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Finals > Neurology > Flashcards

Neurology Flashcards

1
Q

example and action of 5-HT3 antagonists

A

e.g., ondansetron

antiemetics - used in management of chemo-therapy-related nausea

act in chemoreceptor trigger zone of medulla oblongata

S/E - QT prolongation, constipation

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2
Q

features of wernicke’s aphasia

A

receptive aphasia

sentences make no sense, word substitution, neologisms, fluent speech - word salad
impaired comprehension

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3
Q

lesion in wernicke’s aphasia

A

due to lesion of superior temporal gyrus
supplied by inferior division of left MCA

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4
Q

lesion in broca’s aphasia

A

lesion of the inferior frontal gyrus

supplied by the superior division of the left MCA

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5
Q

features of broca’s aphasia

A

non-fluent, laboured, and halting speech
impaired repitition
normal comprehension

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6
Q

features of conduction aphasia

A

speech fluent, repetition poor
aware of errors
normal comprehension

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7
Q

lesion in conduction aphasia

A

due to a stroke affecting the arcuate fasiculus - the connection between Wernicke’s and Broca’s area

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8
Q

features of global aphasia

A

non fluent, comprehension impaired, severe expressive and receptive aphasia

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9
Q

definition of arnold chiari malformation

A

herniation of the cerebellar tonsils through the foramen magnum

may be congenital or acquired (traumatic)

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10
Q

features of arnold chiari malformation

A

non-communicating hydrocephalus may develop as a result of obstruction of cerebrospinal fluid (CSF) outflow
headache
syringomyelia

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11
Q

causes of ataxia

A

Cerebellar hemisphere lesions cause peripheral (‘finger-nose ataxia’)

Cerebellar vermis lesions cause gait ataxia

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12
Q

features of ataxia telangiectasia

A

an autosomal recessive disorder caused by defective ATM gene (encodes for DNA repair enzymes - combined immunodeficiency disorders

cerebellar ataxia - inability to coordinate muscle movement
telangiectasia
IgA deficiency

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13
Q

describe autonomic dysreflexia

A

clinical syndrome in those with SC injury above T6

afferent signals (due to faecal impaction/urinary retention) cause sympathetic spinal reflex via thoracolumbar outflow
parasympathetic response is prevented due to lesion

therefore unbalanced physiological response leads to - extreme hypertension, flushing and sweating above the level of the cord lesion, agitation

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14
Q

definition of bells palsy

A

acute, unilateral, idiopathic, facial nerve paralysis

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15
Q

features of bells palsy

A

LMN - forehead affected
UMN - forehead sparing

post-auricular pain (may precede paralysis)
altered taste
dry eyes
hyperacusis

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16
Q

management of bells palsy

A

oral prednisolone <72 hours of onset
eye care - prevent exposure keratopathy
if paralysis not improved after 3 weeks - urgent ENT referral
refer to plastic surgery if long standing weakness

normally full recovery <3-4m

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17
Q

branchial plexus nerve roots

A

C5 to T1

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18
Q

erb duchenne paralysis

A

damage to C5,6 roots
winged scapula
may be caused by a breech presentation

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19
Q

klumpke’s paralysis

A

damage to T1
loss of intrinsic hand muscles
due to traction

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20
Q

presentation of brain abscess

A

depends upon the site of the abscess
considerable mass effect, raised ICP

dull persistent headache
fever
focal neurology (due to raised ICP) - and nausea, papilloedema, seizures

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21
Q

management of brain abscess

A

surgery - craniotomy, abscess cavity debrided

IV ceftriaxone + metronidazole

ICP mx dexamethasone

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22
Q

features of parietal lobe lesions

A

sensory inattention
apraxias
astereognosis (tactile agnosia)
inferior homonymous quadrantanopia
Gerstmann’s syndrome (lesion of dominant parietal): alexia, acalculia, finger agnosia and right-left disorientation

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23
Q

features of occipital lobe lesions

A

homonymous hemianopia (with macula sparing)
cortical blindness
visual agnosia

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24
Q

features of temporal lobe lesions

A

Wernicke’s aphasia: this area ‘forms’ the speech before ‘sending it’ to Brocas area. Lesions result in word substituion, neologisms but speech remains fluent
superior homonymous quadrantanopia
auditory agnosia
prosopagnosia (difficulty recognising faces)

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25
Q

features of frontal lobe lesions

A

expressive (Broca’s) aphasia: located on the posterior aspect of the frontal lobe, in the inferior frontal gyrus. Speech is non-fluent, laboured, and halting
disinhibition
perseveration
anosmia
inability to generate a list

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26
Q

features of cerebellar lesions

A

midline lesions: gait and truncal ataxia
hemisphere lesions: intention tremor, past pointing, dysdiadokinesis, nystagmus

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27
Q

common source of brain metastases

A

lung (most common)
breast
bowel
skin (namely melanoma)
kidney

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28
Q

features of gliobastoma multiforme

A

most common primary tumour in adults
poor prognosis
solid tumours, central necrosis, rim enhances with contrast

surgical tx with postoperative chemotherapy and/or radiotherapy

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29
Q

features of meningioma

A

second most common primary brain tumour in adults

benign, extrinsic tumours of CNS, located next to dura, cause compressive sx

contrast enhancing on CT

observation, radiotherapy, surgical resection

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30
Q

features of vesticular schwannoma

A

AKA acoustic neuroma

benign tumour arising from CN8
seen in cerebellopontine angle

presentation - hearing loss, facial nerve palsy, tinnitus

observation, radiotherapy or surgery

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31
Q

features of medulloblastoma

A

aggressive paediatric brain tumour
spreads through CSF

surgical resection and chemo

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32
Q

features of ependymoma

A

Commonly seen in the 4th ventricle
May cause hydrocephalus

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33
Q

features of pituitary adenoma

A

benign
secretory or non-secretory, microadenoma or macroadenoma

presents with hormone excess or hormone depletion

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34
Q

features of brown sequard syndrome

A

caused by lateral hemisection of the spinal cord

ipsilateral weakness below lesion
ipsilateral loss of proprioception and vibration sensation
contralateral loss of pain and temperature sensation

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35
Q

indications and moa of carbamazepine

A

used in the treatment of epilepsy, particularly partial seizures

binds to sodium channels and increases their refractory period

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36
Q

features of cataplexy

A

sudden and transient loss of muscular tone caused by strong emotion (e.g. laughter, being frightened). Around two-thirds of patients with narcolepsy have cataplexy.

Features range from buckling knees to collapse.

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37
Q

what are the cavernous sinuses

A

paired and are situated on the body of the sphenoid bone. It runs from the superior orbital fissure to the petrous temporal bone

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38
Q

features of cerebellar disease

A

D - Dysdiadochokinesia, Dysmetria (past-pointing), patients may appear ‘Drunk’
A - Ataxia (limb, truncal)
N - Nystamus (horizontal = ipsilateral hemisphere)
I - Intention tremour
S - Slurred staccato speech, Scanning dysarthria
H - Hypotonia

unilateral cerebellar lesions cause ipsilateral signs

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38
Q

causes of cerebellar syndrome

A

Friedreich’s ataxia, ataxic telangiectasia
neoplastic: cerebellar haemangioma
stroke
alcohol
multiple sclerosis
hypothyroidism
drugs: phenytoin, lead poisoning
paraneoplastic e.g. secondary to lung cancer

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39
Q

definition of cerebral perfusion pressure

A

net pressure gradient causing blood flow to the brain

tightly autoregulated to maximise cerebral perfusion

sharp rise = rising ICP, fall = cerebral ischaemia

CPP= Mean arterial pressure - Intra cranial pressure

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40
Q

features of charcot marie tooth disease

A

most common hereditary peripheral neuropathy - causes predominantly motor loss

foot drop
high arched feet - pes cavus
distal muscle weakness + atrophy
hyporeflexia

physical and occupational therapy

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41
Q

features of cluster headache

A

intense sharp, stabbing pain around one eye lasting 15 mins - 2 hours

clusters typically last 4-12 weeks
accompanied by redness, lacrimation, lid swelling
nasal stuffiness
miosis and ptosis in a minority

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42
Q

management of cluster headache

A

acute
100% oxygen (80% response rate within 15 minutes)
subcutaneous triptan (75% response rate within 15 minutes)

prophylaxis
verapamil is the drug of choice
some evidence to support a tapering dose of prednisolone

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43
Q

features of common peroneal nerve lesion

A

foot drop
weakness of foot dorsiflexion
weakness of foot eversion
weakness of extensor hallucis longus
sensory loss over the dorsum of the foot and the lower lateral part of the leg
wasting of the anterior tibial and peroneal muscles

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44
Q

features of creutzfeldt jakob disease

A

apidly progressive neurological condition caused by prion proteins

dementia (rapid onset)
myoclonus

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45
Q

investigation findings of CJD

A

CSF is usually normal
EEG: biphasic, high amplitude sharp waves (only in sporadic CJD)
MRI: hyperintense signals in the basal ganglia and thalamus

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46
Q

features of degenerative cervical myelopathy

A

Pain (neck, upper or lower limbs)
loss of motor function and dexterity
loss of sensory function - numbness
loss of autonomic function (urinary/faecal incontinence)

Hoffman sign - flick one finger on patients hand, positive test causes reflex twitching

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47
Q

management of degenerative cervical myelopathy

A

MRI cervical spine - disc degeneration, ligament hypertrophy

refer urgently for assessment

early tx = better prognosis
decompressive surgery

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48
Q

risk factors for degenerative cervical myelopathy

A

smoking
genetics
occupation - high axial loading

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49
Q

drugs causing peripheral neuropathy

A

amiodarone
isoniazid
vincristine
nitrofurantoin
metronidazole

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50
Q

DVLA rules for epilepsy and seizures

A

all patient must not drive and must inform the DVLA

1st seizure - 6 months off if idiopathic, 12 months off if positive EEG/structural abnormality

established epilepsy - can drive if seizure free for 12m, full license if no seziures for 5 years

no driving during medication withdrawal and <6m of last dose

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51
Q

dvla rules for syncope

A

simple faint: no restriction
single episode, explained and treated: 4 weeks off
single episode, unexplained: 6 months off
two or more episodes: 12 months off

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52
Q

DVLA rules for stroke/TIA

A

stroke or TIA: 1 month off driving, may not need to inform DVLA if no residual neurological deficit

multiple TIAs over short period of times: 3 months off driving and inform DVLA

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53
Q

dvla rules on brain tumours

A

pituitary tumour: craniotomy: 6 months; trans-sphenoidal surgery ‘can drive when there is no debarring residual impairment likely to affect safe driving’

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54
Q

dvla rules for chronic neurological disorders

A

chronic neurological disorders e.g. multiple sclerosis, motor neuron disease: DVLA should be informed, complete PK1 form (application for driving licence holders state of health)

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55
Q

features of duchenne muscular dystrophy

A

progressive proximal muscle weakness from 5 years
calf pseudohypertrophy

Gower’s sign: child uses arms to stand up from a squatted position

30% of patients have intellectual impairment

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56
Q

neuropathy findings on EMG

A

Neuropathy causes

increased action potential duration (slow)
increased action potential amplitude

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57
Q

myopathy findings on EMG

A

reduced action potential duration (fast)
reduced action potential amplitude

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58
Q

features of encephalitis

A

fever, headache, psychiatric symptoms, seizures, vomiting
focal features e.g. aphasia

HSV-1 is responsible for 95% of cases in adults
typically affects temporal and inferior frontal lobes

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59
Q

investigation findings in encephalitis

A

CSF - lymphocytosis, elevated protein, PCR - HSV, VZV, enterovirus

neuroimaging - can be normal

EEG - lateralised periodic discharges at 2 Hz

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60
Q

features of infantile spasms

A

flexion of head, trunk, limbs → extension of arms (Salaam attack); last 1-2 secs, repeat up to 50 times
progressive mental handicap
EEG: hypsarrhythmia
secondary to serious neurological abnormality
treat with vigabatrin, steroids
poor prognosis

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61
Q

features of typical absence seizures

A

duration few-30 secs; no warning, quick recovery; often many per day
EEG: 3Hz generalized, symmetrical
sodium valproate, ethosuximide

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62
Q

features of juvenile myoclonic epilepsy

A

typical onset is in the teenage years, more common in girls
features:
infrequent generalized seizures, often in morning//following sleep deprivation
daytime absences
sudden, shock-like myoclonic seizure (these may develop before seizures)

treatment: usually good response to sodium valproate

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63
Q

classification of seizures

A
  1. Where seizures begin in the brain - focal vs generalised, unknown onset
  2. Level of awareness during a seizure - aware vs impaired awareness
  3. Other features of seizures - motor, non motor, aura
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64
Q

features of focal seizures

A

start in a specific area, on one side of the brain
level of awareness can vary

focal aware
focal impaired awareness
awareness unknown
motor/non motor/other features e.g., aura

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65
Q

features of generalised seizures

A

engage or involve networks on both sides of the brain at the onset
consciousness lost immediately
motor, non motor

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66
Q

features of temporal lobe seizures

A

can be with or without impairment of consciousness/awareness

aura - rising epigastric sensation - psychic phenomena, possible hallucinations (olfactory, auditory)

seizures last ~1min
may have automatisms - lip smacking etc

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67
Q

features of frontal lobe seizures

A

often motor signs
Head/leg movements, posturing, post-ictal weakness, Jacksonian march

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68
Q

features of parietal lobe seizures

A

Paraesthesia
sensory symptoms

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69
Q

features of occipital lobe seizures

A

visual factors
floaters, flashes

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70
Q

indications for sodium valproate

A

used in males for

generalised TC seizures
myoclonic seizures
tonic or atonic seizures

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71
Q

indications of lamotrigine/levetiracetam

A

used first line for focal seizures in males and females

used in females
either for TC seizures
lamotrigine - tonic/atonic
levetiracetam - myoclonic

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72
Q

indications for ethosuximide

A

first line for absence seizures

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73
Q

indications for starting anti epileptics

A

NICE guidelines suggest starting antiepileptics after the first seizure if any of the following are present:

the patient has a neurological deficit
brain imaging shows a structural abnormality
the EEG shows unequivocal epileptic activity
the patient or their family or carers consider the risk of having a further seizure unacceptable

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74
Q

features of essential tremor

A

autosomal dominant condition which usually affects both upper limbs

postural tremor: worse if arms outstretched
improved by alcohol and rest
most common cause of titubation (head tremor)

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75
Q

causes of extradural haematoma

A

‘low-impact’ trauma e.g., fall
collection is often in the temporal region since the thin skull at the pterion overlies the middle meningeal artery and is therefore vulnerable to injury

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76
Q

features of extradural haematoma

A

lucid intervals - consciousness eventually lost due to expanding haematoma and brain herniation around tentorium cerebelli – causes fixed and dilated pupil due to compression of CN3

biconvex/lentiform, hyperdense collection

limited by suture lines

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77
Q

functions of the facial nerve

A

face: muscles of facial expression
ear: nerve to stapedius
taste: supplies anterior two-thirds of tongue
tear: parasympathetic fibres to lacrimal glands, also salivary glands

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78
Q

causes of bilateral facial nerve palsy

A

sarcoidosis
Guillain-Barre syndrome
Lyme disease
bilateral acoustic neuromas (as in neurofibromatosis type 2)
as Bell’s palsy is relatively common it accounts for up to 25% of cases f bilateral palsy, but this represents only 1% of total Bell’s palsy cases

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79
Q

causes of foot drop

A

Foot drop is a result of weakness of the foot dorsiflexors.

Possible causes :
common peroneal nerve lesion - the most common cause
L5 radiculopathy
sciatic nerve lesion
superficial or deep peroneal nerve lesion
other possible includes central nerve lesions (e.g. stroke) but other features are usually present

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80
Q

features of CN4 palsy

A

supplies superior oblique (depresses eye, moves inward)

vertical diplopia
classically noticed when reading or going downstairs
subjective tilting of objects (torsional diplopia)
compensatory head tilt
affected eye appears to deviate upwards and is rotated outwards

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81
Q

features of friedreich’s ataxia

A

onset 10-15y
autosomal recessive trinucleotide repeat disorder

Gait ataxia and kyphoscoliosis
HOCM, DM

Neurological features
absent ankle jerks/extensor plantars
cerebellar ataxia
optic atrophy
spinocerebellar tract degeneration

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82
Q

pathogenesis of guillain barre syndrome

A

immune-mediated demyelination of the peripheral nervous system often triggered by an infection (classically Campylobacter jejuni)

cross-reaction of antibodies with gangliosides in the peripheral nervous system

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83
Q

features of guillain barre syndrome

A

back/leg pain
progressive, symmetrical weakness of all the limbs
ascending weakness
reflexes are reduced or absent
mild sensory sx
may progress to involve respiratory muscles and cranial nerves

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84
Q

investigation findings of guillain barre syndrome

A

LP - rise in protein, normal WCC

nerve conduction studies - reduced motor nerve conduction velocity (demyelination), prolonged distal motor latency

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85
Q

features of temporal arteritis

A

Typically patient > 60 years old
Usually rapid onset (e.g. < 1 month) of unilateral headache
Jaw claudication (65%)
Tender, palpable temporal artery
Raised ESR

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86
Q

red flag symptoms in headache

A

vomiting
worsening headache with fever
new-onset neurological deficit
new-onset cognitive dysfunction
change in personality
impaired level of consciousness
recent (typically within the past 3 months) head trauma
thunderclap
triggered by cough, sneeze, exercise
orthostatic
sx suggesting GCA/acute narrow angle glaucoma

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87
Q

definition and types of hereditary sensorimotor neuropathy

A

HSMN type I: primarily due to demyelinating pathology

HSMN type II: primarily due to axonal pathology

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88
Q

features of huntingtons

A

develop >35y
chorea
personality changes (e.g. irritability, apathy, depression) and intellectual impairment
dystonia
saccadic eye movements

89
Q

risk factors for idiopathic intracranial hypertension

A

obesity
female sex
pregnancy
drugs (combined oral contraceptive pill, steroids, tetracyclines, retinoids (isotretinoin, tretinoin) / vitamin A, lithium)

90
Q

features of idiopathic intracranial hypertension

A

headache
blurred vision
papilloedema (usually present)
enlarged blind spot
sixth nerve palsy may be present

91
Q

management of idiopathic intracranial hypertension

A

weight loss
carbonic anhydrase inhibitors e.g. acetazolamide
topiramate

92
Q

overview of internuclear ophthalmoplegia

A

causes horizontal disconjugate eye movement
due to lesion in medial longitudinal fasciculus which controls horizontal eye movements by connecting CN3, 4 and 6

93
Q

features of internuclear ophthalmoplegia

A

ipsilateral impaired adduction
contralateral horizontal nystagmus in abducting eye

94
Q

features of intracranial venous thrombosis

A

may cause cerebral infarction - less common than arterial causes

headache (may be sudden onset)
nausea & vomiting
reduced consciousness

95
Q

investigation findings of intracranial venous thrombosis

A

MRI venography/CT venography

non contrast CT head

D dimer

96
Q

management of intracranial venous thrombosis

A

anticoagulation - LMWH then long term warfarin

97
Q

features of sagittal sinus thrombosis

A

seizures, hemiplegia

parasagittal biparietal/bifrontal haemorrhagic infarctions

98
Q

features of cavernous sinus thrombosis

A

periorbital oedema
ophthalmoplegia: 6th nerve damage typically occurs before 3rd & 4th
trigeminal nerve involvement may lead to hyperaesthesia of upper face and eye pain
central retinal vein thrombosis

99
Q

causes of lambert eaton myasthenic syndrome

A

association with small cell lung cancer (+ breast and ovarian)
may be autoimmune
caused by an antibody directed against presynaptic voltage-gated calcium channel in the peripheral nervous system

100
Q

features of lambert eaton myasthenic syndrome

A

non fatiguable - repeated muscle contractions lead to increased muscle strength (but will eventually decrease)
limb girdle weakness
hyporeflexia
autonomic sx - dry mouth, impotence, difficulty micturating

EMG - incremental response to repetitive electrical stimulation

101
Q

management of of lambert eaton myasthenic syndrome

A

treat underlying cancer
immunosuppression - pred, azathioprine
IVIG
plasma exchange

102
Q

indications for lamotrigine

A

sodium channel blocker

Adverse effects
Stevens-Johnson syndrome

103
Q

features of lateral medullary syndrome

A

Wallenberg’s - occurs following occlusion of posterior inferior cerebellar artery

cerebellar fx - ataxia, nystagmus
brainstem fx - ipsilateral dysphagia, facial numbness, CN palsy (horners), contralateral limb sensory loss

104
Q

median nerve supply

A

Motor supply (LOAF)
Lateral 2 lumbricals
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis

sensory supply
Over thumb and lateral 2 ½ fingers
On the palmar aspect this projects proximally, on the dorsal aspect only the distal regions are innervated with the radial nerve providing the more proximal cutaneous innervation.

105
Q

features of median nerve damage at wrist

A

e.g., carpal tunnel
paralysis and wasting of thenar eminence muscles and opponens pollicis (ape hand deformity)
sensory loss to palmar aspect of lateral (radial) 2 ½ fingers

106
Q

features of median nerve damage at elbow

A

unable to pronate
wrak wrist flexion
ulnar deviation of wrist

107
Q

features of medication overuse headache

A

most common cause of chronic daily headache

present for >15 days per month
developed/worsened due to medication - usually opoids and triptans

withdraw opioids gradually, triptans/simple analgesics abruptly

108
Q

meningococcal disease vs meningitis

A

meningococcal disease = any disease caused by neisseria meningitidis

can both present similarly to less serious, viral infections - classical signs often absent in infants with bacterial meningitis

109
Q

features of meningitis

A

headache
fever
nausea/vomiting
photophobia
drowsiness
seizures
neck stiffness
purpuric rash (particularly with invasive meningococcal disease)

110
Q

CSF findings in bacterial meningitis

A

cloudy, low glucose, high protein, high polymorphs

111
Q

CSF findings in viral meningitis

A

clear/cloudy, 60-80% plasma glucose, normal protein, high lymphocytes

112
Q

CSF findings in TB meningitis

A

slightly cloudy, fibrin web, low glucose, high protein, high lymphocytes

113
Q

complications of meningitis

A

sensorineural hearing loss (most common)
seizures
focal neurological deficit
infective
sepsis
intracerebral abscess
pressure
brain herniation
hydrocephalus

114
Q

characteristics of migraine

A

severe, unilateral, throbbing headache
nausea, photophobia and phonophobia
up to 72h
precipitated by aura - visual progressive 5-60mins

115
Q

triggers for migraine

A

tiredness, stress
alcohol
combined oral contraceptive pill
lack of food or dehydration
cheese, chocolate, red wines, citrus fruits
menstruation
bright lights

116
Q

management of migraine

A

5-HT receptor agonists (triptans) - acute tx
5-HT receptor antagonists are used in prophylaxis

1st line - triptans + NSAID/paracetamol

prophylaxis - propranolol, topiramate

117
Q

features of motor neuron disease

A

neuro condition, unknown cause

asymmetric limb weakness
UMN and LMN signs
wasting of small hand muscles
fasciculations
absence of sensory signs and symptoms
doesnt effect external ocular muscles
no cerebellar signs

118
Q

investigation findigns in motor neuron disease

A

EMG - reduced number of action potentials with increased amplitude

119
Q

management of motor neuron disease

A

riluzole - used in AML - prevents stimulation of glutamate receptors

respiratory care = NIV

PEG tube

120
Q

types of motor neuron disease

A

Amyotrophic lateral sclerosis (50% of patients) - LMN sx in arms, UMN sx in legs

primary lateral sclerosis - UMN signs only

progressive muscular atrophy - LMN only, distal muscles affected first

progressive bulbar palsy - palsy of the tongue, muscles of chewing/swallowing and facial muscles due to loss of function of brainstem motor nuclei

121
Q

overview of multiple sclerosis

A

chronic cell-mediated autoimmune disorder characterised by demyelination in the central nervous system

F>M
diagnosed in 20-40

122
Q

subtypes of multiple sclerosis

A

relapsing remitting - acute attacks followed by periods of remission

secondary progressive - relapsing remitting patients who have deteriorated and now have neuro signs between relapses

primary progressive - progressive deterioration from onset

123
Q

features of multiple sclerosis

A

visual
optic neuritis: common presenting feature
optic atrophy
Uhthoff’s phenomenon: worsening of vision following rise in body temperature
internuclear ophthalmoplegia

Sensory
pins/needles
numbness
trigeminal neuralgia
Lhermitte’s syndrome: paraesthesiae in limbs on neck flexion

Motor
spastic weakness: most commonly seen in the legs

Cerebellar
ataxia: more often seen during an acute relapse than as a presenting symptom
tremor

Others
urinary incontinence
sexual dysfunction
intellectual deterioration

124
Q

investigation findings in multiple sclerosis

A

MRI - periventricular plaques

CSF - oligoclonal bands (none in blood), increased intrathecal synthesis of IgG

125
Q
A
126
Q

managing acute relapse of multiple sclerosis

A

High-dose steroids (e.g. oral or IV methylprednisolone) may be given for 5 days to shorten the length of an acute relapse

127
Q

managing multiple sclerosis

A

natalizumab IV/ocrelizumab IV both prevent relapse

for spasticity - baclofen and gabapentin are first-line

bladder dysfuction - intermittent self-catheterisation, anticholinergics

fatigue - mindfulness, CBT

128
Q

types of multiple system atrophy

A

MSA-P - Predominant Parkinsonian features

MSA-C - Predominant Cerebellar features

Shy-Drager syndrome

129
Q

features of multiple system atrophy

A

parkinsonism

autonomic disturbance
erectile dysfunction: often an early feature
postural hypotension
atonic bladder

cerebellar signs

130
Q

overview of myasthenia gravis

A

autoimmune disorder resulting in insufficient functioning acetylcholine receptors - due to antbodies to acetylcholine receptors

associated with thymomas, AI disorders

131
Q

features of myasthenia gravis

A

extraocular muscle weakness: diplopia
proximal muscle weakness: face, neck, limb girdle
ptosis
dysphagia

fatiguability - muscles become progressively weaker during activity, slowly improve after rest

132
Q

investigation findings in myasthenia gravis

A

EMG
CT thorax - exclude thymoma
normal CK
Ach R antibodies

tensilon test - IV edrophonium temporarily reduces muscle weakness

133
Q

management of myasthenia gravis

A

long-acting ACHesterase inhibitors - pyridostigmine

immunosuppression - prednisolone, azathioprine, cyclosporine, MMF

managing myasthenic crisis - plasmapheresis, IVIG

134
Q

overview of myotonic dystrophy

A

autosomal dominant inherited myopathy, features develop around 20-30y

affects skeletal, cardiac and smooth muscle

DM1 - distal weakness more prominent
DM2 - proximal weakness more prominent

135
Q

features of myotonic dystrophy

A

myotonic facies (long, ‘haggard’ appearance)
frontal balding
bilateral ptosis
cataracts
dysarthria
weakness
myotonia - tonic muscle spasm
mild mental impairment
DM
testicular atophy

136
Q

overview of narcolepsy

A

associated with low levels of orexin (hypocretin), a protein which is responsible for controlling appetite and sleep patterns

early onset REM sleep

137
Q

features of narcolepsy

A

onset in teens
hypersomnolence
cataplexy (sudden loss of muscle tone often triggered by emotion)
sleep paralysis
vivid hallucinations on going to sleep or waking up

138
Q

features of neurofibromatosis type 1

A

Café-au-lait spots (>= 6, 15 mm in diameter)
Axillary/groin freckles
Peripheral neurofibromas
Iris hamatomas (Lisch nodules) in > 90%
Scoliosis
Pheochromocytomas

139
Q

features of neurofibromatosis type 2

A

Bilateral vestibular schwannomas
Multiple intracranial schwannomas, mengiomas and ependymomas

140
Q

overview of neuroleptic malignant syndrome

A

rare but dangerous
occurs in patients taking antipsychotics and dopaminergic drugs - dopamine blockade triggers massive glutamate release and subsequent neurotoxicity and muscle damage

occurs <hrs to days of starting an antipsychotic

141
Q

features of neuroleptic malignant syndrome

A

pyrexia
muscle rigidity
autonomic lability: typical features include hypertension, tachycardia and tachypnoea
agitated delirium with confusion

raised CK
AKI secondary to rhabdomyolysis if severe
leukocytosis

142
Q

management of neuroleptic malignant syndrome

A

stop antipsychotic
IV fluids - prevent renal failure
dantrolene
possible ICU

143
Q

common causes of neuropathic pain

A

pain which arises following damage or disruption of the nervous system

diabetic neuropathy
post-herpetic neuralgia
trigeminal neuralgia
prolapsed intervertebral disc

144
Q

treatment of neuropathic pain

A

first-line treatment*: amitriptyline, duloxetine, gabapentin or pregabalin
can switch between them if not effective

tramadol - rescue therapy

145
Q

features of normal pressure. hydrocephalus

A

reversible cause of dementia seen in elderly patients - secondary to reduced CSF absorption at the arachnoid villi

onset few months
urinary incontinence
dementia and bradyphrenia
gait abnormality (may be similar to Parkinson’s disease)

146
Q

management of normal pressure hydrocephalus

A

CT - ventriculomegaly out of proportion to sulcal enlargement

manage with ventriculoperitoneal shunting

147
Q

pathophysiology of parkinsons disease

A

progressive neurodegenerative condition caused by degeneration of dopaminergic neurons in the substantia nigra.

The reduction in dopaminergic output results in a classical triad of features: bradykinesia, tremor and rigidity.

asymmetrical symptoms

148
Q

features of parkinsons disease

A

bradykinesia - or hypokinesia, shuffling gait, difficulty initiating movement

tremor - prominent at rest, worst if stressed/tired, improves with voluntary movement, ‘pill rolling’

rigidity - lead pipe, cogwheel (due to superimposed tremor)

mask-like facies
flexed posture
micrographia
drooling of saliva
psychiatric features
postural hypotension
REM sleep behaviour disorder

149
Q

treatment options for parkinsons

A

for motor sx - levodopa
for nonmotor sx - dopamine agonist, MAOB, levothyroxine

150
Q

causes of parkinsonism

A

Parkinson’s disease
drug-induced e.g. antipsychotics, metoclopramide*
progressive supranuclear palsy
multiple system atrophy
Wilson’s disease
post-encephalitis
dementia pugilistica (secondary to chronic head trauma e.g. boxing)
toxins: carbon monoxide, MPTP

151
Q

overview of patoxysmal hemicrania

A

attacks of severe, unilateral headache, usually in the orbital, supraorbital or temporal region
autonomic features
<30 mins
multiple times a day

responsive to treatment with indomethacin

152
Q

peripheral neuropathies causing motor loss

A

Guillain-Barre syndrome
porphyria
lead poisoning
hereditary sensorimotor neuropathies (HSMN) - Charcot-Marie-Tooth
chronic inflammatory demyelinating polyneuropathy (CIDP)
diphtheria

153
Q

peripheral neuropathies causing sensory loss

A

diabetes
uraemia
leprosy
alcoholism
vitamin B12 deficiency
amyloidosis

154
Q

features of alcoholic neuropathy

A

secondary to both direct toxic effects and reduced absorption of B vitamins
sensory symptoms typically present prior to motor symptoms

155
Q

features of vitamin B12 deficiency

A

subacute combined degeneration of spinal cord
dorsal column usually affected first (joint position, vibration) prior to distal paraesthesia

156
Q

definition and causes of pituitary apoplexy

A

Sudden enlargement of a pituitary tumour (usually non-functioning macroadenoma) secondary to haemorrhage or infarction

Precipitating factors
hypertension
pregnancy
trauma
anticoagulation

157
Q

features of pituitary apoplexy

A

sudden onset headache similar to that seen in subarachnoid haemorrhage
vomiting
neck stiffness
visual field defects: classically bitemporal superior quadrantic defect
extraocular nerve palsies
features of pituitary insufficiency
e.g. hypotension/hyponatraemia secondary to hypoadrenalism

158
Q

management of pituitary apoplexy

A

MRI - diagnostic

urgent steroid replacement due to loss of ACTH
careful fluid balance
surgery

159
Q

features of post-lumbar puncture headache

A

occurs in 1/3 patients - due to leak in CSF following dural puncture

usually develops within 24-48 hours following LP but may occur up to one week later
may last several days
worsens with upright position
improves with recumbent position

160
Q

managment of post-lumbar puncture headache

A

supportive initially (analgesia, rest)
if pain continues for more than 72 hours then specific treatment is indicated, to prevent subdural haematoma
treatment options include: blood patch, epidural saline and intravenous caffeine

161
Q

features of progressive supranuclear palsy

A

parkinson plus syndrome

postural instability and falls - stiff, broad-based gait

impairment of vertical gaze (down gaze worse than up gaze - patients may complain of difficultly reading or descending stairs)

parkinsonism

bradykinesia

cognitive impairment
primarily frontal lobe dysfunction

poor response to L Dopa

162
Q

features of pseudoseizures

A

pelvic thrusting
family member with epilepsy
much more common in females
crying after seizure
don’t occur when alone
gradual onset

163
Q

features of radial nerve damage

A

wrist drop
sensory loss to small area between 1st and 2nd metacarpals
paralysis of triceps if axillary damage

164
Q

features of raised intracranial pressure

A

headache
vomiting
reduced levels of consciousness
papilloedema

Cushing’s triad
widening pulse pressure
bradycardia
irregular breathing

165
Q

management of raised intracranial pressure

A

ix and tx underlying cause
elevate head
IV mannitol
controlled hyperventilation - reducing PCO2 - vasoconstriction of cerebral arteries - reduces ICP
CSF removal

166
Q

common reflexes and nerve roots

A

Ankle S1-S2
Knee L3-L4
Biceps C5-C6
Triceps C7-C8

167
Q

definition and causesof restless legs syndrome

A

syndrome of spontaneous, continuous lower limb movements that may be associated with paraesthesia

common
positive family history in 50% of patients

causes
iron deficiency anaemia
uraemia
diabetes mellitus
pregnancy

168
Q

features of restless legs syndrome

A

akathisia - uncontrollable urge to move legs
symptoms occur at night then day
sx worse at rest
paraesthesias - crawling/throbbing sensation

169
Q

features of reye’s syndrome

A

severe, progressive encephalopathy in children
assx with aspirin use

may have preceding viral illness
encphalopathy - confusion, seizures, cerebral oedema, coma
fatty infiltration of liver, kidneys, pancreas
hypoglycaemia

supportive management

170
Q

management of acute seizures

A

check the airway and apply oxygen if appropriate
place the patient in the recovery position
if the seizure is prolonged give benzodiazepines

rectal diazepam, repeat after 10-15mins if necessary
adult 10-20mg max 30mg

midazolam oromucosal solution

171
Q

adverse effects of sodium valproate

A

teratogenic - neural tube defects, neurodevelopmental delay
p450 inhbitor
nausea
increased appetite, weight gain
ataxia
tremor
hepatotoxicity
pancreatitis
thrombocytopaenia
hyponatraemia

172
Q

features of brown sequard syndrome

A

= spinal cord hemisection

  1. Lateral corticospinal tract - ipsilateral spastic paresis
  2. Dorsal columns - ipsilateral loss of proprioception and vibration sensation
  3. Lateral spinothalamic tract - contralateral loss of pain and temperature
173
Q

features of subacute combined degeneration of the spinal cord

A
  1. Lateral corticospinal tracts - bilateral spastic paresis
  2. Dorsal columns - bilateral loss of proprioception and vibration
  3. Spinocerebellar tracts – bilateral limb ataxia
174
Q

features of friedrich’s ataxia

A
  1. Lateral corticospinal tracts - bilateral spastic paresis
  2. Dorsal columns - bilateral loss of proprioception and vibration
  3. Spinocerebellar tracts – bilateral limb ataxia

+ cerebellar ataxia

175
Q

features of anterior spinal artery occlusion

A
  1. Lateral corticospinal tracts - bilateral spastic paresis
  2. Lateral spinothalamic tracts - bilateral loss of pain and temperature sensation
176
Q

features of syringomyelia

A
  1. Ventral horns - flaccid paresis
  2. Lateral spinothalamic tract - loss of pain and temperature sensation
177
Q

features of neurosyphilis (tabes dorsalis)

A

dorsal columns - loss of proprioception and vibration sensation

178
Q

features of spontaneous intracranial hypotension

A

rare cause of headaches, results from CSF leak from thoracic nerve root sleeves

headache generally much worse when upright

179
Q

management of status epilepticus

A

single seizure lasting >5 minutes, or
>= 2 seizures within a 5-minute period

ABC
benzos - PR diazepam/buccal midazolam prehospital, IV lorazepam in hospital

if ongoing ‘established’ - 2nd line agent levetiracetam, phenytoin or sodium valproate

if no response ‘refractory’ <45mins - induction of general anaesthesia

180
Q

features of anterior cerebral artery stroke

A

Contralateral hemiparesis and sensory loss, lower extremity > upper

180
Q

features of middle cerebral artery stroke

A

Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral homonymous hemianopia
Aphasia

181
Q

features of posterior cerebral artery stroke

A

Contralateral homonymous hemianopia with macular sparing
Visual agnosia

182
Q

features of weber syndrome

A

branches of the posterior cerebral artery that supply the midbrain
Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity

183
Q

features of posterior inferior cerebellar artery stroke

A

Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus

184
Q

features of anterior inferior cerebellar artery stroke

A

Symptoms are similar to Wallenberg’s (see above), but:
Ipsilateral: facial paralysis and deafness

185
Q

features of lacunar stroke

A

present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
strong association with hypertension
common sites include the basal ganglia, thalamus and internal capsule

186
Q

issues to consider in stroke management

A

fluids - oral preferable, IV isotonic saline if needd

glycaemic control - close monitoring needed, high mortality in hyperglycaemia
diabetic patients need intense management

BP management - cautious lowering of BP due to blood flow compromise

feeding - SALT assessment, NG if unsafe swallow

187
Q

use of scoring systems in stroke

A

The FAST screening tool (Face/Arms/Speech/Time) is widely known by the general public following a publicity campaign. It has a positive predictive value of 78%.

A variant of FAST called the ROSIER score is useful for medical professionals. It is validated tool recommended by the Royal College of Physicians.

188
Q

investigation findings in stroke

A

non-contrast CT head - first line

acute ischaemic stroke - low density in grey and white matter, hyperdense artery (responsible arterial clot)

acute haemorrhagic stroke - areas of hyperdense (blood) surrounded by low density (oedema)

189
Q

management of stroke

A

dont lower BP unless complications

aspirin 300mg orally after excluding haemorrhagic

start statin if cholesterol >3.5

190
Q

managing acute ischaemic stroke

A

thrombolysis with alteplase if given <4.5h of stroke sx onset

thrombectomy <6h of sx onset if acute ischemic stroke and confirmed occlusion of proximal anterior circulation

thrombectomy if well 6-24h previously if confirmed occlusion of proximal anterior circulation

191
Q

secondary prevention of stroke

A

clopidogrel

2nd line - aspirin + MR dipyridamole

carotid artery endarterectomy if stenosis >70%

192
Q

features of subacute degeneration of spinal cord

A

dorsal column involvement - vibration and proprioception, tingling/burning/sensory loss

lateral corticospinal tract involvement - muscle weakness, hyperreflexia, spasticity, UMN signs in legs

spinocerebellar tract involvement - sensory ataxia, gait abnormalities, positive rhombergs

193
Q

features of subdural haemorrhage

A

head trauma - lucid interval - gradual decline of consciousness

altered mental status
fluctuations in level of consciousness
focal neurological deficits - weakness, aphasia, visual field defects etc
headache - localised, worsening
seizures - if acute/expanding

papilloedema, pupil changes, gait abnormalities, hemiparesis

behavioural/cognitive changes - memory loss, personality changes, cognitive impairment

N/V, drowniness, raised ICP (cushings triad)

194
Q

classification of subdural haemorrhage

A

collection of blood deep to the dural layer of the meninges

extra-axial

can be unilateral/bilateral

acute (<48h)
subacute - days to weeks post injury
chronic - weeks to months, elderly

195
Q

causes of chronic subdural haematoma

A

Rupture of the small bridging veins within the subdural space rupture and cause slow bleeding
Elderly and alcoholic patients are particularly at risk of subdural haematomas since they have brain atrophy and therefore fragile or taut bridging veins.

crescentic in shape, not restricted by suture lines and compress the brain (‘mass effect’)
hypodense (dark) on CT

196
Q

causes of syringomyelia

A

collection of CSF in spinal cord

Causes include:
a Chiari malformation: strong association
trauma
tumours
idiopathic

syringobulbia - fluid filled cavity in medulla of brainstem

197
Q

features of syringomyelia

A

cape-like loss of sensation to temperature
(preservation of light touch, proprioception and vibration)
spastic weakness (predominantly of the lower limbs)
neuropathic pain
upgoing plantars
autonomic features

treat cause of syrinx/if persistent, place shunt

198
Q

features of third nerve palsy

A

eye is deviated ‘down and out’
ptosis
pupil may be dilated (sometimes called a ‘surgical’ third nerve palsy)

199
Q

causes of third nerve palsy

A

diabetes mellitus
vasculitis e.g. temporal arteritis, SLE
false localizing sign* due to uncal herniation through tentorium if raised ICP
posterior communicating artery aneurysm
pupil dilated
often associated pain
cavernous sinus thrombosis
Weber’s syndrome: ipsilateral third nerve palsy with contralateral hemiplegia -caused by midbrain strokes
other possible causes: amyloid, multiple sclerosis

200
Q

features of thoracic outlet syndorme

A

disorder involving compression of brachial plexus, subclavian artery or vein at the site of the thoracic outlet - can be neurogenic or vascular

neurogenic
painless muscle wasting of hands
hand weakness
numbness, tingling

vascular
subclavian vein compression - painful diffuse arm swelling with distended veins
subclavian artery compression - painful arm claudication

201
Q

causes of thoracic outlet syndrome

A

neck trauma - single acute incident or repeated stresses

anatomical anomalies can either be in the form of soft tissue (70%) or osseous structures (30%) - presence of cervical rib

202
Q

management of thoracic outlet syndrome

A

education, rehabilitation, physiotherapy, or taping

surgical decompression

203
Q

definition of transient ischaemic attack

A

a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction. REF

204
Q

management of TIA

A

aspiring 300mg immediately unless bleeding RF

follow on with antiplatelet therapy - clopidogrel (or aspirin + dypyridamole)

lipid modification

carotid artery endarterectomy - if stroke/TIA in carotids and not severely disabled

specialise review - if multiple, if <7 days rv <24h, if >7days rv <7days

205
Q

types of tremor

A

postural
resting
intention
action

206
Q

features of essential tremor

A

Postural tremor: worse if arms outstretched
Improved by alcohol and rest
Titubation
Often strong family history

207
Q

definition of trigeminal neuralgia

A

pain syndrome characterised by severe unilateral pain - usually idiopathic, may be due to trigeminal roots by tumours/vascular problems

208
Q

features of trigeminal neuralgia

A

brief electric shock pains
abrupt onset/termination in divisions of trigeminal nerve

evoked by light touch, including washing, shaving, smoking, talking, and brushing the teeth

small areas in nasolabial folds/chin more susceptible to pain precipitation

209
Q

treatment of trigeminal neuralgia

A

carbamazepine is first-line
poor response or atypical features (e.g., <50y) - refer to neurology

210
Q

features of tuberous sclerosis

A

genetic condition of autosomal dominant inheritance

neurocutaneous symptoms - depigmented ash leaf spots, shagreen rough patches over spine, angiofibromas on nose, subungual fibromata

neurological features - developmental delay, epilepsy, intellectual impairment

211
Q

features of ulnar nerve damage

A

claw hand
wasting and paralysis of intrinsic hand muscles and hypothenar muscles
sensory loss to medial fingers

radial deviation of wrist

212
Q

features of vestibular schwannoma

A

account for 90% of cerebellopontine angle tumours

vertigo, hearing loss, tinnitus, absent corneal reflex

cranial nerves affected:
VIII - vertigo, unilateral sensorineural hearing loss, unilateral tinnitus

V - absent corneal reflex

VII - facial palsy

213
Q

management of vestibular schwannoma

A

urgent ENT referral

tumors usually slow-growing, benign

MRI cerebellopontine angle
audiometry

214
Q

pathophysiology of homonymous hemianopias

A

incongruous defects: lesion of optic tract
congruous defects: lesion of optic radiation or occipital cortex
macula sparing: lesion of occipital cortex

215
Q

pathophysiology of homonymous quadrantanopias

A

superior: lesion of the inferior optic radiations in the temporal lobe (Meyer’s loop)
inferior: lesion of the superior optic radiations in the parietal lobe
mnemonic = PITS (Parietal-Inferior, Temporal-Superior)

216
Q

pathophysiology of bitemporal hemianopia

A

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

217
Q

features of von hippel lindau syndrome

A

AD condition predisposing to neoplasia

cerebellar haemangiomas: these can cause subarachnoid haemorrhages
retinal haemangiomas: vitreous haemorrhage
renal cysts (premalignant)
phaeochromocytoma
extra-renal cysts: epididymal, pancreatic, hepatic
endolymphatic sac tumours
clear-cell renal cell carcinoma

218
Q

features of wernicke’s encephalopathy

A

oculomotor dysfunction
nystagmus (the most common ocular sign)
ophthalmoplegia: lateral rectus palsy, conjugate gaze palsy

gait ataxia

encephalopathy: confusion, disorientation, indifference, and inattentiveness
peripheral sensory neuropathy

219
Q

management of wernicke’s encephalopathy

A

give thiamine

if untreated, may develop into korsakoff syndrome – + antero- and retrograde amnesia and confabulation

Finals (27 decks)

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