Neurology Flashcards
What is degenerative cervical myelopathy
Loss of fine motor function in both upper limbs
Main risk factor smoking, genetics and occupation
Pain in neck and limbs
Loss of motor function - issues with doing up buttons etc
Loss of sensory function
Hoffman’s sign: Flick one finger on hand and there will be reflex twitching on other hands
MRI cervical spine= gold standard
Need decompressive surgery
What is the difference between an absence seizure and a focal onset impaired awareness seziure
Absence seizure- usually in childhood
Focal onset impaired awareness seizure- may start with an aura (focal aware seizure) then they will loose awareness- will do repetitive movements and stare blankly - can be in adults
What are the features of MS
Usually young women
Optic neuritis
Pins and needles/ numbness, trigeminal neuralgia
Numbness on neck flexion
Lower limb spasticity/ weakness
For diagnosis :
Need to see demyelinated lesions that are separated in space and time
Olgiocloncal bands in CSF
What is the management of epilepsy
Antiepileptics after a second epileptic seizure
To drive need to be 12 months seizure free and can’t drive for 6 months after a seizure
Be careful if on warfarin as antiepileptics can inhibit p450
Sodium val in men / post menopausal women
Lamotrigine used in child baring women
Focal seizures - carbamazepine second line
What is the treatment for Cluster headaches
Acute- oxygen and subcutaneous triptan
Prophylaxis - Verapamil -
What are the features of Guillain Barre syndrome
Immune demyelination after an infection usually campylobacter jejuni
Weakness is ascending from legs first - few sensory symptoms
Lumbar puncture will show rise in protein with a normal WCC
Nerve conduction studies will show decreased motor nerve conduction (demyelination)
Signs will show LMN signs
Hypotonia, flaccid paralysis, arreflexia
What is the difference between Broca and Wernick’s aphasia and what artery is usually affected in stroke of this area
Wernicke’s = what? - the patient can’t understand your command
Inferior division of the left MCA- W is lower than B so inferior
Broca’s = broken - the patient has broken word flow
Superior division of the left MCA
What is conduction aphasia
Speech is fluent and comprehension is normal but repetition is poor
What are the features of encephalitis
Fever, headache, psychiatric symptoms, seizures, vomiting, mental state change
Aphasia
HSV-1 is responsible for most cases and usually affects temporal and inferior and frontal lobes
Think of a history of a recent viral illness
investigate cerebrospinal fluid - PCR for HSV, VZV and eneterovirus
Neuroimaging and EEG
Manage with IV aciclovir
Bilateral medial temporal lobe involvement
What is pituitary apoplexy
Sudden enlargement of a pituitary tumour due to infarction or haemorrhage
Sudden onset headache, vomiting, neck stiffness, bitemporal hemianopia
MRI diagnostic
Urgent steroid replacement due to loss of ACTH
Fluid balance
Surgery
What are some of the posterior stroke syndromes
Locked in syndrome- basilar artery occlusion - quadriparesis with preserved consciousness and ocular movements
Wallenberg’s syndrome (lateral medullary syndrome) - Ipsilateral (same side) Horner’s syndrome, ipsilateral loss of pain and temperature on face, contralateral loss of pain and temperature of the body
What is jugular foramen syndrome
Symptoms involving CN 9,10,11 that pass through the jugular foramen
Can be caused by tumours, infections, granulomatous disease
Signs
Same side weakness of trapezius and sternocleidomastoid
Uvula deviation to the opposite side
Dysphasia and voice change
Loss of gag reflex
Surgical intervention or radiation for tumours
What are the features of an extradural haemorrhage
Between duramater and skull
Head injury to pterion and tearing of middle meningeal artery
Severe headache and oppossite side hemiplegia
Biconvex haematoma limited to the skull
What are the features of a frontal lobe seizure
Jacksonian march (works its way up from arms), head and leg movements
Post ictal weakness
What are the features of a subdural haemorrhage
Between the dura mater and the arachnoid mater of the meninges
More gradual symptoms than extradural
Alcoholism and anticoag use= risk factors
Fluctuating consciousness
Crescent shape on CT - along side of skull
What are the features of a subarachnoid haemorrhage
Occipital headache, seziures, LOC
Trauma, spontaneous rupture of aneurysm in circle of willis
On CT, white area in centre of brain expands bilaterally
IF CT is negative do a lumbar puncture which will have blood in CSF or yellow CSF from haemolysis
Blood is white on CT
What medications and criteria are used for MS
McDonald Criteria
Acute management
1g IV methylprednisolone every 24 hrs for 3 days
If unresponsive to this give plasma exchange
Chronic management
Relapsing remitting MS
1st line- Injections - Beta interferon and galtiramer
Oral agents - teeriflunomide
Biologics- alentuzumab
What are the features of myasthenia Gravis
Autoimmune disorder antibodies against acetylcholine on muscle fibres
Features
Limb muscle weakness- worse on activity
Facial muscle weakness
Bulbar muscle weakness- issues with speech and swallow
Some drugs can make myasthenia gravis worse
Beta blockers
Lithium
Penicillamine
Gent
Phenytoin
strong link with thymus gland tumours
AcHR antibodies
Treatment
Pyridostigimine- cholinesterase inhibitor
Immunosupression
What are the features of Intracranial venous thombosis
Strokes in younger people
Headache, confusion, Nausea/vom, papilloedema
Non-contrast CT will show hyperdensity in the affected sinus
Most common dural venous thrombosis affects the superior saggital sinus
Management is with LMWH
What are the features of a third cranial nerve palsy
Oculomotor nerve paralysis
Down and out eye
Double vision
ptosis, proptosis, fixed pupil dilation
Causes
Surgical: Posterior communicating artery aneurysm
Medical: MS, Vascular (DM or HTN, Vasculitis)
What are the features of a 4th CN palsy
Paralysis of trochlear nerve
Controls the superior oblique which usually pulls eye down and in
Patient have double vision worse on the verticle plane (looking up)
Eye will point up and in at rest - patient may tilt head to compensate with trouble going down stairs etc
Ocular trauma and diabetes are two most common causes
What are the features of a 6th CN palsy
Abducens nerve- controls lateral rectus - abduct eye horizontally away from midline
Double vision in horizontal plane
Can be compromised in raised ICP
Diabetic neuropathy, stroke, infection an trauma
What is the management of a TIA
Lifestyle modification and control of risk factors
Intiation of antiplatelet therapy (aspirin/ clopidogrel)
Can give endartectomy or stenting if
50-70% stenosis of carotid artery
What is the management of a stroke
Rule out Haemorrhage - CT brain
Aspirin 300mg daily for 2 weeks
Thrombolysis with alteplase given within 4.5 hrs onset
Thrombectomy within 24 hrs with IV thrombolysis
In ischaemic stroke- lowering BP can make things worse
In haemorrhagic stroke- treat BP aggressively
What is internuclear opthalmoplegia
Lesion in the medial longitudinal fasiculus - where nerve fibres connect all CNs that affect the eye 3,4,6 - impaired adduction on same side as lesion and nystagmus on opposite side
How are MS relapses treated
500MG steroids orally for 5 days
or
1g IV daily for 3-5 days
What are the different types of motor neurone disease
MND can give UMNL and LMWL signs
ALS- amylotrophic lateral sclerosis - asymmetric limb weakness, muscle wasting and fasiculations
Progressive Bulbar palsy- affects muscles of talking and swallowing
MND - older man, insidious onset, weakness in upper limbs first, clumsy, slurred speech
LMND signs
- Lower- affects older people
Treatment - no real treatment
Rilizole - slows progression
No sensory symptoms, no cerebellar symptoms, eye movements spared,
What are the features of parkinsons
Reduced dopamine in basal ganglia
Resting tremour, 4-6Hz rigidity, bradykinesia, asymmetrical tremor
Treat with Levodopa and carbidopa (stops levodopa being metabolised before the brain) - can lead to side effects- Chorea, abnormal movements, excessive motor activity
COMT inhibitors can be used when levodopa effectiveness needs extended
Dopamine agonists can also be used to delay levodopa use but cause pulmonary fibrosis
Monoamine oxidase inhibitors- used to delay end dose symptom worsening with levodopa
What are the features of Bell’s palsy
Unilateral lower motor neurone facial palsy- forehead not spared
Presents within 72 hrs symptoms- prednisolone 50mg for 10 dats
or
60mg for 5 days followed by a 5 day reducing regime of 10mg per day
What are the features of an acoutsic neuroma
Tumour of scwann cells around auditory nerve
Vestibular scwannomas
30-60
Unilateral sensorineural hearing loss
Unilateral tinnitus
Dizzy/imbalance
Fullness in ear
Facial nerve palsy
What are the features of Huntingtons chorea
Triple nucleotide repeat
Anticipation- gets worse down gens
Chorea, dystonia, rigidity, personality change, dysphagia
No treatment
What is the treatment for myasthenic crisis
worsening of symptoms due to illness
IV immunoglobulins/ plasmapheresis
What are the features of Lambert Eaton Myasthenic syndrome
Autoimmune condition similar to myasthenia gravis
Associated with paraneoplastic syndrome - SCLC
Less pronounced more insidious symptos
Proximal muscle weakness, autonomic dysfunction
Absent reflexes when rested but present immediately after muscle contraction
Treat underlying malignancy and same treatment as MG
What are the features of Charot Marie Tooth Disease
Affects peripheral and sensory neurones
Autosomal dominant inherited
Before 10 or in 40s
Distal muscle wasting -champagne legs
Lower leg weakness
Hand weakness reduced muscle tone
No cure - physios, OT etc
What are the symptoms of Guillian Barre syndrome
Affects peripheral NS after Infection- camplylobacter
Symmetrical ascending weakness
Starts within 4 weeks of infection
Autonomic dysfunction too
Diagnosis with brighton criteria, nerve conduction studies through spinal nerves, lumbar puncture
Management
VTE
IV immunoglobulins
Plasmapheresis
What are the features of neurofibromatosis
Type 1 gene 17 - autosomal dominant
Cafe au lait spots, bony dysplasia, yellow brown spots on iris, neurofibromas, glioma of optic pathway
Two or more neurofibromas on skin- signficiant
Neurofibromatosis 2
Chr 22
Associated with acoustic neuromas
What are the features of tuberous sclerosis
Autosomal dominant
Development of harmtomas
TSC1- Chr 9
TSC2- Chr 16
Ash leaf spots, shagreen patches (thick dimpled), angiofibromas (papules over nose and cheeks), ungual fibromas (painless lumps), poliosis ( patch of white hair)
Can cause epilpesy, learning disability, brain tumour
Rhabdomyomas in heart, retinal hamatomas
What is syringomyelia
Collection of cerebrospinal fluid in the spinal cord
Spinothalamic - P and T- pain and temperature
Only loss of temperature sensation
affecting the neck shoulders and arms
Spastic weakness in lower limbs
Neuropathic pain, upping planters and scoliosis over years
What are the features of amaurosis fugax
A stroke that affects the retinal/ opthalamic artery
A painless curtain coming down vertically into the vision of one eye
Will be in the same side eye as the stroke
What is Cushing’s triad in raised ICP
- Widening pulse pressure
- Bradycardia
- Irregular breathing
These are attempts to maintain cerebral perfusion pressure
Indicates brain herniation
What are some of the causes and features of idiopathic intracranial hypertension
Causes
Tetracyclines, steroids, COCP, retinoids, lithium
Obesity, female sex and pregnancy
Features
Headache, blurred vision, papilloedema, enlarged blind spot, 6th nerve palsy
Management
Weight loss
Toprimarate
Carbonic anhydrase inhibitors
What are the features of a temporal lobe seizure
Can be aware or non aware
Aura- rising epigastric sensation, deja vu or smell, hearing hallucinations
automatisms- lip smacking etc
What is neuroleptic malignant syndrome
In patients taking antipsychotics
Pyrexia, muscle rigidity/ cramps
Hypertension, tachycardia, tachypnoea
Delirium with confusion
Raised CK and leukocytosis (raised WCC)
Stop antipsychotic
