Neurology Flashcards
What conditions are a contraindication to triptans?
Ischaemic heart disease, hypertension and previous stroke or TIA
First line prevention of uncomplicated migraine
Beta blocker e.g. atenolol, propanolol
Sensation of being hit in the back of head, smoking history, EDS
Ruptured berry aneurysm
Periorbital headache with ptosis, lacrimation, conjunctival inflammation
Cluster headache
History of TIA and AF with stepwise decline in memory
Vascular dementia
First line management of mild to moderate dementia
Donepezil, rivastigmine or galantamine
Management of moderate to severe dementia
Memantine (NMDA antagonist)
Why are people with Down syndrome more likely to get Alzheimer’s?
Amyloid precursor protein is found on chromosome 21
Drug to reduce severity of attacks in MS
3 day course oral methylprednisolone
Drug to reduce relapse rate in MS
Beta-interferon
Pt is unable to extend knee due to muscle spasm - should botox be injected into extensor or flexor muscles?
Flexors. e.g. biceps femoris if unable to extend knee
What would you see on CSF panel in MS patient?
<1 white cell, <1 red cell, CSF glucose:serum glucose=0.6, protein 0.5 (normal 0.2-0.45g/L), distinct bands of IgG on Western Blot
Pathological hallmark of MS on MRI
Plaques of gadolinium-enhancing T2 hyperintensity
What type of stroke is caused by small vessel infarction?
Lacunar stroke (no cortical signs e.g. hemianopia, speech problems)
First line investigation for suspected subarachnoid haemorrhage
CT non-contrast (detects 90% within48h onset)
WHich nerves are affected first in PNS pathology?
Long nerves e.g. legs before arms
Anticonvulsant causing elevated liver enzymes and hepatic dysfunction
Sodium valproate
How does phenytoin work?
By blocking voltage-gated sodium channels to prevent further action potentials
Pt’s plasma phenytoin level is 7mg (ref 10-20mg) after initial management of seizure with phenytoin, how can a further seizure be prevented?
Increase dose of phenytoin
(current levels are below therapeutic window)
Side effects of sodium valproate
Think VALPROATE
- Vomiting
- Appetite (increased, weight gain)
- Liver failure
- Pancreatitis
- Reversible hair loss
- Oedema
- Ataxia
- Teratogencity/tremor/thrombocytopenia
- Encephalopathy
What is Jacksonian march?
Leg starts twitching, and movement moves up her right trunk to involve right arm (or left)
In status epilepticus pts, what should be given after buccal diazepam?
IV midazolam
Jacksonian march and Todd’s palsy are features of what type of seizure?
Focal seizure without impairment of consciousness - frontal lobe origin
Features of temporal lobe seizures
Aura initially (e.g. feeling sick, a sense of anxiety or smelling unusual smells)
Followed by impaired awareness
- stare blankly
- automatisms (e.g. lip-smacking or fidgeting with their hands)
Post-ictal phase
- slightly confused
- unsure of what has happened.
How to differentiate between temporal lobe and absence seizures?
Absence seizures only last a few seconds and do not have a post-ictal phase
In what type of seizures is carbamazepine most used?
Partial/focal
First line for focal seizures
Lamotrigine or leviteracetam
Def of status epilepticus
A seizure lasting 5 minutes or more
OR multiple seizures over 5 minutes without returning to a full level of consciosuness between episodes.
Which cranial nerves carry parasympathetic fibres?
X
IX
VII
III
mTBI features
Loss of consciousness
Amnesia
Fencing posture
What happens to neurons in mTBI?
Neurons pulled apart, leak contents into brain
Neurons that don’t die release NTs and ion fluxes
- K otu, Ca in, battery remotes round the wrong way
What happens in post-cpncussive phase?
Diminished blood flow due to metabolic cascade
Results in poor cerebral response to 2nd injury
- brain more vulnerable
Unilateral supratentorial arterial bleed suggests what type of haematoma
Extradural haematoma
Vomiting post-head injury suggests…?
SKull fracture
Cushing’s reflex in head injury
Increased blood pressure, decreased heart rate, irregular breathing
Next line management of IIH patient with one eye decr visual acuity, bilateral papilloedema and some haemorrhage on 250mg acetazolamide
Refer to surgeons for consideration of optic nerve fenestrations
What is Ramsay Hunt II syndrome?
Reactivation of varicella zoster virus in the geniculate ganglion.
Unilateral acute facial nerve paralysis, erythematous vesicular rash in the ear canal.
Lumbar spinal stenosis pain gets better when patient does what?
Bend forward when sitting down
Peripheral neuropathy is caused by which TB drug?
Isoniazid
Presentation of Wernicke’s encephalopathy
Tetrad of confusion, ataxia, nystagmus and opthalmoplegia
Hx of alcohol dependency
Manage with thiamine to avoid the development of Korsakoff syndrome
Which muscle disorder is managed with prednisolone and pyridostigmine?
Myasthenia gravis
Management of essential tremor
Propranolol!!!! primidone, topiramate, gabapentin, clonazepam.
Management of Ramsay Hunt syndrome
Prednisolone and acyclovir
Which antibody is most commonly positive in myasthenia gravis?
Nicotinic acetylcholine receptor (nAChR)
What drug is given in conjunction with levadopa in PD and why?
Carbidopa
- reduces the breakdown of levodopa peripherally, leading to a better therapeutic effect.
Name a nausea drug that makes Parksinonism symptoms worse
Metoclopramide
- it’s a dopamine antagonist but also has a bit of 5HT3 antagonism
Right upper and lower limb motor power and sensation both reduced - where is the infarct?
MCA
Wernicke’s vs Broca’s apahasia
Wernicke = word salad
Broca = broken speech
What is hereditary spastic paraparesis?
Degeneration of corticospinal tracts and sometimes dorsal column
Presents with spasticity, hyperreflexia and gait disturbance
Scissor gait suggests?
Increased muscle tone in the adductor muscles
e.g. due to herediatry spastic paraparesis
Hemiplegia, homonymous hemianopia, and Wernicke’s dysphasia - where is the infarct?
Lateral hemisphere - supplied by MCA
Investigation to diagnose encephalitis
CSF viral PCR
- most common cause is HSV
Proximal muscle weakness which improves on repetition with Hx of small cell lung cancer?
Lambert Eaton syndrome
Excessive alcohol intake assoc with peripheral neuropathy, hyporeflexia and muscle atrophy of lower limbs suggests which deficiency?
Thiamine
Xanthochromia in CSF?
Subarachnoid haemorrhage
- CT angio
Management of Bell’s palsy
Prednisolone
Features of Lewy body dementia
Cognitive impairment and non-threatening visual hallucinations assoc with Parkinsonian triad
Clin pres of progressive supranuclear palsy
Parkinsonian triad of tremor, hypertonia, and bradykinesia
- with a vertical gaze palsy
Common non-motor symptom of parkinson’s
Anosmia
Postural hypotension
Management of on and off motor symptoms in Parkinson’s
MAO-B inhibitor - such as rasagiline
COMT inhibitor - entacapone
Dopamine antagonist
What medication is given alongside levadopa to increase its bioavailability?
Carbidopa
- it reduces the breakdown of levodopa peripherally, leading to a better therapeutic effect.
BP contraindication for thrombolysis
blood pressure greater than 180/110mmHg
PMN WCC, raised protein and low glucose suggest which cause of meningitis?
Bacterial
Left homonymous hemianopia with macular sparing would result from infarct in which cerebral artery?
Right posterior cerebral
- posterior cerebral artery supplies corresponding occipital cortex which encodes contralateral visual field
- macular sparing because macular vision is encoded bilaterally like the forehead
When is aspirin given in stroke?
Aspirin 300mg 24h after after alteplase treatment for 2 weeks afterwards
- only if CT has ruled out haemorrhagic stroke
Test to confirm narcolepsy
Multiple Sleep latency test
Management of jerky movements in hands etc known as choreoathetosis
Tetrabenazine
Test to monitor for resp failure in GBS pts
Regular FVC
Which drug can be used to reduce the risk of long term neurological symptoms in bacterial meningitis?
Dexamethasone IV
- given within 4h of IV antibiotics
Mechanism of action of dipyridamole
Inhibits phosphodiesterase and adenosine deaminase
Dupuytren’s contracture caused by which antiepileptic?
Phenytoin
How long after onset can you provide thrombolysis?
4.5 h
- thrombolyse first and then aspirin 24h later after CT to confirm no subsequent haemorrhage
Headache accompanied by vertigo, diplopia, dysarthria and tinnitus, as well as bilateral visual symptoms and bilateral paresthesias.
Basilar migraine
- manage ibuprofen
How does anticipation occur in Huntington’s?
Spermatogenesis
Acute dystonic reaction is usually caused by what type of drug?
Dopamine antagonist e.g. metaclopramide
- forced extension of the neck, rigid opening of the jaw, and sustained upward deviation of the eyes.
LP changes in GBS
isolated rise in CSF protein
Only licensed med in MND?
Riluzole
types of stroke reformat this
AICA: lateral pontine syndrome = Marie-Foix. CN7 and 8. ipsilateral (unless stated otherwise):
VAN - H = vertigo, ataxia, anaesthesia (CL body, IL face), nystagmus and Horner’s.
Hx of head injury and CT showing only one ventricle, ?haemorrhage
Subdural haemorrhage
Does extradural or subdural haemorrhage have a faster symptom onset?
Extradural
Ipisilateral occulomotor palsy and contralateral limb weakness suggests infarct affecting which artery
Posterior cerebral artery
Lesion of which cranial nerve would present with nystagmus?
CNVIII
- balance etc
Sudden vertigo, deafness, vomiting, ipsilateral facial paralysis
Anterior inferior cerebellar infarct
Management of hypoglycaemia in pt with IV access but no swallow ability
100ml 20% glucose
What does hyperattenuation on CT mean in stroke?
Haemorrhagic stroke
Is ischaemic heart disease contraindicative to thrombolysis or thrombectomy?
NOOOOOO
Management of essential thrombocytosis
Hydroxycarbamide
To which artery is thrombectomy most beneficial?
Proximal middle cerebral artery
Which lobe is affected if pt is right handed?
Left (always contralateral to handedness)
UMN signs post-stroke
Clonus, hypertonia, muscle weakness
LMN signs post-stroke
Hypotonia, muscular atrophy, hyporeflexia, fasciculations
Long term stroke prophylaxis
Clopidogrel 75mg OD
Atorvastatin 80mg OD
Clumsy hand dysarthria is a type of…
Lacunar infarct syndrome
INR level contradicating thrombolysis?
INR >1.7
Type of stroke causing locked in syndrome
Basilar artery stroke
- only get vertical eye movements and blinking
How to investigate the cause of a young person’s stroke post-DVT with no APS Hx?
Bubble echocardiogram
- ?patent foramen ovale
Specific epileptic symptoms and where they originate from
Frontal Lobe: Jacksonian March
Parietal Lobe Paraesthesia
Occipital Lobe: Visual phenomena
Temporal Lobe: HEAD*
Triad of myoclonic jerks, absence seizures and generalised TC seizures
Juvenile myoclonic epilepsy
Which hormone is raised post-ictally and can help differentiate between NEAD and true epilepsy?
Prolactin
Bilaterak reduced power more prominent in RHD with normal tone and reflexes, some prox thigh fasciculations and pos anti GM1 Abs
Multifocal motor neuropathy
What does pos rombergs test mean?
Sensory ataxia (loss of proprioception in distal legs
First line for neuropathic pain
Gabapentin, pregablin, duloextine, amitryptiline
Most common visual defect assoc with optic neuritis
Central scotoma
SCDC involves which tracts of the spinal cord?
Dorsal and lateral
- spinothalamic unaffected so pain and temp sense are maintained
Resting tremor and bradykinesia and rigidity
triad of Parkinson’s
Temporal lobe lesions on MRI in a young boy with HSV
Viral encephalitis
WHich facial muscle is spared in stroke?
Anterior part of occipitofrontalis muscle
Loss of taste to ant 2/3 of tongue, ear pain and deafness?
Bell’s palsy
Subdural haemorrhage ocurs from bleeding from whcih vessels
Bridging vessels between dural venous sinuses and cortex
Stroke with no motor symptoms is likely….
Post cerebral artery infarct
Wernickes area is supplied by….
Inf division of MCA on dominant side
Stroke with only symptom being contralateral numbness?
LACS
Spindle cells and psammoma bodies on tumour histology
Meningioma
Post communicating artery aneurysm would likely present with which cranial nerve palsy?
CNIII
- diplopia and nystagmus
Contralateral hemiparesis and sensory lss with lower etxremity more affected
Anterior cerebral artery infarct
First line investigation of Horner’s syndrome
CXR for pancoast tumour
- less likely post-thyroidectomy or surgical trauma
Where is the lesion if pt presents with RAPD?
Optic nerve
- think optic neuritis
Aphasia, headache, psychiatric symptoms, fever
HSV encephalitis
- aphasia indicates temporal lobe involvement
- LP would show lymphocytosis and incr protein
Tremor worse with alcohol and grabbing things
Essential tremor
-auto dominant usually
Transient painful visual loss in one eye, horizontal diplopia, electric pain after a bath
MS (MRI brain and spine)
1. Optic neuritis
2. Internuclear ophthalmoplegia
3. Lermitte’s
L5 radiculopathy presents with
Weakness of foot dorsiflexors, inverters and everters
NP pain in lumbar, posterior thigh, antlat leg, foot and big toe
Sensory loss at first webbed space
Bacterial infection on LP
Pos culture
Incr white cells (PMN leukocytes, immune response)
Incr protein (bacterial replication)
Decr glucose (bacteria eats it)
Meningitis prophylaxis
People in household should get 500mg one off oral ciprofloxacin
- don’t think this is on Tayside formulary
- under 12s get 250mg
Wallenberg’s syndrome
Infarct of lateral medulla
- post inf cerebellar artery
- ipisilateral horner syndrome
- contralateral pain and temp loss
- ataxia/nystagmus
- CN 9,10,11,12 palsy
Groggy after unwitnessed collapse
SPECIFIC sign of post-ictal phase of epileptic seizure
Ipsilateral CNIII palsy and contralateral weakness
Weber’s syndrome
- “pt presents with left down and out eye and right sided weakness of limbs”
Management of Bell’s palsy
Oral prednisolone
+ otoscopy to check for Ramsay Hunt (usually ext ear vesicular rash but can also appear on TM)
Common peroneal vs tibial nerve function
TIPPED
- Tibial Inverts and Plantarflexes
- Peroneal Everts and Dorsiflexes (palsy = footdrop)
Clinical difference between mononeuritis multiplex and MS
Mononeuritis only has LMN signs
- MS has both but UMN signs predominate on examination
Which symptoms do not present in TIA?
Headache (suggests migrane etc)
Shaking/motor signs before attack (suggests seizure)
Most common cause medical CNIII palsy
Diabetes
Hypersensitive carotid sinus reflex is caused by…
Hypoglossal nerve
- when pressure applied to neck HR decr
Why are Ca channel blockers used in haemorrhage?
Prevention of vasospasm-induced cerebral ischaemia to allow for optimal perfusion
Mx menière’s disease
Diuretics and low salt diet
How to diff between ischaemic and haemorrhagic stroke on CT?
Ischaemic stroke: HYPO-dense area on CT
Haemorrhagic stroke: HYPER-dense area on CT
Anti epileptic causing stones and WL
Topiramate
- topaz crystals in the kids
Migraine prophylaxis
Topiramate
- teratogenic
Amitriptyline
- if u don’t know contraception status
‘Loss of grey-white matter differentiation’ on CT in a pt woken up confused with slurred speech
Cytotoxic oedema 2o to ischaemic stroke
Gm pos rod cause of meningitis in pregnancy
Listeria
- from food e.g. soft cheese
- can cause chorioamnionitis and pre term labour
ARDS + pyrexial, tachycardic and has laboured breathing. She also appears floppy and lethargic, but there are no dysmorphic features, mother ate loads of cheese in pregnancy
Listeria
- meconium stained liquor is also a RF
Crescent-shaped homogeneously hyper-dense extra-axial collection adjacent to the left fronto-parietal convexity
Subdural haematoma
- recurrent falls and confusion with risk factors including alcohol use, age, recent trauma, anticoag use)
Parkinsonism + defective upward gaze + personality change
Pro-gaze-ssive supranuclear balls-y
- prog supranuclear palsy
Brown Sequard T10 on right side findings
Increased tone and hypereflexia, extensor plantar response and reduced joint position sense in the right leg, loss of pain and temperature sensation from the left leg up to the level of the umbilicus. Normal examination of the arms
How many doses of benzo should you try in status epilepticus before trying something else?
2 doses max
- move on to phenytoin or valproate
- after 20 mins there is serious risk and gen anaesthesia should be considered
Establishes status epilepticus?
> 20 mins seizure activity
10 mins with no response to benzos
Burr hole vs craniotomy in acute subdural haemorrhage
Craniotomy
- burr hole for chronic
Why is high BP (>190 systolic) a contraindication to thrombolysis?
High BP + Thrombolysis = Brain haemorrhage
Barthel index
To assess functional independence in post-stroke pts
Type of sweaty problems in Horner’s syndrome
Anhidrosis
How can you relieve acute dystonia?
Anticholinergic
- procyclidine or biperiden
What is Todd’s palsy?
Essentially paralysis/exhaustion after a frontal lobe focal seizure
What does split hand mean in MND?
The radial aspect of the hand is far more affected than the ulnar aspect
Ipsilateral: facial paralysis/pain and temperature loss/deafness
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus
AICA
AICAnt hear you
Which cranial nerves are affected y the cerebellar strokes?
AICA = CN5, 6, 7, 8
PICA = CN9, 10, 11, 12
What type of bitemp hemianopia would present first?
Lower
- due to craniopharyngeoma
Is Bell’s palsy upper or lower MN problem?
Lower - two Ls in Bell’s
Gradual onset severe headache associated with nausea and three episodes of vomiting
Sensory loss of posterolateral aspect of leg and lateral aspect of foot, weakness in plantar flexion of foot, reduced ankle reflex, positive sciatic nerve stretch test
S1 root lesion
First line management of trigeminal neuralgia
Carbamazepine
First line management of an acute dystonic reaction
Procyclicdine
First line treatment of Wernicke’s encephalopathy
IV pabrinex
India ink stain meningitis
Cryptococcus neoformans
First line prophylaxis for migrain
Propranolol
- topiramate if contraindicated e.g. in asthma
WHen can LP in SAH be done?
12h after onset
- this is when blood will break down and xanthochromia will be seen
Acetylcholine receptor antibodies
Myasthenia gravis
Anti voltage gated calcium channel antibodies
LEMS
PICA stroke/lat medullary/Wallenberg
DANVAH
Dysphagia, ipsilateral Ataxia, ipsilateral Nystagmus, Vertigo, Anaesthesia, ipislateral Horner’s
Where is the lesion in internuclear ophthalmoplegia?
Lesion on the contralateral Medial Longitudinal Fasciculus (MLF)
Frontal balding and unable to let go when shaking hand, prog hand weakness
Myotonic dystrophy
- trinucleotide repeat
What eye condition may indicate TIA?
Amaurosis fugax
- essentially is an eye TIA
- vision goes without pain and them comes back
- cotton wool spots and hard exudates
Type 1 vs 2 CMT
Inherited polyneuropathy with champagne bottle legs
Type 1 = demyelinating
Type 2 = axonal
Familial ALS mutation
SOD1
Risk factors for thiamine defic (and 2o wernicke’s encephalopathy)
Alcohol abuse, malnutrition, bariatric surgery, and hyperemesis gravidarum
Most common cause of intracranial haemorrhage, can be exacerbated by straining or valsalva maneouevres
Hypertension
Huntington’s shows atrophy of….
Caudate nucleus and putamen
How does parietal lobe damage present?
contralateral visual field, astereognosis, constructional apraxia (non-dominant), dressing apraxia (non-dominant) and ideomotor apraxia (dominant). Right hemisphere (i.e. non-dominant) parietal lesions are particularly prone to producing visual neglect.
Noncontrast CT hyperdensity
Thombosis
Severe, throbbing headache occurring all across her head, nausea and vomiting, non contrast CT shows hyperdensity in sagittal sinus
Intracranial venous thrombosis
Delta sign on CT in context of stroke
Filling defect in sagittal sinus
Management of severe hypoglycaemia
20% glucose solution IV
Hypo or hyperreflexia in SCDC?
Hyperreflexia
Alternative to clopidogrel in TIA prevention
Change to dual therapy with aspirin and modified-release dipyridamole
Stroke presenting with contralateral homonymous hemianopia with macular sparing and visual agnosia
Posterior cerebral artery
Sweaty and anxious pt with history of bilateral lower limb paraplegia 2o to transection of spinal cord, Cushing’s signs
Faecal impaction / urinary retention are the most common triggers of autonomic dysreflexia
Elec imbalance following SAH
Hyponatraemia
Management of myasthenic crisis
intravenous immunoglobulin, plasmapheresis
Pit adenoma vs craniopharyngioma
Pit adenoma
- pushes up from below = superior quantrantopia
Craniopharyngioma
- pushes down from above = inferior quantropia
How to remember where uvula/tongue deviates to in cranial nerve palsy?
CNX = uvulA = Away
CNXII = Tongue = Towards
Midbrain stroke characterised by the an ipsilateral CN III palsy and contralateral hemiparesis
Weber’s syndrome
Bleeding in subdural haemorrhage is due to
bridging veins between cortex and venous sinuses
As well as MRI, what other inv should all TIA patients get?
Carotid artery doppler
How does hyperventilation work to reduce raised ICP?
Hyperventilation -> reduce CO2 -> vasoconstriction of the cerebral arteries -> reduced ICP
Derm reaction caused by carbamazepine
Stephen Johnson
- watch for new med changes and new rash covering mouth and significant area of skin
Negative CSF findings with lower limb weakness, progressive
GBS
- neg CSF is essential for diagnosis
Loss of pain and temp sensation but intact DCML senses in Chiari malformation
Syringomyelia
- dilatation of a CSF space within the spinal cord
First seizure but normal imaging and EEG - driving?
Stop driving for 6 months
Which primary cancers most commonly met to the brain?
Left Brained Metastases Can Kill
Lung >Breast > Melanoma > Colorectal > Kidney
Improvement in muscle power with exercise
LEMS
Symmetrical tremor in PD
Drug induced
Management MG vs MG crisis
MG - pyridostigmine
MG Crisis - Ig
