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Finals > Neurology > Flashcards

Neurology Flashcards

1
Q

What do if CT negative for SAH

A

If within 6 hours then no need to rescan
If was done after 6 hours do an LP after 12 hours post sx

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2
Q

What is done if SAH confirmed

A

CT angio

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3
Q

Management of aneurysmal SAH

A

Analgesia
Stop any anti-thrombotics
Nimodipine to prevent vasospasm
Interventional radiologist will treat it with a coil or it can be treated by neurosurgeon with clipping on craniotomy

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4
Q

Complications of SAH

A

Re-bleeding
Hydrocephalus
Vasospasm
Hyponatraemia

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5
Q

What does sudden worsening of symptoms post SAH suggest

A

Rebleeding
Do CT again

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6
Q

What would cause a intracerebral haemorrhage patient to deteriorate

A

Hydrocephalus

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7
Q

Presentation of acute sinusitis

A

Facial pain worse on leaning forward
Nasal obstruction and discharge

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8
Q

Causes of acute sinusitis

A

Commonly rhinovirus
If bacterial then strep pneumoniae or HIB

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9
Q

What can be used for anticoagulation post stroke if AF

A

Warfarin
Dabigatran
Apixaban

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10
Q

Difference in when start long term anticoagulation for AF post TIA vs stroke

A

TIA= immediately
Stroke= 2 weeks later

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11
Q

What antiplatelets are given for stroke and then long term

A

Aspirin 300mg for 2 weeks
Clopidogrel long term

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12
Q

If in stroke and TIA, clopidogrel is contraindicated, what use instead

A

Aspirin and dipyridamole lifelong

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13
Q

How differentiate LBD and parkinsons disease with dementia

A

Parkinsons dementia occurs after a long parkinsons like history
Dementia starts same time as extrapyramidal symptoms in LBD

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14
Q

How investigate neoplastic chord compression

A

MRI whole spine within 24 hours and give high dose dexamethasone in meantine

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15
Q

What medication want to stop in dementia

A

TCAs as risk of worsening cognitive function

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16
Q

Management of migraines

A

1st line- NSAID ideally or paracetamol
2nd line- oral triptan

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17
Q

When is prophylaxis indcated for migraines

A

Having significant effect on life due to frequency or severity

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18
Q

First line for migraine prophylaxis

A

Propranolol

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19
Q

Second line prophylaxis for migraine

A

Topiramate

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20
Q

What can lead to idiopathic intracranial HTN

A

Obesity
Pregnacny
COCP
Tetracyclines
Steroids

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21
Q

Presentation of idiopathic intracranial HTN

A

Headache
Blurred vision
Papilloedema
Enlarged blind spot
Sixth nerve palsy

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22
Q

Signs on examination of IIH

A

6th nerve palsy
Enlarged blind spot
Papilloedema

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23
Q

Management of IIH

A

Lose weight
Start medications
1st line - acetazolamide (carbonic anydrase inhibitors)
2nd topiramate

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24
Q

Which anti-epileptic causes macrocytic anaemia

A

Phenytoin due to reduced folate metabolism

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25
Q

What are rare severe adverse effects of phenytoin

A

TEN
Hepatitis
Aplastic anaemia

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26
Q

Presentation of GBS

A

Preceding gastroenteritis
Initial leg or back pain
Ascending symmetrical weakness of limbs
Can also include
- swallowing difficulty
- cranial nerve defects
- mild sensory defects
- resp effort affected

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27
Q

What is GBS

A

Immune mediated demyelination of the PNS triggered by an infection

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28
Q

Investigations for GBS and their findings

A

LP
- isolated raised protein
Nerve conduction
- decreased motor nerve conduction

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29
Q

What is most common cause of GBS

A

Campylobacter jejuni infection

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30
Q

Causes of trigeminal neuralgia

A

Idiopathic but can be causes by compression from tumours or vascular problems
Commonly seen in MS

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31
Q

Presentation of trigeminal neuralgia

A

Unilateral disorder where get electric shock like sensation
Evoked by shaving, smoking, talking or brishing teeth

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32
Q

Management of trigeminal neuralgia

A

First line carbamazepine
If fails to respond or red flag features refer to neuro

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33
Q

Red flag signs of trigeminal neuralgia

A

Under 40
Deafness or ear problems
Sensory problems
Optic neuritis
FHx of MS

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34
Q

Presentation of charcot marie tooth disease

A

Mainly motor loss
- foot drop
- high arched feet
- muscle weakness if hands and feet
- hyporeflexia
- stork leg deformity
- lots of ankle sprains

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35
Q

Management of Charcot marie tooth disease

A

There is no cure, and management is focused on physical and occupational therapy

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36
Q

Believed aetiology of bells palsy

A

HSV

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37
Q

Who is bells palsy commonly seen in

A

Young people aged 20-40
Pregnant women

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38
Q

Management of bells palsy

A

If within 72 hours give prednisolone
Eye care important to prevent keratopathy- aritifical tears and lubricants

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39
Q

Eye care for bells palsy

A

Artifical tears and lubricants
May have to tape eyes closed if unable to shut at night

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40
Q

When refer bells palsy to ENT

A

If after 3 weeks is no real improvement

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41
Q

On top of facial paralysis what may also encounter in bells palsy

A

Post auricular pain preceding paralysis
Altered taste
Dry eyes
Hyperacusis

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42
Q

Cutaneous features of tuberous sclerosis

A

Ash leaf spots
Cafe au lait spots
Subungal fibromata
Adenoma sebaceum
Shagreens patch

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43
Q

What is adenoma sebaceum

A

Angiofibromas seen in butterfly distribution over nose
Seen in tuberous sclerosis

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44
Q

MOA of triptans

A

Serotonin (5-HT) agonists

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45
Q

When take a triptan

A

At outset of headache not aura

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46
Q

Side effects of triptans

A

Triptan sensations- tingling, chest and throat tightness, heaviness

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47
Q

Contraindications of triptans

A

SSRI, SNRI
IHD

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48
Q

First time seizure assessment

A

CT and BM
Refer to outpatient clinic where have EEG and anti-epileptic may be started

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49
Q

First line for tonic-clonic seizures

A

Sodium valproate if male
Lamotrigine or levetiracetam if female

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50
Q

First line for focal seizures

A

Lamotrigine or levetiracetam

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51
Q

Second line for focal seizures

A

Carbamazepine

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52
Q

First line for absence seizures

A

Ethosuximide

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53
Q

Second line for absence seizures

A

Sodium valproate if male
Lamotrigine or levetiracetam if female

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54
Q

Myoclonic seizures management

A

Sodium valproate if male
Levetiracetam if female

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55
Q

In ALS, what are mutations often seen in

A

Superoxide dismutase

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56
Q

Presentation of progressive bulbar palsy

A

Palsy of the tongue, chewing muscles, swallowing and facial muscles

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57
Q

Which MND has worst prognosis

A

Progressive bulbar palsy

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58
Q

What are the types of MND

A

Amyotropic lateral sclerosis
Progressive muscular dystrophy
Progressive bulbar palsy
Primary lateral sclerosis

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59
Q

Types of motor neurone signs seen in the different MNDs

A

ALS
- LMN in arms
- UMN in legs
PLS
- UMN only
Progressive muscular atrophy
- LMN only
- affects distal then proximal muscle groups

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60
Q

Which medications most commonly associated with medication overuse headaches

A

Opioids
Triptans

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61
Q

Management of medication overuse headaches

A

Principally need to stop analgesia even though will worsen headache
- slowly withdraw opioids
- simple analgesia and triptans stop abruptly

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62
Q

Management of acute MS relapse

A

High dose oral or IV methylprednisolone for 5 days

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63
Q

Main drug used for preventing relapse of MS

A

Natalizumab

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64
Q

Management of fatigue in MS

A

Rule out anaemia etc
Give amantadine first line then trial CBT or mindfulness

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65
Q

Management of spasticity in MS

A

Baclofen and gabapentin given first line
2nd line options- diazepam and physio

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66
Q

Management of bladder dysfunction in MS

A

Do USS first to determine if significant residual volume
If residual volume- intermittent self-catheterisation
If no residual volume- anticholinergics

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67
Q

What is it when visual fields oscillate in MS

A

Oscillopsia

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68
Q

How manage oscillopsia in MS

A

Gabapentin

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69
Q

Which anti-emetic give in migraines

A

Metoclopramide or prochlorperazine

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70
Q

What type of seizure if twitching and jerks in legs and arms in AM where maintain consciousness

A

Myoclonic

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71
Q

Long term mangement of TIA

A

Long term clopidogrel
Aspirin and dipyrimadole if can’t tolerate clopidogrel

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72
Q

What can cause subacute degeneration of the spinal chord

A

Vit B12 deficency
Inhaled nitrous oxide

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73
Q

Which parkinsons medication most linked to impulse disorders

A

Dopamine receptor agonists

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74
Q

If there is macula sparing in vision, where is lesion

A

Occipital cortex

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75
Q

If a young man develops tunnel vision, what is diagnosis

A

Retinitis pigmentosa

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76
Q

Where is lesion if developing tunnel vision

A

Peripheral retina

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77
Q

How does retinitis pigmentosa present

A

Early blindness
Nighttime blindness first symptom often
Tunnel vision as peripheral vision lost

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78
Q

Management of brain abscess

A

IV ceftriaxone and metronidazole
Dexamethasone
Surgery to debride abscess

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79
Q

What test use to differentiate functional from organic weakness

A

Hoover sign

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80
Q

What is hoover sign

A

If someone was genuinely trying to lift up their leg they would feel the other leg pressing down against bed

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81
Q

What are pseudoseizures

A

Seen in patients with mental illness where they fake having a seizrue

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82
Q

Signs someone has had a pseudoseizure

A

pelvic thrusting
family member with epilepsy
much more common in females
crying after seizure
don’t occur when alone
gradual onset

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83
Q

How differentiate between a seizure and pseudoseizure biochemically

A

Serum prolactin

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84
Q

What is hoffmans sign

A

If flick distal phalynx then with UMN lesion there will be flexion in the index and thumb

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85
Q

What is sign seen on examination typically in uncal herniation

A

6th nerve palsy

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86
Q

NF1 presentation

A

Café-au-lait spots
Axillary/groin freckles
Peripheral neurofibromas
Iris hamatomas
Scoliosis
Pheochromocytomas
Gastrointestinal stromal tumour

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87
Q

NF2 presentation

A

Bilateral vestibular schwannomas
Multiple intracranial schwannomas, mengiomas and ependymomas

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88
Q

Myasthenic crises management

A

IVIG
Plasmapharesis
Monitor FVC with spirometry (less than 1.5L= contact ITU)- BiPAP or mechanical ventilation may be required

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89
Q

Long term management for myasthenia

A

Long acting acetylcholinesterase inhibitor- pyridostigmine
May require immunosuppression with steroids or azathioprine

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90
Q

Most common primary tumour for brain mets

A

Lung

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91
Q

What is an antalgic gait

A

Limp caused by weight on the affected limb

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92
Q

What is an ataxic gait

A

Wide based gait
Struggle to do toe to heel walk

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93
Q

How to rememeber causes of cerebellar disease

A

PASTRIES
Posterior fossa tumour
Alcohol
MS
Trauma
Rarer causes
Inherited
Epilepsy tx
Stroke

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94
Q

What is a chiari formation

A

Where a part of brain herniates through a malformation in skull leading to compression of the spinal chord

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95
Q

Sensory loss in syringomyelia

A

Cape distribution
Neck, shoulders and arms
Pain and temperature

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96
Q

Autonomic dysfunction in syringiomyelia

A

Horners
Bladder and bowel problems

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97
Q

Presentation of syringiomyelia

A

Cape distribution pain and temp sensory loss
Spastic weakness in leegs
Upgoing plantars
Neuropathic pain

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98
Q

Investigations for syringiomyelia

A

MRI brain to look for chiari formation
MRI spine to look for tethered chord

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99
Q

Management of syringiomyelia

A

Treat cause like surgery
Drain if permenant or symptomatic

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100
Q

NPH MRI finding

A

Ventriculomegaly with an absence of sulcal enlargement

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101
Q

Triad of NPH

A

Incontinence
Dementia
Gait abnormality

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102
Q

Pathophysiology of NPH

A

Reduced absorption secondary to prior meningitis, trauma or bleed

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103
Q

Management of NPH

A

Ventriculoperitoneal shunt but very risky as high risk of bleeing, seizures and infection

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104
Q

Pathophysiology of cervical degenerative myelopathy

A

Compression of spinal chord in cervical area due to degenerative changes in the area
Typically smoking is main risk factor for it

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105
Q

Presentation of cervical degenerative myelopathy

A

Pain
- in neck directly
- in arms
Motor problems
- loss of dexterity in hands
- weakness
Sensory problems
Autonomic dysfunction

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106
Q

What is good indicator on examination for degenerative cervical myelopathy

A

Positive hoffmans sign

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107
Q

What is uthoffs phenomena

A

Worsening vision when temperature rises
MS

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108
Q

What is L’hermittes sign

A

Limb parasthesia when flex neck

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109
Q

Classical parkinsons triad

A

Tremor
Bradykinesia
Rigidity

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110
Q

Bradykinesia parkinsons presentation

A

Slow, shuffling gait
Difficulty initiating movements
Povert of movement

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111
Q

Characteristics of parkinsons tremor

A

Worse at rest
Helped by voluntary movements
Worse when tired or stressed

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112
Q

What is pill rolling tremor seen in

A

Parkinsons

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113
Q

What is rigidity described as in parkinsons

A

Leadpipe
Can be cogwheel superimposed from tremor

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114
Q

Extra features of parkinsons

A

Micrographia
Drooling
Autonomic dysfunction- postural drop
Depression
Loss of REM sleep

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115
Q

Drug induced parkinsons vs idiopathic

A

Drug induced
- bilateral
- rapid onset
- rest tremor and rigidity rare

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116
Q

If clinical diagnosis uncertain for parkinsons, what can use

A

123I‑FP‑CIT single photon emission computed tomography (SPECT)

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117
Q

Cluster headache presentation

A

Intense headache behind the eye, stabbing
Occur in clusters lasting 15-120 mins
Get over a period of time then remit for a bit
Associated with stuffy nose, red face and lacrimation

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118
Q

If someone presents to GP with cluster headache what do

A

Refer to neurology

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119
Q

What investigation will be done by neurology for cluster headaches

A

MRI with gadolinium contrast- may show underlying tumour

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120
Q

Acute management of cluster headache

A

High flow O2
Subcut triptan

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121
Q

What can be given for cluster headache prophylaxis

A

Verapamil

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122
Q

What often triggers autonomic dysfunction

A

Faecal impaction or urinary retention

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123
Q

What type of hallucination is smelling roses

A

Focal olfactory

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124
Q

How manage neuropathic pain

A

1 of amitryptylline, duloxetine, pregabalin or gabapentin
If fail to work switch
If resistant refer to pain clinic

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125
Q

What can use for localised neuropathic pain

A

Caspaicin

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126
Q

Which anti-emetic can cause prolonged QT

A

Ondensatron

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127
Q

Difference in appearance of ischaemic vs haemorrhagic stroke on CT

A

Haemorrhagic= hyperdense
Hypodense area and hyperdense artery = ischaemic

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128
Q

What is the hyperdense artery sign

A

Here the affected artery appears hyperdense due to accumulation

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129
Q

Presentation of sporadic creutzfield jacobs disease

A

Older patient
Rapid onset dementia
Myoclonus
Mutism
Psychiatric symptoms

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130
Q

Presentation of variant CJD

A

Younger patient
Psychiatric problems early

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131
Q

Investigations for CJD

A

CSF is usually normal
EEG: biphasic, high amplitude sharp waves (only in sporadic CJD)
MRI: hyperintense signals in the basal ganglia and thalamus

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132
Q

Antibodies in lambert eaton

A

voltage-gated calcium channel in the peripheral nervous system

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133
Q

Presentation of lambert eaton syndrome

A

Proximal myopathy of lower limbs
Autonomic dysfunction- dry mouth
Improves with exercise
Tenderness in muscles
Hyporeflexia which improves after exercise

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134
Q

Investigations for lambert eaton syndrome

A

EMG- shows incremental response to repetitive electrical stimulation

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135
Q

What is roughened skin over the lumbar spine in association with seizures

A

Shagreens patches seen in tuberous sclerosis

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136
Q

If not responded to 2 rounds of IV lorazepam what are options to start

A

Phenytoin
Sodium valproate
Levetiracetam

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137
Q

What is impaired in dorsal column disorders

A

Proprioception
Vibration
Light touch

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138
Q

Presentation of subacute degeneration of the spinal chord

A

Dorsal column involvement
- distal tingling/burning/sensory loss
- impaired vibration and proprioception
Corticospinal tracts
- weakness
- UMN signs
Spinocerebellar involvement
- gait abnormalities

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139
Q

What does positive rombergs indicate

A

B12 deficiency due to spinocerebellar tract involvement

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140
Q

What is the spinocerebellar tracts function

A

Sensory pathway relaying information about balance and proprioception to cerebellum

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141
Q

An aneurysm or aneurysm rupture in what vessel can lead to third nerve palsy

A

Posterior communicating artery

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142
Q

If have unprovoked seizure with normal imaging, when can drive next

A

6 months
Must notify DVLA

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143
Q

What is inheritance of essential tremor

A

Autosomal dominant

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144
Q

What are features of an essential tremor

A

Worse when arms outstretched
Can affect head, vocal chords and jaw
Improved by alcohol and rest

145
Q

Where can essential tremor also affect

A

Vocal chords- can get change in voice
Head and jaw can be affected

146
Q

Management of essential tremor

A

Propanolol

147
Q

What is new definition of a TIA

A

Transient episode of neurologic dysfunction caused by ischaemia without acute infarction visible on imaging
NOT BASED ON TIME BUT IMAGING

148
Q

Sensory predominant peripheral neuropathy causes

A

Alcohol
Vit B12
DM
Amyloid
Uraemia
Leprosy

149
Q

Motor predominant peripheral neuropathy causes

A

Guillain-Barre syndrome
porphyria
lead poisoning
hereditary sensorimotor neuropathies (HSMN) - Charcot-Marie-Tooth
chronic inflammatory demyelinating polyneuropathy (CIDP)
diphtheria

150
Q

What malignancy most likely to cause myasthenia gravis

A

Thymoma

151
Q

What is presentation if pontine artery stroke

A

Low GCS
Bilateral pinpoint pupils
Paralysis

152
Q

What does high stepping gait indicate

A

Foot drop- is walking technique used to accommodate

153
Q

Causes of high stepping gait

A

Peripheral neuropathy

154
Q

What is nature of parkinsons referral to neuro

A

Urgent

155
Q

What diet advised for epilepsy

A

Ketogenic

156
Q

Management of low pressure headache post LP

A

Fluids, coffee and rest
2nd line- blood patch, IV caffeine

157
Q

Which drugs exacerbate myasthenia

A

Beta blockers
Lithium
Phenytoin
Abx
Stress

158
Q

Causes of facial nerve palsy

A

Sarcoid
Petrous temporal fracture
Cholesteatoma
Parotid tumours
HIV
MS
DM

159
Q

If seize with whole body but consciousness intact, what is it

A

Pseudoseizure

160
Q

What use to image demyelinating lesions in MS

A

MRI with contrast

161
Q

What is jacksonian march

A

Seizure will initially start with affecting a peripheral body part then spread over whole limb and can become generalised

162
Q

Most common complication of meningitis

A

Sensorineural hearing loss

163
Q

How is nutrition give in MND

A

Percutaneous gastrostomy tube (PEG)

164
Q

What resp care is given for MND

A

BiPAP at night

165
Q

What is management of MND

A

Riluzole if ALS
Resp care- BiPAP
Nutrition- PEG tube

166
Q

What is riluzole

A

Drug used in MND which blocks glutamate receptors

167
Q

If first line for focal seizures does not work, what do

A

Give either lamotrigine or levetiracetam depending on what trialled first
Second line is carbamazepine

168
Q

LP finding in MS

A

Raised oligoclonal bands

169
Q

How remember what visual defect a parietal or temporal lesion will cause

A

PITS
Parietal- inferior
Temporal- superior

170
Q

Difference in bitemp hemianopia caused by pituitary tumour vs craniopharyngioma

A

Pituitary tumour- upper defect
Craniopharyngioma- lower defect

171
Q

Which focal seizures often present with an aura

A

Temporal

172
Q

Examples of temporal focal seizure auras

A

Rising epigastric sensation
Deja vu
Hallucinations- rare

173
Q

If want to test CSF that is leaking out of nose or ear, what is quick bedside test can do

A

Check for glucose which will be present if CSF

174
Q

What is further classification of focal temporal seizures

A

Impaired awareness or aware

175
Q

Atonic seizure management

A

Sodium valproate if male
Lamotrigine if female (lAmotri for atonic and not levetiracetam)

176
Q

TIA management if taking an anticoagulant

A

Refer for immediate assessment and imaging

177
Q

Management of TIA immediately

A

Give 300mg aspirin unless
- on anticoagulant then refer for imaging
- taking low dose aspirin- continue dose until review
- aspirin CI

178
Q

Best imaging for intracranial venous thrombosis

A

MRI venography

179
Q

Management of intracranial thrombosis

A

LMWH

180
Q

What are the types of intracranial venous thrombosis

A

Sagittal sinus
Cavernous sinus
Lateral sinus

181
Q

What does empty delta sign on venography suggest

A

Sagittal sinus thrombosis

182
Q

How manage neuroleptic malignant syndrome

A

Stop antipsychotic- transfer to medical ward
IV fluids
Dopamine agonists- bromocriptine

183
Q

Presentation of neuroleptic malignant syndrome

A

Side effect of antipsychotics
- pyrexia
- muscle rigidity
- agitation and confusion
- autonomic instability- HTN, tachycardia

184
Q

Blood findings of neuroleptic malignant syndrome

A

Leukocytosis
Raised CK
Can get AKI secondary to rhabdo

185
Q

How position head if raised ICP

A

Head elevation to 30 degrees

186
Q

Management of raised ICP

A

Head elevation to 30 degrees
Controlled hyperventilation
Put in shunt if from raised ICP

187
Q

Cushings triad

A

Widened pulse pressure
Bradycardia
Irregular breathing

188
Q

Investigation for narcolepsy

A

Multiple sleep latency EEG

189
Q

How manage narcolepsy

A

Daytime stimulants
Nighttime sodium oxybate

190
Q

What is sodium oxybate

A

A strong sedative

191
Q

What is an example of daytime stimulant used in narcolepsy

A

Modafinil

192
Q

Narcolepsy presentation

A

Excessive sleepiness
Cataplexy
Vivid hallucinations when falling asleep
Sleep paralysis

193
Q

Where refer for degenerative cervical myelopathy

A

Spinal surgery

194
Q

What Hz is parkinsons tremor typically

A

3-5
Essential tremor is 6-12

195
Q

When can drive after a TIA

A

Can drive after a month if no symptoms
No need to inform DVLA

196
Q

Are subdural bleeds limited by suture lines

A

No

197
Q

What is klumpkes syndrome

A

C8 and T1 nerve root injury

198
Q

What tends to causes klumpkes syndrome

A

Birth injury
Falling from tree and trying to grab a branch

199
Q

Presntation of klumpkes syndrome

A

Claw grip from loss of intrinsic muscles in hand
Sensory loss in dermatomes C8 and T1

200
Q

If someone with parkinsons presents to hospital and does not have a safe swallow for dopamine, what give

A

Dopamine patch agonist

201
Q

What is mononeuritis multiplex

A

Simultaneous involvement at least 2 different areas of the peripheral nervous system

202
Q

What is a polyneuropathy

A

a general symmetrical degeneration of peripheral nerves that spreads towards the centre of the body.

203
Q

Differentiating mononeuritis multiplex from polyneuropathy

A

Mononeuritis multiplex asymmetrical

204
Q

When can AEDs be withdrawn

A

If 2 years no seizures
Must be stopped over 2-3 months

205
Q

In parkinsons what is it really important to do when patient admitted

A

They continue to have dopamine agonists as will go into acute dystonia
If unable to swallow then give patch

206
Q

What anaesthetic would MG patients be resistant to

A

Suxamethonium

207
Q

What dementia is associated with MND

A

Frontotemoral dementia

208
Q

Where is seizure if post ictal dysphasia

A

Temporal

209
Q

What is classic features of parietal lobe seizures

A

Parasthesia

210
Q

What is classical feature of frontal seizures

A

Motor symptoms
Head/leg movements
Post-ictal weakness
Jacksonian march

211
Q

What is contained within the cavernous sinus

A

3-6
Oculomotor nerve
Trochlear nerve
Opthalmic nerve (CNV1)
Maxillary nerve (CNV2)
Abducens

212
Q

What causes cavernous sinus syndrome

A

Cavernous sinus tumours typically tumours that invade the cavernous sinus such as nasopharyngeal tumours

213
Q

Patient with nasopharyngeal tumour develops; proptosis, absent coreal reflex, horners syndrome and pain on eye movements

A

Cavernous sinus syndrome

214
Q

Presentation of cavernous sinus syndrome

A

Proptosis
Trigeminal nerve lesions
- absent corneal reflex
Horners
Third nerve palsy

215
Q

If have painful third nerve palsy, what need to rule out

A

Posterior communicating artery

216
Q

Sudden onset headache with isolate hypotension

A

Pituitary apoplexy from pituitary insufficiency
If bleed then HR up

217
Q

What is pituitary apoplexy

A

Sudden enlargement of pituitary tumour from infarction or haemorrhage

218
Q

Presentation of pituitary apoplexy

A

Sudden onset headache
Vomiting
Neck stiffness
Visual defects (bitemp superior quadrantopia)
Hypotension from pituitary insufficiency

219
Q

How investigate pituitary apoplexy

A

MRI

220
Q

Management of pituitary apoplexy

A

Urgent steroid replacement
Surgery

221
Q

What is an arnold chiari malformation

A

Herniation of cerebellar tonsils through foramen magnum

222
Q

Features of arnold chiari malformation

A

Non-communicating hydrocephalus
Headache
Syringomyelia

223
Q

Multiple system atrophy presentation

A

Parkinsons
Early autonomic disturbance
- postural drop
- impotence
Cerebellar signs

224
Q

What questionnaire measures impairment from stroke

A

NIHSS

225
Q

What scale is used to differentiate stroke from stroke mimics in the acute setting

A

ROSIER

226
Q

Management of chronic subdurals

A

If symptomatic or very large
- burr hole evacuation
Asymptomatic and found incidentally
- conservative

227
Q

Management of acute subdural

A

Small
- conservative
Large
- depressive craniectomy or monitor intracranial pressure

228
Q

If starting a phenytoin infusion for status epilepticus what need to do

A

Place on a cardiac monitor

229
Q

If patient has locked in syndrome, what is location of stroke

A

Basilar

230
Q

Presentation of middle cerebral artery stroke

A

Arm and facial hemiparesis plus sensory loss

231
Q

Presentation of posterior cerebral artery

A

Contralateral homonymous hemianopia with macula sparing
Visual agnosia

232
Q

What is visual agnosia

A

Impairment in recognising objects visually but would be able to identify via touch or smell

233
Q

What is the basilar artery

A

Artery leading up to the circle of willis

234
Q

What are the pontine arteries

A

Arteries branching off the basilar artery

235
Q

What is the regional blood supply to the brain

A
236
Q

What is blood supply to the midbrain

A

Branches of the posterior cerebral artery

237
Q

What is presentation of midbrain stroke

A

Ipsilateral CN III palsy
Contralateral upper and lower limb weakness

238
Q

What is weber syndrome

A

Get stroke in branch of posterior cerebral artery supplying the midbrain. Presents with ipsilateral CN III palsy and contralateral limb problems

239
Q

What is other name for lateral medullary syndrome

A

Wallenberg

240
Q

What causes lateral medullary syndrome

A

Stroke in the posterior inferior cerebellar artery

241
Q

Presentation of lateral medullary syndrome

A

Ataxia and nystagmus
Horners
Ipsilateral pain or loss of pain in face
Contralateral pain in trunk or limbs

242
Q

What causes lateral pontine syndrome

A

Anterior inferior cerebellar artery

243
Q

Presentation of lateral pontine syndrome

A

Same as wallenbergs- Ataxia and nystagmus, horners, ipsilateral pain or loss of pain in face, contralateral pain in trunk or limbs
PLUS
Hearing loss and facial paralysis (CN7+8) involvement

244
Q

Lacunar stroke presentation

A

Isolated hemiparesis or sensory loss
Or plus ataxia

245
Q

Sites of lacunar infarcts

A

Mainly caused by HTN
- Thalamus
- Basal ganglia
- Internal capsule

246
Q

Other than managing the infarct itself what 5 things need to be considered post stroke

A

Fluid balance
Glycaemic control
BP control
Feeding assessment
Assessing disability

247
Q

Fluid balance important points post stroke

A

Review daily as hypovolaemia leads to poor perfusion and hypervolaemia leads to oedema
Oral hydration recommended but may need IV saline if swallow not intact

248
Q

Glycaemia management post stroke

A

Important to keep between 4-11
Hyperglycaemia associated with poor mortality

249
Q

Management post stroke if diabetic

A

Intense management
If diabetic optimise with IV glucose and insulin

250
Q

How manage hypertension post stroke

A

Should avoid antihypertensives unless HTN emergency like dissection, nephropathy, encephalopathy or MI/HF

251
Q

What must all stroke patients be screened for in 24 hours after event

A

Swallow

252
Q

What do if is any concern about swallow after stroke

A

Withold all oral intake including food/drugs/fluids
Get specialist assessment within 24 hours

253
Q

Management of impaired swallow post stroke

A

NG tube feed within 24 hours unless had thrombolytic therapy
If NG not tolerated arrange nasal bridle tube or gastrostomy

254
Q

What is a nasal bridle tube

A

Nasal loop used to stop NG tube from being pulled out

255
Q

What score is used to determine disability post stroke and requirement for rehab team

A

Barthel index

256
Q

When start statin post stroke

A

If cholesterol over 3.5
Do after 48 hours

257
Q

If swallow impaired post stroke how administer aspirin

A

Rectally

258
Q

According to the bamford/oxford stroke classification, what are the main types

A

Total anterior
Partial anterior
Lacunar infarcts
Posterior circulation
Extra syndromes- lateral medullary, weber

259
Q

What are 3 things assess in bamford stroke classification

A

Unilateral hemiparesis or sensory loss
Homonymous hemianopia
HIgher cognitive dysfunction

260
Q

In bamford stroke classification, what are examples of higher cognitive dysfunction

A

Aphasia
Apraxia

261
Q

What is difference between PACI and TACI

A

PACI= 2 of
TACI= 3 of
- Unilateral hemiparesis or sensory loss
- Homonymous hemianopia
- Higher cognitive dysfunction

262
Q

Difference in pathology of PACI and TACI

A

TACI= middle and anterior cerebral arteries involved
PACI= smaller vessels of these involved

263
Q

Ipsilateral CN III lesion with contralateral limb weakness

A

Midbrain stroke

264
Q

Where is brocas area

A

Frontal lobe

265
Q

Where is wernickes area

A

Superior temporal gyrus

266
Q

What is function of wernickes area

A

Area that comprehends speech

267
Q

What is function of brocas area

A

Expressive area that generates speech

268
Q

What is difference in arterial supply of brocas and wernickes area

A

Brocas- superior division of left MCA
Wernickes- inferior division of left MCA

269
Q

Post TIA when are carotid dopplers recommended

A

ASAP unless not candidate for endarterectomy

270
Q

What is preferred investigation for TIA

A

MRI diffusion weighted as best identifies area of ischaemia
Ideally do on same day as specialist assessment

271
Q

Difference in drug used to reduce ICP in different pathologies

A

Infection or malignancy= dexamethasone
Traumatic brain injuries= IV mannitol

272
Q

If brain bleed or traumatic injury, what drug use to reduce ICP

A

IV mannitol

273
Q

What cranial nerves affected by acoustic neuromas

A

5, 7, 8

274
Q

A 69-year-old woman presents with a 3 week history of a headache which is worse on the right side. She is generally unwell and feels ‘weak’, noting particular difficulty in getting up from a chair

A

GCA from PMR

275
Q

LP finding of IIH

A

Very high opening pressure
Normal CSF

276
Q

What is restless leg syndrome

A

Syndrome of spontaneous continuous leg movements assoc with parasthesia
Very common- 2-10%

277
Q

Presentation of restless leg syndrome

A

Uncontrollable urge to move legs (akathisia)- worse at rest and at night
Parasthesias- weird sensations in legs
Movements of legs in sleep

278
Q

Causes of restless leg syndrome

A

Idiopathic with strong family history
DM
IDA
Pregnancy

279
Q

Investigations for restless leg syndrome

A

Rule out possible causes
- Iron studies
- HbA1c

280
Q

First line treatment for restless leg syndrome

A

Dopamine agonists- ropinirole
Walking, stretching, massaging

281
Q

Second line options for restless leg syndrome

A

Benzos
Gabapentin

282
Q

When do patients need specialist review by for TIA

A

In last 7 days= within 24 hours
Over 7 days ago= within 7 days
Need for admission under stroke physician if
- crescendo TIA
- suspected cardioembolic source
- carotid artery stenosis

283
Q

When may admit patient with TIA for observation

A

Crescendo TIA
Cardioembolic source
Suspected carotid artery stenosis aetiology

284
Q

What is a cresecendo TIA

A

If have multiple in short space of time

285
Q

If a patient under 55 presents with a stroke what investigations must be done

A

Thrombophilia screen
- ANA
- antiphospholipid syndrome
- lupus anticoagulant
- ESR
- syphilis serology

286
Q

Management of GBS

A

First line= IVIG
Can do plasmapharesis

287
Q

Rfs for MS

A

Vit D deficiency
Female
Aged 20-40

288
Q

What use for nausea in parkinsons

A

Domperidone- blocks dopamine receptors but does not cross BBB

289
Q

What is type of seizure if becomes upset the unresponsive and wanders the house

A

Focal seizures with impaired awareness- automatisms evident

290
Q

DANISH

A

Dysdiadochokinesia
Ataxia
Nystagmus
Intention tremor
Slurred speech
Hypotonia

291
Q

If have hyperdense area in the centre of brain what could be

A

Basilar artery thrombus

292
Q

What % of right handed people have speech centre on right side

A

10%

293
Q

What % of left handed people have speech centre on left

A

60-70%

294
Q

What is cut off INR for thrombolysis

A

1.7 and below

295
Q

Absolute CIs to thrombolysis

A
  • Previous intracranial haemorrhage
  • Seizure at onset of stroke
  • Intracranial neoplasm
  • Suspected subarachnoid haemorrhage
  • Stroke or traumatic brain injury in preceding 3 months
  • Lumbar puncture in preceding 7 days
  • Gastrointestinal haemorrhage in preceding 3 weeks
  • Active bleeding
  • Pregnancy
  • Oesophageal varices
  • Uncontrolled hypertension >185/110
296
Q

If doing head CT scan and identify proximal infarction what do next

A

Convert to CT angio

297
Q

When can offer thrombectomy up to 24 hours post symptoms

A

If proximal anterior circulation stroke and is area of salvageable brain tissue identified on diffusion weighted MRI

Consider if posterior circulation stroke

298
Q

Management of DCM

A

Decompressive surgery
Can observe if very mild

299
Q

Corneal reflex nerve

A

CN V1

300
Q

Progressive supranuclear palsy presentation

A

Parkinsons+ dysarthria and difficulty looking upwards

301
Q

Internuclear opthalmoplegia presentation

A

Ipsilateral impaired eye adduction
Horizontal nystagmus in abucting eye on other side

302
Q

Causes of internuclear opthalmoplegia

A

MS
Vascular cause

303
Q

What is affected in internuclear opthalmoplegia

A

Medial longitudinal fasciculus

304
Q

When give aspirin in stroke

A

If thrombolysis or thrombectomy not possible

305
Q

If a patient is not aphasic where is stroke most likely to have occured

A

Anterior cerebral arteries

306
Q

In exacerbations of neuropathic pain what can be used

A

Tramadol

307
Q

What is the cerebellar vermis

A

Central part of cerebellum which separates the hemispheres

308
Q

Where in cerebellum is lesion if develop ataxic gait

A

Cerebellar vermis

309
Q

What is an example of peripheral ataxia

A

Finger nose ataxia

310
Q

If develop finger nose ataxia where is lesion

A

Cerebellar hemisphere

311
Q

What is todds paresis

A

After a focal motor seizure can develop weakness

312
Q

If undergo haemorrhagic transformation of ischaemic stroke how manage

A

Stop aspirin/alteplase
Control BP to under 140 systolic
CT and neurosurgery referral

313
Q

If patient undergoes surgery for DCM then later develop neuro problems what is likely cause

A

Recurrent DCM

314
Q

Difference in supply of internal vs external carotid arteries

A

Internal- circle of willis
External- mainly facial arteries eg lingual, maxillary etc

315
Q

What investigation do for LBD

A

SPECT/DAT scan

316
Q

How manage spasticity in MND

A

Baclofen

317
Q

NCS and EMG findings in MND

A

NCS is normal
EMG is reduced number of action potentials and increased amplitude

318
Q

Investigations for MND

A

MRI
NCS and EMG
CLINICAL DIAGNOSIS

319
Q

Types of MS

A

Relapsing remitting- most common
Primary progressive-Progressive deterioration from the onset of the disease course
Secondary progressive- initial relapsing remitting then progresses
Clinically isolated syndrome- 1 demyelinating event which may progress to MS or remain isolated

320
Q

Definitive management options for SAH

A

IR will place platinum coil
Neurosurgeons can do craniotomy and clip

321
Q

How manage hydrocephalus from SAH

A

Short term= ventricular drain
Long term= can put in ventriculoperitoneal drain

322
Q

CT scan of extradural

A

Limited by suture lines
Crescent shaped

323
Q

Extradural haematoma management

A

If no focal neurology can do radiological monitoring
Otherwise need to do decompressive craniectomy and fix artery

324
Q

Intracerebral haemorrhage investigation finding and management

A

Area of hyperdensity in cortex
Conservative under care of strokes, if LOC and massive clot then can do surgical management

325
Q

Suspected brain tumour referral guidelines

A

MRI within 2 weeks for adults
MRI within 48 hours if young person with new onset cerebellar or neurological dysfunction

326
Q

Investigations for brain tumour

A

Fundoscopy to look for papilloedema
MRI first line
Biopsy is gold standard

327
Q

What must worry about if new onset personality

A

Brain tumour in frontal lobe- do MRI

328
Q

What is most common tumour in brain

A

Metastases are most common
Most common primary is meningioma but if malignant then glioblastoma is most common

329
Q

MRI meningioma vs glioblastoma

A

Meningioma- well circumscribed with dural tail where attatched to dura
Gliobastoma- ring enhancing lesion with lots of vasogenic oedema

330
Q

If have diagnosed MG what need to do next as an investigation

A

CT/MRI thorax to check for thymoma

331
Q

Investigations for MG

A

Antibodies- anti ACHr and MUSK
NCS- reduced after repeated stimulation
MRI/CT thorax- to look for thymoma
Tensilon test with edrophonium

332
Q

What is tensilon test

A

Used if diagnostic uncertainty for MG
Give IV edrophonium which blocks acetylcholinesterase- if have MG will temporarily relieve weakness

333
Q

What happens to reflexes in LEMS

A

Reduced/absent
If exercise can improve

334
Q

Management of LEMS

A

Immunosuppression- steroids, azathioprine

335
Q

Serious causes of tremor to rule out

A

Parkinson’s disease
Multiple sclerosis
Huntington’s chorea
Hyperthyroidism
Fever
Dopamine antagonists (e.g., antipsychotics)

336
Q

Huntingtons inheritance details

A

AD
Anticipation as gets worse in future younger generations with earlier presentation

337
Q

Hungtingtons features

A

Psych- depression and dementia first presentation
Then develop chorea, muscle rigidity, dysarthria, eye movement disorders and dysphagia

338
Q

Investigation for huntingtons

A

Genetic testing

339
Q

How manage chorea in huntingtons

A

Tetrabenzine

340
Q

Management of parkinsons

A

First line depends if motor symptoms affecting daily life, if so then Levodopa
If not then choose between levodopa, dopamine agonist or MOA-B

341
Q

Drug options for parkinsons

A

Levodopa
Dopamine agonists- ropinirole, cabergoline, bromocriptine
MAO-B inhibitors- raseligine, seligine
COMT inhibitors

342
Q

What needs to be given with levodopa

A

Peripheral decarboxylase inhibitor (e.g., carbidopa and benserazide)

343
Q

What is problem of leveodopa

A

Dyskinesia common
- athetosis
- acute dystonia
- chorea
Less effective over time

344
Q

Main side effects of dopamine agonists

A

Impulse disorders
Pulmonary fibrosis

345
Q

What are COMT inhibitors

A

Inhibit catechol-o-methyltransferase (COMT). The COMT enzyme metabolises levodopa in the brain. Entacapone is taken with levodopa (and a decarboxylase inhibitor) to slow the breakdown of the levodopa in the brain. It extends the effective duration of the levodopa

346
Q

Principles of parkinsons management

A

Levodopa is the best treatment so only use if severe symptoms initially or if not that bad then want to delay its use as very severe SEs and becomes less effective

347
Q

In controlled hyperventilation for raised ICP what attempting to do

A

Reduce Co2 leading to vasoconstriction and reduced ICP

348
Q

If is 4th nerve palsy and at rest is issue where will eye be positioned

A

Deviated laterally upwards

349
Q

Where do nerve roots leave spine in relation to the vertebra

A

Above except C8 which comes out below

350
Q

What happens in conduction aphasia

A

Link between wernickes and brocas is affected
Arcuate fasiculus

351
Q

Name for area of brain connecting brocas and wernickes

A

Arcuate fasiculus

352
Q

Features of conductive aphasia

A

Speech fluent
Comprehension fine
Word finding difficulty
Hard to make repetitions

353
Q

In aphasia what are causes of fluent speech

A

Receptive
Conductive
Determined by if comprehension impaired

354
Q

In aphasia what are causes of non-fluent speech

A

Expressive
Global
Determined by if comprehension impaired

355
Q

Difference in anatomy pseudobulbar vs bulbar palsy

A

Bulbar= LMN includes brainstem nuclei and cranial nerves
Pseudobulbar= UMN from lesions to corticobulbar tract in cortex

356
Q

Difference in signs between pseudobulbar and bulbar palsy

A

Bulbar- LMN signs so fasiculations and atropy of tongue and pharyngeal muscles, absent or reduced jaw jerk and gag reflex
Pseudobulbar- UMN so spasticity of tongue, increased gag reflex

357
Q

Which cranial nerves affected in pseudobulbar and bulbar palsy

A

5,7,10,11,12

358
Q

Causes of bulbar vs pseudobulbar palsy

A

Bulbar- MND, GBS
Pseudobulbar- strokes, MS, tumours in high brainstem

Finals (29 decks)

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