Neurology Flashcards
Multiple sclerosis cells affected
Oligodendrocytes
3 types of MS
- relapsing remitting (95%)
- primary progressive
- secondary progressive
Genetic mutation for MS
HLA DRB1
Pathophysiology
Astrocytic and macrocytic activation
Causes demyelination
Investigations for MS
- MRI - demyelination in time and place
- CSF oligocloncal bands
Scoring system for MS
Kurtzke Expanded disability score
Management of MS
- DMARD: interferon or glatiramer
(second line dimethyl fumarate)
Management of primary progressive MS
Ocrelizumab in primary progressive
Given IV
Anti CD-20 antibody
Management of secondary progressive MS
spionmod
Management of relapse of MS
IV Methylprednisolone for 5 days
NPH management
Shunt if not suitable for surgery will require frequent CSF taps
Acoustic neuroma symptoms
- unilateral tinnitus
- hearing loss
- loss of corneal reflex
Sub acute degeneration of the spinal cord cause
Vitamin B12 deficiency
Temporal lobe epilepsy
Lip smacking
Frontal lobe epilepsy
Jacksonian march
Indications to start DMARDs in MS
Relapsing-remitting disease + 2 relapses in past 2 years + able to walk 100m unaided
OR
Secondary progressive disease + 2 relapses in past 2 years + able to walk 10m (aided or unaided)
First line DMARD for MS
Natalizumab
(Given IV, recombinant monoclonal antibody against alpha-4 beta-1-integrin found on leucocytes, has the strongest evidence base)
Management of tiredness in MS
Amantadine once other causes ruled out
Management of spasticity in MS
Baclofen and gabapentin
Management of bladder dysfunction in MS
Significant residual volume: self-catheterisation
No significant residual volume: anti-cholinergics
Management of oscillopsia (visual fields oscillating) in MS
Gabapentin
Brocas dysphagia (able to comprehend but cannot speak coherently) where in the brain?
Inferior frontal gyrus
Imaging for urinary incontinence in MS
USS MUST DO BEFORE STARTING MANAGEMENT (anticholinergics may make it worse in some cases)
Good prognostic indicators for MS
- female
- young age of onset (i.e. 20s or 30s)
- relapsing-remitting disease
- sensory symptoms only
- long interval between first two relapses
- complete recovery between relapses
MND drug management
Riluzole
Riluzole MOA
Prevents stimulation of glutamate receptors
Other treatments for MND
Non-invasive ventilation, normally BiPAP (can increase life by 7 months)
PEG for feeding
GBS pattern of weakness
Ascending
Most common cause of GBS
Campylobacter
GBS investigations
- LP - rise in protein but normal WCC
- Nerve conduction studies
GBS nerve conduction findings
- Decreased motor nerve conduction velocity (due to demyelination)
- Prolonged distal motor latency
- Increased F wave latency
GBS management
Immunoglobulins, also require regular FVC monitoring
anterior cerebral artery presentation
contralateral hemiparesis and sensory loss (legs >arms)
middle cerebral artery presentation
contralateral hemiparesis and sensory loss (arms > legs), contralateral homonymous hemianopia and aphasia
posterior cerebral artery presentation
contralateral homonymous hemianopia with macular sparing, visual agnosia
Webers syndrome
(Posterior cerebral artery that supplies the midbrain): ipsilateral CN III palsy, contralateral weakness of upper and lower extremity
Wallenburg syndrome
Lateral medullary syndrome (posterior inferior cerebellar artery) ipsilateral facial pain and temperature loss, contralateral limb/torso pain, ataxia and nystagmus
Lateral pontine syndrome
(anterior inferior cerebellar artery): similar to Wallenbergs but also have ipsilateral facial paralysis and deafness
Stroke management
- Rule out haemorrhagic, once ruled out for aspirin 300mg
- Thrombolysis if within 4.5 hours
- May have thrombectomy if within 6 hours
Indications for a thrombectomy
Confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA if within 6 hours of symptoms and if thrombolysis (if within 4.5 hours)
As soon as possible to people who were last known to be well between 6 and 24 hours if confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA AND if there is the potential to salvage brain tissue as shown by imaging such as CT perfusion or diffusion weighted MRI sequences showing limited infarct core volume
Long term management of stroke
Aspirin 75mg and clopidogrel 75mg
If cannot tolerate clopidogrel for dipyradimole
When to offer carotid artery endarectomy
If carotid stenosis >70% unilaterally or >50% bilaterally
Management of a TIA
Aspirin 300mg
Long term management of TIA
Clopi (unless AF then for DOAC)
Further investigation post TIA
If more than one TIA or suspected cardioembolic source → need for discussion
If patient has had a suspected TIA in the last 7 days → seen within 24 hours
If has had a suspected TIA more than a week ago → see within 7 days
Why is levodopa given with co-careldopa
Prevents the peripheral break down and therefore reduces the risk of side effects
Parkinsons, consequences of meds
End of dose weaning off (decline of motor activity)
On-off phenomenon
Dyskinesia when having the maximum dose
Management of restless legs
Ensure treated for iron deficiency
Ropinirole/pramipexole
First line management for motor symptoms in Parkinsons
levodopa and co-careldopa
Neurofibromatosis cause of hypertension
Phaeochromocytoma
SAH investigation
CT head, if done <6 hours and normal need to think of other pathology
if >6 hours for LP (needs to be done >12 hours)
then need to work out why a spontaneous SAH –> CT angiogram
SAH management
Oral nimodipine
Neurovascular coiling
Brain abscess management
IV ceftriaxone and metronidazole
Right incongronous homonymous hemianopeia
Incongronous - optic tract
Congronous - optic radiation lesion
Macula sparing: lesion of occipital cortex
Superior bitemporal hemianopeia common cause
Pituitary tumour
Inferior bitermoral hemianopeia common cause
Craniopharyngioma
Side effect of phenytoin
Folate deficiency
Cerebellar symptoms
How to distinguish neuromyelitis optica and MS
Neuromyelitis optica is NMO IgG positive
Palatal myoclonus lesion
Olivary nucleus
Food bourne botulism mx
Heptavelent antitoxin
Status epilepticus management
IV/IM loraz 4mg or PR diazepam 10mg
Forehead sparing where is the lesion
UMN
Forehead not spared where is the lesion
LMN
Benign essential tremor management
Propranolol or topimarate
(primidone is second line as can cause tiredness)
Pontine haemorrhage
Pinpoint pupils, severe headache, reduced GCS, no movement of eyes on turning
Transient global amnesia
Amnesia but is aware of who they are. It is a benign condition, no increased risk of vascular events.
Warfarin and antiepileptic
Lamotrigine is safe
Most common inherited polyneuropathy
Charcot-Marie
Largest risk factor for stroke
AF (rheumatic)
Drug management of TIC
risperidone
Management of a stroke, how long should you take aspirin for
aspirin 75mg for 2 weeks then switch to clopidogrel 75mg. If clopi not tolerated then can switch to aspirin and dipyradimole
Miller Fisher syndrome
Descending paralysis
Eyes normally affected first
HSV encephalitis
Affects the temporal lobes, petechial haemorrhages can be seen on CT
Paraneoplastic cerebellar degeneration
Rapidly progressive cerebellar signs + evidence of ovarian carcinoma
When to use amantadine in Parkinsons
Used to treat dyskinesia in later stages of the disease
When to use COMT in Parkinsons
Can help with motor fluctuations later in the disease course
Best diagnostic test for CJD
LP
Cavernius sinus thrombosis
CN III, IV, V, VII affected
Sagittal sinus thrombosis
Seizures and bilateral motor deficits
Dose of pyridostigmine bromide
30mg QDS for 2-4 days if not effective can increase to 60mg qds and if this is ineffective may require oral pred
