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
Extradural haemorrhage occurs between the skull and dura mater and is usually caused by..
Rupture of the middle meningeal artery in the temporoparietal region
Subdural haemorrhage occurs between the dura mater and arachnoid mater and is caused by..
Rupture of the bridging veins in the outermost meningeal layer
What does the following fundoscopy show?
Papilloedema
What does the following fundoscopy show?
Optic neuritis
What does this clinical sign show?
Right facial LMN lesion - Bell’s Palsy
What does this clinical sign show?
Right facial UMN lesion - Stroke
Thoracic outlet syndrome (TOS) is a disorder involving compression of..
Brachial plexus, subclavian artery or vein
What does the following clinical sign show?
Vesicles in the ear canal in a patient with Ramsay Hunt syndrome
What does the following MRI show?
Chiari malformation with syrinx
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 does the following MRI show?
Glioblastoma multiforme - solid tumours with central necrosis and a rim that enhances with contrast
Spindle cells in concentric whorls and calcified psammoma bodies
Meningioma
Rosenthal fibres (corkscrew eosinophilic bundle)
Pilocytic astrocytoma
Small, blue cells. Rosette pattern of cells with many mitotic figures
Medulloblastoma
_______________ 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
What does the following MRI show?
Meningioma
What does the following CT show?
Glioblastoma multiforme
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
Charcot-Marie-Tooth disease
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
What does the clinical picture show?
MG - affects proximal muscles of the limbs and small muscles of the head and neck
+ Facial weakness. Autonomic dysfunction - urinary retention, ileus or heart arrhythmias.
What does the clinical picture show?
GBS
High signal T2 lesions
Periventricular plaques
Dawson fingers
MS
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
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 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
What does the clinical picture show?
PD
Which specific signs indicate meningeal irritation?
What does the clinical picture show?
Horner’s syndrome
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)
Red flag signs for trigeminal neuralgia
What does the MRI show?
Diffuse axonal injury
Vertigo + vomiting. Gaze direction + changing horizontal nystagmus. Head thrust test negative
Posterior circulation infarct
What is Hoffman’s sign?
Investigate the cause of ataxia; if positive means sensory ataxia
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
Ix for SAH
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
Which arteries are affected in SAH?
Circle of willis
DCML
Epidural haematoma causes __________ herniation
Transtentorial
Werenick’s - _______ temporal gyrus
Broca’s - _________ frontal gyrus
Superior
Inferior
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
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
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
Contraindications to thrombolysis
