Neurology Flashcards
What are the features of UMN lesions?
Hypertonia, weakness, hyperreflexia
What are the features of LMN lesions?
Fasciculations, hypotonia, weakness, hyporeflexxia
What are the features of Parkinsonism?
Tremor- resting
Rigidity- cogwheel
Akinesia/Bradykinesia
Postural Instablity
Gait shuffling gait reduced arm movement
Postural tug
Resting tremor tremor will worsen with distraction ask patient to count
Facial
Dyskinesia can be an indication SE of L Dopa
Glabellar tap
Check vertical gaze palsy
Dysdiadochokinesis
Duck move
PSP
Cerebellar and pyramidal
Postural hypotension
Handwriting
Cognitive function
Gaze palsy and cerebellar signs MSA
What are the causes of Parkinsonism?
- Primary (Degenerative)
a) Parkinson’s diease
b) Parkinsons plus syndrome or atypical Parkinson’s
- PSP
- Multisystem atrophy
- Corticobasal degeneration
- Dementia with levy body - Secondary
a) Vascular: lower body prominent
b) Infections: HIV, syphyllis
c) Drug induced Parkinsonism: metoclopramide, typical antipsychotics, lithium
d) toxin induced: methanol, manganase
How do you differentiate between the Parkinson’s plus syndrome?
- PSP: severe postural instability, falls, dysphagia, supra nuclear vertical palsy
- Multisystem atrophy: Progressive autonomic dysfunction before motor symptoms with cerebellar signs
- Corticobasal degeneration: Asymmetric Parkinsonism, dystonia, myoclonus
What are the types of stroke?
Ischemic: embolic, atherosclerotic
Haemorrhagic: intracerebral, SAH, subdural, extrudual
Venous
What are the risk factors for stroke?
Smoking, hypertension, DM, AF, TIA, carotid artery stenosis, family history, alcohol abuse, oral contraceptive pill, PFO/ASD
What are the features of lacunar infarct?
Pure motor
Pure sensory
Ataxia hemiparesis
Dysarthria
What are the features of anterior circulation infarction (ACA) ?
Contralateral leg weakness and sensory impairment with similar but Midler upper limb signs
Face is spared
Loss of voluntary micturition resulting in urinary incontinence
What are the features of middle cerebral artery infarction (MCA)?
Contralateral weakness and sensory impairment face and arm > leg
Inability to detect sensory stimuli
Homonymous quarant/hemianopia (PITS)
Expressive and/or receptive dysphasia
Hemi-neglect/inattension usually affects the left side of the body (non-dominant) resulting from right lobe infarct
What are the features of posterior circulation infarction?
- Posterior inferior cerebellar artery (PICA) [lateral medullary] syndrome
- ipsilateral pain and pinprick impairment in the face
- contralateral trunk and extremity pain
- dysphagia, hoarsenesss of voice
- ipsilateral horners syndrome
- ipsilateral cerebellar signs - Anterior inferior cerebellar artery (AICA)
- ipsilateral sensory impairment in the face
- contralateral trunk and extremity to pain
- paralysis of ipsilateral muscles of mastication
- paralysis of ipsilateral face (LMN) - Posterior cerebral artery (PCA)
- contralateral homonymous hemianopia with macular sparing
- contralateral loss of pain and temperature
What is Weber’s syndrome?
3rd nerve palsy and contralateral hemiplegia due to infarction of the medial midbrain
What are the causes of an ischaemic stroke?
Cardiac: AF, valvular, MI
Structural: carotid/aortic atherosclerosis, vasculitis
Haematological: Sickle cell, polycythaemia, APS
Others: drugs- heroin, MELAS, CADASIL
What are the differential diagnosis of stroke?
Structural:
- space occupying lesions, abscess
Infection:
- viral encephalitis, parasitic
Neuroinflammatory:
- MS, neurosarcoid, Behcet
Metabolic: hypoglycaemia
Hemiplegic migraine
Todds paresis following a focal seizure
What are the investigations carried out for stroke?
Bedside: vitals- oxygen sats, glucose, BP, 12 lead ECG
Blood test: FBC, clotting ESR, TFT, LFT, ANA and blood culture, fasting glucose, Hba1c and lipids
- thrombophilia screening if young)
Imaging:
CT brain- often normal in the acute phase proceed with MRI
CXR to rule out aspiration
What are the other investigations that should be carried out within 24 hours following a stroke?
Holter
TTE
Transcranial doppler
Carotid doppler
Outline the management of stroke
Acute:
1. Thrombolysis if within 3 hour window
- If more than 3 hours s
- aspirin 300mg STAT + for 2 weeks then followed by 75mg
- Statin
- ACE inhibitor
- Carotid endartectomy >70%
Conservative:
SLT review
OT , Physiotherapy, MDT
What are the contraindications to thrombolysis?
AVM/intracranial haemorrhage/ AVM
Bleeding risk
Pancreatitis/pericarditis
Systolic BP >185 or diastolic >110
What is the NIH stroke score?
Assess the severity of stroke
NIHSS between 5-20 eligible for thrombolysis
What are the findings of a cerebellar syndrome?
Dysdiadochokinesis
Ataxia
Nystagmus
Intention tremor
Scanning dysarthria
Hypotionia/hyporeflexia
DANISH
What are the causes of cerebellar syndrome?
Paraneoplastic syndrome
Alcoholic cerebellar degeneration
Sclerosis (MS)
Tumour (posterior fossa SOL)
Rare (Friedrich’s and ataxia telangiectasia)
Iatrogenic (Phenytoin texicity)
Endocrine (Hypothyroidism)
Stroke (brain stem vascular event)
What are the signs of MS?
Ataxia
Cranial nerve palsy
UMN spasticity and weakness, brisk reflexes and altered sensation
- relapsing and remitting
Autonomic: urinary retention or incontinence
Uhtoff phenomenon: worsening symptoms after a hot bath or exercise
Lhermitte sign: lightening pains down the spine on neck flexion due to cervical plaques
What investigations would you do for MS?
MRI: periventricular white matter plaques
Visual evoked potentials for optic neuritis
CSF: oligoclonal bads
What is INO?
It is a lesion at the medial longitudinal fasciculus that causes the ipsilateral eye to the lesion to fail to adduct and have nystagmus
How would you manage MS?
Acute setting:
During a relapse high dose steroids IV methylprednisolone (need to ensure patient is counselled)
Chronic: MDT approach
- Disease modifying treatments IFN beta and glatiramer to reduce relapse rate, monoclonal antibody therapy
- PT/OT/MSW/neurologist
Causes of foot drop
Muscle- weak anterior tibialis any cause of myopathy
Nerve- common perineal nerve palsy–>
Sciatic nerve palsy
Lumbosacrap plexopathy
L5 root lesion
Anterior horn cell
Spinal cord/brain lesion
Distal weakness
Hyporeflexia
No fasciculations
Wasting of the small muscles
Clawing of the hand
Peripheral motor neuropathy
1. Multifocal neuropathy
2. CIDP
3. Hereditary motor neuropathy
4. T2DM although more likely to have sensory componenet
What are the features of Friedrich’s Ataxia?
Pes cavus
Pyramidal weakness in legs
Cerebellar signs
Impaired vibration and joint sense
Distal muscle wasting
What else would you examine for in Friedreichs Ataxia?
Check for nystagmus, scanning of speech and intention tremor
Examine heart for Hypertrophic cardiomyopathy
Eyes- optic atrophy
Spine- kyphoscoliosis
Urine- sugar
Intellectual deterioration
What is the mode of inheritance of Friedrich’s ataxia?
Autosomal recessive
Triple repeat expansion on chromosome 9
What are the features of poliomyelitis?
Wasting and deformity of one lower limb or both with one side
Clonus and power 0/5
Patient will have splints
How will you complete examination for post polio syndrome?
History of vaccinations
Perform MRI scan as well as EMG
What are the features of facioscapulohumeral dystrophy?
Prominent ptosis
Difficulty in closing the eyes
Marked facial weakness with dull expressionless face with lips open and slack
Wasted sternomastoids
Winging of the scapula
Inheritance of autosomal dominant localised on chromosome 4
What are the features of flaccid paraparesis?
Reduced tone bilaterally
Wasting and weakness bilaterally
Reduced/absent reflexes
Mute/downgoing planters
No sensory loss
Causes of flaccid paraparesis
Anterior horn cell disease MND/poliomyelitis
Cauda equina syndrome
Lumbosacral plexomathy
Motor neuropathy :
- inflammatory: GBS, CIPD, multifocal motor neuropathy, sarcoid, vasculitis
- infectious: HIV, diphtheria
- toxins
- metabolic: diabetic amyotrophy, porphyria
- drugs: ciclosporin, gold, penicillamine
- congenital: Charcot marie tooth disease (HSMN)
NMJ disorders:
MG, LEMS
LMN lesions
What are the features of spastic paraparesis?
Increased tone bilaterally
Pyramidal weakness bilaterally
Increased reflexes
Sponging plantars and clonus
What are the causes of spastic paraparesis?
Demyelination (MS)
Cord compression
Trauma
Anterior horn cell disease MND
What are the features of Charcot Marie Tooth?
Wasting of calves
Clawing of toes
Weakness of dorsiflexion
Foot drop
Absent ankle jerks
Associated with clawing of the hands
What are the types of Charcot Marie Tooth?
Type 1- Glial myelinopathy a demyelinating neuropathy (marked slowing of conduction in motor nerves)
Type 2- An axonal neuropathy (little or no slowing of nerve conduction
Distal spinal. muscular atrophy
What are the features of myotonic dystrophy?
Frontal bladness
Ptosis with a smooth forehead
Cataracts
Difficulty in opening the eyes after firm closure
Expressionless face with temporals/masseter and sternomastoid wasting
Other features:
Cardiomyopathy and cardiac conduction defects
Low serum ing level
External opthalmoplegia
EMG; waxing and waning of the potentials, dive bomber effect
What is the inheritance of myotonic dystrophy?
Autosomal dominant inheritance
Type 1- more common and more severe is caused by expansion of CTG repeat
Management of Parkinson’s disease
Investigations
Basic blood test
MRI brain to rule out structural abnormalities
DAT scan
Management
MND
Multifocal motor neuropathy → acquired auto immune
ALS
Progressive
Cervical M
