saddle anaesthesia
why is a PMH of prostate cancer important in a diagnosis of cauda equina syndrome?
prostate cancer can metastasise to the spine
what is the treatment for cauda equina syndrome?
spinal decompression surgery
how do you differentiate between a stroke and Bell’s palsy?
lift eyebrows -> no wrinkles = BP, wrinkles = stroke
if a suspected stroke resolves with no symptoms what is it?
TIA
four risk factors for stroke and TIA?
increasing age, a. fib, smoking, HTN, obesity, DM, alcohol
what inheritance pattern is duchenne muscular dystrophy?
x-linked recessive
Why does Duchenne muscular dystrophy almost exclusively affect boys?
Boys only need one copy of the gene for the disease to manifest as they only have one X chromosome, whereas girls need both copies due to the recessive nature of the condition
appears to understand what you are saying, but is struggling to speak and is slurring his words. What type of aphasia is this?
Broca’s aphasia
what artery is affected when presenting with amaurosis fugax?
anterior cerebral artery
what does an ABCD2 score assess?
- chance of stroke after TIA
ABCD2 score: - Age > 60yrs =1.
- Blood pressure > 140/90mmHg = 1.
- Clinical features (Unilateral weakness = 2.
- Speech disturbance without weakness = 1.
- Duration of symptoms (>1hr = 2. 10-59min = 1).
- Diabetes = 1.
what test is used to confirm epilepsy?
electroencephalogram (EEG)
3 medications used in tonic-clonic seizures?
lamotrigrigine, carbamazepine, levetriacetam
What are the 2 big differentials for epilepsy?
syncope, non-ectopic seizures
how do you treat raised ICP?
IV mannitol
what nerve is affected in carpal tunnel syndrome?
median nerve
Give 2 examination tests for carpal tunnel syndrome.
Phalen’s test, Tinel’s test
What are the roots for the median nerve?
C6-8, T1
loss of sensation in lateral leg and foot, inversion is weak, eversion is unaffected, what is the cause?
L5 radiculopathy
which group of muscles is supplied by the ulnar nerve?
hypothenar muscles
what is the first line medication for trigeminal neuralgia?
carbamazepine
what can granulomatosis with polyangiitis present with?
epistaxis, sinusitis, saddle shaped nose, haemoptysis, glomerulonephritis
what investigations would you do for granulomatosis with polyangitis?
c-ANCA lab testing, imaging, biopsy of affected organs
what would biopsy of affected organs show in someone with granulomatosis with polyangiitis?
necrotising granulomatous inflammation
what is the treatment for granulomatosis with polyangiitis?
immunosuppressive drugs
what 4 investigations can be done in suspected dementia?
Mini-Mental State Assessment, MRI, CSF analysis, confusion screen
which type of dementia behaves in a stepwise like progression of deterioration?
vascular
ischaemic stroke in the anterior cerebral artery will cause what?
contralateral lower limb weakness
ischaemic stroke in the middle cerebral artery will cause what?
- contralateral motor and sensory weakness / loss of upper limbs
- facedrop
- aphasia / dysphasia
ischaemic stroke in the posterior cerebral artery will cause what?
acute vision loss, memory loss
ischaemic stroke of which artery causes hemiparesis of the lower contralateral face, speech impairment and contralateral weakness?
middle cerebral artery
ischaemic stroke of which artery causes contralateral lower limb weakness?
anterior cerebral artery
ischaemic stroke of which artery causes acute vision loss and memory loss?
posterior cerebral artery
What brain pathology results from the rupture of berry-aneurysms?
subarachnoid haemorrhage
describe myasthenia gravis
- autoimmune disease mediated by nicotinic acetylcholine receptor (AChR) antibodies on the post-synaptic side of the neuromuscular junction
- mainly affects muscles of the eyes and face
what are the appropriate treatments for myasthenia gravis?
pyridostigmine, prednisolone, thymectomy
what symptoms would occur in a temporal lobe seizure?
automatisms e.g. lip smacking, chewing and fiddling
what symptoms would occur in a frontal lobe seizure?
motor features e.g. peddling movements of the leg
what is the difference between a complex partial seizure and a simple partial seizure?
simple PS do not affect awareness and there are no post-ictal symptoms, unlike complex
what are the presentations of progressive bulbar palsy (MND)?
LMN involvement of CN 9, 10, 11 12 resulting in:
- dysarthria
- dysphagia
- nasal regurgitation of fluids / choking
- absent jaw jerk reflex
- flaccid and fasciculating tongue
- change in speech
what would a cerebellar tumour present with?
DASHING
- Dysdiadochokinesis
- Ataxia
- Slurred speech
- Hypotonia
- Intention tremor
- Nystagmus
- Gait abnormality
why are lumbar punctures contraindicated in raised ICP?
a lumbar puncture would withdraw CSF, and may provoke immediate coning of the brain through the opening where skull meets spinal cord
how can a brain tumour increase ICP?
- once the tumour becomes large enough there comes a point where no more CSF can be removed from ventricles by brain -> rapid rise in ICP.
- This leads to herniation of the brain
which nerve is responsible for opening the fist?
radial
which muscles are involved with opening the fist?
BEST
- Brachioradialis
- Extensors
- Supinator
- Triceps
what signs suggest ulnar nerve damage?
claw hand, good luck sign - unable to cross fingers
what does damage to the median nerve look like?
- affects precision grip muscles (LOAF) “can’t open jam jar”
- wasting of the thenar eminence and sensory loss / weakness of the abductor pollicis brevis
what would damage to the axillary nerve look like?
weakness in shoulder abduction
what do parietal lobe seizures present with?
sensory disturbances
what do temporal lobe seizures present with?
aura
what do frontal lobe seizures present with?
motor features
Which vitamin is deficient in Wernicke encephalopathy?
vit b1 (thiamine)
what is first line treatment for viral meningitis?
analgesia, antipyretics and hydrate
give 3 symptoms of Horner’s syndrome
anhydrosis, miosis, ptosis
what can cause Horner’s syndrome?
pancoast tumour
presentations of Brown-Sequard Syndrome?
Ipsilateral loss of position, vibration sensation and motor control at the level of the lesion
what is first line medication used for subarachnoid haemorrhages??
nimodipine
first line investigation for MS?
MRI then LP
what is the first line acute treatment for a migraine?
sumatriptan
which tonic-clonic epilepsy medication is teratogenic?
sodium valproate - lamotrigine is next best option
what receptors are affected in myasthenia gravis?
nicotinic acetylcholine receptors
what would compression of the L5 nerve root cause?
pain in outer leg, weakness in dorsiflexion of ankle
What is the diagnostic criteria for multiple sclerosis?
2+ lesions disseminated by time and space AND exclusion of other similarly presenting conditions
On CT scan it is found that a patient with MS has a spinal cord lesion – name 2 symptoms that might be present?
- Numb/tingling limbs
- Leg weakness
- Bladder/Sexual dysfunction
- Lhermitte’s sign
What affect does heat have on patients with MS and why is this the case?
Worsens symptoms – the new myelin is ineffective
In a subdural haematoma where does the bleeding come from?
bridging veins between cortex and venous sinuses
Between which two meningeal layers do subdural haematomas form?
internal dural layer and arachnoid mater
Alcoholics are at a higher risk of subdural haematomas, why is this?
alcohol causes veins to become thin walled making them more susceptible to damage
What is the preferred management for subdural haematomas?
decompression surgery
Give 3 signs of brainstem compression.
ipsilateral pupil dilation, coma, bilateral limb weakness, deep/irregular breathing
What is the gold standard investigation for an epidural haemorrhage?
CT head
define an epileptic seizure
paroxysmal event that causes change of behaviour / cognitive processes due to hypersynchronous neuronal discharges in the brain
name 3 causes of epilepsy
idiopathic, cortical scarring due to head injury, brain tumour, dementia, alcohol withdrawal
give 3 risk factors for epilepsy
family history, premature babies, abnormal blood vessels in brain, dementia, drugs, stroke/tumour/infection
what 2 categories can epileptic seizures be classified into?
primary generalised, partial/focal
Give 2 features that would differentiate Epilepsy from Syncope
tongue biting, cyanosis, post ictal symptoms
immediate first step in course of action in suspected stroke?
CT head
name 4 potential clinical features found in brain tumours?
coma, dysdiadochokinesis, N/V, seizures
what can differentiate compression of spinal cord from cauda equina syndrome?
- additional sensory loss one dermatome below where sensation is already reduced
- UMN signs below level of compression
describe the mechanism of action of the drugs neostigmine and pyridostigmine that are used to treat myasthenia gravis?
blocks active site of acetylcholinesterase, increasing amount of Ach available to the post-synaptic membrane
Adult patients with acute ischaemic stroke should receive alteplase treatment within what time after onset of their symptoms?
< 4.5 hours
what would you see on a CT in PD?
normal
name 2 things seen histologically in PD?
- loss of dopaminergic neurones
- presence of Lewy-bodies
name 4 things seen on a physical exam in PD
- Resting tremor / pill-rolling tremor
- Rigidity (either smooth/lead-pipe or oscillating/cog-wheel)
- Bradykinesia / slowness of movement
- ‘Freezing’ when starting to walk (start-hesitation), when turning or when crossing a
threshold e.g. a doorway, reduced arm swing
what would Huntington’s show on an MRI?
atrophy of the caudate nucleus and putamen
what is the cause of Huntington’s disease?
> 38 repeats of the CAG coding gene for Huntingtin protein
what is Lambert-Eaton Myasthenic Syndrome?
- autoantibodies against presynaptic voltage-gated calcium channels
- typically presents with
proximal weakness which improves through repetitive use - can be secondary to small cell lung cancer
what is given for acute flare ups of MS?
IV methylprednisolone
what is given as long term prophylaxis for MS flare ups?
IV beta-interferon
how do you determine between idiopathic and vascular PD?
- Vascular -> bilateral onset with lower
limb predominance, leading to presentation with falls and gait problems - Idiopathic -> more likely to have unilateral onset with upper limb predominance, leading to a presentation with Bradykinesia.
what is Uhthoff’s phoenomenon?
a transient worsening of neurological symptoms related to a demyelinating disorder such as multiple sclerosis when the body becomes overheated
how do you determine between left and right anterior cerebral artery stroke presentations?
- RACA - left sided hemiparesis
- LACA - right sided hemiparesis
what is given for prophylaxis for cluster headaches?
verapamil
what are Jacksonian seizures?
- type of focal partial seizure which originates from the frontal lobe
- usually begins with a tingling or twitching sensation in a small area
- followed by jerking movements which move proximally at the same side of the body
what is the treatment for malaria?
oral quinine / doxycycline
what is the term to describe a seizure that affects both hemispheres?
generalised
Describe the pathophysiology of paroxysmal electrical discharges, give examples of any neurotransmitters or receptors you mention.
- Area of the brain becomes over active.
- Either too much excitatory e.g. glutamate stimulates NMDA receptors
- Or lack inhibitory e.g. GABA stimulates GABA receptors
give 4 potential causes of a seizure
brain tumour, trauma, infection, drugs
what type of genetic disorder is Huntington’s?
triplet repeat
Describe the genetic pathophysiology of Huntington’s disease
- Huntington gene contains triplet repeat of CAG (10-35)
- CAG codes for glutamine
- in Huntington’s CAG repeated more than 35 times
- this leads to too much glutamine which builds up in the caudate and putamen
- this causes cell death.
what is chorea?
Jerky involuntary movements involving hips, shoulders and face and parkinsonian features
define anticipation
signs and symptoms of a genetic condition becoming more severe/appearing earlier as the disorder is passed on from generation to next
what structure within the brain is the striatum part of?
basal ganglia
List 2 symptoms of complicated malaria.
shock, cerebral malaria, kidney failure, acute respiratory distress syndrome
List the 3 stages of malaria infection.
- exo-erythrocytic stage
- endo-erythrocytic stage
- hypnozoite stage
How would you treat uncomplicated malaria?
quinine, doxycycline
name 3 causes of Wernicke’s encephalopathy
- Chronic alcoholism
- Eating disorders
- Malnutrition
- Prolonged vomiting
what may Wernicke’s encephalopathy present with?
liver disease
What is the triad of Wernicke’s encephalopathy?
confusion, ataxia, ophthalmoplegia
what is delirium tremens?
rapid onset of confusion usually caused by withdrawal from alcohol
how do you treat delirium tremens?
chlordiazepoxide and lorazepam
define weakness
impaired ability to move a body part at will
how do you differentiate MND to myasthenia gravis?
MND never affects eye movements
What is the only medication shown to improve survival of patients suffering from MND and how does it work?
- riluzole
- inhibits glutamate release and is an NMDA receptor antagonist
what will a cerebellar stroke present with?
ataxia, headache, vertigo, vomiting
what can speed up presentations of myasthenia gravis?
infection
what are the nerve roots for carpel tunnel syndrome?
C5-T1
MND: UMN presentations is damage to what?
motor cortex neuronal cell
MND: LMN presentations is damage to what?
anterior horn cell
define stroke
Sudden-onset neurological deficit due to ischaemic or haemorrhagic compromise in blood supply / acute onset of focal neurological deficit of vascular origin which lasts over 24 hours
best answer for first line management for blindness associated with temporal ateritis?
IV methylprednisolone
what is advised in regards to driving after TIA?
dont notify DVLA but no driving for 1 month
prophylaxis for cluster headache?
verapamil
Myasthenia Gravis is an autoimmune disease. What do the antibodies specifically target in this disease?
nicotinic acetylcholine receptors
tendon reflexes in MSG?
initially normal but fatigable
Which serum antibody might you expect to see in a patient with MSG?
- Anti-AChR (acetylcholine receptor) OR
- anti-MuSK (muscle specific tyrosine kinase)
treatment for MSG?
anticholinesterase, prednisolone and alendronate for osteoporosis prophylaxis
