Neurology Flashcards
What causes a contralateral bilateral inferior quadrantanopia?
Infarct in the parietal lobe
“PITS”:
Parietal - Inferior quadrantanopia
Temporal - Superior quadrantanopia
Where is an upper motor lesion?
Brain or spinal cord
Where is a lower motor lesion?
Anterior horn cell
Motor nerve roots
Peripheral motor nerve
Typical signs of an upper motor neurone lesion include..
Spasticity
Hyperreflexia
Upgoing plantars (downgoing in MND)
Typical signs of a lower motor neurone lesion include.
Marked atrophy
Fasciculations
What is the most important parameter to monitor in a patient with GBS?
Forced vital capacity - the neuropathy can ascend to involve the abdominal muscles and then the diaphragm. The patient may develop respiratory failure and ultimately respiratory arrest
Symmetrical distal muscular atrophy, resulting in the appearance of “champagne bottle legs” before progressing to claw hands
CMT
Ascending pattern of weakness that improves upon repetition/usage. History of smoking
LEMS with an underlying cause of SCLC
Two discrete incidents of neuropathy, accompanied by gradual recovery and affecting both sensory and motor function in the case of the common peroneal nerve palsy
Mononeuritis multiplex
Tremor affecting both hands and is worse when the patient tries to do something
Essential tremor
History of weakness, which she reports is better in the morning than in the evening. Proximal limb weakness and mild bilateral ptosis, exacerbated by prolonged upgaze. Reflexes and sensation are intact
MG
Repeated muscle contractions lead to increased muscle strength. History of limb weakness. Reduced power in the proximal muscles of the lower limb and hypo-reflexia in the knee and ankle reflexes
LEMS
What causes a left homonymous hemianopia?
Right parietal lobe infarct
Progressive and bilateral upper motor neuron weakness
Primary lateral sclerosis
A mixture of upper and lower motor neuron signs
Spinal-onset amyotrophic lateral sclerosis
Fatigable weakness which improves upon rest. diplopia and bulbar features including speech disturbance
Myasthenia gravis
Parkinson’s plus syndrome with a key feature being that motor symptoms are often confined to one limb
Cortico-basal degeneration
Long-term side effect of levodopa use?
Drug induced dyskinesias
Tx for on and off symptoms/motor fluctuations in PD?
A COMT inhibitor (Entacapone and tolcapone.) or a dopamine antagonist (Ropinirole, rotigotine, Apomorphine)
Six-month history of double vision “that starts in the afternoon and worsens towards the end of the day
Myasthenia gravis
Tx for MG
Immunosuppressive therapy (such as steroids) and anticholinesterase inhibitors (like pyridostigmine or neostigmine)
Tx for acute/severe MG
IV immunoglobulin (IVIG) or plasmapheresis
The hallmark diagnositc test for Guillain-Barré syndrome is..
“Albumino-cytologic dissociation” which means raised protein with a normal white cell count
T or F: The diagnosis of a TIA is time based
False - tissue based
What are the associate effects of an anterior cerebral artery lesion?
Contralateral hemiparesis and sensory loss, lower extremity > upper
What are the associated effects of a middle cerebral artery lesion?
Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral homonymous hemianopia
Aphasia
What are the associated effects of a posterior cerebral artery lesion?
Contralateral homonymous hemianopia with macular sparing
Visual agnosia - impairment in recognising visually presented objects
What are the associated effects of a lesion on the branches of the posterior cerebral artery that supply the midbrain?
Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity
What are the associated effects of a lesion on posterior inferior cerebellar artery?
Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus
What are the associated effects of a lesion on anterior inferior cerebellar artery?
Symptoms are similar to Wallenberg’s but:
Ipsilateral: facial paralysis and deafness
What are the associated effects of a lesion on retinal/ophthalmic artery?
Amaurosis fugax
What are the associated effects of a lesion on basilar artery?
‘Locked-in’ syndrome
Eye is deviated ‘down and out’
Ptosis
Pupil may be dilated (sometimes called a ‘surgical’ third nerve palsy)
Third nerve palsy
Tx for generalised tonic-clonic seizures
Males: sodium valproate
Females: lamotrigine or levetiracetam
Girls aged under 10 years and who are unlikely to need treatment when they are old enough to have children or women who are unable to have children may be offered sodium valproate first-line
Tx for focal seizures
First line: lamotrigine or levetiracetam
Second line: carbamazepine, oxcarbazepine or zonisamide
Tx for absence seizures (Petit mal)
First line: ethosuximide
Second line:
Male: sodium valproate
Female: lamotrigine or levetiracetam
Carbamazepine may exacerbate absence seizures
Tx for myoclonic seizures
Males: sodium valproate
Females: levetiracetam
Tx for tonic or atonic seizures
Males: sodium valproate
Females: lamotrigine
In acoustic neuroma, CN VIII is affected. What are the clinical signs for this?
Vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
In acoustic neuroma, CN V is affected. What are the clinical signs for this?
Absent corneal reflex
In acoustic neuroma, CN VII is affected. What are the clinical signs for this?
Facial palsy
Describe Cushing’s triad
Bradycardia (also known as a low heart rate)
Irregular respirations
Widened pulse pressure
Reduces Glasgow coma score, quadriplegia, miosis, and absent horizontal eye movements
Pontine haemorrhage
Pinpoint Pupils points to pons!
Outline the oxford classification of stroke
Total anterior circulation infarcts (TACI)
Partial anterior circulation infarcts (PACI)
Lacunar infarcts (LACI)
Posterior circulation infarcts (POCI)
Total anterior circulation infarcts involves which arteries?
Middle and anterior cerebral arteries
Partial anterior circulation involves which arteries?
Smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
Lacunar infarcts involves which arteries?
Perforating arteries around the internal capsule, thalamus and basal ganglia
Posterior circulation infarcts involves which arteries?
Vertebrobasilar arteries
Weakness and wasting of small muscles in hand, loss of reflexes in upper limb and loss of pain/temperature sensation with preserved/vibration sensation
Syringomyelia
Medication overuse headache
Simple analgesia + triptans: stop abruptly
Opioid analgesia: withdraw gradually
Differentiate between DLB and PDD
DLB: DLB can develop Parkinson’s disease-like motor symptoms late in their disease course
PDD: PDD develops late in the course of Parkinson’s disease AFTER the onset of the classic motor symptoms.
Sensation affected over the anterolateral aspect of the thigh without any motor deficits
Which nerve is affected?
Lateral cutaneous nerve palsy
Plantar flexors of the ankle and flexors of the toes. Sensory loss would be expected on the sole of the foot
Which nerve is affected?
Tibial nerve palsy
Medial compartment of the thigh, which are responsible for hip adduction
Which nerve is affected?
Obturator nerve palsy
Weakness of foot dorsiflexion and foot eversion
Which nerve is affected?
Common peroneal nerve lesion
Unilateral headache, nausea, photophobia
Migraine
Tx for status epilepticus
Oh Dear/My Lord Phone Anaesthetics
Oxygen
Diazepam (PR) / Midazolam (Buccal) if Prehospital
Lorazepam (IV) if Hospital
Phenytoin (IV) if two doses of Lorazepam are ineffective
Anaesthetics (Intubate and Barbituates/Propofol if persistent after phenytoin)
Side effects for Clozapine
SCAM
Seizures
Constipation/clozapine-induced gastrointestinal hypomotility (CIGH)
Agranulocytosis
Myocarditis
Obese, young female with headaches / blurred vision
Idiopathic intracranial hypertension
Tx for alcohol withdrawal syndrome
Long-acting benzodiazepines first-line, such as chlordiazepoxide or diazepam.
PD often begins unilaterally and then progresses. Even years following diagnosis, symptoms are worse on one side than another
Bilateral also implies a non-typical disease, such as drug induced parkinsonism. motor symptoms are generally rapid onset and bilateral
rigidity and rest tremor are uncommon
Imaging technique in TIA
MRI brain with diffusion-weighted imaging
Imaging technique in stroke
Non-contrast CT head scan
Pain on neck flexion - Pain on head facing down - Sinusitis; Increased ICP; Meningitis; SAH
Phonophobia - Avoidance of sound - Migraine
Epiphora - Eye watering - Cluster headache
Bilateral tight band pain - Feels like band squashing head - Tension headache
Recent viral illness - ?Infx spread - ?Encephalitis/Meningitis
Ophthalmoplegia, ataxia and areflexia with minimal or no limb weakness or sensory symptoms
Miller Fisher syndrome (A variant of GBS that starts with the eyes and a descending rather than ascending muscle weakness)
Central scotoma (an enlarged central blind spot)
Pain with eye movement
Impaired colour vision
Relative afferent pupillary defect
Optic neuritis - MS
Tx for acute relapse of MS
1st line: oral methylprednisolone 0.5g daily for 5 days
If failed or not tolerated on severe relapse: admission for IV methylprednisolone
Tx for fatigue of MS
Rule out any other potential medical cause
Reassurance and explanation
Non-drug-based therapies: mindfulness, CBT, exercise programmes
Tx for spasticity/mobility issues of MS
1st line: consider baclofen or gabapentin (risk of addiction and respiratory depression, especially in existing opioid users)
2nd line: consider tizanidine or dantrolene
3rd line: consider a benzodiazepine
Tx for ataxia of MS
No recommended treatment. Consider physio or OT referral
Tx for mental health problems of MS
1st line for emotional lability: Amitriptylinen
Offer CBT to patients having issues coping with MS (depression more common in these patients)
Tx for pain of MS
MSK/neuropathic pain is treated the same
Tx for sexual dysfunction of MS
PDE-5 inhibitors for erectile dysfunction in men
Referral to counselling services
If symptoms are both new, and lasted longer than 24hrs these are most likely to be an acute relapse of MS and therefore treated with..
Methylprednisolone (IV or oral)
Which disease modifying drugs are used in MS and what is their purpose?
Natalizumab - once-monthly infusion
Ocrelizumab
Fingolimod - may reduce the percentage of relapses but is not a treatment for acute relapses
Tx for essential tremor
Propranolol is first-line
Primidone is sometimes used
Postural tremor: worse if arms outstretched
Improved by alcohol and rest
Essential tremor
Tx for cluster headache
Acute: 100% oxygen and subcutaneous triptan
Prophylaxis: verapamil
Tx for acute migraine
Triptan + NSAID or triptan + paracetamol
Triptan to treat
Propranol to prevent
Tx for prophylaxis of migraine
1st line: Topiramate, atl. is propranolol (unless asthmatic)
2nd line: Amitriptyline (risk of birth defects, also a sedative as it is a tricyclic)
Triptan to treat
Propranol to prevent
Outline the MRC scale
Distinguish between an upper and lower motor neurone lesion
The forehead will be spared in an upper motor neurone lesion so the patient can move their forehead on the affected side. In a lower motor neurone lesion, the forehead is not spared, and the patient cannot move their forehead on the affected side.
Tx for bell’s palsy
Prednisolone
Eye care (if pain, refer to ophthalmology for exposure keratopathy, eye is taped shut at night)
If no improvement after 3 weeks, refer urgently to ENT
In purely motor signs, suspect..
Guillain-Barre syndrome
Tx for Parkinson’s
If motor symptoms are affecting quality of life: levodopa
If motor symptoms are nor affecting quality of life: Dopamine agonist: bromocriptine, ropinirole, cabergoline, apomorphine
Levodopa
MAO‑B inhibitor: selegiline
If continues to have symptoms despite optimal levodopa treatment or has developed dyskinesia:
Addition of a dopamine agonist
MAO‑B inhibitor
Or catechol‑O‑methyl transferase (COMT) inhibitor as an adjunct: entacapone, tolcapone
Vertical diplopia
Trigeminal nerve
Horizontal diplopia
Abducens nerve
Differentiate between hypoglossal and vagus nerve lesions
CN XII (hypoglossal): ‘lick your wounds’ so your tongue would go toward the lesion
CN X (vagus): nerve is scared of the damaged side so
uvula runs away from it
Efferent loss of gag reflex
CN X (Vagus)
Afferent loss of gag reflex
CN IX (Glossopharyngeal)
Loss of sensation to the skin over the “sergeant’s patch”, lateral arm and lateral forearm
Wasting of the deltoid, supraspinatus and infraspinatus muscles and the anterior compartment of the arm
Loss of shoulder abduction and external rotation, elbow flexion and wrist supination
Biceps reflex is absent. Wrist flexion, wrist extension and finger movements are usually preserved
What is the diagnosis? Which nerve is affected?
Brachial plexus injury - Erb’s palsy (C5/C6)
Damage to musculocutaneous, axillary, suprascapular and nerve to subclavius
If C7 was also injured, then elbow and wrist extension will also be diminished and the wrist may be held in fixed flexion
Loss of skin sensation in the medial forearm and arm, median and ulnar distributions of the hand, the sensory supply to the lateral dorsum of the hand is preserved
generalised wasting of hand muscles with a loss of MCPJ flexion, IPJ extension, finger abduction and adduction, and opposition
Claw hand deformity. The wrist is classically held supinated
What is the diagnosis? Which nerve is affected?
Brachial plexus injury - klumpke’s (C8/T1)
Damage to median and ulnar nerves
If the hand was paralysed it would be C8 and T1 and be called Klumpke’s. since it is just T1, the C8 component of the ulnar nerve is still working so it is only weakened
When is an carotid artery endarterectomy indicated?
If asymptomatic, carotid stenosis threshold is 70%
If symptomatic, carotid stenosis threshold is 50%
Outline the aphasia classification
Can repeat words but cannot generate spontaneous speech
Lesions result in sentences that make no sense, word substitution and neologisms but speech remains fluent - ‘word salad’
Wernick’s (receptive) aphasia
Speech is non-fluent, laboured, and halting. Repetition is impaired
Comprehension is normal
Broca’s (expressive) aphasia
Speech is fluent but repetition is poor. Aware of the errors they are making
Comprehension is normal
Conduction aphasia
Severe expressive and receptive aphasia
May still be able to communicate using gestures
Global aphasia
Wernicke’s (receptive) aphasia is caused by which lesion?
Due to a lesion of the superior temporal gyrus. It is typically supplied by the inferior division of the left MCA
Broca’s (expressive) aphasia is caused by which lesion?
Due to a lesion of the inferior frontal gyrus. It is typically supplied by the superior division of the left MCA
Conductive aphasia is caused by which lesion?
Due to a stroke affecting the arcuate fasiculus - the connection between Wernicke’s and Broca’s area
Global aphasia is caused by which lesion?
Lesion in both the superior and inferior temporal gyrus
+ a stroke affecting the arcuate fasiculus
A stroke of this Left middle cerebral artery would cause contralateral homonymous quadrantanopia or hemianopia, due to the damage to the optic radiation
A stroke of this Right middle cerebral artery would cause left homonymous hemianopia, due to the damage to the optic radiation
The symptoms of a stroke are typically contralateral to the side of the brain where the stroke has occurred. This is because the motor fibres (corticospinal tract) that control our movements decussate or cross over in the medulla oblongata, a part of the brainstem. Hence, damage to one side of the brain will result in motor deficits on the opposite side of the body.
Guillain Barre tends to affect legs first and progress to arms in a gloves and stocking fashion, which can cause problems with finger adduction/abduction
Adduction
Red flags for headaches
SAINT POISON
Severe
Affected personality
I (Eyes - visual changes)
Neuro deficit (Consciousness, focal, cognition)
Triggers (Cough, valsalva, posture change, sneeze etc.)
Pregnant
Older
Injury
Secondary risk factors (immunocompromise, malignancy risk)
Onset sudden
New symptoms (a change in severity, location etc.)
An isolated result of high protein in the CSF is indicative of..
Guillian barre = protein barrr = high protein
Low glucose and high white cells and protein in the CSF
Bacterial meningitis
Urinary incontinence + gait abnormality + dementia = ?
Normal Pressure Hydrocephalus
‘Wet, Wobbly and Wacky’:
Wet = urinary incontinence
Wobbly = ataxia
Wacky = cognitive disturbance/dementia
If there are no abnormalities detected on EEG post an epilepsy attack, a patient cannot drive for ___ months regarding car and motorbike licenses
6 months
If there are abnormalities detected on EEG post an epilepsy attack, a patient cannot drive for ___ months regarding car and motorbike licenses
12 months
If a patient had one seizure and wants to drive using a group 2 license, they must have been seizure free for ___ years
5 years
If a patient had more than one seizure and wants to drive using a group 2 license, they must have been seizure free for ___ years
10 years
Unilateral electric shock-like pains in the face triggered by light touch (such as combing hair or washing) suggest..
Trigeminal neuralgia
Tx for trigeminal neuralgia
Carbamazepine
Tx for IIH
Weight loss
Semaglitide and topiramate may be considered
Carbonic anhydrase inhibitors e.g. acetazolamide
Surgery: optic nerve sheath decompression and fenestration to prevent damage to the optic nerve. A lumboperitoneal or ventriculoperitoneal shunt to reduce ICP
Blood test results for Neuroleptic malignant syndrome
A raised creatine kinase
AKI (secondary to rhabdomyolysis) in severe cases
A leukocytosis
Tx for Neuroleptic malignant syndrome
Stop antipsychotic
IV fluids to prevent renal failure
Dantrolene, bromocriptine or dopamine agonist may be used
Differentiate between serotonin syndrome and neuroleptic malignant syndrome
Cerebellar hemisphere lesions cause..
Peripheral (‘finger-nose ataxia’)
Cerebellar vermis lesions cause..
Gait ataxia
Tx for acute subdural haematoma
Small or incidental acute subdurals can be observed conservatively. Surgical options include monitoring of intracranial pressure and decompressive craniectomy
Tx for chronic subdural haematoma
Surgical decompression with burr holes
LPs aren’t contraindicated in IIH patients because the pressure is the constant throughout the whole of the space that the CSF occupies (e.g. brain and spinal cord)
The reason LPs are contra-indicated in other causes of raised ICP are because there is often a pressure gradient between the CSF of the brain and the spinal cord - in these patients, by performing an LP, you can subsequently create a pressure gradient which then results in ‘coning’ which is the reason for why they are contraindicated.
Which tests are normally done to exclude other diagnosis when presenting with a TIA
MRI (including diffusion-weighted and blood-sensitive sequences
Blood glucose
All TIA patients should have an ___________ after imaging unless they are not a candidate
Urgent carotid dopple
Whenever the cause of the stroke is unclear, in a young individual with no known stroke risk factors, ______________ can be performed to further investigate other potential causes
Screening blood tests - antinuclear antibodies, antiphospholipid antibodies, anticardiolipin antibodies, lupus anticoagulant, coagulation factors, erythrocyte sedimentation rate, homocysteine and syphilis serology
Autonomic dysreflexia can only occur if the spinal cord injury occurs above the ___ level
T6 level
GCS for eye opening
4 - Like Four Eyes - Eye
GCS for verbal response
5 - V Like the Roman Numeral - Verbal
GCS for motor response
6 - Last one and it goes 456 - Move
To be counted as localising, the arm must be brought above the clavicle, else it should be scored as ‘flexing’
Which posture is shown here? How much does this score on the GCS?
Decorticate posturing - may be significant damage to areas including the cerebral hemispheres, the internal capsule, and the thalamus
This is an abnormal flexion response to pain so 3 points
The cerebral cortex lies above the cerebellum, so when a patient’s arms flexed up toward the face , he is pointing to his “core” (de-cor-ticate).
Which posture is shown here? How much does this score on the GCS?
Decerebrate posturing - indicates brain stem damage. It is exhibited by people with lesions or compression in the midbrain and lesions in the cerebellum
This is an abnormal extension response to pain so 2 points
Progression from decorticate posturing to decerebrate posturing is often indicative of..
Uncal (transtentorial) or tonsilar brain herniation (often referred to as coning)
Which tracts are affected in Subacute Combined Degeneration?
(S)pinocerebellar tracts
Lateral (C)orticospinal tracts
(D)orsal column
Distal tingling/burning/sensory loss is symmetrical and tends to affect the legs more than the arms
Impaired proprioception and vibration sense
Dorsal column involvement
Muscle weakness, hyperreflexia, and spasticity
Upper motor neuron signs typically develop in the legs first
Brisk knee reflexes
Absent ankle jerks
Extensor plantars
Lateral corticospinal tract involvement
Sensory ataxia → gait abnormalities
Positive Romberg’s sign
Spinocerebellar tract involvement
What can precipitate subacute combined degeneration of the cord in a patient?
Replacing folate without vitamin B12
For those who thought this sounded like an absence seizure (and therefore generalised, which can be a complication of bacterial meningitis) - I gathered that the distinguishing feature here was the aura of a ‘weird sensation’ is what pointed to temporal lobe seizure. And any focal neurologic sign with intracranial infection points to encephalitis
Tx for encephalitis
IV aciclovir
Confusion, gait ataxia, nystagmus + ophthalmoplegia
Wernicke’s encephalopathy
What is the treatment for Wernicke’s encephalopathy? What is the consequence of this condition if left untreated?
Urgent replacement of thiamine
If left untreated - will develop into Korsakoff Syndrome
Why is aspirin given as the initial treatment to the following patient?
How do Lacunar strokes present?
unilateral weakness and/or sensory deficits of the face and arm, arm and leg, or all 3, a pure sensory stroke, or ataxic hemiparesis
Myasthenia gravis has a strong association with..
Autoimmune diseases
Crescent-shaped white-grey discrete lesion
Subdural haemorrhage caused by shearing of bridging veins between cortex and venous sinus
Bridges are crescent-shaped, hence crescent description = bridging veins
Berry aneurysm
Subarachnoid haemorrhage
Extra-dural haematoma
Middle meningeal artery
____________ is a contraindication to triptan use
Cardiovascular disease
Why is contrast imaging used in MS?
You are trying to see ‘dissemination of lesions in time’ i.e. to know that the demyelinating lesions occurred at different times. This is because newer lesions will take up contrast, but older lesions will not take up contrast but will still be visible on T2. Therefore you need contrast to identify this.
Loss of dorsiflexion and eversion suggests..
Common peroneal nerve lesion
TIPPED
Tibial - inversion - plantarflex
Peroneal - eversion - dorsalflex
In ____________ eversion tends to be spared while inversion is weak and sensory involvement tends to be great
L5 radiculopathy. There’s also pain involved
What are common side effects of Lamotrigine?
Rash - Stevens-Johnson syndrome
Sore throat
_______________ are found in the CSF of 80% of MS patients
Oligoclonal bands
Ulnar nerve vs Klumpke’s palsy
In an ulnar nerve palsy, the sensory loss is limited to the hypothenar eminence, little finger, and half the ring finger. In Klumpke’s palsy, the sensory loss covers the entire C8 and T1 dermatomes.
What is C1M?
Herniation of the cerebellar tonsils through the foramen magnum
What are the two causes of disturbed CSF flow in C1M?
Syringomyelia (common; ~50%)
Hydrocephalus (uncommon)
Which segments does Syringomyelia occur in?
Cervical and thoracic
Which tract is affected by Syringomyelia?
Compression of the spinothalamic tracts decussating in the anterior white commissure
Dissociative loss of sensation of pain, temperature and non-discriminative touch. There is classically a ‘cape-like’ distribution of this sensory loss
Syringomyelia
Triad sx for normal pressure hydrocephalus
Urinary incontinence, cognitive impairment, and gait disturbance - wet, wacky and wobbly
Neuroimaging findings for normal pressure hydrocephalus
Ventriculomegaly out of proportion to sulcal enlargement
Neuroimaging findings for raised ICP
Midline shift
What does sulcal widening on neuroimaging indicate?
Normal ageing process
How can a vestibular schwannoma cause CN V and VII involvement?
Because it occurs at the cerebellopontine angle where CNV, VII, VIII are located. So they all get ‘squished’ and don’t function
Bitemporal hemianopia
lesion of optic chiasm
upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour
lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma
The _________ lobe is the second most common origin site of focal partial seizures after the temporal lobe
Frontal
Supracondylar fracture of humerus is most commonly associated with _______ nerve damage
Fracture of the proximal humerus is most commonly associated with _______ nerve damage
Fracture of the shaft of the humerus is most commonly associated with _______ nerve damage
Supracondylar fracture of humerus is most commonly associated with ulnar nerve damage
Fracture of the proximal humerus is most commonly associated with axillary nerve damage
Fracture of the shaft of the humerus is most commonly associated with radial nerve damage
Drugs that cause SJS
Never Press Skin As (IT) Can Peel
NSAIDS, Phenytoin, Sulfa drugs, Allopurinol, (IV immunoglobulin), Carbamazapine, Penicillins
carbamazepine, lamotrigine, allopurinol, sulfonamide, phenobarbital.
Other drugs most commonly associated with SJS:
Phenytoin
Salicylates
Sertraline
Imidazole antifungal agents
Nevirapine
Syringomyelia vs diabetic neuropathy
SM: a ‘cape-like’ (neck, shoulders and arms)
loss of sensation to temperature but the preservation of light touch, proprioception and vibration
DN: Glove and stocking. Proprioception and vibration lost
LEMS vs MG
Weakness in Lambert Eaton improves after exercise, unlike myasthenia gravis; which worsens after exercise
Symptoms of electric shock-like pains on one side of her face, with multiple episodes a day lasting for 30-60 seconds
Trigeminal neuralgia
Following a first seizure, patients must be seizure for ____________ before they may reapply to the DVLA for their license to be reissued. If the patient has a formal diagnosis of epilepsy they must be seizure-free for at least ____________ before they may reapply to the DVLA for their license to be reissued.
Following a first seizure, patients must be seizure for 6 months before they may reapply to the DVLA for their license to be reissued. If the patient has a formal diagnosis of epilepsy they must be seizure-free for at least 12 months before they may reapply to the DVLA for their license to be reissued.
Unable to dorsiflex the ankle, evert the foot or extend his toes. There is loss of sensation of the dorsum of the foot
Common peroneal nerve lesion
_____________ is used to treat cerebral oedema in patients with brain tumours
Dexamethasone
LOAF muscles of the hand are __________ innervation, all other flexor hand muscles are __________
LOAF muscles of the hand are median innervation, all other flexor hand muscles are ulnar
L ateral two lumbricals
O pponens pollicis
A bductor pollicis brevis
F lexor pollicis brevis
LOAF of Bread - B for aBductor pollicis
I think the different lies in the fact that polyneuropathy affects both sides and in a similar pattern like for example the peripheral neuropathy in diabetes does. Whereas mononeuritix multiplex affects in a sporadic and non consistent way different nerve trunks.
Head/leg movements, posturing, post-ictal weakness, Jacksonian march
Frontal lobe seizure
Paraesthesia
Parietal lobe seizure
Floaters/flashes
Occipital lobe seizure
Automatisms (e.g. lip smacking/grabbing/plucking)
Temporal lobe seizure
DeCuSSate - D & C letters come earlier ie Dorsal column & Corticospinal tract decussate earlier (ipsilateral signs), S letter comes later ie Spinothalamic tract decussates later (contralateral sign)
ipsilateral weakness below lesion
ipsilateral loss of proprioception and vibration sensation
contralateral loss of pain and temperature sensation
Brown-Sequard syndrome
Ix for a brain abscess
Imaging with CT scanning
Mx for brain abscess
Craniotomy - abscess may reform because the head is closed following abscess drainage
IV antibiotics: IV 3rd-generation cephalosporin + metronidazole
intracranial pressure management: e.g. dexamethasone
On neurological examination, you notice a high-frequency tremor, most pronounced on the left, when the patient holds up his arms in front of him. The tremor is absent when the patient relaxes his arms and hands and there is no evidence of any ataxia or hypotonia
essential tremor
Café-au-lait spots (>= 6, 15 mm in diameter)
Axillary/groin freckles
Peripheral neurofibromas
Lisch nodules
Pheochromocytomas
NF1
Finger-nose ataxia
Cerebellar hemisphere lesion
Hypokinetic (e.g. Parkinsonism) or hyperkinetic (e.g. Huntington’s)
Basal ganglia lesion
Sensory symptoms, dyslexia, dysgraphia
Parietal lobe lesion
Motor symptoms, expressive aphasia, disinhibition
Frontal lobe
The most common secondary brain tumours are…
Lung, breast, kidney, melanoma and colorectal
The symptoms described here would fit with a form of aphasia (most likely global given her need for written instructions) and therefore her dominant hemisphere must be affected. Although you do not know the handedness of the patient in the scenario, the most likely affected side is the left as the percentage of right and left handed individuals with a dominant left hemisphere is 90% and 60% respectively, making the left always the most likely affected side regardless of handedness.
Reflexes mnemonic
S1-S2 button my shoe
L3-L4 kick the door
C5-C6 pick up sticks
C7-C8 open the gate
Which anti-emetic is used in Parkinson’s disease?
Domperidone
(Remember this as a guy with tremor opening a bottle of Dom Perignon)
PICA/LS
DANVAH” - Dysphagia, ipsilateral Ataxia, ipsilateral Nystagmus, Vertigo, Anaesthesia (Ipsilateral facial numbness and contralateral pain loss on the body)
IIH vs intracranial venous thrombosis
IIH: typically no visual symptoms but there is papilloedema
IVT: impaired vision, focal neurological deficits, cranial nerve palsies
Hyperdensity in the affected sinus
Filling defect (‘the empty delta sign’)
Intracranial venous thrombosis
Ix for IVT
Non-contrast CT
CT venogram
Mx for IVT
LMWH and addressing risk factors
Tx for IIH
Weight loss
CA-i: acetazolamide
Alt.: topiramate and candesartan
Resistant cases: lumbar punctures, surgical CSF shunting or optic nerve sheath fenestration
In Babinski sign there is a spread of the sensory input beyond the ___ myotome to ___ and ___
S1 myotome to L4 and L5
Subarachnoid haemorrhage is associated with..
PKD
Sub-arachnoid haemorrhage can occur secondary to a..
Ruptured berry aneurysm
Occipital headache often described as a “thunderclap” or “being hit at the back of the head”
SAH
Hypo vs hyperdense area on CT
Ischaemic stroke: HYPO-dense area on CT
Haemorrhagic stroke: HYPER-dense area on CT
Differentiate between Barthel index and NIHSS
Barthel index: asses functional independence/activities of daily living
NIHSS: extent and severity of neurological impairment
Which organism is the most common cause of encephalitis?
HSV
Chronic management of a stroke for prevention
Aspirin 300mg 2 weeks + clopi
then drop the aspirin and only continue the clopidogrel
if clopi is contraindicated then dipyradamole with aspirin long term
In a ‘surgical’ third nerve palsy there is pupil involvement. This is because..
Parasympathetic (constrictive) fibres run on the outside of the nerve. External compression will impair function of these fibres, causing pupil dilation
The most common cause of a surgical third nerve palsy is a ______________________. Other causes include..
The most common cause of a surgical third nerve palsy is a posterior communicating artery aneurysm. Other causes include cavernous sinus lesions (infection, thrombosis, tumour infiltration)
In raised ICP, if the GCS is <8 then you should..
Intubate then transfer to ICU
Damage to the right occipital lobe would cause a..
Left sided homonymous hemianopia with macular sparing
Conversely, damage to the left occipital lobe would cause a right sided homonymous hemianopia with macular sparing
Obstructive (or non-communicating) hydrocephalus vs communicating hydrocephalus
Obstructive: Flow of CSF is blocked along one or more of the narrow passages connecting the ventricles. Common sites include the foramen of Monro (e.g. due to colloid cysts), cerebral aqueduct (e.g. due to aqueduct stenosis), or fourth ventricle (e.g. due to posterior fossa tumour).
Communicating: CSF can exit the ventricular system, but absorption into the bloodstream is impeded. Commonly due to problems in the subarachnoid space, often stemming from complications like subarachnoid haemorrhage and infective meningitis
Target SBP in haemorrhagic stroke?
<140 to maintain cerebral perfusion
Contraindications to thrombolysis
Anticoagulation with an INR >1.7
Unknown time of onset of her symptoms - risk of intracranial haemorrhage should she receive alteplase
Plus head trauma, GI/IC haemorrhage, recent surgery, abnormal BP/platelet count
Causes of peripheral neuropathy
ABCDE
Alcohol
B12/Folate
Chronic Renal Failure
Diabetes Mellitus
Everything Else - Vasculitis and Paraneoplastic syndromes
Car/motorbike license:
One off seizure = ?
More than one seizure = ?
Seizure following change in antiepileptic medications = ?
One off seizure = reapply in 6 months
More than one seizure = reapply in one year
Seizure following change in antiepileptic medications = reapply to drive if seizure was more than 6 months ago or you’ve been back on previous medication for 6 months
Bus/coach/lorry license:
One off seizure: ?
More than one seizure: ?
One off seizure: reapply in 5 years or if you haven’t taken anti epileptic medications for 5 years
More than one seizure: reapply once you haven’t had a seizure for 10 years or you haven’t taken any anti-epileptic medication for 10 years
Most common visual defect presented in optic neuritis
Central scotoma
Which nerves are affected in bulbar palsy?
Ninth (glossopharyngeal), tenth (vagus), and twelfth (hypoglossal) cranial nerves
Subjective abdominal symptoms, and then staring, followed by lip smacking and a period of disorientation
Temporal seizure
Sudden jerking of a limb, trunk, or face. Consciousness is preserved and these movements can be violent and unpredictable
Myoclonic seizure
Loss of muscle tone, causing a fall
Atonic seizure
LP results show a raised PMN WCC, raised protein and low glucose
Bacterial
Symptoms that point towards Ramsay Hunt over Bell’s palsy
Burning pain, vertigo and vesicular rash
Signs and symptoms of cerebellar dysfunction
Dysdiadochokinesia: An inability to perform rapid alternating hand movements.
Ataxia: A broad-based, unsteady gait.
Nystagmus: Involuntary eye movements.
Intention tremor: Observed during the ‘finger-nose test’.
Slurred speech.
Hypotonia.
Truncal ataxia and gait instability
Lesions to the cerebellar vermis
Cerebral dysfunction signs in the ipsilateral limb
Cerebellar hemisphere lesion
Clinical signs for raised ICP
Cushing’s triad:
Bradycardia, hypertension and irregular/abnormal breathing
Bilateral findings of upper limb weakness, spasticity on arm extension, brisk triceps’ reflexes, and suppressed C6 reflexes. His biceps reflexes are normal bilaterally. There is sensory loss over his middle fingers
Cervical Myelopathy
Differentiate between conduction aphasia and Wernicke’s
Conductive is simply an impaired repetition with preserved comprehension, whereas Wernicke’s is impaired repetition plus impaired comprehension
The fibers that control the lower face travel from the cortex down to the brainstem. In the brainstem, these fibers cross over to the opposite, or contralateral, facial nerve.
The fibers that control the upper face take a slightly different path. After travelling down to the brainstem, half of the fibers cross over to the contralateral facial nerve, and half remain on the same side and contribute to the ipsilateral facial nerve.
Therefore, the eyes and forehead receive innervation from both hemispheres, while the lower face only receives innervation from the contralateral hemisphere
LMN - Ipsilateral
UMN - Contralateral
Side effects of phenytoin
P= p450 interactions
H = hirsutism
E= enlarged gums
N = nystagmus
Y= yellow skin ie jaundice
T = teratogen
O = osteomalacia
I = intereference with b12 metabolism
N = neuropathies
+ megaloblastic anaemia
Status epilepticus: rule out _________ and _________ before thinking of other causes
Status epilepticus: rule out hypoxia and hypoglycaemia before thinking of other causes
Which drugs can increase the risk of IIH?
A LOST Cause
A - Vitamin A, amiodarone & retinoids
L - lithium/levothyroxine
O - OCP
S - steroids
T - tetracycline, sulphonamides
C - cimetidine, cyclosporin
Cushing Reflex Vitals as the Opposite to Hypovolaemic Shock
- Hypertension (HV Shock = Hypotension)
- Bradycardia (HV Shock = Tachycardia)
- Wide Pulse Pressure (HV Shock = Narrow Pulse Pressure)
Generalised tonic-clonic seizures (GTCS) and myoclonic episodes shortly after waking
Juvenile myoclonic epilepsy - seizures in the morning/following sleep deprivation
Strong postural relationship with the headache generally much worse when upright
Spontaneous intracranial hypotension
Ix for Spontaneous intracranial hypotension
MRI with gadolinium
Tx for Spontaneous intracranial hypotension
Bed rest, hydration, or a procedure called an epidural blood patch
When is preventative treatment indicated in migraines?
When migraines occur >1/week on average
A 63 year old male presents to the Emergency Department with complete left sided paralysis and double vision. This came on suddenly. On examination, he was unable to abduct his right eye and had an absent corneal reflex. Where is the lesion?
Right pons
Cranial nerve lesions are ipsilateral, except trochlear. Abducting the right eye is the lateral rectus muscle, supplied by the Abducens nucleus (VI). This comes out of the pons. Additionally, the absent corneal reflex (utilises CN V: afferent and VII: efferent in the reflex) is absent, further implicating the pons. Corticospinal fibres travel through the pons and decussate later in the medulla, hence hemiparesis would be contralateral to the site of the lesion
Neck stiffness and positive Kernig’s sign
Meningism
Symptoms continue to deteriorate without any periods of recovery or relapse.
Primary progressive MS
Initially have the relapsing-remitting form of MS. Symptoms in this stage now start to steadily progress without the periods of recovery that had previously occurred
Secondary progressive MS
Patient experiences a cycle of relapses, followed by a period of recovery with no symptoms
Relapsing-remitting
Bilateral symptoms suggests drug induced/ idiopathic Parkinson’s
Drug-induced
Which symptoms are not normally seen in MND?
Doesn’t affect external ocular muscles
No cerebellar signs
Abdominal reflexes are usually preserved and sphincter dysfunction if present is a late feature
Nerve conduction studies shows normal motor conduction
Electromyography shows a reduced number of action potentials with increased amplitude
Motor neuron disease
If a patient is on warfarin/a DOAC/ or has a bleeding disorder and they are suspected of having a TIA, they should be admitted immediately for..
Imaging to exclude a haemorrhage
Humeral, middle arm and supracondylar injuries damage which nerves?
|A| Top of the arm (humeral head dislocation) = Axillary nerve injury
|R| Middle of the arm (midshaft) = Radial nerve injury
| |
| |
|M| Supracondylar = Median nerve injury
C4 shoulder shrugs
C5 shoulder abduction and external rotation; elbow flexion
C6 wrist extension
C7 elbow extension and wrist flexion
C8 thumb extension and finger flexion
T1 finger abduction
L2 hip flexion
L3 knee extension
L4 ankle dorsiflexion
L5 great toe extension
S1 ankle plantarflexion
S4 bladder and rectum motor supply
What is the most common complication of Meningitis?
Sensorineural hearing loss
Other:
Seizures
Focal neurological deficit
Sepsis, intracerebral abscess
Brain herniation, hydrocephalus
Differentiate between Tuberous sclerosis and Neurofibromatosis
Hoffman’s sign is seen in which two conditions?
DCM
Multiple Sclerosis
Which anti-epileptic causes weight gain?
Sodium Val-Pro-Weight!
Unilateral spastic paresis and loss of proprioception/vibration sensation with loss of pain and temperature sensation on the opposite side
Brown-Sequard syndrome
Neuropathic pain drugs
Don’t - Duloxetine
Get - Gabapentin
Pain - Pregabalin
Again - Amitriptyline
Fever, headache and a focal neurological deficit in the form of arm weakness + seizure
Brain abscess
Triad dementia, myoclonus, and rigidity + mutism
CJD
Paraesthesias affecting thumb and first finger
Grip weakness and dropping objects unintentionally
Wasting over the thenar eminence
A positive Hoffmans sign
DCM
Resting tremor, rigidity, bradykinesia, postural instability
Dysarthria and reduced vertical eye movements
Progressive supranuclear palsy
PSP = problem seeing planes = vertical gaze palsy
Which test is done if falls occur soon after the diagnosis of Parkinson’s disease?
An alternative diagnosis should be considered, most likely a Parkinsons-plus syndrome such as PSP - so test for CN III, IV, VI
Features of NMS
FEVER
Fever
Encephalopathy
Vitals dysregulation - increase in HR, RR, Fever
Enzyme - CK increase
Rigidity
Ptosis, a dilated pupil, and an eye deviated downwards and outwards on the left side
3rd nerve palsy
Horizontal diplopia that worsens when looking to the left side due to weakness in abduction of the left eye
6th nerve palsy
Upwards and rotated outwards, along with worsening double vision when looking to the left
4th nerve palsy
Vertical diplopia noticed when reading a book or going downstairs
Subjective tilting of objects (torsional diplopia)
Head tilt
when looking straight ahead, the affected eye appears to deviate upwards and is rotated outwards
4th nerve palsy
Left-sided ptosis and miosis and the patient has left-sided ataxia
Left posterior inferior cerebellar artery/ lateral medullary syndrome
Pupil is enlarged with the eye pointed outwards and downwards
Branch of the posterior cerebral artery/ Weber’s syndrome
Paralysis and loss of proprioception on the same side as the lesion, and loss of pain and temperature sensation on the opposite side as the lesion
Brown-Sequard syndrome
Symptoms of temporal lobe seizures
THREAD - Temporal, Hallucinations, Rising Epigastrium, Automatism, Deja Vu
Which primary cancer is most likely to be responsible for brain lesions?
Left Brained Metastases Can Kill
Lung >Breast > Melanoma > Colorectal > Kidney
Distal sensory loss, tingling + absent ankle jerks/extensor plantars + gait abnormalities/Romberg’s positive
Subacute combined degeneration of the spinal cord
Migraine triggers
CHOCOLATE
Chocolate
Hangovers
Orgasms
Cheese/caffeine
Oral contraceptives
Lie-ins
Alcohol
Travel
Exercise
Stroke vs bell’s palsy
Stroke Spares forehead
One sided facial paralysis and unable to raise eyebrow
Bell’s palsy
_________ is used in increased ICP due to TBI whereas _________ is used in increased ICP due to tumours
Mannitol is used in increased ICP due to TBI whereas dexamethasone is used in increased ICP due to tumours
Gently flicking one finger on a patient’s hand. A positive test results in reflex twitching of the other fingers on the same hand in response to the flick
DCM - Hoffman’s sign
DCM can often be confused with..
Carpal tunnel syndrome
Disc degeneration and ligament hypertrophy, with accompanying cord signal change
DCM
Gold standard investigation for DCM
MRI
Tx for DCM
Urgent referral for assessment by specialist spinal services (neurosurgery or orthopaedic spinal surgery)
Decompressive surgery + physiotherapy within 6 months of diagnosis
A high-stepping gait develops to compensate for foot drop. If found unilaterally then a ________________ should be suspected. Bilateral foot drop is more likely to be due to ________________
A high-stepping gait develops to compensate for foot drop. If found unilaterally then a common peroneal nerve lesion should be suspected. Bilateral foot drop is more likely to be due to peripheral neuropathy
To differentiate between flexion and withdrawing you need to apply _______________ to see if the patient pulls away from the stimulus or remains flexed
To be counted as localising, the arm must be brought above the ___________, else it should be scored as ‘flexing’
To differentiate between flexion and withdrawing you need to apply nail bed pressure to see if the patient pulls away from the stimulus or remains flexed
To be counted as localising, the arm must be brought above the clavicle, else it should be scored as ‘flexing’
When is Carbemazepine taken? Which type of seizures does it worsen?
Carbemazepine is taken in the (AM) - Worsens (A)bsence & (M)yoclonic Seizures.
Hyperventilation ==> Decreases CO2 ==> Decreases vasodilation (i.e. increases vasoconstriction) ==> Decreases total cerebral blood volume ==> Decreases ICP
Intracranial pressure and blood pressure are not the same thing. Blood pressure in the cerebral vessels could be high but overall intracranial pressure would be lowered because overall there is less volume in the cranium
Everything we do in raised ICP is to make the intracranial contents ‘smaller’.
- vasoconstrict through controlled hyperventilation
- head tilt 35 degrees in midline position to optimise venous drainage
- anaesthetise to reduce metabolic activity
- analgese to make brain smaller (idk how)
- control BM (osmotic)
- cool brain = smaller brain (controller hypothermia, think this is variably used)
Non-communicating hydrocephalus
Headache
Syringomyelia
Arnold-Chiari malformation
Arnold-Chiari malformation is downward displacement, or herniation, of the cerebellar tonsils through the __________ __________
Arnold-Chiari malformation is downward displacement, or herniation, of the cerebellar tonsils through the foramen magnum
Autonomic dysreflexia explanation
Loss of proprioception, light touch and vibration sense (sensory ataxia and a positive Romberg’s test) in SCDC is due to damage in which column?
Damage to the posterior columns
Spastic weakness and upgoing plantars (UMN signs) in SCDC is due to damage in which columns?
Damage to lateral columns
Absent ankle and knee jerks (LMN signs) in SCDC is due to damage in which columns?
Damage to peripheral nerves
What visual problem is caused by PSP?
PSP = problem seeing planes = vertical gaze palsy
Typically LMN signs in arms and UMN signs in legs
In familial cases the gene responsible lies on chromosome 21 and codes for superoxide dismutase
Which type of MND is this?
Amyotrophic lateral sclerosis
UMN signs only
Which type of MND is this?
Primary lateral sclerosis
LMN signs only
Affects distal muscles before proximal
Carries best prognosis
Which type of MND is this?
Progressive muscular atrophy
Palsy of the tongue, muscles of chewing/swallowing and facial muscles due to loss of function of brainstem motor nuclei
Carries worst prognosis
Which type of MND is this?
Progressive bulbar palsy
Xanthochromia is used in the diagnosis of..
Subarachnoid haemorrhage
Mnemonic for Syringomyelia
Syringomyelia - sPinoThalamic (Pain and Temperature)
due to compression of the spinothalamic tract fibres decussating in the anterior white commissure of the spine and Temperature)
Drugs that may exacerbate myasthenia
Pretty - Procainamide
Queen - Quinidine
Allowed - Abx (gentamicin, macrolides, quinolone, tetracycline)
People to - Penicillamine
Learn - Lithium
and Pack - Phenytoin
Bibles - Beta blockers
Chiari malformations are often associated with ___________ due to disturbed cerebrospinal fluid flow at the foramen magnum
Chiari malformations are often associated with syringomyelia due to disturbed cerebrospinal fluid flow at the foramen magnum
Syringomyelia vs Syringobulbia
Syringomyelia - collection of cerebrospinal fluid within the spinal cord
Syringobulbia - fluid-filled cavity within the medulla of the brainstem.
Ix for Syringomyelia
Full spine MRI with contrast to exclude a tumour or tethered cord
A brain MRI is also needed to exclude a Chiari malformation
Tx for Syringomyelia
Treatment will be directed at treating the cause of the syrinx. In patients with a persistent or symptomatic syrinx, a shunt into the syrinx can be placed
Tx for MND
Riluzole
Non-invasive ventilation (usually BIPAP) is used at night
Percutaneous gastrostomy tube (PEG)
MOA of Riluzole
Prevents stimulation of glutamate receptors
What are the most common types of venous thrombosis?
Sagittal
Followed by lateral sinus thromboses and cavernous sinus thromboses
What is an alternative to MRI venography when inve
CT venography is an alternative
Mx for intracranial venous thrombosis
Acutely: Low molecular weight heparin
Long term: Warfarin
Seizures and hemiplegia
Parasagittal biparietal or bifrontal haemorrhagic infarctions
Empty delta sign
Sagittal sinus thrombosis
Periorbital oedema
Ophthalmoplegia: 6th nerve damage typically occurs before 3rd & 4th
Trigeminal nerve - hyperaesthesia of upper face and eye pain
Central retinal vein thrombosis
Cavernous sinus thrombosis
6th and 7th cranial nerve palsies
Lateral sinus thrombosis
Tx for acute subdural haematoma
Small/incidental: Observation
Surgery: Monitoring of intracranial pressure and decompressive craniectomy
Tx for chronic subdural haematoma
Small haematoma/no neurological deficits: Observation
Confused/neurological deficits: Surgical decompression with burr holes is required
Tx for NMS
Dantrolene
Bromocriptine
Triptans are contraindicated in patients with…
CAD as they have the potential to cause coronary vasospasm
Tx for brain abscess
surgery
Craniotomy is performed and the abscess cavity debrided
(the abscess may reform because the head is closed following abscess drainage)
IV antibiotics: IV 3rd-generation cephalosporin + metronidazole
intracranial pressure management: e.g. dexamethasone
First line treatment for neuropathic pain
AGPD - اكتب (kinda)
Amytriptyline
Gabapentin
Pregabalin
Duloxetine
If one doesn’t work, switch to another
Tx for exacerbations of neuropathic pain
Tramadol
Tx for localised neuropathic pain (e.g. post-herpetic neuralgia)
Topical capsaicin
Patients are typically young thin women possessing long neck and drooping shoulders
Thoracic outlet syndrome
In PD, if excessive daytime sleepiness develops then patients should not drive. Medication should be adjusted to control symptoms. ________ can be considered if alternative strategies fail
Modafinil
In PD, if orthostatic hypotension develops then a medication review looking at potential causes should be done. If symptoms persist then ________ (acts on peripheral alpha-adrenergic receptors to increase arterial resistance) can be considered
Midodrine
Consider ____________ to manage drooling of saliva in people with Parkinson’s disease
Glycopyrronium bromide
Incongruous defects are usually due to a lesion of the…
Optic tract - due to the dual blood supply to the LGN and optic tract
Congruous defects occur due to lesions of..
Optic radiation or occipital cortex - occurs behind the LGN in the radiation or cortex
Macula sparing is due to a lesion of…
Occipital cortex
Bitemporal hemianopia with upper quadrant defect > lower quadrant defect..
Inferior chiasmal compression, commonly a pituitary tumour
Bitemporal hemianopia with upper quadrant defect < lower quadrant defect..
Superior chiasmal compression, commonly a craniopharyngioma
Vitamin B1/B12 is thiamine
B1 - Th1amine
Contraindications for lumbar punctures
GCS < 13 or fall > 2
Papilloedema
Shock
Immunocompromised
Seizure
What does the following CSF finding show?
Normal
Does the following CSF finding show bacterial or viral meningitis?
Viral meningitis
Does the following CSF finding show bacterial or viral meningitis?
Bacterial meningitis
Cloudy CSF appearance
TB/Fungal
Patients with meningococcal meningitis are at risk of..
Waterhouse-Friderichsen syndrome (adrenal insufficiency secondary to adrenal haemorrhage)
What does the following MRI show?
HSV encephalitis
There is hyperintensity of the affected white matter and cortex in the medial temporal lobes and insular cortex
Herpes simplex encephalitis typically occurs in the ________ and ________ lobe
Temporal and inferior frontal lobes
EEG pattern: lateralised periodic discharges at 2 Hz
HSV
LEMS VS MG
Lifting eases, Moving sucks
LEMS: Better with movement
MG: Worse with movement
Which antibodies are associated with MG?
ACh receptor antibodies
Which antibodies are associated with LEMS?
Voltage-gated calcium-channel antibodies
Which antibodies are associated with MS?
Not auto-abs, it’s just demyelination in the central nervous system
Finger-nose ataxia
Cerebellar vermis lesion
Hypokinetic (e.g. Parkinsonism) or hyperkinetic (e.g. Huntington’s)
Basal ganglia lesion
Sensory symptoms, dyslexia, dysgraphia
Parietal lobe
Motor symptoms, expressive aphasia, disinhibition
Frontal lobe
Which anti-emetic is given in parkinson’s?
Domperidone
A LOST Cause - idiopathic intracranial hypertension causative drugs
A - Vitamin A & metabolites
L - lithium/levothyroxine
O - OCP
S - steroids
T - tetracycline
C - cimetidine
Most common cause of a stroke in individuls under the age of 40
Carotid artery dissection
Leg pain and weakness that is relieved with rest, worse on walking downhill, as well as numbness and tingling in the legs and decreased sensation and strength in the lower extremities
Spinal claudication
Spinal = Steep (Walking downhill)
Peripheral = Push (Walking uphill)
Leg pain with exertion relieved by rest but is typically worse when walking uphill rather than downhill
Peripheral artery disease
Spinal = Steep (Walking downhill)
Peripheral = Push (Walking uphill)
Which anti-epileptic is contraindicated in COCP?
Levetiracetam
Neck, shoulder and arm pain
Paresthesia that affects the arm, forearm and fourth and fifth fingers
Pancoast syndrome
Brachial plexus involves the lower segment of nerve roots coming off of the cervical spine (C5-T1) and compression most often affects C8 and T1 specifically
Neck and arm pain
Numbness and weakness in the biceps and forearm, down to the interdigital space between the thumb and index finger
C6 Radiculopathy
A lesion of the spinal cord results in urinary retention and constipation due to..
Increased sphincter tone, preventing the passage of urine or faeces
A cauda equina lesion would result in urinary and faecal incontinence due to..
Flaccid paralysis of the urethral sphincter
The presence of autonomic dysfunction indicates that the lesion is above the level of..
T6
Lesions in the brain tend to cause bilateral/unilateral deficits, lesions of the spinal cord tend cause bilateral/unilateral deficits
Lesions in the brain tend to cause unilateral deficits, lesions of the spinal cord are often bilateral
If all four limbs are affected, the spinal cord lesion is likely..
Cervical
If only the lower limbs are affected, the spinal cord lesion is likely..
Thoracic
If the patient has respiratory difficulties and their diaphragm has been affected, then the spinal cord lesion is likely above..
C3
Spastic paralysis and UMN signs
Loss of fine touch, vibration and proprioception
Loss of pain and temperature
Lower limbs affected first
Brown-Sequard syndrome
Or complete transection
Spastic paralysis and UMN signs
Loss of pain and temperature
Fine touch, vibration and proprioception preserved
Lower limbs affected first
Anterior cord syndrome
Spastic paralysis and UMN signs may be present
Pain and temperature present
Loss of fine touch, vibration and proprioception
Lower limbs affected first
Posterior cord syndrome
Spastic paralysis and UMN signs may be present
Loss of pain and temperature
Fine touch, vibration and proprioception preserved
Upper limbs affected first
Syringomyelia
The terminal end of the spinal cord is termed the ________ ___________. Beyond this is a collection of spinal nerves composed of lumbar, sacral, and coccygeal nerves. This makes up the ________ ________
The terminal end of the spinal cord is termed the conus medullaris. Beyond this is a collection of spinal nerves composed of lumbar, sacral, and coccygeal nerves. This makes up the cauda equina
_________ or _________ can cause posterior cord syndrome
Subacute degeneration of the cord due to vitamin B12 deficiency
Multiple sclerosis
_________, _________ or _________ can cause brown sequard syndrome
Gun-shot wound
Stabbings
Road-traffic collision
_________ or _________ can cause central cord syndrome
Intramedullary tumor
Syringomyelia
Extradural haemorrhage occurs between the skull and dura mater and is usually caused by..
Rupture of the middle meningeal artery in the temporoparietal region
Extradural haemorrhage is associated with a fracture of the __________ bone
Temporal
Young patient with a traumatic head injury and an ongoing headache. They have a period of improved neurological symptoms and consciousness, followed by a rapid decline over hours
Extradural haemorrhage
Subdural haemorrhage occurs between the dura mater and arachnoid mater and is caused by..
Rupture of the bridging veins in the outermost meningeal layer
Subdural haemorrhages may occur in..
Elderly and alcoholic patients, who have more atrophy in their brains, making the vessels more prone to rupture
Subarachnoid haemorrhage involves bleeding between the pia mater and the arachnoid membrane. This is usually the result of..
Ruptured cerebral aneurysm.
Sudden-onset occipital headache during strenuous activity, such as heavy lifting or sex
Subarachnoid Haemorrhage
CSF sample with a raised RCC and xanthochromia
Xanthochromia
Ix for subarachnoid Haemorrhage
CT
If normal do a lumbar puncture
Tx for SAH
Endovascular coiling
Neurosurgical clipping
Nimodipine to prevent vasospasm as a complication
Complications of SAH
Vasospasm
Seizures
Hydrocephalus
What does the following fundoscopy show?
Papilloedema
What does the following fundoscopy show?
Optic neuritis
Normal consensual pupillary reflex
RAPD present
When testing the direct pupillary reflex, there is a reduced pupil response in the affected eye
Optic neuritis
Proximal muscle weakness,
Autonomic dysfunction, causing dry mouth, blurred vision, impotence and dizziness
Reduced or absent tendon reflexes
LEMS
A lesion in the __________ causes a conjugate lateral gaze disorder
Abducens (CN VI)
Tx for LEMS
Amifampridine
Pyridostigmine
IV immunoglobulins
Plasmapheresis
CSF shows raised protein with a normal cell count and glucose
GBS
Tx for GBS
VTE prophylaxis (pulmonary embolism is a leading cause of death)
IV immunoglobulins
Plasmapheresis is an alternative to IVIG
What does this clinical sign show?
Right facial LMN lesion - Bell’s Palsy
What does this clinical sign show?
Right facial UMN lesion - Stroke
Absent corneal reflex + proptosis
Cavernous sinus thrombos
3rd nerve palsy = ptosis + dilated pupil
Posterior communicating artery aneurysm
Drugs for status epilepticus in the pre-hospital setting eg GP
Midazolam - Mouth
Diazepam - Dirty/Rectal
Lorazepam - Line - IV
Shoulder movement weakness, which is best elicited by asking the patient to place the dorsum of their hand on the opposite buttock to test extension, adduction and internal rotation
Thoracodorsal nerve
Very weak elbow flexion and weak forearm supination which can be very disabling.
Musculocutaenous nerve
Numbness over the sergeant’s patch and profound weakness of shoulder abduction from 15-90°
Deltoid wasting and weakness of shoulder flexion, extension and external rotation
Axillary nerve
Wrist drop” deformity with very weak extension of the elbow, wrist and fingers.
Radial nerve - humerus or radius fractures
Wasting of the thenar eminence, weak grip strength and a “hand of benediction” deformity due to an inability to flex the index or middle fingers.
Median nerve - supracondylar fractures
Wasting of the hypothenar eminence and intrinsic muscles of the hand, a “claw hand” deformity due to an inability to extend the ring and little fingers, and weak finger abduction and adduction
Ulnar nerve - upracondylar fractures of the humerus, medial epicondylar fractures, compression at either the cubital tunnel in the elbow or Guyon’s canal in the wrist
Migraine triggers
CHOCOLATE
Chocolate
Hangovers
Orgasms
Cheese
Caffeine
The oral contraceptive pill
Lie-ins
Alcohol
Travel
Exercise
When can you stop AED?
If seizure free >2 years with AEDs being stopped over 2-3 months
Adverse effects of Levodopa
Dyskinesia
‘On-off’ effect
Postural hypotension
Cardiac arrhythmias
Nausea & vomiting
Psychosis
Reddish discolouration of urine upon standing
Tibial vs common peroneal nerve damage
TIPPED
Tibial: Inversion-Plantarflexion
Peroneal: Eversion-Dorsiflexion
When calculating the GCS, the arm must be brought above the ________ to be counted as localising, else it should be scored as ‘flexing’
Clavicle
Thoracic outlet syndrome (TOS) is a disorder involving compression of..
Brachial plexus, subclavian artery or vein
TOS develops when neck trauma occurs to individuals with anatomical osseous predispositions such as..
Scalene muscle hypertrophy and anomalous bands
Painless muscle wasting of hand muscles, with patients complaining of hand weakness e.g. grasping
Numbness and tingling
Cold hands, blanching or swelling
Neurogenic TOS
Painful diffuse arm swelling with distended veins
Painful arm claudication and in severe cases, ulceration and gangrene
Vascular TOS
Ix for TOS
Chest and cervical spine plain radiographs
CT or MRI to rule out cervical root lesions
Venography or angiography may be helpful in vascular TOS
Anterior scalene block may be used to confirm neurogenic TOS and check the likelihood of successful surgical treatment
Tx for TOS
Education, rehabilitation, physiotherapy, or taping
Surgical decompression
Asymmetric cerebellar syndrome, affecting the right side of her body. The timing of onset is over weeks
Multiple Sclerosis
If subacute, then cerebellar infarct
Tx for bacterial meningitis
Ceftriaxone
If allergic then chloramphenicol
Slow, thick speech, a spastic tongue, brisk jaw jerk reflex, emotional lability, and additional upper motor neurone features
Pseudobulbar palsy
Extradural haemorrhages are limited/not limited by suture lines
Lentiform (biconvex) = Limited
Areflexia, ataxia, ophthalmoplegia
Miller Fisher syndrome
Fluctuating levels of consciousness following a head injury
Extradural haemorrhage
What does the following clinical sign show?
Vesicles in the ear canal in a patient with Ramsay Hunt syndrome
A migraine can last for about..
4 - 72 hours
A cluster headache can last for about..
15 minutes to 2 hours
Which condition causes sympathetic (adrenergic) blockage?
Horner syndrome
Reduced GCS, paralysis and small bilateral pupils that remain small even in bright light
Pontine haemorrhage
Reduced power in legs, normal sensation and reduced knee and ankle reflexes
GBS
Decreased motor nerve conduction velocity
Prolonged distal motor latency
Increased F wave latency
GBS
Cranial nerve involvement:
Diplopia
Bilateral facial nerve palsy
Oropharyngeal weakness is common
GBS
Headache, fever, focal neurology, nausea, papilloedema, seizures
Brain abscess
Loss of sensory and motor function of multiple non-contiguous nerves, eventually becoming symmetrical
Mononeuritis multiplex
Causes of mononeuritis multiplex
WARDS PLC
Wegener’s
Amyloidosis
Rheumatoid Arthritis
Diabetes
Sarcoid
PAN
Leprosy
Carcinomatosis
Weakness is symmetrical from the beginning and progresses bilaterally. Reflexes are lost in affected parts but particularly at the ankles. Sensory complaints and loss of sensation are most pronounced distally, and in the feet before the hands in most cases
Polyneuropathy
Neurologic signs are asymmetrical, with a distribution that may be proximal in one limb and distal in another. Weakness and zones of sensory loss correspond to involvement of one or more spinal/cranial roots. Pain in the sensory distribution of the roots is a common feature
Polyradiculopathy
Weakness in dorsiflexion and eversion of the foot. Sensory change ends a limited distance above the ankle
Peroneal nerve or to the L5 nerve root
Weakness in dorsiflexion and eversion + inversion of the foot. Sensory change extends almost up to the knee on the anterior surface of the foreleg
Tibial nerve (affected only with L5 root lesions)
Oculomotor dysfunctions seen in Wernicke’s encephalopathy
Nystagmus
Ophthalmoplegia: lateral rectus palsy, conjugate gaze palsy
Decreased red cell transketolase
Wernicke’s encephalopathy
In status epilepticus, IV _____________, _____________ or _____________ should be given if not responding to benzodiazepines
IV levetiracetam, phenytoin or sodium valproate
Temporary loss of vision through one eye, which returns to normal afterwards
Amaurosis fugax: Retinal/ophthalmic artery
A wide-based gait with loss of heel to toe walking
Ataxic gait
Limping caused by pain that is worse when weight-bearing on the affected limb
Antalgic gait
Lifting the affected leg up higher to prevent their foot from dragging across the floor as they walk.
High stepping gait
Weakness in the pelvic girdle and thigh muscles and is characterised by the patient circumducting their leg when walking
Waddling gait
Anti-GQ1b antibodies are found in…
Miller-Fisher syndrome
Rapid onset dementia and myoclonus
Creutzfeldt-Jakob disease
Painful headache that is worse on bending forward
Sinusitis
Lost the ability to abduct thumb
Median nerve
Facial nerve palsy
“Face, ear, taste, tear”
Face: muscles of facial expression
Ear: nerve to stapedius
Taste: supplies anterior two-thirds of tongue
Tear: parasympathetic fibres to lacrimal glands, also salivary glands
An extended target time of up to 24 hours for a thrombectomy may be considered in which circumstance?
If there is the potential to salvage brain tissue shown by CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
DVLA guidelines for patients with established epilepsy or those with multiple unprovoked seizures
May qualify for a driving licence if they have been free from any seizure for 12 months
If there have been no seizures for 5 years (with medication if necessary) a ’til 70 licence is usually restored
DVLA guidelines for withdrawal of epilepsy medication
Should not drive whilst anti-epilepsy medication is being withdrawn and for 6 months after the last dose
DVLA guidelines for stroke or TIA
1 month off driving, may not need to inform DVLA if no residual neurological deficit
DVLA guidelines for multiple TIAs over short period of times
3 months off driving and inform DVLA
Expansion of central canal in Syringomyelia interferes with anterior white commisure of spinothalamic tract, causing a loss of..
Pain
Temperature
Pressure
Crude touch
Expansion of central canal in Syringomyelia interferes with lower motor neurones of corticospinal tract, causing a..
Muscle atrophy
Muscle weakness
Paralysis
What does the following MRI show?
Chiari malformation with syrinx
Widespread convulsions without conscious impairment
Pseudoseizure
High arched feet and neuro signs. Progressive over years
CMT
Hyperthermia, muscle rigidity, autonomic instability, altered mental status
Neuroleptic malignant syndrome
Parkinson’s vs Drug induced
PADS
PD: Asymmetrical
DI: Symmetrical
If there is difficulty differentiating between essential tremor and Parkinson’s disease NICE recommend considering..
123I‑FP‑CIT single photon emission computed tomography (SPECT)
What does the following image show?
Normal susbtantia nigra on the right
Loss of pigmented cells in PD on the left
What type of aura is described to occur with migraines?
Flashes of light, blind spots and zigzag patterns (spreading scintillating scotoma aka ‘jagged crescent’)
In trauma, to test if the fluid draining from the nose or ear is CSF, check for..
Beta-2-transferrin and glucose
Lhermitte’s sign is seen in which conditions..
Multiple sclerosis, subacute combined degeneration of the cord and in cervical stenosis
Uhthoff’s phenomenon: worsening of vision following rise in body temperature
Multiple sclerosis
Triptan is contra-indicated in..
Ischaemic heart disease or cerebrovascular disease
_____________ is the most common primary tumour in adults and is associated with a poor prognosis
Glioblastoma multiforme
What does the following MRI show?
Glioblastoma multiforme - solid tumours with central necrosis and a rim that enhances with contrast
In GM, there is disruption of the blood-brain barrier and therefore are associated with..
Vasogenic oedema
Pleomorphic tumour cells border necrotic areas
Glioblastoma multiforme
Tx for GM
Surgical with postoperative chemotherapy and/or radiotherapy. Dexamethasone is used to treat the oedema.
________ is the second most common primary brain tumour in adults
Meningioma
Meningiomas arise from..
Arachnoid cap cells of the meninges and are typically located next to the dura
Meningiomas cause symptoms by compression/invasion
Compression
Where are meningiomas located?
At the falx cerebri, superior sagittal sinus, convexity or skull base
Spindle cells in concentric whorls and calcified psammoma bodies
Meningioma
Ix for meningioma
CT (will show contrast enhancement) and MRI, and treatment will involve either observation, radiotherapy or surgical resection
Antoni A or B patterns are seen. Verocay bodies (acellular areas surrounded by nuclear palisades)
Vestibular schwannoma
_____________ is the most common primary brain tumour in children
Pilocytic astrocytoma
Rosenthal fibres (corkscrew eosinophilic bundle)
Pilocytic astrocytoma
A _________________ is an aggressive paediatric brain tumour that arises within the infratentorial compartment. It spreads through the CSF system
Medulloblastoma
Small, blue cells. Rosette pattern of cells with many mitotic figures
Medulloblastoma
Tx for Medulloblastoma
Surgical resection and chemotherapy
_______________ are commonly seen in the 4th ventricle and may cause hydrocephalus. Histology shows perivascular pseudorosettes
Ependymomas
________________ are benign, slow-growing tumour common in the frontal lobes. Histology shows calcifications with ‘fried-egg’ appearance
Oligodendromas
_______________ is a vascular tumour of the cerebellum associated with von Hippel-Lindau syndrome. Histology shows foam cells and high vascularity
Haemangioblastoma
Patients will present with the consequences of hormone excess (e.g. Cushing’s due to ACTH, or acromegaly due to GH) or depletion. Compression of the optic chiasm will cause a bitemporal hemianopia due to the crossing nasal fiber
Pituitary adenoma
____________ is the most common paediatric supratentorial tumour
Craniopharyngioma
A _______________ is a solid/cystic tumour of the sellar region that is derived from the remnants of Rathke’s pouch. It may present with hormonal disturbance, symptoms of hydrocephalus or bitemporal hemianopia
Craniopharyngioma
What does the following MRI show?
Meningioma
What does the following CT show?
Glioblastoma multiforme
Sensory inattention
Apraxias
Astereognosis (tactile agnosia)
Inferior homonymous quadrantanopia
Gerstmann’s syndrome (lesion of dominant parietal): alexia, acalculia, finger agnosia and right-left disorientation
Parietal lobe lesion
Homonymous hemianopia (with macula sparing)
Cortical blindness
Visual agnosia
Occipital lobe lesions
Wernicke’s aphasia
Superior homonymous quadrantanopia
Auditory agnosia
Prosopagnosia (difficulty recognising faces)
Temporal lobe lesion
Broca’s aphasia
Disinhibition
Perseveration
Anosmia
Inability to generate a list
Frontal lobes lesions
Gait and truncal ataxia
Midline cerebellum lesions
Intention tremor, past pointing, dysdiadokinesis, nystagmus
Hemisphere cerebellum lesions
Wernicke and Korsakoff syndrome occurs in which area of the brain?
Medial thalamus and mammillary bodies of the hypothalamus
Hemiballism occurs in which area of the brain?
Subthalamic nucleus of the basal ganglia
Hyperkinetic involuntary movement - sudden, violent, flinging
Huntington chorea occurs in which area of the brain?
Striatum (caudate nucleus) of the basal ganglia
Parkinson’s disease occurs in which area of the brain?
Substantia nigra of the basal ganglia
Kluver-Bucy syndrome (hypersexuality, hyperorality, hyperphagia, visual agnosia) occurs in which area of the brain?
Amygdala
Hyperorality - excessive chewing, sucking
Hyperphagia - excessive eating
Infrequent generalized seizures, often in morning
Daytime absences
Sudden, shock-like myoclonic seizure
Juvenile myoclonic epilepsy (Janz syndrome)
Neurologists now start antiepileptics following a first/ second/ third epileptic seizure
Second
Areas of low density in the grey and white matter of the territory. ‘Hyperdense artery’ sign
Acute ischaemic strokes
Hyperdense material (blood) surrounded by low density (oedema)
Acute haemorrhagic strokes
Charcot-Marie-Tooth disease
Petechial rash, fever, neck stiffness, vomiting and confusion
Meningitis
What does the image show?
Petechial, non-blanching rash - meningitis
Rashes which do not disappear with pressure
Weakness and reduction in sensation over the fourth and fifth fingers medial digits of the right hand. Commonly occurs in people who lean on their elbow, sleep with their arm hanging off the bed, or with impact over the “funny bone”
Cubital tunnel syndrome - affects ulnar nerve
Ix for SAH
CT, followed by lumbar puncture 12 hours post headache if CT normal
Tingling involving both legs from the knees down. Reduced sensation in both legs distally, with absent ankle reflexes, but preserved power. Plantars are down-going
Peripheral neuropathy
“Glove-and-stocking” distribution, with foot involvement preceding hand involvement
Sensory peripheral neuropathies
____________ and __________ would indicate large fibre involvement in sensory peripheral neuropathies
Paraesthesia and proprioceptive ataxiaa
____________, ____________ and __________ would indicate small fibre involvement in sensory peripheral neuropathies
Burning sensations, allodynia (pain from non-painful stimuli), and hyperalgesia (increased pain response)
Worsening back pain and leg weakness with walking, along with relief of symptoms with forward bending
Spinal claudication
Leg pain that worsens with walking and improves with rest, weak or absent peripheral pulses, cold and pale extremities, and, in severe cases, non-healing ulcers on the extremities
Peripheral vascular disease
Ix for spinal claudication
X-ray, MRI, and CT scan to identify the degree of spinal canal narrowing
Electromyography and nerve conduction studies
Tx for spinal claudication
Decompression surgery or lumbar spinal fusion
Most common causes of autonomic neuropathy
HIV, Lyme disease, Chagas disease, autoimmune diseases (SLE) and amyloidosis
Vasovagal syncope vs postural hypotension
There is usually a precipitant for postural hypotension such as going from sitting to standing
Vasovagal syncope is precipitated by prolonged standing, heat or emotion
Electromyograph (EMG) reveals diffuse denervation
MND (progressive bulbar palsy)
Bulbar palsy is a condition typified by lower motor neurone lesions affecting cranial nerves..
Glossopharyngeal (IX), vagus (X), and accessory (XII)
Absent or normal jaw jerk reflex
Absent gag reflex
Flaccid, fasciculating tongue
Nasal speech, often described as “quiet”
Bulbar palsy
Upper motor neurone lesion of the cranial nerves. Signs include dysarthria, dysphagia, and emotional lability
Pseudobulbar palsy
Ix for IIH
Ophthalmoscopy
CT/MRI (MRI Venogram may be performed to rule out secondary causes such as venous sinus thrombosis)
LP (Diagnostic)
Tx for IIH
Weight loss
Acetazolamide (peripheral paraesthesia)
Alt: Topiramate and candesartan
If progressive visual loss then therapeutic lumbar punctures (if not in theatre within 24 hours of admission), surgical CSF shunting or optic nerve sheath fenestration
Recurrent episodes of vertigo, sensorineural hearing loss, tinnitus, and a feeling of fullness in the ear
Ménière’s disease
Unilateral hearing loss and cranial nerve dysfunction.
Acoustic Neuroma
Vertigo, absence of hearing loss and tinnitus. Recent viral illness
Vestibular neuritis
Most common cause of ICH?
Hypertension (uncontrolled)
No function below the level of the head and a ventilator is needed to maintain respiration
At what level did a transection of the spinal cord occur to present with this clinical picture?
C1-C3
Quadriplegia, however they can still breath on their own
At what level did a transection of the spinal cord occur to present with this clinical picture?
C4-C5 (phrenic nerve is spared so can breathe on their own)
Complete loss of trunk and lower limb function, however some movements of the upper limb will be intact, allowing for functions such as feeding or using a wheelchair
At what level did a transection of the spinal cord occur to present with this clinical picture?
C6-C8
Paraplegic
At what level did a transection of the spinal cord occur to present with this clinical picture?
T1-T9
Some level of dysfunction of the lower limbs resulting in difficulties with walking and ambulation
At what level did a transection of the spinal cord occur to present with this clinical picture?
T10 and L3
Lesions affecting the __________, __________ or __________ nerve can cause double vision (diplopia) and nystagmus
Oculomotor (CN III)
Trochlear (CN IV)
Abducens (CN VI)
Internuclear ophthalmoplegia is caused by a lesion in the..
Medial longitudinal fasciculus
A lesion in the abducens (CN VI) causes a..
Conjugate lateral gaze disorder
Multiple sclerosis may present with focal weakness, for example..
Incontinence
Horner syndrome
Facial nerve palsy
Limb paralysis
Multiple sclerosis may present with focal sensory symptoms, for example..
Trigeminal neuralgia
Numbness
Paraesthesia (pins and needles)
Lhermitte’s sign
Lhermitte’s sign indicates disease in the cervical spinal cord in the..
Dorsal column
Sensory ataxia can cause ___________ and ___________
Positive Romberg’s test
Pseudoathetosis
What type of ataxia is seen in MS?
Sensory and cerebellar
Tx for fatigue in MS
Amantadine, modafinil or SSRIs
Mindfulness training and CBT
Tx for bladder dysfunction in MS
If significant residual volume → intermittent self-catheterisation
If no significant residual volume → anticholinergics may improve urinary frequency
Tx for oscillopsia in MS
Gabapentin
Tx for spasticity in MS
Baclofen or gabapentin
Tx for neuropathic pain in MS
Amitriptyline or gabapentin
What does the clinical picture show?
MG - affects proximal muscles of the limbs and small muscles of the head and neck
Difficulty climbing stairs, standing from a seat or raising their hands above their head
MG
Prolonged upward gazing will exacerbate diplopia on further testing
MG
Repeated blinking will exacerbate ptosis
MG
Repeated abduction of one arm 20 times will result in unilateral weakness when comparing both sides
MG
Tx for MG
Pyridostigmine
+ Prednisolone, azathioprine, cyclosporine, mycophenolate mofetil
Thymectomy
Tx for MG crises
Plasmapheresis
Intravenous immunoglobulins
Non-invasive ventilation or mechanical ventilation
+ Facial weakness. Autonomic dysfunction - urinary retention, ileus or heart arrhythmias.
What does the clinical picture show?
GBS
Ix for MG
Single fibre EMG (high sensitivity)
CT thorax to exclude thymoma
CK normal
Antibodies to acetylcholine receptors
Tensilon test: IV edrophonium reduces muscle weakness temporarily - not commonly used any more due to the risk of cardiac arrhythmia
Ix for MS
MRI
CSF
Visual evoked potentials - delayed preserved waveform
High signal T2 lesions
Periventricular plaques
Dawson fingers
MS
Ix for GBS
LP
Nerve conduction studies
LP shows rise in protein with a normal white blood cell count
GBS
Nerve condution studies show: Decreased motor nerve conduction velocity
Prolonged distal motor latency
increased F wave latency
GBS
Decreased motor nerve conduction velocity is due to demyelination!
Tx for GBS
Supportive care
VTE prophylaxis (pulmonary embolism is a leading cause of death)
IV immunoglobulins (IVIG) first-line
Plasmapheresis is an alternative to IVIG
If resp failure: intubation, ventilation and ICU
Saddle anaesthesia, urinary retention, incontinence or bilateral neurological signs
Cauda equina
Intermittent neurogenic claudication
Spinal stenosis
Age under 40, gradual onset, morning stiffness or night-time back pain
Ankylosing spondylitis
Back pain + fever or a history of IV drug use
Spinal infection
Bilateral sciatica is a red flag for..
Cauda equina syndrome
Unilateral pain from the buttock radiating down the back of the thigh to below the knee or feet. “Electric” or “shooting” pain, paraesthesia, numbness and motor weakness. Reflexes may be affected
Sciatica
Mx for low risk acute lower back pain
Self-management
Education
Reassurance
Analgesia
Staying active and continuing to mobilise as tolerated
Mx for medium risk acute lower back pain
Physiotherapy
Group exercise
Cognitive behavioural therapy
NSAIDs
Codeine
Benzodiazepines (e.g., diazepam)
Radiofrequency if originating in the facet joints
Mx of Sciatica
Amitriptyline
Duloxetine
Back pain worse in the morning and on standing
On examination there may be pain over the facets. The pain is typically worse on extension of the back
Facet joint
Usually gradual onset
Unilateral or bilateral leg pain (with or without back pain), numbness
Pain may be described as ‘aching’, ‘crawling’
Relieved by sitting down, leaning forwards and crouching down
Spinal stenosis
Pain on walking, relieved by rest
Absent or weak foot pulses and other signs of limb ischaemia
Past history may include smoking and other vascular diseases
Peripheral arterial disease
Raccoon eyes and bruising behind the ears/periorbital bruising due to rupture of the tiny perforator arteries
Frontal bone fracture
Which vessel is damaged in a extradural haematoma?
EXTRAMILE
Middle meningeal artery
Which vessel is damaged in a subdural haematoma?
Bridging veins between cortex and venous sinus
Which vessel is damaged in a subarachnoid haemorrhage?
Subarachnoid
Anterior communicating artery aneurysm (‘berry aneurysm’)
Arteriovenous malformation
Finger abduction and thumb adduction
Ulnar
Triceps weakness, diminished triceps reflex and numbness along the middle finger
C7
Inability to pronate the forearm or flex the wrist, loss of sensation over lateral 3½ fingers on the palmar aspect
Median nerve
Flexion at distal interphalangeal joints - pinch grip
Anterior interosseous nerve
Which tracts are affected in Brown-Sequard syndrome?
Lateral corticospinal tract
Dorsal columns
Lateral spinothalamic tract
Which tracts are affected in subacute combined degeneration of the spinal cord (vitamin B12 & E deficiency)?
Lateral corticospinal tracts
Dorsal columns
Spinocerebellar tracts
Which tracts are affected in friedrich’s ataxia?
Lateral corticospinal tracts
Dorsal columns
Spinocerebellar tracts
Good differential for SCDSC!
Which tracts are affected in anterior spinal artery occlusion?
Lateral corticospinal tracts
Lateral spinothalamic tracts
Which tracts are affected in syringomyelia?
Inthe central canal, expanding CSF filled “syrinx” compresses the spinothalamic tract neurons decussating in the anterior white commissureexpanding cavity
Which tracts are affected in MS?
Asymmetrical, varying spinal tracts involved
Which tracts are affected in neurosyphilis (tabes dorsalis)?
Dorsal columns
Ipsilateral spastic paresis below lesion
Ipsilateral loss of proprioception and vibration sensation
Contralateral loss of pain and temperature sensation
Brown-Sequard syndrome
Bilateral spastic paresis
Bilateral loss of proprioception and vibration sensation
Bilateral limb ataxia
Subacute combined degeneration of the spinal cord (vitamin B12 & E deficiency)
Bilateral spastic paresis
Bilateral loss of proprioception and vibration sensation
Bilateral limb ataxia
Cerebellar ataxia
Intention tremor
Friedrich’s ataxia
Bilateral spastic paresis
Bilateral loss of pain and temperature sensation
Anterior spinal artery occlusion
Flacid paresis (typically affecting the intrinsic hand muscles)
Loss of pain and temperature sensation
Syringomyelia
Combination of motor, sensory and ataxia symptoms
Multiple sclerosis
Ix for RLS
Diagnosis is clinical although bloods such as ferritin to exclude iron deficiency anaemia may be appropriate
Conservative mx for RLS
Walking, stretching, massaging affected limbs
Treat any iron deficiency
Medical mx for RLS
Dopamine agonists are first-line treatment (e.g. Pramipexole, ropinirole)
Benzodiazepines
Gabapentin
Spastic weakness and hyporeflexia
GBS
Weakness of extensor hallucis longus
Sensory loss over the dorsum of the foot and the lower lateral part of the leg
Wasting of the anterior tibial and peroneal muscles
Common peroneal nerve lesion
Mx for post-lumbar puncture headache
Blood patch, epidural saline and intravenous caffeine
Diffuse headaches, blurred vision, pulsatile tinnitus (the ‘woosh’ sound she describes) and the bilateral papilloedema
IIH
Which scoring system is used to distinguish between ischemic and haemorrhagic strokes?
Siriraj stroke score
No tremor at rest but bilateral tremor when extends arms out in front
Essential tremor
Medical mx for essential tremor
Propranolol, primidone, topiramate, gabapentin, clonazepam
Surgical mx for essential tremor
Deep brain stimulation
Focused ultrasound thalamotomy
Radiosurgical (Gamma Knife)
Thalamotomy
What does the clinical picture show?
PD
Levodopa should be combined with a decarboxylase inhibitor to prevent..
Peripheral side effects such as nausea and vomiting
Low mood, difficulties with concentrating, coordination problems, and irritability. As the disease progresses, chorea and dementia occur
Huntington’s Disease
Mx for chorea in HT
Tetrabenazine
Mx for depression in HT
SSRI
Mx for psychosis in HT
Atypical antipsychotics
Most common cause of death in HT
1st - complications related to physical decline such as pneumonia
2nd - suicide
The eyes are open and rolled up, pupils dilate, elbows flex, arms pronate and it may be associated with incontinence, moaning, cyanosis and apnoea
Tonic phase
Movements with the frequency of movements gradually decreasing and amplitude increasing. This phase may be associated with tongue biting, cyanosis and apnoea
Clonic phase
At rest, the eye points upwards and inwards and the patient may present with a tilted head to compensate for the palsy
Trochlear nerve palsy (4th)
Widely known for being a ‘false localising sign’ due to the path of the nerve within the brain, making it easily compromised in a state of raised intracranial pressure
Abducens nerve (6th)
Patients typically remain conscious/unconscious during myoclonic seizures
Conscious
Which specific signs indicate meningeal irritation?
CSF clear or turbid
100-200 PMNs
Culture results positive
Protein raised
Low glucose
Bacterial
Protein raised due to bacterial protein contamination
Low glucose as bacteria use as an energy source
Misnomer
CSF clear or slightly turbid
15-500x109 lymphocytes
Negative culture results
0.5-1g/l protein
Glucose normal
Viral/aseptic meningitis
Glucose normal because viruses use cell machinery to replicate
CSF clear or slightly turbid
Fibrin web may develop
30-500x109 lymphocytes plus PMNs
Negative gram stain (need Auramine staining)
Protein 1-6g/L
Glucose 0-2.2
Tubercular meningitis
Opening pressure is high
immunocompromised patient
India Ink staining positive
Crytococcal meningitis (fungi)
Mx for bacterial meningitis
2g of IV ceftriaxone twice daily to ensure CNS penetration, with IV amoxicillin added in patients at age extremes for listeria coverage
Mx for viral meningitis
IV aciclovir
If allergic to penicillin, alternatives such as chloramphenicol may be used
What can cause trigeminal neuralgia?
Malignancy
Arteriovenous malformation
Multiple sclerosis
Sarcoidosis
Lyme disease
Alternative mx for trigeminal neuralgia if carbamazepine is intolerable
Phenytoin
Lamotrigine
Gabapentin
Surgical mx for trigeminal neuralgia
Microvascular decompression
Treat underlying cause: removing tumor or addressing an arteriovenous malformation
Alcohol or glycerol injections: used to damage the trigeminal nerve and reduce pain signals
Drugs that can cause IIH
Oral contraceptive pill
Steroids
Tetracycline
Vitamin A
Lithium
Alt. mx for IIH if acetazolamide is intolerable
Topiramate and candesartan
Pelvic thrusting, head movements, eyes being closed, a duration of more than 3 minutes and postictal weeping
Non-epileptic attack disorder/ pseudoseizure
In epilepsy, the head is fixed and eyes remain open with postictal confusion, tongue biting and incontinence, as well as a raised prolactin on bloods
Partial ptosis, miosis and anhidrosis of the affected side of the face
Horner’s syndrome
Horner’s syndrome + neck pain in a young patient
Carotid artery dissection - red flag
What does the clinical picture show?
Horner’s syndrome
Most common cause of Horner’s syndrome
Pancoast tumour
Gram-positive, lancet-shaped organism in meningitis
Streptococcus pneumoniae
Gram positive rods in meningitis
Listeria Monocytogenes
Gram-negative diplococcus in meningitis
Neisseria meningitidis
Mx for raised ICP
Elevate head to 30*
IV mannitol
Controlled hyperventilation to reduce pCO2
a cut-off of ____________ is often used to determine if further treatment is needed to reduce the ICP
> 20 mmHg
Anti-GQ1b antibodies
Miller Fisher syndrome
Mx for focal seizures
Lamotrigine or Levetiracetam
Focal bilateral temporal lobe involvement
Encephalitis
Impaired function of the corticospinal tracts (spastic paraparesis) and dorsal columns (sensory ataxia, loss of fine touch and proprioception) bilaterally
The knee jerks are present and plantars upgoing, but the ankle jerks are mute
Subacute combined degeneration of the cord
Peripheral hereditary neuropathy + LMN signs
Charcot-Marie-Tooth Syndrome
Lower limb spastic hypertonia, ankle clonus, pyramidal weakness (extensors stronger than flexors in the lower limbs), hyper-reflexia and upgoing plantars (upper motor neurone signs). There is scissoring gait
Hereditary spastic paraparesis
Which medication is contra-indicated due to previous strokes?
Sumatriptan - constricts cerebral blood vessels
Spastic hemiparesis of cerebral palsy
Ipsilateral arm and leg affected
Spastic diplegia of cerebral palsy
4 limbs are affected but the lower limbs more than the upper limbs
Spastic quadriplegia of cerebral palsy
4 limbs are affected but the upper limbs more than the lower limbs
What can cause spastic paraparesis?
Bihemispheric lesion (such as cerebral palsy or multiple sclerosis)
Lesion affecting the spinal cord (such as cord compression, disc prolapse, infection, trauma)
Rare causes - familial spastic paraparesis
A way to distinguish a bihemispheric lesion from a cord lesion is that..
In a cord lesion there will be a sensory level, 1-2 spinal cord segment levels below the actual spinal cord lesion
Ix for SCDC
Assessment of B12 and folate levels
Homocysteine levels: raised level despite normal B12 could indicate a functional B12 deficiency
MRI of the spine to exclude cervical myelopathy
Nerve conduction studies - axonal neuropathy
Homocysteine - amino acid produced when proteins are broken down
Mx for SCDC
Vitamin B12 replacement - hydroxocobalamin 1 mg IM on alternate days until there is no further improvement, followed by maintenance treatment with hydroxocobalamin 1 mg IM every two months
Involuntary and violent wide-amplitude flinging movements of the proximal right arm following a stroke
Hemiballismus secondary to a lesion in the left subthalamic nucleus
Involuntary muscle jerks of the proximal right arm following a stroke
Myoclonus secondary to a lesion in the left subthalamic nucleus
Central (first order neurones) Horner’s
Spinal cord lesions above level T1 - stroke, tumors, or syringomyelia
Preganglionic (second order neuron) Horner’s
Cervical rib, subclavian artery aneurysm
Pancoast tumor
Postganglionic (third order neuron) Horner’s
Dissection of the internal carotid artery - anticoagulation and carotid artery surgery
Third order neurons DO NOT anhydrosis
Common sites of obstruction in non-communicating/obstructive hydrocephalus
Foramen of Monro (e.g. due to colloid cysts)
Cerebral aqueduct (e.g. due to aqueduct stenosis)
Fourth ventricle (e.g. due to posterior fossa tumour)
Common sites of obstruction in communicating hydrocephalus
Subarachnoid space (haemorrhage) or infective meningitis
Tx for hemiplegic migraines
1st line: Verapamil
Alt: Acetazolamide, flunarizine or topiramate
2nd line: Lamotrigine
Autoimmune vs HS encephalitis
Autoimmune: paraneoplastic syndrome (usually secondary to small cell lung cancer or ovarian teratoma)
HS: temporal lobes changes
Gram-negative rod
Campylobacter jejuni
Raised ICP can cause a ______________ due to herniation
Third nerve palsy - ptosis, pupil dilatation and an absent light reflex with intact consensual constriction
MND is associated with which proteins?
Misfolding of the TDP-43 protein
Mutation in the SOD-1 gene
Which type of MND is characterised by a combination of upper and lower motor neurone signs, associated with frontotemporal dementia and thenar atrophy?
ALS
Which type of MND presents only with LMN signs?
Progressive muscular atrophy
Which type of MND presents only with UMN signs?
Primary lateral sclerosis
Progressive Bulbar and pseudobulbar palsy is caused by damage to cranial nerves..
9, 10, 12
Which type of MND presents with dysphagia, reduced jaw and gag reflexes and tongue fasciculations?
Bulbar palsy
Which type of MND presents with dysphagia, slow speech and brisk jaw reflex?
Pseudobulbar palsy
Next step if status epilepticus continues >45 minutes?
General anaesthesia or phenobarbital
4-6 hertz in a tremor
Parkinson’s Tremor
6-12 hertz in a tremor
Benign Essential Tremor
Levels of vertebrae
Coffee at 7, tea at 12, liquor at 5
Cervical - 7
Thoracic - 12
Lumbar - 5
Sacrum
Coccyx
DVLA guidelines if had a simple faint
No restriction
DVLA guidelines if single episode of syncope, explained and treated
4 weeks off
DVLA guidelines if single episode of syncope and unexplained
6 months off
DVLA guidelines if two or more episodes of syncope
12 months off
DVLA guidelines if stroke or TIA
1 month off driving, may not need to inform DVLA if no residual neurological deficit
DVLA guidelines if multiple TIAs over short period of times
3 months off driving and inform DVLA
DVLA guidelines if craniotomy e.g. for meningioma
1 year off driving
DVLA guidelines if craniotomy for a pituitary tumour
6 months
DVLA guidelines if trans-sphenoidal surgery for a pituitary tumour
Can drive when there is no debarring residual impairment likely to affect safe driving
DVLA guidelines if narcolepsy/cataplexy
Cease driving on diagnosis, can restart once ‘satisfactory control of symptoms’
DVLA guidelines if chronic neurological disorders e.g. multiple sclerosis, motor neuron disease
DVLA should be informed, complete PK1 form (application for driving licence holders state of health)
Progressive hypophonia and weakness of facial muscles, including the ‘hanging jaw’ sign
Myasthenia gravis
Red flag signs for trigeminal neuralgia
Tx for juvenile myoclonic epilepsy
Sodium valproate (both males and females)
Cubital tunnel syndrome vs C8/T1 radiculopathy
CTS: Sensory depravation in palmar and dorsal aspects of 1 and 1/2 fingers medially + weakness of adductor pollicis muscle
C8/T1 radiculopathy: Sensory depravation in palmar and dorsal aspects of 1 and 1/2 fingers medially + forearm
APM: difficulty maintaining strong pinch grip between thumb and fingers
Hyperextension of the metacarpophalangeal joints and flexion at the distal and proximal interphalangeal joints of the 4th and 5th digits
Claw hand - ulnar nerve
Wasting and paralysis of intrinsic hand muscles (except lateral two lumbricals) + hypothenar muscles
Ulnar nerve damage
Clinical signs for ulnar damage at elbow
Claw hand + radial deviation of wrist
Upward gaze of the eyes, hypermetropia (difficulty seeing things at a close distance, e.g., reading) or double vision when looking down (vertical diplopia)
Trochlear nerve
Eye fixed medially (towards nose) and cannot abduct
Abducens nerve
CSF is usually normal
EEG: biphasic, high amplitude sharp waves
MRI: hyperintense signals in the basal ganglia and thalamus
CJD
Rapid onset of dementia + myoclonus
CJD
Recreational nitrous oxide inhalation may also result in..
Vitamin B12 deficiency → subacute combined degeneration of the spinal cord
Ix for Diffused axonal injury
MRI
What does the MRI show?
Diffuse axonal injury
Symmetrical distal neuropathy seen in the context of other diseases (including diabetes mellitus)
Small fibre neuropathy
Shooting pains along outer thigh + numbness and painful tingling over the area, which is also highly sensitive to light touch and heat
Meralgia paresthetica - compression of lateral cutaneous nerve
Shooting pains along the limbs following flexion of the neck
Lhermitte phenomenon in multiple sclerosis
Hot potato/ Donald duck speech
Pseudobulbar palsy
Vertigo + vomiting. Gaze direction + changing horizontal nystagmus. Head thrust test negative
Posterior circulation infarct
Unilateral hemiparesis
Significant dysphasia of speech
Hemispatial neglect on visual examination
Partial Anterior Circulation Infarct
Higher cognitive dysfunction such as dysphasia or hemispatial neglect would count as one criteria only. So this patient only has 2/3 of the criteria given they don’t have Homonymous Hemianopia
Lesion in the subthalamic nucleus would cause which clinical sign?
Hemiballismus + gross motor movement impairment
Dysarthria, intention tremor and an ataxic gait
Cerebellar signs
DANISH (Dysdiadokinesia, ataxia, nystagmus, intention tremor, speech, hypotonia)
When is a preventative given in a migraine?
When migraines occur >1/week on average
Until then, oral triptans (nasal is under 18)
Unilateral supratentorial arterial bleed
Extradural haematoma
Unilateral infratentorial venous bleed
Subdural haematoma
When can you give Topiramate to women of child-bearing age?
If not planning on having kids (post-menopause, contraceptives etc)
Parkinisonism and involves spontaneous activity by an affected limb, or akinetic rigidity of that limb
Cortico-basal degeneration
Causes of ischaemic stroke
Thrombus or embolus (DVT)
Atherosclerosis
Shock (hypoxia)
Vasculitis
Causes of haemorrhagic stroke
Intracerebral (HT, cerebral amyloid angiopathy, vascular malformation)
Subarachnoid
Sympathomimetic drugs e.g. cocaine
High-attenuating amorphous substance filling the sulci within the brain
Subarachnoid hemorrhage
Albumino-cytologic dissociation
Guillain-Barré syndrome
Elevated protein in CSF without a corresponding increase in WBC
Surgical Tx for extradural haemorrhage
Ligation of the damaged blood vessel
Surgical Tx for acute subdural haemorrhage
Craniotomy
Surgical Tx for chronic subdural haemorrhage
Burr hole craniostomy
Surgical Tx for subarachnoid haemorrhages
Endovascular coiling
Pain improved on bending over/walking uphill
Spinal claudication
Spinal = Steep (walking downhill)
Peripheral = Push (walking uphill
Pain worst on bending over/walking uphill
Peripheral vascular disease
Spinal = Steep (walking downhill)
Peripheral = Push (walking uphill)
Acute cord compression in the setting of anticoagulation (atrial fibrillation) and possible iatrogenic dural puncture (epidural analgesia)
Epidural haematoma
Bilateral hyperreflexia, spasticity, and a positive Babinski’s sign
Deep and localized back pain
Sensory disturbance below level of lesion
Spinal cord compression
Ix for spinal cord compression
Urgent MRI
Mx for spinal cord compression
Radiation therapy
Surgical decompression within 48 hrs
Dexamethasone if malignancy on MRI or those with high clinical suspicion, given at 16 mg daily in divided doses, along with proton pump inhibitors (PPI)
Bilateral hyperintensity of the temporal lobes.
Herpes simplex virus (HSV) encephalitis
Enlarged blind spots and constriction of the visual filed
IIH
Inherited syndrome is characterised by tremors, myoclonus and tonic-clonic seizures
Familial adult myoclonic epilepsy
Persistent weakness or paralysis in the part of the body following a seizure
Todd’s paresis
Brief seizures in children that usually occur at night, with facial twitching or paraesthesias present
Benign rolandic epilepsy
Occurs as a result of hypoperfusion of the brain and increased vagal tone in children, and may be as a response to fear or anxiety, or as a result of “breath-holding attacks”. Typically there is a loss of consciousness and limb jerking that is brief (<1 minute)
Reflex anoxic seizure
Causes of an ataxic gait
PASTRIES
P - Posterior fossa tumour
A - Alcohol
S - Multiple sclerosis
T - Trauma
R - Rare causes
I - Inherited (e.g. Friedreich’s ataxia)
E - Epilepsy treatments
S - Stroke
Most common form of GBS
Acute inflammatory demyelinating polyradiculoneuropathy
Inability to flex the 1st, 2nd and 3rd digits of the hand
Median nerve
Cheyne-Stokes respiration
Uncal herniation
Function of extensor muscles of the posterior forearm
Produce extension at the wrist and fingers
Innervated by the radial nerve
The interossei are supplied by the..
Ulnar nerve
Involves vertebrobasilar arteries. Presents with 1 of the following:
- cerebellar or brainstem syndromes
- loss of consciousness
- isolated homonymous hemianopia
Posterior circulation infarcts
Diminished reflexes and impaired balance and sensation
Chronic inflammatory demyelinating polyradiculoneuropathy
Miosis, ptosis, anhidrosis, and enophthalmos
Horner’s syndrome
Ptosis, down & out deviation of the eye, and a dilated pupil
Raised ICP - third nerve palsy
Huntington’s disease results in degeneration of ___________ and ___________ neurons in the striatum of the basal ganglia
Cholinergic and GABAergic
Huntington’s disease causes a defect in huntingtin gene on chromosome ___
4
Encephalomalacia affecting the left motor cortex
Focal seizures
When are epileptics started?
Neurological deficit
Brain imaging shows a structural abnormality
EEG shows unequivocal epileptic activity
Patient or their family or carers consider the risk of having a further seizure unacceptabl
What is Jendrassik manoeuvre?
Compares a reflex with/without distraction e.g. clenching teeth
What is Hoffman’s sign?
Investigate the cause of ataxia; if positive means sensory ataxia
What is Romberg’s test?
Reflex test to investigate corticospinal tract lesions
Encephalitis typically affects which lobes?
Temporal and inferior frontal lobes
Types of Encephalitis?
Anti-NMDA Receptor - most common
Limbic - underlying malignancy
Differentiate between upper quadrant defect and lower quadrant defect
UP LOC
Upper - Pitiuitary
LOwer - Craniopharyngiomaa
Chronic form of GBS. Can present with numbness and tingling in extremities
Chronic inflammatory demyelinating polyneuropathy
How long do cluster headaches last?
15 minutes to 3 hours
In which lobe does Broca’s aphasia occur?
Be (Brocas) Expressive in (inferior) front (frontal) of Everyone
The left visual field is picked up by the nasal retina in the left eye, and the temporal retina in the right eye
These go through the optic nerves and when they reach the chiasm, nasal fibres cross to opposite sides, and temporal fibres do not cross.
This means that the left visual field information ends up in the right temporal lobe
Superior and inferior also swap
Absent corneal reflex + proptosis
Cavernous sinus thrombosis
Posterior communicating artery aneurysm (pupil dilated)
= Think: 3rd nerve palsy = ptosis + dilated pupil
Patients with meningococcal meningitis are at risk of..
Waterhouse-Friderichsen syndrome (adrenal insufficiency secondary to adrenal haemorrhage)
Commonly caused by N. meningitis
The _____________ nerves are frequently injured during axillary dissection
intercostobrachial
An 8-year-old boy falls onto an outstretched hand and sustains a supracondylar fracture. In addition to a weak radial pulse the child is noted to have loss of pronation of the affected hand
Median
A 23-year-old rugby player sustains a Smiths Fracture. On examination opposition of the thumb is markedly weakened
Median
Ix for SAH
weakness of foot dorsiflexion
weakness of foot eversion
weakness of extensor hallucis longus
sensory loss over the dorsum of the foot and the lower lateral part of the leg
wasting of the anterior tibial and peroneal muscles
Common peroneal nerve lesion
Steele-Richardson-Olszewski syndrome
Unusual constellation of supranuclear gaze palsy, progressive axial rigidity, pseudobulbar palsy, and mild dementia .This disease is now a well-recognized atypical parkinsonian syndrome (or Parkinson-plus disorder)
Inverted champagne bottle sign and pes cavus
Charcot-Marie-Tooth
Unilaterally dilated pupil with a sluggish or fixed light response
3rd nerve compression secondary to tentorial herniation
Bilaterally dilated pupil with a sluggish or fixed light response
Poor CNS perfusion
Bilateral 3rd nerve palsy
Unilaterally dilated pupil with a cross reactive (Marcus - Gunn)
Optic nerve injury
Bilaterally constricted pupil with difficult to assess light response
Opiates
Pontine lesions
Metabolic encephalopathy
Unilaterally constricted pupil with a preserved response
Sympathetic pathway disruption
Reduced Glasgow coma score, quadriplegia, miosis, and absent horizontal eye movements.
Pontine haemorrhage
Differentiate between viral meningitis and GBS based on lumbar puncture findings
Viral meningitis - raised white cells and predominant lymphocytes
GBS - isolated raise in protein
Dorsiflexion of the great toe elicited by irritation downward of the medial side of the tibia. (UMN lesion sign similar to Babinski’s)
Oppenheim’s sign
Worsening of demyelinating symtpoms (classically vision) due to increased body temperature
Uhthoff’s phenomonon
LMS vs Weber’s
Lateral medullary syndrome
* ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner’s
* contralateral: limb sensory loss
Weber’s syndrome
* ipsilateral III palsy
* contralateral weakness
Type II resp failure (hypoxia and hypercapnia) in GBS vs MG
GBS: reduced or absent tendon reflexes
MG: normal reflexes
Loss of pain sensation (analgesia)
Loss of temperature sensation (thermoanesthesia)
Motor function impairment
Loss of autonomic functions
Vibration, proprioception, fine touch preserved
ASAI
High-frequency tremor, most pronounced on the left, when the patient holds up his arms in front of him
Changes in his voice with the appearance of a mild vibrato
Essenital tremor
Long-standing cough and shortness of breath
Waddling gait
Hyporeflexia
LEMS
Where does jacksonian march originate from?
Michael Jackson was the Frontman of the Jackson 5
Jacksonian march = Frontal Lobe
Sudden, painful visual loss in a patient with diabetes. Accompanied by headache, nausea, redness of the eye and seeing haloes
Acute angle closure glaucoma
Mild symptoms, redness of the eye and nausea. On examination, the cornea may be bulging and the pupil may be dilated and/or unresponsive to light
Acute open-angle glaucoma
Posterior cerebral artery stroke can cause visual symptoms but this usually presents as contralateral homonymous hemianopia due to infarction of the…
Occipital cortex
In a posterior cerebral artery stroke, there may be hemisensory loss and/or burning pain affecting one side of the body if there is an infarction of..
Thalamus
In a posterior cerebral artery stroke, there may be oculomotor palsy if the ______ territory is affected
Central
What needs to be monitored when starting phenytoin in status epileptics?
Cardiac - pro arrhythmogenic effects (unpredictable pharmacokinetics so levels are also required following initial loading)
Which arteries are affected in SAH?
Circle of willis
The presence of similar amounts red blood cells in all three samples is suggestive of a SAH
If there is a small amount of red blood cells in the first bottle, and a decreasing amount (or no further red blood cells) in the second and third bottles then this may be a..
Traumatic lumbar puncture with the spinal needle passing through local blood vessel.
DCML
Unilateral absence of movements and muscle rigidity with a tremor. It is a progressive neurological disorder that can also affect cognition
Corticobasal syndrome
Which type of sleep disorder occurs in PD?
REM sleep behaviour disorder
Features of Wernicke’s encephalopathy
CAN OPEN
Confusion
Ataxia
Nystagmus
Ophthamoplegia
PEripheral
Neuropathy
What is the most common psychiatric feature in PD?
Depression
Ix for LBD
DaTscan (SPECT)
Mx for LBD
Acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine)
Memantine
__________ should be avoided in Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism
Neuroleptics
E.g. Patient deteriorated after recieving an antipsychotic agent
Which lobe does AZ occur in?
Temporal - cortex and hippocampus
Which structure is impacted by dyskinetic cerebral palsy?
Basal ganglia
Which structure is generally spared in dementia syndrome?
Medulla oblongata
Deficit of acetylcholine from damage to an ascending forebrain projection
AZ
Tau proteins are excessively phosphorylated, impairing its function
AZ
A normal ___________ level supports the diagnosis of MG since it suggests there is no muscle inflammation or damage
Creatine kinase (CK)
Cranial nerves carrying parasympathetic fibres
III VII IX X
Oculomotor
Facial
Glassopharyngeal
Vagus
Damage to the _______ nerve in the bony canal may result in impaired innervation to stapedius and therefore sounds are no longer dampened
Facial
Sensory loss over anterior thigh
Weak hip flexion, knee extension and hip adduction
Reduced knee reflex
Positive femoral stretch test
L3 nerve root compression
Sensory loss anterior aspect of knee and medial malleolus
Weak knee extension and hip adduction
Reduced knee reflex
Positive femoral stretch test
L4 nerve root compression
Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
L5 nerve root compression
Facial dropping + absent corneal reflex
Facial nerve (efferent)
Absent corneal reflex + jaw deviates to weak side
Trigeminal (afferent)
History of malignancy - sensory loss and numbness in dermatome corresponding to spinal level. Tendon reflexes increased below level of lesion and absent at level of lesion
Neoplastic spinal cord compression
GBS is LMN/UMN
LMN
Mnemonic for:
C5-6
C7-8
L2-3
L3-4
L4-5
L5-S1
S1-2
C5-6 pick up sticks
C7-8 lay them straight
L2-3 lift my knee
L3-4 kick the door
L4-5 toes point to the sky
L5-S1 kick my bum
S1-2 stand on my shoe
Which sign to differentiate between CTS and DCM?
DCM: Positive Hoffman’s sign
The brachioradialis reflex tests predominantly for the integrity of the..
C6 (and partially C5)
Parasympathetic fibres in the eye are supplied by ________ blood vessels as opposed to vasa nervorum
Pial
Sleep paralysis - REM/Non-REM sleep (if troublesome clonazepam may be used)
Night terrors - REM/Non-REM sleep
Sleep paralysis - REM sleep (if troublesome clonazepam may be used)
Night terrors - Non-REM sleep
Function of Riluzole
Prevents stimulation of glutamate receptors
Riluzole used mainly in..
amyotrophic lateral sclerosis
Orthostatic tremor
Affects the legs
All TIA patients should have an urgent carotid doppler unless they are not a candidate for carotid endarterectomy..
Stenosis of <70% OR a complete blockage of their carotid artery
Epidural haematoma causes __________ herniation
Transtentorial
Nuchael rigidity
Meningitis/SAH
Which haematoma is not limited by suture lines?
Subdural (SNS - SMS)
6 tests in suspected brain death
Please Check Out Cute And Neatly
Pupillary reflex
Corneal reflex
Oculo-vestibular reflex
Cough reflex
Absent response to supraorbital pressure
No spontaneous respiratory effort
Medication overuse headache timeline
15 days or more. Symptoms resolve within 2 months
Decreased GCS and abnormal posturing (with fixed flexion of both arms, called the ‘mummy baby’ pose), on the background of a subdural haemorrhage + CN III palsy
Brain herniation
Anterior spinal artery syndrome occurs due to infarction of….
Corticospinal and spinothalamic tracts following traumatic injury to the aorta or due to atherosclerosis
Function of the dorsal columns is preserved because of their blood supply from the posterior spinal artery
Does levodopa not also cause postural hypo as a side effect?
Yes, but if it was only due to the levodopa, you would expect reflex tachycardia to compensate for the low BP. The lack of reflex tachycardia suggests autonomic dysfunction
__________ is a common complication of intraventricular haemorrhage
Hydrocephalus
C5 - T1 movements
C5 - shoulder abduction
C6 - elbow extension
C8 - thumb extension
T1 - finger abduction/adduction
Werenick’s - _______ temporal gyrus
Broca’s - _________ frontal gyrus
Superior
Inferior
____________ may be used as ‘rescue therapy’ for exacerbations of neuropathic pain
Tramadol
_____________ may be used for localised neuropathic pain (e.g. post-herpetic neuralgia)
Topical capsaicin
About 25% of cases of ALS begin as….
Progressive bulbar palsy termed ‘bulbar-onset’ ALS
Amyotrophic lateral sclerosis (50% of patients)
Typically LMN signs in arms and UMN signs in legs
In familial cases the gene responsible lies on chromosome 21 and codes for superoxide dismutase
Primary lateral sclerosis
UMN signs only
Progressive muscular atrophy
LMN signs only
Affects distal muscles before proximal
Carries best prognosis
Progressive bulbar palsy
Palsy of the tongue, muscles of chewing/swallowing and facial muscles due to loss of function of brainstem motor nuclei
Carries worst prognosis
___________ is a hydroxytryptamine (HT) receptor agonist
Sumatriptan
In trigeminal neuraligia, failure to respond to carbamazepine treatment or atypical features (e.g. < 50 years old) should prompt…
Referral to neurology
Damage to pyramidal pathways ( pyramidal weakness)
Increased tone and reflexes, a flexed hip and elbow, and a ‘clasp-knife’ spasticity
‘Scissor’ gait
Can be monoplegic, diplegic, or hemiplegic
Spastic
Damage to the basal ganglia pathways
Presents with choreiform movements
Can exhibit signs of Parkinsonism
Dyskinetic/ athetoid
Damage to cerebellar pathways
Presents with uncoordinated movements
Exhibits signs of cerebellar lesions
Ataxic
Spasticity, increased deep tendon reflex and persistent primitive reflexes
Cerebral palsy
Meningitistypically leads to which type of hydrocephalus?
Communicating due to impaired absorption of CSF rather than non-communicating caused by obstruction (ACM)
Wernicke’s encephalopathy is a condition in which thiamine deficiency causes neuronal death in certain areas with high metabolic requirements. These include..
Mamillary bodies
Periaqueductal grey matter
The floor of the fourth ventricle
Thalamus
Ankle and plantar reflex are lost but the knee jerk is intact
Sciatic nerve lesions
Proximal fibular fracture, extrinsic compression (such as a cast), or knee dislocation
Common peroneal nerve lesion
Neurological signs combined with abdominal pain is ___________ or _________ until proven otherwise
Acute intermittent porphyria or lead poisoning
The ______________ pathway is a dopaminergic pathway emanating from the hypothalamus to the median eminence. Inhibition of this pathway leads to a raised prolactin
Tuberoinfundibular
The __________ pathway is involved in the pathophysiology of Parkinson’s disease
Nigrostriatal
The ___________ pathway is thought to be overactive in schizophrenia which causes a patient’s positive symptoms such as hallucinations
Mesolimbic
The ___________ pathway is thought to be abnormal in schizophrenia, which causes the negative symptoms e.g. avolition
Mesocortical
Single, homogenous-enhancing lesion and a positive (rather than negative) thallium SPECT scan
CNS lymphoma
High-signal demyelinating white matter lesions are typically seen on MRI
CT may show single or multiple lesions
Progressive multifocal leukoencephalopathy
Sensory loss up to the shin level while maintaining normal muscle power. bilateral extensor plantar response and absent reflexes
SCDSP
Muscle weakness and atrophy that typically starts in one limb before spreading
ALS
Sensory deficits following a glove-and-stocking distribution pattern
T2DM
Diffuse cerebral oedema may require…
Decompressive craniotomy
ICP monitoring is appropriate in those who have GCS ______ and ______ CT scan
ICP monitoring is mandatory in those who have GCS ______ and ______ CT scan
ICP monitoring is appropriate in those who have GCS 3-8 and normal CT scan
ICP monitoring is mandatory in those who have GCS 3-8 and abnormal CT scan
Minimum of cerebral perfusion pressure of ________ in adults
Minimum cerebral perfusion pressure of between ________ and ________ mmHg in children
Minimum of cerebral perfusion pressure of 70mmHg in adults
Minimum cerebral perfusion pressure of between 40 and 70 mmHg in children
A sudden-onset headache, reaching maximum intensity within ____ minutes, is a red flag requiring further evaluation to exclude a subarachnoid haemorrhage
5 minutes
Flexion of head, trunk, limbs → extension of arms (Salaam attack); last 1-2 secs, repeat up to 50 times
Progressive mental handicap
EEG: hypsarrhythmia
Infantile spasms (West’s syndrome)
Tx for Infantile spasms (West’s syndrome)
Vigabatrin and steroids
Duration few-30 secs; no warning, quick recovery; often many per day
EEG: 3Hz generalized, symmetrical
Typical (petit mal) absence seizures
atypical absences, falls, jerks
90% moderate-severe mental handicap
EEG: slow spike
May be an extension of infantile spasms
Lennox-Gastaut syndrome
Tx of Lennox-Gastaut syndrome
Ketogenic diet
Most common in childhood, more common in males
Paraesthesia (e.g. unilateral face), usually on waking up
Benign rolandic epilepsy
Typical onset is in the teenage years, more common in girls
infrequent generalized seizures, often in morning//following sleep deprivation
Daytime absences
Sudden, shock-like myoclonic seizure (these may develop before seizures)
Juvenile myoclonic epilepsy (Janz syndrome)
Tx for Juvenile myoclonic epilepsy (Janz syndrome)
Sodium valproate
PMH of PD, postural hypotension, normal HR
PD due to autonomic failure
PMH of PD, postural hypotension, reflex tachycardia
4 D’s:
Deconditioning
Dysfunctional heart: aortic stenosis
Dehydration: disease (acute illness, adrenal insufficiency), dialysis, drugs (diuretics, narcotics)
Drugs: anti-anginals, anti-parkinsonian medications (levodopa), antidepressants, antipsychotics, anti-benign prostatic hyperplasia drugs (tamsulosin)
What is the treatment for the following CT?
Sulfadiazine and pyrimethamine
Toxoplasmosis: single/multiple ring enhancing lesions
What is the treatment for the following CT?
Steroids (may significantly reduce tumour size)
Chemotherapy (e.g. methotrexate) + with or without whole brain irradiation
Surgical may be considered for lower grade tumours
Primary CNS lymphoma: single or multiple homogenous enhancing lesions
Widespread demyelination due to infection of oligodendrocytes by JC virus (a polyoma DNA virus)
symptom
Progressive multifocal leukoencephalopathy (PML)
CT: single or multiple lesions, no mass effect, don’t usually enhance
MRI: high-signal demyelinating white matter lesions are seen
Progressive multifocal leukoencephalopathy (PML)
Innervation of the anterior two-thirds of the tongue
Taste: chorda tympani branch of the facial nerve via special visceral afferent fibres
Sensation: lingual branch of the mandibular (V3) division of the trigeminal nerve via general visceral afferent fibres
Innervation of the posterior two-thirds of the tongue
Taste and sensation: glossopharyngeal nerve via a mixture of special and general visceral afferent fibres
Innervation of the base of the tongue
Taste and sensation: internal branch of the superior laryngeal nerve (itself a branch of the vagus nerve)
In which space is a lumbar puncture performed?
Subarachnoid space
Biconvex collection of blood
Epidural haematoma
Biconcave collection of blood
Subdural haematoma
Circulation of CSF
Lateral ventricles (via foramen of Munro)
3rd ventricle
Cerebral aqueduct (aqueduct of Sylvius)
4th ventricle (via foramina of Magendie and Luschka)
Subarachnoid space
Reabsorbed into the venous system via arachnoid granulations into superior sagittal sinus
This most common cause of cavernous sinus thrombosis is…
Infection - spreads due to the anastomosis between the facial vein and superior ophthalmic veins
The ________ nerve is most commonly affected in CST
Abducens
Complications of meningitis
Neurological sequalae:
Sensorineural hearing loss (most common)
Seizures
Focal neurological deficit
Infective/sepsis
Intracerebral abscess
Pressure
Brain herniation
Hydrocephalus
Bilateral foot drop is more likely to be due to…
Peripheral neuropathy
Unilateral foot drop is more likely to be due to…
Peroneal nerve lesion
Peripheral neuropathy - peripheral neuropathy causes
Guillain-Barre syndrome
Porphyria
Lead poisoning
Hereditary sensorimotor neuropathies - CMT
CIDP
Diphtheria
Peripheral neuropathy - predominately sensory loss
Diabetes
Uraemia
Leprosy
Alcoholism
Vitamin B12 deficiency
Amyloidosis
A stroke would cause an ________ motor neurone lesion that would manifest in spastic (hypertonic) weakness and increased reflex responses.
Upper
The sciatic nerve most commonly arises from…
L4 to S3
Uncontrolled hypertension with a systolic blood pressure of ____________ and or diastolic blood pressure of ____________ would be a contraindication to thrombolysis in stroke due to increase bleeding risk
Systolic blood pressure of >185mmHg and or diastolic blood pressure of >110mmHg
Lateral pontine syndrome (__________ syndrome)
Ventral pontine syndrome (__________ syndrome)
Lateral pontine syndrome (Marie-Foix syndrome)
Ventral pontine syndrome (Millard-Gubler syndrome)
Anterior inferior cerebellar artery - lateral pontine syndrome
In disk prolapse the _____________ is the structure which usually herniates
Nucleus pulposus
Causes of Mononeuritis multiplex
WARDS PLC
Wegener’s, Amyloidosis, Rheumatoid Arthritis, Diabetes, Sarcoid, PAN, Leprosy, Carcinomatosis.
Contraindications to thrombolysis
Vertical nystagmus - ?
Horizontal nystagmus - ?
Vertical nystagmus (looking up and around your brain to your cerebellum) - cerebellar stroke
Horizontal nystagmus (looking side to side i.e. your ears) - viral labrynthitis
Transverse myelitis typically presents with __________ and ____________ below the affected level within the spinal cord
Tabes dorsalis, a manifestation of tertiary syphilis, entails infiltration of the spinal cord by the infection. It typically results in ____________ and ____________
Transverse myelitis typically presents with both spastic paraparesis and complete sensory loss below the affected level within the spinal cord
Tabes dorsalis, a manifestation of tertiary syphilis, entails infiltration of the spinal cord by the infection. It typically results in diminished proprioception and vibration sense.
Headache, fever and focal neurology and suggestive of a…
Brain abscess
Drugs used in urge incontinence
Oxybutynin (immediate release)
Tolterodine (immediate release)
Darifenacin (once daily preparation)
Solifenacin
The following aura symptoms are atypical and may prompt further investigation/referral…
motor weakness
double vision
visual symptoms affecting only one eye
poor balance
decreased level of consciousness
Confirm death by..
Confirming the patients identity
Checking for any obvious signs of life
Checking response to verbal and painful stimuli
Assessing pupils - they should be fixed and dilated
Feeling a central pulse
Listening for heart sounds and respiratory sounds for a total of 5 minutes
Seizure Ix
CT head, FBC, U&Es, Serum calcium, LFTs, ABG, Blood glucose, Urine tox screen -
Tx for patients with a suspected tricyclic antidepressant overdose..
sodium bicarbonate
Cavernous sinus thrombosis is another important complication in sinusitis but usually presents with..
Unilateral facial oedema, photophobia, proptosis and palsies of the cranial nerves which pass through it (III, IV, V, VI)
