Neurology Flashcards
What do if CT negative for SAH
If within 6 hours then no need to rescan
If was done after 6 hours do an LP after 12 hours post sx
What is done if SAH confirmed
CT angio
Management of aneurysmal SAH
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
Complications of SAH
Re-bleeding
Hydrocephalus
Vasospasm
Hyponatraemia
What does sudden worsening of symptoms post SAH suggest
Rebleeding
Do CT again
What would cause a intracerebral haemorrhage patient to deteriorate
Hydrocephalus
Presentation of acute sinusitis
Facial pain worse on leaning forward
Nasal obstruction and discharge
Causes of acute sinusitis
Commonly rhinovirus
If bacterial then strep pneumoniae or HIB
What can be used for anticoagulation post stroke if AF
Warfarin
Dabigatran
Apixaban
Difference in when start long term anticoagulation for AF post TIA vs stroke
TIA= immediately
Stroke= 2 weeks later
What antiplatelets are given for stroke and then long term
Aspirin 300mg for 2 weeks
Clopidogrel long term
If in stroke and TIA, clopidogrel is contraindicated, what use instead
Aspirin and dipyridamole lifelong
How differentiate LBD and parkinsons disease with dementia
Parkinsons dementia occurs after a long parkinsons like history
Dementia starts same time as extrapyramidal symptoms in LBD
How investigate neoplastic chord compression
MRI whole spine within 24 hours and give high dose dexamethasone in meantine
What medication want to stop in dementia
TCAs as risk of worsening cognitive function
Management of migraines
1st line- NSAID ideally or paracetamol
2nd line- oral triptan
When is prophylaxis indcated for migraines
Having significant effect on life due to frequency or severity
First line for migraine prophylaxis
Propranolol
Second line prophylaxis for migraine
Topiramate
What can lead to idiopathic intracranial HTN
Obesity
Pregnacny
COCP
Tetracyclines
Steroids
Presentation of idiopathic intracranial HTN
Headache
Blurred vision
Papilloedema
Enlarged blind spot
Sixth nerve palsy
Signs on examination of IIH
6th nerve palsy
Enlarged blind spot
Papilloedema
Management of IIH
Lose weight
Start medications
1st line - acetazolamide (carbonic anydrase inhibitors)
2nd topiramate
Which anti-epileptic causes macrocytic anaemia
Phenytoin due to reduced folate metabolism
What are rare severe adverse effects of phenytoin
TEN
Hepatitis
Aplastic anaemia
Presentation of GBS
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
What is GBS
Immune mediated demyelination of the PNS triggered by an infection
Investigations for GBS and their findings
LP
- isolated raised protein
Nerve conduction
- decreased motor nerve conduction
What is most common cause of GBS
Campylobacter jejuni infection
Causes of trigeminal neuralgia
Idiopathic but can be causes by compression from tumours or vascular problems
Commonly seen in MS
Presentation of trigeminal neuralgia
Unilateral disorder where get electric shock like sensation
Evoked by shaving, smoking, talking or brishing teeth
Management of trigeminal neuralgia
First line carbamazepine
If fails to respond or red flag features refer to neuro
Red flag signs of trigeminal neuralgia
Under 40
Deafness or ear problems
Sensory problems
Optic neuritis
FHx of MS
Presentation of charcot marie tooth disease
Mainly motor loss
- foot drop
- high arched feet
- muscle weakness if hands and feet
- hyporeflexia
- stork leg deformity
- lots of ankle sprains
Management of Charcot marie tooth disease
There is no cure, and management is focused on physical and occupational therapy
Believed aetiology of bells palsy
HSV
Who is bells palsy commonly seen in
Young people aged 20-40
Pregnant women
Management of bells palsy
If within 72 hours give prednisolone
Eye care important to prevent keratopathy- aritifical tears and lubricants
Eye care for bells palsy
Artifical tears and lubricants
May have to tape eyes closed if unable to shut at night
When refer bells palsy to ENT
If after 3 weeks is no real improvement
On top of facial paralysis what may also encounter in bells palsy
Post auricular pain preceding paralysis
Altered taste
Dry eyes
Hyperacusis
Cutaneous features of tuberous sclerosis
Ash leaf spots
Cafe au lait spots
Subungal fibromata
Adenoma sebaceum
Shagreens patch
What is adenoma sebaceum
Angiofibromas seen in butterfly distribution over nose
Seen in tuberous sclerosis
MOA of triptans
Serotonin (5-HT) agonists
When take a triptan
At outset of headache not aura
Side effects of triptans
Triptan sensations- tingling, chest and throat tightness, heaviness
Contraindications of triptans
SSRI, SNRI
IHD
First time seizure assessment
CT and BM
Refer to outpatient clinic where have EEG and anti-epileptic may be started
First line for tonic-clonic seizures
Sodium valproate if male
Lamotrigine or levetiracetam if female
First line for focal seizures
Lamotrigine or levetiracetam
Second line for focal seizures
Carbamazepine
First line for absence seizures
Ethosuximide
Second line for absence seizures
Sodium valproate if male
Lamotrigine or levetiracetam if female
Myoclonic seizures management
Sodium valproate if male
Levetiracetam if female
In ALS, what are mutations often seen in
Superoxide dismutase
Presentation of progressive bulbar palsy
Palsy of the tongue, chewing muscles, swallowing and facial muscles
Which MND has worst prognosis
Progressive bulbar palsy
What are the types of MND
Amyotropic lateral sclerosis
Progressive muscular dystrophy
Progressive bulbar palsy
Primary lateral sclerosis
Types of motor neurone signs seen in the different MNDs
ALS
- LMN in arms
- UMN in legs
PLS
- UMN only
Progressive muscular atrophy
- LMN only
- affects distal then proximal muscle groups
Which medications most commonly associated with medication overuse headaches
Opioids
Triptans
Management of medication overuse headaches
Principally need to stop analgesia even though will worsen headache
- slowly withdraw opioids
- simple analgesia and triptans stop abruptly
Management of acute MS relapse
High dose oral or IV methylprednisolone for 5 days
Main drug used for preventing relapse of MS
Natalizumab
Management of fatigue in MS
Rule out anaemia etc
Give amantadine first line then trial CBT or mindfulness
Management of spasticity in MS
Baclofen and gabapentin given first line
2nd line options- diazepam and physio
Management of bladder dysfunction in MS
Do USS first to determine if significant residual volume
If residual volume- intermittent self-catheterisation
If no residual volume- anticholinergics
What is it when visual fields oscillate in MS
Oscillopsia
How manage oscillopsia in MS
Gabapentin
Which anti-emetic give in migraines
Metoclopramide or prochlorperazine
What type of seizure if twitching and jerks in legs and arms in AM where maintain consciousness
Myoclonic
Long term mangement of TIA
Long term clopidogrel
Aspirin and dipyrimadole if can’t tolerate clopidogrel
What can cause subacute degeneration of the spinal chord
Vit B12 deficency
Inhaled nitrous oxide
Which parkinsons medication most linked to impulse disorders
Dopamine receptor agonists
If there is macula sparing in vision, where is lesion
Occipital cortex
If a young man develops tunnel vision, what is diagnosis
Retinitis pigmentosa
Where is lesion if developing tunnel vision
Peripheral retina
How does retinitis pigmentosa present
Early blindness
Nighttime blindness first symptom often
Tunnel vision as peripheral vision lost
Management of brain abscess
IV ceftriaxone and metronidazole
Dexamethasone
Surgery to debride abscess
What test use to differentiate functional from organic weakness
Hoover sign
What is hoover sign
If someone was genuinely trying to lift up their leg they would feel the other leg pressing down against bed
What are pseudoseizures
Seen in patients with mental illness where they fake having a seizrue
Signs someone has had a pseudoseizure
pelvic thrusting
family member with epilepsy
much more common in females
crying after seizure
don’t occur when alone
gradual onset
How differentiate between a seizure and pseudoseizure biochemically
Serum prolactin
What is hoffmans sign
If flick distal phalynx then with UMN lesion there will be flexion in the index and thumb
What is sign seen on examination typically in uncal herniation
6th nerve palsy
NF1 presentation
Café-au-lait spots
Axillary/groin freckles
Peripheral neurofibromas
Iris hamatomas
Scoliosis
Pheochromocytomas
Gastrointestinal stromal tumour
NF2 presentation
Bilateral vestibular schwannomas
Multiple intracranial schwannomas, mengiomas and ependymomas
Myasthenic crises management
IVIG
Plasmapharesis
Monitor FVC with spirometry (less than 1.5L= contact ITU)- BiPAP or mechanical ventilation may be required
Long term management for myasthenia
Long acting acetylcholinesterase inhibitor- pyridostigmine
May require immunosuppression with steroids or azathioprine
Most common primary tumour for brain mets
Lung
What is an antalgic gait
Limp caused by weight on the affected limb
What is an ataxic gait
Wide based gait
Struggle to do toe to heel walk
How to rememeber causes of cerebellar disease
PASTRIES
Posterior fossa tumour
Alcohol
MS
Trauma
Rarer causes
Inherited
Epilepsy tx
Stroke
What is a chiari formation
Where a part of brain herniates through a malformation in skull leading to compression of the spinal chord
Sensory loss in syringomyelia
Cape distribution
Neck, shoulders and arms
Pain and temperature
Autonomic dysfunction in syringiomyelia
Horners
Bladder and bowel problems
Presentation of syringiomyelia
Cape distribution pain and temp sensory loss
Spastic weakness in leegs
Upgoing plantars
Neuropathic pain
Investigations for syringiomyelia
MRI brain to look for chiari formation
MRI spine to look for tethered chord
Management of syringiomyelia
Treat cause like surgery
Drain if permenant or symptomatic
NPH MRI finding
Ventriculomegaly with an absence of sulcal enlargement
Triad of NPH
Incontinence
Dementia
Gait abnormality
Pathophysiology of NPH
Reduced absorption secondary to prior meningitis, trauma or bleed
Management of NPH
Ventriculoperitoneal shunt but very risky as high risk of bleeing, seizures and infection
Pathophysiology of cervical degenerative myelopathy
Compression of spinal chord in cervical area due to degenerative changes in the area
Typically smoking is main risk factor for it
Presentation of cervical degenerative myelopathy
Pain
- in neck directly
- in arms
Motor problems
- loss of dexterity in hands
- weakness
Sensory problems
Autonomic dysfunction
What is good indicator on examination for degenerative cervical myelopathy
Positive hoffmans sign
What is uthoffs phenomena
Worsening vision when temperature rises
MS
What is L’hermittes sign
Limb parasthesia when flex neck
Classical parkinsons triad
Tremor
Bradykinesia
Rigidity
Bradykinesia parkinsons presentation
Slow, shuffling gait
Difficulty initiating movements
Povert of movement
Characteristics of parkinsons tremor
Worse at rest
Helped by voluntary movements
Worse when tired or stressed
What is pill rolling tremor seen in
Parkinsons
What is rigidity described as in parkinsons
Leadpipe
Can be cogwheel superimposed from tremor
Extra features of parkinsons
Micrographia
Drooling
Autonomic dysfunction- postural drop
Depression
Loss of REM sleep
Drug induced parkinsons vs idiopathic
Drug induced
- bilateral
- rapid onset
- rest tremor and rigidity rare
If clinical diagnosis uncertain for parkinsons, what can use
123I‑FP‑CIT single photon emission computed tomography (SPECT)
Cluster headache presentation
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
If someone presents to GP with cluster headache what do
Refer to neurology
What investigation will be done by neurology for cluster headaches
MRI with gadolinium contrast- may show underlying tumour
Acute management of cluster headache
High flow O2
Subcut triptan
What can be given for cluster headache prophylaxis
Verapamil
What often triggers autonomic dysfunction
Faecal impaction or urinary retention
What type of hallucination is smelling roses
Focal olfactory
How manage neuropathic pain
1 of amitryptylline, duloxetine, pregabalin or gabapentin
If fail to work switch
If resistant refer to pain clinic
What can use for localised neuropathic pain
Caspaicin
Which anti-emetic can cause prolonged QT
Ondensatron
Difference in appearance of ischaemic vs haemorrhagic stroke on CT
Haemorrhagic= hyperdense
Hypodense area and hyperdense artery = ischaemic
What is the hyperdense artery sign
Here the affected artery appears hyperdense due to accumulation
Presentation of sporadic creutzfield jacobs disease
Older patient
Rapid onset dementia
Myoclonus
Mutism
Psychiatric symptoms
Presentation of variant CJD
Younger patient
Psychiatric problems early
Investigations for CJD
CSF is usually normal
EEG: biphasic, high amplitude sharp waves (only in sporadic CJD)
MRI: hyperintense signals in the basal ganglia and thalamus
Antibodies in lambert eaton
voltage-gated calcium channel in the peripheral nervous system
Presentation of lambert eaton syndrome
Proximal myopathy of lower limbs
Autonomic dysfunction- dry mouth
Improves with exercise
Tenderness in muscles
Hyporeflexia which improves after exercise
Investigations for lambert eaton syndrome
EMG- shows incremental response to repetitive electrical stimulation
What is roughened skin over the lumbar spine in association with seizures
Shagreens patches seen in tuberous sclerosis
If not responded to 2 rounds of IV lorazepam what are options to start
Phenytoin
Sodium valproate
Levetiracetam
What is impaired in dorsal column disorders
Proprioception
Vibration
Light touch
Presentation of subacute degeneration of the spinal chord
Dorsal column involvement
- distal tingling/burning/sensory loss
- impaired vibration and proprioception
Corticospinal tracts
- weakness
- UMN signs
Spinocerebellar involvement
- gait abnormalities
What does positive rombergs indicate
B12 deficiency due to spinocerebellar tract involvement
What is the spinocerebellar tracts function
Sensory pathway relaying information about balance and proprioception to cerebellum
An aneurysm or aneurysm rupture in what vessel can lead to third nerve palsy
Posterior communicating artery
If have unprovoked seizure with normal imaging, when can drive next
6 months
Must notify DVLA
What is inheritance of essential tremor
Autosomal dominant
What are features of an essential tremor
Worse when arms outstretched
Can affect head, vocal chords and jaw
Improved by alcohol and rest
Where can essential tremor also affect
Vocal chords- can get change in voice
Head and jaw can be affected
Management of essential tremor
Propanolol
What is new definition of a TIA
Transient episode of neurologic dysfunction caused by ischaemia without acute infarction visible on imaging
NOT BASED ON TIME BUT IMAGING
Sensory predominant peripheral neuropathy causes
Alcohol
Vit B12
DM
Amyloid
Uraemia
Leprosy
Motor predominant peripheral neuropathy causes
Guillain-Barre syndrome
porphyria
lead poisoning
hereditary sensorimotor neuropathies (HSMN) - Charcot-Marie-Tooth
chronic inflammatory demyelinating polyneuropathy (CIDP)
diphtheria
What malignancy most likely to cause myasthenia gravis
Thymoma
What is presentation if pontine artery stroke
Low GCS
Bilateral pinpoint pupils
Paralysis
What does high stepping gait indicate
Foot drop- is walking technique used to accommodate
Causes of high stepping gait
Peripheral neuropathy
What is nature of parkinsons referral to neuro
Urgent
What diet advised for epilepsy
Ketogenic
Management of low pressure headache post LP
Fluids, coffee and rest
2nd line- blood patch, IV caffeine
Which drugs exacerbate myasthenia
Beta blockers
Lithium
Phenytoin
Abx
Stress
Causes of facial nerve palsy
Sarcoid
Petrous temporal fracture
Cholesteatoma
Parotid tumours
HIV
MS
DM
If seize with whole body but consciousness intact, what is it
Pseudoseizure
What use to image demyelinating lesions in MS
MRI with contrast
What is jacksonian march
Seizure will initially start with affecting a peripheral body part then spread over whole limb and can become generalised
Most common complication of meningitis
Sensorineural hearing loss
How is nutrition give in MND
Percutaneous gastrostomy tube (PEG)
What resp care is given for MND
BiPAP at night
What is management of MND
Riluzole if ALS
Resp care- BiPAP
Nutrition- PEG tube
What is riluzole
Drug used in MND which blocks glutamate receptors
If first line for focal seizures does not work, what do
Give either lamotrigine or levetiracetam depending on what trialled first
Second line is carbamazepine
LP finding in MS
Raised oligoclonal bands
How remember what visual defect a parietal or temporal lesion will cause
PITS
Parietal- inferior
Temporal- superior
Difference in bitemp hemianopia caused by pituitary tumour vs craniopharyngioma
Pituitary tumour- upper defect
Craniopharyngioma- lower defect
Which focal seizures often present with an aura
Temporal
Examples of temporal focal seizure auras
Rising epigastric sensation
Deja vu
Hallucinations- rare
If want to test CSF that is leaking out of nose or ear, what is quick bedside test can do
Check for glucose which will be present if CSF
What is further classification of focal temporal seizures
Impaired awareness or aware
Atonic seizure management
Sodium valproate if male
Lamotrigine if female (lAmotri for atonic and not levetiracetam)
TIA management if taking an anticoagulant
Refer for immediate assessment and imaging
Management of TIA immediately
Give 300mg aspirin unless
- on anticoagulant then refer for imaging
- taking low dose aspirin- continue dose until review
- aspirin CI
Best imaging for intracranial venous thrombosis
MRI venography
Management of intracranial thrombosis
LMWH
What are the types of intracranial venous thrombosis
Sagittal sinus
Cavernous sinus
Lateral sinus
What does empty delta sign on venography suggest
Sagittal sinus thrombosis
How manage neuroleptic malignant syndrome
Stop antipsychotic- transfer to medical ward
IV fluids
Dopamine agonists- bromocriptine
Presentation of neuroleptic malignant syndrome
Side effect of antipsychotics
- pyrexia
- muscle rigidity
- agitation and confusion
- autonomic instability- HTN, tachycardia
Blood findings of neuroleptic malignant syndrome
Leukocytosis
Raised CK
Can get AKI secondary to rhabdo
How position head if raised ICP
Head elevation to 30 degrees
Management of raised ICP
Head elevation to 30 degrees
Controlled hyperventilation
Put in shunt if from raised ICP
Cushings triad
Widened pulse pressure
Bradycardia
Irregular breathing
Investigation for narcolepsy
Multiple sleep latency EEG
How manage narcolepsy
Daytime stimulants
Nighttime sodium oxybate
What is sodium oxybate
A strong sedative
What is an example of daytime stimulant used in narcolepsy
Modafinil
Narcolepsy presentation
Excessive sleepiness
Cataplexy
Vivid hallucinations when falling asleep
Sleep paralysis
Where refer for degenerative cervical myelopathy
Spinal surgery
What Hz is parkinsons tremor typically
3-5
Essential tremor is 6-12
When can drive after a TIA
Can drive after a month if no symptoms
No need to inform DVLA
Are subdural bleeds limited by suture lines
No
What is klumpkes syndrome
C8 and T1 nerve root injury
What tends to causes klumpkes syndrome
Birth injury
Falling from tree and trying to grab a branch
Presntation of klumpkes syndrome
Claw grip from loss of intrinsic muscles in hand
Sensory loss in dermatomes C8 and T1
If someone with parkinsons presents to hospital and does not have a safe swallow for dopamine, what give
Dopamine patch agonist
What is mononeuritis multiplex
Simultaneous involvement at least 2 different areas of the peripheral nervous system
What is a polyneuropathy
a general symmetrical degeneration of peripheral nerves that spreads towards the centre of the body.
Differentiating mononeuritis multiplex from polyneuropathy
Mononeuritis multiplex asymmetrical
When can AEDs be withdrawn
If 2 years no seizures
Must be stopped over 2-3 months
In parkinsons what is it really important to do when patient admitted
They continue to have dopamine agonists as will go into acute dystonia
If unable to swallow then give patch
What anaesthetic would MG patients be resistant to
Suxamethonium
What dementia is associated with MND
Frontotemoral dementia
Where is seizure if post ictal dysphasia
Temporal
What is classic features of parietal lobe seizures
Parasthesia
What is classical feature of frontal seizures
Motor symptoms
Head/leg movements
Post-ictal weakness
Jacksonian march
What is contained within the cavernous sinus
3-6
Oculomotor nerve
Trochlear nerve
Opthalmic nerve (CNV1)
Maxillary nerve (CNV2)
Abducens
What causes cavernous sinus syndrome
Cavernous sinus tumours typically tumours that invade the cavernous sinus such as nasopharyngeal tumours
Patient with nasopharyngeal tumour develops; proptosis, absent coreal reflex, horners syndrome and pain on eye movements
Cavernous sinus syndrome
Presentation of cavernous sinus syndrome
Proptosis
Trigeminal nerve lesions
- absent corneal reflex
Horners
Third nerve palsy
If have painful third nerve palsy, what need to rule out
Posterior communicating artery
Sudden onset headache with isolate hypotension
Pituitary apoplexy from pituitary insufficiency
If bleed then HR up
What is pituitary apoplexy
Sudden enlargement of pituitary tumour from infarction or haemorrhage
Presentation of pituitary apoplexy
Sudden onset headache
Vomiting
Neck stiffness
Visual defects (bitemp superior quadrantopia)
Hypotension from pituitary insufficiency
How investigate pituitary apoplexy
MRI
Management of pituitary apoplexy
Urgent steroid replacement
Surgery
What is an arnold chiari malformation
Herniation of cerebellar tonsils through foramen magnum
Features of arnold chiari malformation
Non-communicating hydrocephalus
Headache
Syringomyelia
Multiple system atrophy presentation
Parkinsons
Early autonomic disturbance
- postural drop
- impotence
Cerebellar signs
What questionnaire measures impairment from stroke
NIHSS
What scale is used to differentiate stroke from stroke mimics in the acute setting
ROSIER
Management of chronic subdurals
If symptomatic or very large
- burr hole evacuation
Asymptomatic and found incidentally
- conservative
Management of acute subdural
Small
- conservative
Large
- depressive craniectomy or monitor intracranial pressure
If starting a phenytoin infusion for status epilepticus what need to do
Place on a cardiac monitor
If patient has locked in syndrome, what is location of stroke
Basilar
Presentation of middle cerebral artery stroke
Arm and facial hemiparesis plus sensory loss
Presentation of posterior cerebral artery
Contralateral homonymous hemianopia with macula sparing
Visual agnosia
What is visual agnosia
Impairment in recognising objects visually but would be able to identify via touch or smell
What is the basilar artery
Artery leading up to the circle of willis
What are the pontine arteries
Arteries branching off the basilar artery
What is the regional blood supply to the brain
What is blood supply to the midbrain
Branches of the posterior cerebral artery
What is presentation of midbrain stroke
Ipsilateral CN III palsy
Contralateral upper and lower limb weakness
What is weber syndrome
Get stroke in branch of posterior cerebral artery supplying the midbrain. Presents with ipsilateral CN III palsy and contralateral limb problems
What is other name for lateral medullary syndrome
Wallenberg
What causes lateral medullary syndrome
Stroke in the posterior inferior cerebellar artery
Presentation of lateral medullary syndrome
Ataxia and nystagmus
Horners
Ipsilateral pain or loss of pain in face
Contralateral pain in trunk or limbs
What causes lateral pontine syndrome
Anterior inferior cerebellar artery
Presentation of lateral pontine syndrome
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
Lacunar stroke presentation
Isolated hemiparesis or sensory loss
Or plus ataxia
Sites of lacunar infarcts
Mainly caused by HTN
- Thalamus
- Basal ganglia
- Internal capsule
Other than managing the infarct itself what 5 things need to be considered post stroke
Fluid balance
Glycaemic control
BP control
Feeding assessment
Assessing disability
Fluid balance important points post stroke
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
Glycaemia management post stroke
Important to keep between 4-11
Hyperglycaemia associated with poor mortality
Management post stroke if diabetic
Intense management
If diabetic optimise with IV glucose and insulin
How manage hypertension post stroke
Should avoid antihypertensives unless HTN emergency like dissection, nephropathy, encephalopathy or MI/HF
What must all stroke patients be screened for in 24 hours after event
Swallow
What do if is any concern about swallow after stroke
Withold all oral intake including food/drugs/fluids
Get specialist assessment within 24 hours
Management of impaired swallow post stroke
NG tube feed within 24 hours unless had thrombolytic therapy
If NG not tolerated arrange nasal bridle tube or gastrostomy
What is a nasal bridle tube
Nasal loop used to stop NG tube from being pulled out
What score is used to determine disability post stroke and requirement for rehab team
Barthel index
When start statin post stroke
If cholesterol over 3.5
Do after 48 hours
If swallow impaired post stroke how administer aspirin
Rectally
According to the bamford/oxford stroke classification, what are the main types
Total anterior
Partial anterior
Lacunar infarcts
Posterior circulation
Extra syndromes- lateral medullary, weber
What are 3 things assess in bamford stroke classification
Unilateral hemiparesis or sensory loss
Homonymous hemianopia
HIgher cognitive dysfunction
In bamford stroke classification, what are examples of higher cognitive dysfunction
Aphasia
Apraxia
What is difference between PACI and TACI
PACI= 2 of
TACI= 3 of
- Unilateral hemiparesis or sensory loss
- Homonymous hemianopia
- Higher cognitive dysfunction
Difference in pathology of PACI and TACI
TACI= middle and anterior cerebral arteries involved
PACI= smaller vessels of these involved
Ipsilateral CN III lesion with contralateral limb weakness
Midbrain stroke
Where is brocas area
Frontal lobe
Where is wernickes area
Superior temporal gyrus
What is function of wernickes area
Area that comprehends speech
What is function of brocas area
Expressive area that generates speech
What is difference in arterial supply of brocas and wernickes area
Brocas- superior division of left MCA
Wernickes- inferior division of left MCA
Post TIA when are carotid dopplers recommended
ASAP unless not candidate for endarterectomy
What is preferred investigation for TIA
MRI diffusion weighted as best identifies area of ischaemia
Ideally do on same day as specialist assessment
Difference in drug used to reduce ICP in different pathologies
Infection or malignancy= dexamethasone
Traumatic brain injuries= IV mannitol
If brain bleed or traumatic injury, what drug use to reduce ICP
IV mannitol
What cranial nerves affected by acoustic neuromas
5, 7, 8
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
GCA from PMR
LP finding of IIH
Very high opening pressure
Normal CSF
What is restless leg syndrome
Syndrome of spontaneous continuous leg movements assoc with parasthesia
Very common- 2-10%
Presentation of restless leg syndrome
Uncontrollable urge to move legs (akathisia)- worse at rest and at night
Parasthesias- weird sensations in legs
Movements of legs in sleep
Causes of restless leg syndrome
Idiopathic with strong family history
DM
IDA
Pregnancy
Investigations for restless leg syndrome
Rule out possible causes
- Iron studies
- HbA1c
First line treatment for restless leg syndrome
Dopamine agonists- ropinirole
Walking, stretching, massaging
Second line options for restless leg syndrome
Benzos
Gabapentin
When do patients need specialist review by for TIA
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
When may admit patient with TIA for observation
Crescendo TIA
Cardioembolic source
Suspected carotid artery stenosis aetiology
What is a cresecendo TIA
If have multiple in short space of time
If a patient under 55 presents with a stroke what investigations must be done
Thrombophilia screen
- ANA
- antiphospholipid syndrome
- lupus anticoagulant
- ESR
- syphilis serology
Management of GBS
First line= IVIG
Can do plasmapharesis
Rfs for MS
Vit D deficiency
Female
Aged 20-40
What use for nausea in parkinsons
Domperidone- blocks dopamine receptors but does not cross BBB
What is type of seizure if becomes upset the unresponsive and wanders the house
Focal seizures with impaired awareness- automatisms evident
DANISH
Dysdiadochokinesia
Ataxia
Nystagmus
Intention tremor
Slurred speech
Hypotonia
If have hyperdense area in the centre of brain what could be
Basilar artery thrombus
What % of right handed people have speech centre on right side
10%
What % of left handed people have speech centre on left
60-70%
What is cut off INR for thrombolysis
1.7 and below
Absolute CIs to thrombolysis
- 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
If doing head CT scan and identify proximal infarction what do next
Convert to CT angio
When can offer thrombectomy up to 24 hours post symptoms
If proximal anterior circulation stroke and is area of salvageable brain tissue identified on diffusion weighted MRI
Consider if posterior circulation stroke
Management of DCM
Decompressive surgery
Can observe if very mild
Corneal reflex nerve
CN V1
Progressive supranuclear palsy presentation
Parkinsons+ dysarthria and difficulty looking upwards
Internuclear opthalmoplegia presentation
Ipsilateral impaired eye adduction
Horizontal nystagmus in abucting eye on other side
Causes of internuclear opthalmoplegia
MS
Vascular cause
What is affected in internuclear opthalmoplegia
Medial longitudinal fasciculus
When give aspirin in stroke
If thrombolysis or thrombectomy not possible
If a patient is not aphasic where is stroke most likely to have occured
Anterior cerebral arteries
In exacerbations of neuropathic pain what can be used
Tramadol
What is the cerebellar vermis
Central part of cerebellum which separates the hemispheres
Where in cerebellum is lesion if develop ataxic gait
Cerebellar vermis
What is an example of peripheral ataxia
Finger nose ataxia
If develop finger nose ataxia where is lesion
Cerebellar hemisphere
What is todds paresis
After a focal motor seizure can develop weakness
If undergo haemorrhagic transformation of ischaemic stroke how manage
Stop aspirin/alteplase
Control BP to under 140 systolic
CT and neurosurgery referral
If patient undergoes surgery for DCM then later develop neuro problems what is likely cause
Recurrent DCM
Difference in supply of internal vs external carotid arteries
Internal- circle of willis
External- mainly facial arteries eg lingual, maxillary etc
What investigation do for LBD
SPECT/DAT scan
How manage spasticity in MND
Baclofen
NCS and EMG findings in MND
NCS is normal
EMG is reduced number of action potentials and increased amplitude
Investigations for MND
MRI
NCS and EMG
CLINICAL DIAGNOSIS
Types of MS
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
Definitive management options for SAH
IR will place platinum coil
Neurosurgeons can do craniotomy and clip
How manage hydrocephalus from SAH
Short term= ventricular drain
Long term= can put in ventriculoperitoneal drain
CT scan of extradural
Limited by suture lines
Crescent shaped
Extradural haematoma management
If no focal neurology can do radiological monitoring
Otherwise need to do decompressive craniectomy and fix artery
Intracerebral haemorrhage investigation finding and management
Area of hyperdensity in cortex
Conservative under care of strokes, if LOC and massive clot then can do surgical management
Suspected brain tumour referral guidelines
MRI within 2 weeks for adults
MRI within 48 hours if young person with new onset cerebellar or neurological dysfunction
Investigations for brain tumour
Fundoscopy to look for papilloedema
MRI first line
Biopsy is gold standard
What must worry about if new onset personality
Brain tumour in frontal lobe- do MRI
What is most common tumour in brain
Metastases are most common
Most common primary is meningioma but if malignant then glioblastoma is most common
MRI meningioma vs glioblastoma
Meningioma- well circumscribed with dural tail where attatched to dura
Gliobastoma- ring enhancing lesion with lots of vasogenic oedema
If have diagnosed MG what need to do next as an investigation
CT/MRI thorax to check for thymoma
Investigations for MG
Antibodies- anti ACHr and MUSK
NCS- reduced after repeated stimulation
MRI/CT thorax- to look for thymoma
Tensilon test with edrophonium
What is tensilon test
Used if diagnostic uncertainty for MG
Give IV edrophonium which blocks acetylcholinesterase- if have MG will temporarily relieve weakness
What happens to reflexes in LEMS
Reduced/absent
If exercise can improve
Management of LEMS
Immunosuppression- steroids, azathioprine
Serious causes of tremor to rule out
Parkinson’s disease
Multiple sclerosis
Huntington’s chorea
Hyperthyroidism
Fever
Dopamine antagonists (e.g., antipsychotics)
Huntingtons inheritance details
AD
Anticipation as gets worse in future younger generations with earlier presentation
Hungtingtons features
Psych- depression and dementia first presentation
Then develop chorea, muscle rigidity, dysarthria, eye movement disorders and dysphagia
Investigation for huntingtons
Genetic testing
How manage chorea in huntingtons
Tetrabenzine
Management of parkinsons
First line depends if motor symptoms affecting daily life, if so then Levodopa
If not then choose between levodopa, dopamine agonist or MOA-B
Drug options for parkinsons
Levodopa
Dopamine agonists- ropinirole, cabergoline, bromocriptine
MAO-B inhibitors- raseligine, seligine
COMT inhibitors
What needs to be given with levodopa
Peripheral decarboxylase inhibitor (e.g., carbidopa and benserazide)
What is problem of leveodopa
Dyskinesia common
- athetosis
- acute dystonia
- chorea
Less effective over time
Main side effects of dopamine agonists
Impulse disorders
Pulmonary fibrosis
What are COMT inhibitors
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
Principles of parkinsons management
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
In controlled hyperventilation for raised ICP what attempting to do
Reduce Co2 leading to vasoconstriction and reduced ICP
If is 4th nerve palsy and at rest is issue where will eye be positioned
Deviated laterally upwards
Where do nerve roots leave spine in relation to the vertebra
Above except C8 which comes out below
What happens in conduction aphasia
Link between wernickes and brocas is affected
Arcuate fasiculus
Name for area of brain connecting brocas and wernickes
Arcuate fasiculus
Features of conductive aphasia
Speech fluent
Comprehension fine
Word finding difficulty
Hard to make repetitions
In aphasia what are causes of fluent speech
Receptive
Conductive
Determined by if comprehension impaired
In aphasia what are causes of non-fluent speech
Expressive
Global
Determined by if comprehension impaired
Difference in anatomy pseudobulbar vs bulbar palsy
Bulbar= LMN includes brainstem nuclei and cranial nerves
Pseudobulbar= UMN from lesions to corticobulbar tract in cortex
Difference in signs between pseudobulbar and bulbar palsy
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
Which cranial nerves affected in pseudobulbar and bulbar palsy
5,7,10,11,12
Causes of bulbar vs pseudobulbar palsy
Bulbar- MND, GBS
Pseudobulbar- strokes, MS, tumours in high brainstem
