Neurology Flashcards
1
Q
What are the types of strokes ?
A
Ischaemia or infarction
Intracranial haemorrhage - haemorrhagic
2
Q
How can blood supply to the brain be disrupted ?
A
A thrombus
Atherosclerosis
Shock
Vasculitis
3
Q
What is a TIA ?
A
Temporary neurological dysfunction caused by ischaemia but without infarction.
Symptoms have a rapid onset and often resolve before the patient is seen.
4
Q
What are some symptoms of strokes ?
A
Asymmetrical
Limb weakness
Facial weakness
Dysphasia
Visual field defects
Sensory loss
Ataxia and vertigo ( PCA infarction )
5
Q
What are some risk factors for a stroke ?
A
Previous TIA or stroke
AF
Carotid artery stenosis
HTN
DM
Raised cholesterol
FH
Smoking
Obesity
Vasculitis
COCP
6
Q
What are some examples of 5-HT3 antagonists ?
A
Ondansetron
7
Q
When are 5-HT3 antagonists used ?
A
Chemotherapy - related nausea
8
Q
Where do 5-HT3 antagonists act ?
A
They mainly act in the chemoreceptor trigger zone area of the medulla oblongata.
9
Q
What are some adverse effects of 5-HT3 antagonists ?
A
Prolonged QT interval
Constipation
10
Q
What are some features of Wernicke’s aphasia ?
A
A lesion of the superior temporal gyrus
The lesion results in sentences that make no sense, word substitution and neologisms but speech remains fluent.
Comprehension is impaired
11
Q
What are some features of broca’s aphasia ?
A
A lesion of inferior frontal gyrus
Speech is non-fluent, laboured and halting
Repetition is impaired
Comprehension is normal
12
Q
What is a conduction aphasia ?
A
Classically due to a stroke affecting the arcuate fasiculus - the connection between wernicke’s and Broca’s area
Speech is fluent but repetition is poor
Comprehension is normal
13
Q
What is Arnold-chiari malformation ?
A
Describes the downward displacement or herniation of the cerebellar tonsils through the foramen magnum.
14
Q
What are some features of Arnold-chiari malformation ?
A
Non-communicating hydrocephalus
Headache
Syringomyelia
15
Q
Where would a lesion that causes peripheral ataxia be ?
A
Cerebellar hemisphere lesions
16
Q
Where would the lesion be to cause gait ataxia ?
A
Cerebellar vermis lesion
17
Q
What is ataxia telangiectasia ?
A
An autosomal recessive disorder caused by a defect in the ATM gene which encodes for DNA repair enzymes.
It typically presents in early childhood with abnormal movements.
18
Q
What are some features of ataxia telangiectasia ?
A
Cerebellar ataxia
Telangiectasia
Recurrent chest infections ( IgA deficiency )
19
Q
What is Bell’s palsy ?
A
May be defined as an acute, unilateral, idiopathic facial nerve paralysis.
20
Q
What are some features of Bell’s palsy ?
A
Lower motor neuron facial nerve palsy - forehead affected
Post-auricular pain
Altered taste
Dry eyes
Hyperacusis
21
Q
What is the management of Bell’s palsy ?
A
No treatment
Prednisolone only
Combination of antivirals and prednisolone
22
Q
Where is the origin of the brachial plexus ?
A
Anterior rami of C5 to T1
23
Q
What are the sections of the brachial plexus ?
A
Roots
Trunks
Divisions
Cords
Branches
24
Q
What is Erb-Duchenne paralysis ?
A
Damage to the C5-C6 roots caused by a breech presentation.
25
What is Klumpke’s paralysis ?
Caused by damage to T1 due to traction causing loss of intrinsic hand muscles.
26
What can cause a brain abscess ?
Extension of sepsis from middle ear or sinuses
Trauma or surgery to the scalp
Penetrating head injuries
Embolic events from endocarditis
27
What are some features of brain abscesses ?
Headache - dull, persistent
Fever
Focal neurology - oculomotor or abducens nerve palsy
Nausea
Papilloedema
Seizures
28
What are the investigations for brain abscesses ?
CT scans
29
What is the management of brain abscesses ?
Surgery - craniotomy
IV abx - cephalosporin + metronidazole
Dexamethasone for intracranial pressure management
30
If a lesion is present in the parietal lobe what features are present ?
Sensory inattention
Apraxia
Tactile agnostic
Inferior homonymous quadrantanopia
31
If a lesion is present in the occipital lobe what features are present ?
Homonymous hemianopia
Cortical blindness
Visual agnosia
32
If a lesion is present in the temporal lobe what features are present ?
Wernicke’s aphasia
Superior homonymous quadrantanopia
Auditory agnosia
Difficulty recognising faces
33
If a lesion is present in the frontal lobe what features are present ?
Broca’s aphasia
Disinhibition
Perseveration
Anosmia
34
If a lesion is present in the cerebellum what features are present ?
Gait
Truncal ataxia
Intention tremor
Past pointing
Dysdiadokinesis
Nystagmus
35
What area is affected in Parkinson’s disease ?
Substantia nigra of the basal ganglia
36
What area is affected in Huntington’s disease ?
Striatum ( caudate nucleus ) of the basal ganglia
37
What tumours commonly spread to the brain ?
Lung
Breast
Bowel
Skin
Kidney
38
What is the management of glioblastoma ?
Surgical with postoperative chemotherapy and/or radiotherapy.
39
What is the most common primary brain tumour ?
Glioblastoma
40
What is a meningioma ?
Typically benign, extrinsic tumours of the CNS.
Arising from the arachnoid cap cells of the meninges
41
What is the management of meningiomas ?
Observation
Radiotherapy
Surgical resection
42
What is a vestibular schwannoma ?
A benign tumour arising from the 8th cranial nerve
43
What are some features of vestibular schwannomas ?
Hearing loss
Facial nerve palsy
Tinnitus
44
What is the management of a vestibular schwannoma ?
Observation
Radiotherapy
Surgery
45
What is a pituitary adenoma ?
Benign tumours of the pituitary gland which either secretory or non-secretory.
46
What is brown - sequard syndrome ?
Caused by lateral hemisection of the spinal cord
47
What are some features of brown - sequard syndrome ?
Ipsilateral weakness below lesion
Ipsilateral loss of proprioception and vibration sensation
Contralateral loss of pain and temperature sensation
48
What is carbamazepine the first line treatment for ?
Partial seizures - epilepsy
49
What is the mechanism of action of carbamazepine ?
It binds to sodium channels increases their refractory period.
50
What are the adverse effects of carbamazepine ?
P450 enzyme inducer
Dizziness and ataxia
Drowsiness
Headache
Visual disturbance
Steven-Johnson syndrome
51
What is cataplexy ?
The sudden and transient loss of muscular tone caused by strong emotion ( laughter and being frightened ).
52
What conditions are associated with cataplexy ?
Narcoplexy
53
What are the features of cataplexy ?
Buckling knees to collapse
54
Where are the cavernous sinuses located ?
On the body of the sphenoid bone
It runs from the superior orbital fissure to the petrous temporal bone.
55
Are unilateral cerebellar lesions contra or ipsilateral ?
Ipsilateral
56
What are the symptoms for cerebellar lesions ?
Dysdiadochokinesia
Ataxia
Nystagmus
Intention tremor
Slurred speech
Hypotonia
57
What are some causes of cerebellar lesions ?
Friedreich’s ataxia
Stroke
Alcohol
MS
Hypothyroidism
Phenytoin, lead poisoning
58
Where is the CSF located ?
Arachnoid mater and pia mater
59
How is the CSF reabsorbed back into the circulation ?
Lateral ventricles
-
3rd ventricle
-
Cerebral aqueduct
-
4th ventricle
-
Subarachnoid space
-
Into venous system via arachnoid granulations
60
What are some risk factors for cluster headaches ?
Men
Smokers
Alcohol
61
What are some features of cluster headaches ?
Intense sharp, stabbing pain around one eye
- pain once or twice a day
- redness, lacrimation, lid swelling
- nasal stuffiness
62
What are the investigations for cluster headaches ?
Neuroimaging - to see if there are underlying brain lesions
MRI with gadolinium
63
What is the management of cluster headaches ?
Acute - 100% oxygen, subcut triptan
Prophylaxis - verapamil
64
In paediatric practice what are the most common CNS tumours ?
Astrocytomas
65
What is the most characteristic feature of a common peroneal nerve lesion ?
Foot drop
66
What are some other features of common peroneal nerve lesion ?
-Weakness of foot dorsiflexion
-Weakness of foot eversion
-Weakness of the extensor hallucis longus
-Sensory loss over the dorsum of the foot and lower lateral part of the leg
67
What is the function of cranial nerve 1 ( Olfactory nerve ) ?
Smelling
68
What is the function of cranial nerve 2 ( optic nerve ) ?
Sight
69
Which muscles are innervated by the 3rd cranial nerve ( oculomotor nerve ) ?
Medial rectus
Inferior oblique
Superior rectus
Inferior rectus
70
What is the function of cranial nerve 3 ( Oculomotor nerve ) ?
Eye movement
Pupil constriction
Accommodation
Eyelid opening
71
How does a 3rd cranial nerve lesion present ?
Ptosis
‘Down and out’ eye
Dilated fixed pupil
72
What is the function of cranial nerve 4 ( trochlear nerve ) ?
Eye movement
73
What muscle is innervated by the trochlear nerve ?
Superior oblique
74
How does an injury to the trochlear nerve present ?
Defective downward gaze
Vertical diplopia
75
What is the function of cranial nerve 5 ( trigeminal nerve ) ?
Facial sensation
Mastication
76
How does an injury to the 5th cranial nerve present ?
Trigeminal neuralgia
Loss of corneal reflex
Loss of facial sensation
Paralysis of mastication muscles
77
What is the function of cranial nerve 6 ( abducens nerve ) ?
Eye movement
78
What muscle is innervated by the abducens nerve ?
Lateral rectus
79
How does a abducens nerve palsy present ?
Palsy results in defective abduction
Horizontal diplopia
80
What is the function of cranial nerve 7 ( facial nerve ) ?
Facial movement
Taste ( anterior 2/3rds of tongue )
Lacrimation
Salivation
81
How can a facial nerve palsy present ?
Flaccid paralysis of upper + lower face
Loss of corneal reflex
Loss of taste
Hyperacusis
82
What is the function of cranial nerve 8 ( vestibulocochlear nerve ) ?
Hearing
Balance
83
How does an 8th nerve palsy present ?
Hearing loss
Vertigo
Nystagmus
84
What is the function of cranial nerve 9 ( glossopharyngeal nerve ) ?
Taste ( posterior 1/3 of tongue )
Salivation
Swallowing
85
How can lesions of the glossopharyngeal nerve present ?
Hypersensitive carotid sinus reflex
Loss of gag reflex
86
What is the function of cranial nerve 10 ( vagus nerve ) ?
Phonation
Swallowing
87
How can a vagus nerve palsy present ?
Uvula deviates away from site of lesion
Loss of gag reflex
88
What is the function of cranial nerve 11 ( accessory nerve ) ?
Head and shoulder movement
89
how does a lesion of the accessory nerve present ?
Weakness turning head to contralateral side
90
What is the function of cranial nerve 12 ( hypoglossal nerve ) ?
Tongue movement
91
How does a hypoglossal nerve palsy present ?
Tongue deviates towards the side of lesion
92
How does the 1st cranial nerve exit the skull ?
Cribriform plate
93
How does the 2nd cranial nerve exit the skull ?
Optic canal
94
How does the 3rd cranial nerve exit the skull ?
Superior orbital fissure
95
How does the 4th cranial nerve exit the skull ?
Superior orbital fissure
96
How does the 5th cranial nerve ( V1, V2 & V3 ) exit the skull ?
V1 - superior orbital fissure
V2 - foramen rotundum
V3 - foramen ovale
97
How does the 6th cranial nerve exit the skull ?
Superior orbital fissure
98
How does the 7th cranial nerve exit the skull ?
Internal auditory meatus
99
How does the 8th cranial nerve exit the skull ?
Internal auditory meatus
100
How does the 9th cranial nerve exit the skull ?
Jugular foramen
101
How does the 10th cranial nerve exit the skull ?
Jugular foramen
102
How does the 11th cranial nerve exit the skull ?
Jugular foramen
103
How does the 12th cranial nerve exit the skull ?
Hypoglossal canal
104
Which nerves are involved in the corneal reflex ( afferent and efferent limbs ) ?
Afferent - ophthalmic nerve ( V1 )
Efferent - facial nerve
105
Which nerves are involved in the gag reflex ( afferent and efferent limbs ) ?
Afferent limb - glossopharyngeal nerve
Efferent limb - vagus
106
Which nerves are involved in the pupillary light reflex ( afferent and efferent limbs ) ?
Afferent limb - optic nerve
Efferent limb - oculomotor
107
What is Creutzfeldt-Jakob disease ?
A rapidly progressive neurological condition caused by prion proteins. These proteins induce the formation of amyloid folds resulting in tightly packed beta-pleated sheets resistant to proteases.
108
How does Creutzfeldt-Jakob disease present ?
Dementia
Myoclonus
109
What investigations are there for diagnosing Creutzfeldt-Jakob disease ?
CSF is usually normal
EEG - biphasic high amplitude sharp waves
MRI
110
What are some symptoms of degenerative myelopathy ?
pain
loss of motor function
loss of sensory function causing numbness
loss of autonomic function
111
what is the management of degenerative cervical myelopathy ?
decompressive surgery
close observation is an option for mild stable disease
112
what is the gold standard investigation for degenerative cervical myelopathy ?
MRI of the cervical spine
113
what drugs can cause peripheral neuropathy ?
amiodarone
isoniazid
vincristine
ntrofurantoin
metrondiazole
114
what are the features of encephalitis ?
fever
headache
psychiatric symptoms
seziures
vomiting
focal features - aphasia
peripheral lesions
115
what are some investigations for encephalitis ?
CSF - LP
neuroimaging
EEG
116
what is the management of encephalitis ?
IV aciclovir if suspected encephalitis
117
what are infantile spasms ?
brief spasms beginning in the first few months of life
118
what are the possible treatments of infantile spasms ?
vigabatrin and steroids
119
what are some features of juvenile myoclonic epilepsy ?
infrequent generalised seizures
daytime absences
usdden, shock like myoclonic seizure
120
what is the treatment of juvenile myoclonic epilepsy ?
good response to sodium valproate
121
what are some features of febrile convulsions ?
ages between 6 months - 5 years
occurs due to a viral infection
brief - tonic or tonic clonic
122
what are some features of alcohol withdrawal seizures ?
history of alcohol excess
benzos given to reduce the risk
occur in patients with excessive alcohol intake who suddenly stop
123
what is a focal seizure ?
( partial seizures )
start in a specific area - on one side of the brain
124
what is a generalised seizure ?
these engage or involve networks on both sides of the brain at the onset
consciousness is completely lost
125
what are some specific types of generalised seizures ?
tonic clonic
tonic
clonic
typical absence
myoclonic
atonic
126
what are some other features to ask about in patients who are having a seizure ?
biting their tongue
urinary incontinence
post-ictal period for around 15 minutes
127
what are some investigations for patients having seizures ?
EEG
MRI
128
what is the management of epilepsy ?
start anti-epileptics after the second seizure
driving advice - cant drive for 6 months following a seizure, for established epilepsy they must be seizure for 12 months
women should be placed on contraception
129
what is the mechanism of sodium valproate ?
increases GABA activity
130
what are the indications for sodium valproate ?
generalised seizures
131
what are some adverse side effects of sodium valproate ?
increased appetite and weight gain
P450 inhibitor
alopecia
ataxia
tremor
hepatitis
pancreatitis
teratogenic - neural tube defect
132
what is the mechanism of action for carbamazepine ?
binds to sodium channels increasing their refractory period
133
when is carbamazepine indicated ?
second line for focal seizures
134
what are some adverse effects for carbamazepine ?
P450 inducer
dizziness and ataxia
drowsiness
leucopenia
visual disurbance
135
what is the mechanism of action of lamotrigine ?
sodium channel blocker
136
what are the indications for lamotrigine ?
generalised seizures
focal seizures
137
what are mechanism of aciton of lamotrigine ?
binds to sodium channels increasing their refractory period
138
what are the adverse effects of phenytoin ?
p450 inducer
dizziness and ataxia
drowsiness
megaloblastic anaemia
peripheral neuropathy
139
what are some features of a focal seizure in the temporal lobe ?
with or without impairment of consciousness
aura - rising epigastric sensation
last around 1 minute
automatisms are common ( lip smacking )
140
what are some features of focal seizures in the frontal lobe ?
head/leg movements
posturing
post-ictal weakness
141
what are some features of focal seizures in the parietal lobe ?
paraesthesia
142
what are some features of focal seizures in the occipital lobe ?
floaters / flashes
143
what is the medication management for generalised tonic-clonic seizures ?
males = sodium valproate
females - lamotrigine / levetiracetam
144
what is the medication management for focal seizures ?
first line - lamotrigine or levetiracetam
second line - carbamazepine
145
what is the medication management for absence seizures ?
first line - ethosuximide
second line :
- males - sodium valproate
-females - lamotrigine or levetiracetam
146
what is the medication management for myoclonic seizures ?
males - sodium valproate
females - levetiracetam
147
what is the medication management for tonic or atonic seizures ?
males - sodium valproate
females - lamotrigine
148
what is an essential tremor ?
an autosomal dominant condition which usually affects both upper limbs
149
what are some features of essential tremor ?
postural tremor - worse if arms are outstretched
improved by alcohol and rest
150
what is the management of essential tremor ?
propanolol - first line
primidone is sometimes used
151
what is an extradural haematoma ?
a collection of blood that is between the skull and the dura
152
what is the main cause of an extradural haemotoma ?
trauma - low impact ( blow to the head or fall )
153
where is a extradural haematoma usually located ?
temporal region - at the pterion which overlies the middle meningeal artery
154
what is the classical presentation of an extradural haematoma ?
a patient who initially loses then briefly regain consciousness after a low impact head injury
as the haematoma expands the uncus of the temporal lobe herniates around the tentorium cerebello causing fixed dilated pupils
155
what is seen on imaging in an extradural haematoma ?
it appears as a biconvex hyperdense collection around the surface of the brain
they are limited by the suture lines of the skull
156
what is the management of an extradural haematoma ?
craniotomy and evacuation of the haematoma is defintive treatment
157
what does the facial nerve supply ?
muscles of facial expression
nerve to stapedius ( ear )
supplies anterior 2/3 of tongue
parasympathetic fibres to lacrimal glands and salivary glands
158
what can cause a bilateral facial nerve palsy ?
sarcoidosis
guillain-barre syndrome
lyme disease
bilateral acosutic neuromas
159
what can cause a unilateral facial nerve palsy ?
bell's palsy
ramsey hunt syndrome
acoustic neuroma
parotid tumour
HIV
DM
MS
stroke
160
what is the difference between bell's palsy and a stroke ?
LMN or a bell's palsy isnt forehead sparing while a stroke is
161
what are the 3 branches of the facial nerve ?
greater petrosal nerve
nerve to stapedius
chorda tympani
162
what is foot drop ?
a result from weakness of the foot dorsiflexors
163
what are some causes of foot drop ?
common peroneal nerve lesion
L5 radiculopathy
sciatic nerve lesion
superficial or deep peroneal nerve lesion
164
what is suggestive of L5 radiculopathy on examination ?
weakness of hip abduction
165
what is the management of foot drop if examination indicates a peroneal neuropathy ?
conservative management - avoid leg crossing, squatting and kneeling
166
how long does foot drop usually take to resolve ?
2-3 months
167
what are some features of a fourth nerve palsy ?
vertical diplopia
subjective tilting of objects
head tilt
eyes deviate upwards and routed outwards
168
what is friedreich's ataxia ?
an early onset hereditary ataxia
autosomal recessive, trinucleotide repeat disorder characterised by a GAA repeat on chromosome 9.
169
what is the typical age of onset of friedreich's ataxia ?
10-15 years old
170
what are the most common presenting features of friedreich's ataxia ?
gait ataxia
kyphoscoliosis
171
what are some neurological features of friedreich's ataxia ?
absent ankle jerk / extensor plantars
cerebellar ataxia
optic atrophy
172
what are the modalities of the GCS ?
motor response
verbal response
eye opening
173
what are the different options in the motor response of the GCS ?
6 - obeys command
5 - localised to pain
4 - withdraws from pain
3 - abnormal flexion to pain
2 - extending to pain
1 - none
174
what are the different options in the verbal response of the GCS ?
5 - orientated
4 - confused
3 - words
2 - sounds
1 - none
175
what are the different options in the eye opening of the GCS ?
4 - spontaneous
3 - to speech
2 - to pain
1 - none
176
what is guillain barre syndrome ?
an immune mediated demyelination of the peripheral nervous system often triggered by an infection
177
what is the pathogenesis of guillain barre syndrome ?
cross - reaction of antibodies in the peripheral nervous system
178
what are the initial symptoms of guillain barre syndrome ?
back/leg pain
179
what are the characteristic features of guillain barre syndrome ?
progressive symmetrical weakness of all limbs
usually ascending
reduced or absent reflexes
180
what are some other features ( less common ) of guillain barre syndrome ?
history of gastroenteritis
resp muscle weakness
cranial nerve involvement
urinary retention
181
what are some investigations of guillain barre syndrome ?
LP - rise in protein with a normal WBC count
nerve conduction studies
182
what are some features of a migraine ?
recurrent severe headache - unilateral and throbbing
associated with aura, nausea and photosensitivity
183
what are some features of a tension headache ?
recurrent non-disabling bilateral headache
tight band
184
what is a cluster headache ?
pain occurs once or twice a day lasting 15 mins to 2 hours
intense pain behind the eye
restless during attack
accompanied by redness, lacrimation and lid swelling
185
what are some features of temporal arteritis ?
typically affects the over 60s
rapid onset
unilateral
tender palpable temporal artery
raised ESR
186
what are some causes of an acute single episode of headache ?
meningitis
encephalitis
subarachnoid haemorrhage
head injury
sinusitis
glaucoma
187
what are some causes of a chronic headache ?
chronically raised ICP
Paget's disease
psychological
188
what are some features of a headache history that would prompt further investigations ?
immunocompromised
under 20 with history of malignancy
vomiting
worsening headache with fever
thunderclap headache
new onset neurological/cognitive deficit
recent head trauma
189
what is herpes simplex encephalitis ?
virus characteristically affects the temporal lobes
190
what are some features of herpes simplex encephalitis ?
fever, headache, seizures, vomiting
aphasia
cold sores
191
what is seen on investigations in herpes simplex encephalitis ?
CSF - elevated proteins and lymphocytosis
CT - medial temporal and inferior frontal changes
MRI is better
EEG
192
what is the management of herpes simplex encephalitis ?
IV aciclovir
193
what is huntington's disease ?
an autosomal dominant neurogenerative condition.
progressive and incurable
trinucelotide repeat disorder
194
what are some features of huntington's disease ?
develops after 35 years old
chorea
personality changes and intellectual impairment
dystonia
saccadic eye movements
195
what is idiopathic intracranial hypertension ?
a condition classically seen in young overweight females
196
what are some risk factors for idiopathic intracranial hypertension ?
obesity
female
pregnancy
drugs - COCP, steroids
197
what are some features of idiopathic intracranial hypertension ?
headache
blurred vision
papilloedema
enlarged blind spot
6th nerve palsy may be present
198
what is the management of idiopathic intracranial hypertension ?
weight loss
carbonic anhydrase inhibitor
topiramate
199
what are some general features of intracranial venous thrombosis ?
headache
nausea and vomiting
reduced consciousness
200
what investigations should be performed when suspecting intracranial venous thrombosis ?
MRI venography
non-contrast CT head
d-dimers elevated
201
what is the management of intracranial venous thrombosis ?
anticoagulation - low molecualr weight heparin ( acutely ), warfarin ( longer use )
202
what are some causes of cavernous sinus syndrome ?
cavernous sinus thrombosis
local infection
neoplasia
trauma
203
what are some features of cavernous sinus thrombosis ?
peri-orbital oedema
ophthalmoplegia
204
what is lambert-eaton syndrome ?
autoimmune disorder caused by an antibody directed against presynaptic voltage gated calcium channel in the PNS.
205
what is lambert-eaton syndrome associated with ?
small cell lung cancer
lesser extent breast cancer
206
what are the features of lambert-eaton syndrome ?
repeated muscle contractions
limb-girdle weakness
hyporeflexia
autonomic symptoms - dry mouth, impotence,
207
what is the treatment of lambert-eaton syndrome ?
treatment of underlying cancer
immunosuppression
IV immunoglobulin
208
what is the mechanism of action of levodopa ?
prevents peripheral metabolism of L-dopa to dopamine
209
what are some adverse effects of levodopa ?
dyskinesia
on-off effect
postural hypotension
cardiac arrythmias
nausea and vomiting
psychosis
210
what features are present if there is damage to the median nerve at the wrist ?
paralysis and wasting of thenar eminence muscles and opponens pollicis
sensory loss - palmar aspect of lateral 2.5 fingers
211
what features are present if there is damage to the median nerve at the elbow ?
features of the damage of the wrist
+
unable to pronate forearm
weak wrist flexion
ulnar deviation of wrist
212
what are the features of medication overuse headache ?
present for 15 days or more per month
worsened by symptomatic medication
patients using opioids or triptans most at risk
213
what is the management of medication overuse headache ?
simple analgesics and triptans withdrawn abruptly
opioids withdrawn gradually
214
what are the symptoms of meningitis ?
headache
fever
nausea / vomiting
photophobia
drowsiness
seizures
215
in bacterial meningitis what is seen on LP ?
cloudy
low glucose
high protein
high neutrophils
215
what are the signs of meningitis ?
neck stiffness
purpuric rash
215
in viral meningitis what is seen on LP ?
clear
high glucose
normal / raised protein
high lymphocytes
216
in TB meningitis what is seen on LP ?
slightly cloudy , fibrin web
low glucose
high protein
217
what are some complications of meningitis ?
sensorineural hearing loss
seizures
focal neurological deficit
sepsis
intracerebral abscess
brain herniation
hydrocephalus
218
what are some triggers of a migraine ?
tiredness
stress
alcohol
COCP
lack of food
dehydration
menstruation
bright lights
219
what is the management of migraines ?
acute - oral triptans + NSAID or paracetamol
prophylaxis - propanolol, topiramate
220
what is motor neuron disease ?
a neurological condition of unknown cause which can present with both UMN and LMN signs.
221
what are some features that would suggest motor neuron disease ?
asymmetrical limb weakness
wasting of small hand muscles
fasciculations
222
how is a diagnosis of motor neuron disease made ?
clinically
MRI to exclude cervical cord compression
223
what are some management options for motor neuron disease ?
riluzole
respiratory care - BiPAP
nutrition - PEG tube
224
what is the mechanism of action for riluzole ?
prevents stimulation of glutamate receptors
225
what is multiple sclerosis ?
a chronic cell-mediated autoimmune disorder characterised by demyelination in the CNS.
226
what is the most common sub-type of multiple sclerosis ?
relasping-remitting disease
227
what are some features of multiple sclerosis ?
optic neuritis
optic atrophy
sensory changes - pins/needles, numbness
trigeminal neuralgia
spastic weakness
ataxia
tremor
urinary incontinence
228
what is seen on investigation in multiple sclerosis ?
MRI - high signal T2 lesions, periventricular plaques
CSF - oligoclonal bands
229
what is the management of multiple sclerosis ?
acute relapse - high dose steroids
DMARDs - reduce the risks
230
what is myasthenia gravis ?
an autoimmune disorder resulting in insufficient functioning ach receptors.
231
what are the features of myasthenia gravis ?
fatigability
extra-ocular weakness - diplopia
proximal muscle weakness
ptosis
dysphagia
232
what conditions are associated with myasthenia gravis ?
thymomas
autoimmune disorders - pernicious anaemia, thyroid disorders, rheumatoid, SLE
233
what are some investigations for myasthenia gravis ?
single fibre electromyography
CT thorax to exclude thymoma
antibodies to ach receptors
234
what is the management of myasthenia gravis ?
long acting ach inhibitors - pyridostigmine
thymectomy
235
what is the management of myasthenic crisis ?
plasmapheresis
IV immunoglobulins
236
what drugs can exacerbate myasthenia gravis ?
penicillamine
quinidine
beta blockers
lithium
phenytoin
abx
237
what is narcolepsy ?
a condition where there are low levels of orexin - a protein responsible for controlling appetite and sleep patterns
238
what are some features of narcolepsy ?
typical onset in teenage years
hypersomnolence
cataplexy
sleep paralysis
239
what is the investigation for narcolepsy ?
multiple sleep latency EEG
240
what is the management for narcolepsy ?
daytime stimulants - modafinil
241
what is neuroleptic malignant syndrome ?
a rare but dangerous condition seen in patients taking anti-psychotic medication. it may occur with dopaminergic drugs for Parkinsons usually when the drug is suddenly stopped or dose reduced.
242
what are the typical features of neuroleptic malignant syndrome ?
pyrexia
muscle rigidity
autonomic lability - hypertension, tachycardia and tachypnoea
delirium
243
what are some complications of neuroleptic malignant syndrome ?
AKI secondary to rhabdomyolysis
leucocytosis
244
what is the management of neuroleptic malignant syndrome ?
stop antipsychotics
IV fluids to prevent renal failure
dantrolene may be useful
245
what is neuropathic pain ?
defined as pain which arises following damage or disruption of the nervous system.
246
what are some examples were neuropathic pain occurs ?
diabetic neuropathy
post-herpetic neuralgia
trigeminal neuralgia
prolapsed intervertebral disc
247
what is the management of neuropathic pain ?
first line - amitriptyline, duloxetine, gabapentin or pregabalin
248
what is normal pressure hydrocephalus ?
a reversible cause of dementia seen in elderly patients.
249
what is the pathogenesis of normal pressure hydrocephalus ?
secondary to reduced CSF absorption at the arachnoid villi.
these changes may be secondary to ehad injury, subarachnoid haemorrhage or meningitis.
250
what is the classical triad of features of normal pressure hydrocephalus ?
urinary incontinence
dementia and bradyphrenia
gait abnormality
( develop over a few months )
251
what is seen on imaging in normal pressure hydrocephalus ?
hydrocephalus with ventriculomegaly in the absence of, or out of proportion to, sulcal enlargement
252
what is the management of normal pressure hydrocephalus ?
ventriculoperitoneal shunting
253
what is parkinsons disease ?
a progressive neurodegenerative condition caused by degeneration of dopaminergic neurons in the substantia nigra.
254
what is the classical triad of parkinsons disease ?
bradykinesia
tremor
rigidity
255
what is bradykinesia ?
poverty of movement
short shuffling steps with reduced arm swinging
difficulty in initiating movement
256
what is the tremor like in parkinsons disease ?
worse when stressed or tired
improves with voluntary movement
typically pill rolling
257
other than the classic triad of parkinson's disease what are some other features are present ?
mask like facies
flexed posture
micrographia
drooling of saliva
depression
impaired olfaction
fatigue
258
what are the features of drug induced parkinsonism ?
motor symptoms are generally rapid onset and bilateral
rigidity and rest tremor are uncommon
259
how is a diagnosis of parkinson's disease made ?
clinically
260
what is the first line management of parkinson's disease ?
levodopa
261
why is levodopa usually prescribed with a decarboxylase inhibitor ?
it prevents the peripheral metabolism of levodopa to dopamine outside of the brain and hence can reduce the side effects
262
what are some common adverse effects of levodopa ?
dry mouth
anorexia
palpitations
postural hypotension
psychosis
263
what are some examples of dopamine receptor agonists ?
bromocriptine
cabergoline
264
what are some adverse effects of dopamine receptor agonists ?
pulmonary fibrosis
cardiac fibrosis
hallucinations
postural hypotension
265
what is an example of a MAOI ?
selegiline
266
what is the management of drug induced parkinsonism ?
anti-muscarinics
267
what are some causes of parkinsonism ?
parkinson's disease
drug induced
wilson's disease
post-encephalitis
toxins - CO
268
what are some conditions that cause predominately motor loss peripheral neuropathy ?
guillain-barre syndrome
porphyria
lead poisoning
269
what are some conditions that cause predominately sensory loss peripheral neuropathy ?
diabetes
uraemia
alcoholism
leprosy
vitamin b12 deficiency
amyloidosis
270
how does alcohol cause neuropathy ?
secondary to both direct toxic effects and reduced absorption of B vitamins
271
if phenytoin is taken during pregnancy what conditions can develop ?
cleft palate
congenital heart disease
272
what is pituitary apoplexy ?
sudden enlargement of a pituitary tumour ( usually non-functioning macroadenoma ) secondary to haemorrhage or infarction.
273
what are some precipitating factors for pituitary apoplexy ?
hypertension
pregnancy
trauma
anticoagulation
274
what are the features of pituitary apoplexy ?
sudden onset headache
vomiting
neck stiffness
visual field defect
extraocular nerve palsy
features of pituitary insufficiency - hypotension
275
what is the investigation for diagnosing pituitary apoplexy ?
MRI
276
what is the management of pituitary apoplexy ?
urgent steroid replacement due to loss of ACTH
careful fluid balance
surgery
277
what are some typical features of post-LP headache ?
develops within 24-48 hours
last several days
worse in upright position
278
what is the normal ICP ?
7-15mmHg
279
what are the causes of raised ICP ?
idiopathic intracranial hypertension
traumatic head injury
infection - meningitis
tumours
hydrocephalus
280
what are the features of raised ICP ?
headache
vomiting
reduced levels of consciousness
papilloedema
cushing's triad
281
what is the cushing's triad ?
widening pulse pressure
bradycardia
irregular breathing
282
what investigations are needed for raised ICP ?
CT/MRI
283
what is the management of raised ICP ?
investigate and treat the underlying cause
head elevation to 30 degrees
IV mannitol
controlled hyperventilation
shunts
284
how does controlled hyperventilation lower ICP ?
reduce pCO2 causing vasoconstriction of the cerebral arteries reducing ICP
285
what nerve roots are tested in the ankle reflex ?
S1-S2
286
what nerve roots are tested in the knee reflex ?
L3-L4
287
what nerve roots are tested in the biceps reflex ?
C5-C6
288
what nerve roots are tested in the triceps reflex ?
C7-C8
289
what is restless legs syndrome ?
a syndrome of spontaneous continuous lower limb movement that may be associated with paraesthesia.
290
what are some clinical features of restless leg syndrome ?
uncontrollable urge to move legs
worse at rest
paraesthesia - crawling or throbbing sensation
291
what are some causes and associations of restless legs syndrome ?
family history
iron deficiency anaemia
uraemia
DM
pregnancy
292
what is the management of restless leg syndrome ?
simple measures - walking, stretching
treat any iron deficiency
dopamine agonist
benzodiazepines
gabapentin
293
what is Reye's syndrome ?
a severe, progressive encephalopathy affecting children that is accompanied by fatty infiltration of the liver, kidneys and pancreas.
294
what is the aetiology of reye's syndrome ?
association with aspirin use and viral cause
295
what are some features of reye's syndrome ?
preceding illness
encephalopathy - confusion, seizures
hypoglycaemia
fatty infiltration of the liver, kidneys and pancreas
296
what is the management of reye's syndrome ?
supportive
297
what is the injury causing brown-sequard syndrome ?
spinal cord hemisection
298
what tracts are affected in brown-sequard syndrome ?
lateral corticospinal tract
dorsal columns
lateral spinothalamic tract
299
what are the features of brown-sequard syndrome ?
ipsilateral spastic paresis below lesion
ipsilateral loss of proproception and vibration sensation
contralateral loss of pain and temperature sensation
300
what tracts are affected in an anterior spinal artery occlusion ?
lateral corticospinal tracts
lateral spinothalamic tract
301
what are the features of anterior spinal artery occlusion ?
bilateral spastic paresis
bilateral loss of pain and temperature sensation
302
what tracts are affected in syringomyelia ?
ventral horns
lateral spinothalamic tract
303
what are the features of syringomyelia ?
flaccid paresis
loss of pain and temperature sensation
304
what functions does the dorsal column medial lemniscus pathway carry ?
fine and discriminative touch
proprioception
305
what functions does the spinothalamic tract carry ?
coarse touch
pressure sensation
temperature sensation
306
which matter does the motor pathway travel through ?
white
307
308
what function does the corticospinal tract carry ?
speed and agility of voluntary movements
309
310
what is status epilepticus ?
a single seizure lasting longer than 5 minutes
or
2 seizures within 5 minute period without the person returning to normal between them
311
what is the management of status epilepticus ?
ABC - airway adjunct, oxygen and check glucose
first line - benzodiazepines
second line - levetiracetam ( if non resolving )
312
what are the features associated with a stroke of the anterior cerebral artery ?
contra-lateral hemiparesis and sensory loss
313
what are the features associated with a stroke of the middle cerebral artery ?
contra-lateral hemiparesis and sensory loss
contra-lateral homonymous hemianopia
aphasia
314
what are the features associated with a stroke of the posterior cerebral artery ?
contralateral homnoymous hemianopia with macular sparing
visual agnosia
315
what are the features present in a retinal / ophthalmic artery lesion ?
amaurosis fugax
316
what is the presentation of a basilar artery lesion ?
locked in syndrome
317
how does a lacunar stroke present ?
either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
318
where are the common sites for lacunar strokes ?
basal ganglia
thalamus
internal capsule
319
what is a stroke ?
( cerebrovascular accident )
represents a sudden interruption in the vascular supply of the brain.
320
what are the 2 main types of a stroke ?
ischaemic
haemorrhagic
321
what is the essential problem in ischaemic strokes ?
blockage in the blood vessel stops blood flow
322
what is the essential problem in haemorrhagic strokes ?
blood vessel bursts leading to reduction in blood flow
323
what are the 2 subtypes of ischaemic stroke ?
thrombotic stroke
embolic stroke
324
what are the subtypes of haemorrhagic strokes ?
intracerebral haemorrhage
subarachnoid haemorrhage
325
what are the risk factors for ischaemic strokes ?
age
hypertension
smoking
hyperlipidaemia
DM
AF
326
what are some risk factors for haemorrhagic stroke ?
age
hypertension
arteriovenous malformation
anticoagulation therapy
327
what are some features of a stroke ?
motor weakness
speech problems
swallowing problems
visual field defects - homonymous hemianopia
balance problems
328
what are some symptoms of cerebral hemisphere infarcts ?
contra-lateral hemiplegia
contra-lateral sensory loss
homnoymous hemianopia
dysphagia
329
what are some symptoms of a brainstem infarct ?
quadriplegia
locked in syndrome
330
what is the criteria for the oxford stroke classification ?
unilateral hemiparesis and/or hemisensory loss of the face, arm and leg
homonymous hemianopia
higher cognitive dysfunction - dysphasia
331
which arteries are involved in a TACs infarct ?
middle and anterior cerebral arteries
332
how may of the oxford stroke classification is needed for a TACs stroke ?
all 3
333
what arteries are affected in a PACs stroke ?
smaller arteries of the anterior circulation ( upper or lower division of the middle cerebral artery )
334
how many of the oxford stroke is required for a PACs stroke ?
2
335
according to the oxford stroke classification what criteria is needed for a diagnosis of a lacunar infarct ?
1 of the following :
- unilateral weakness ( and/or sensory deficit ) of face and arm, leg
- pure sensory troke
- ataxic hemiparesis
336
what arteries are involved in a POC infarct ?
vertebrobasilar arteries
337
according to the oxford stroke classification what features are required for a POCs stroke ?
cerebellar or brainstem syndromes
loss of consciousness
isolated homonymous hemianopia
338
what does the FAST campaign stand for ?
Face - has their face fallen on one side ?
Arms - can they raise both arms and keep them there ?
Speech - slurred ?
Time - 999
339
what investigations are required when suspecting a stroke ?
CT - non contrast head
MRI
340
why is neuroimaging an urgency in strokes ?
to determine whether a patient is suitbale for thrombolytic therapy to treat early ischaemic strokes.
341
what is the management of ischaemic strokes ?
once haemorrhagic strokes are excluded patients should be given aspirin 300 mg as soon as possible
thrombolysis with alteplase
342
what is a TIA ?
stroke symptoms that resolve within 24 hours
343
what is the immediate antithrombotic therapy for a TIA ?
give aspirin 300mg immediately
344
what is the management of a haemorrhagic stroke ?
supportive
stop anticoagulants and anti-thrombotic
lower BP
345
what are some contraindications for thrombolysis ?
previous intracranial haemorrhage
seizure at onset of stroke
intracranial neoplasm
suspected subarachnoid haemorrhage
LP in preceding 7 days
active bleeding
oesophageal varices
uncontrolled HTN
346
what is the secondary prevention for a stroke ?
first line - clopidogrel
second line - aspirin plus modified release dipyridamole
347
what is the time frame to offer someone thrombolysis after a stroke ?
4.5 hours
348
what is a subdural haemorrhage ?
a collection of blood deep to the dural layer of the meninges.
349
what are the neurological symptoms of a subdural haemorrhage ?
altered mental state
weakness on one side
aphasia
visual field defect
headache
seizures
350
what are the physical examination findings for subdural haemorrhage ?
papilloedema
pupil changes
gait abnormalities
hemiparesis or hemiplegia
351
what are the behavioural and cognitive changes in a subdural haemorrhage ?
memory loss
irritability
apathy
depression
cognitive impairment - difficulty focusing
352
what is the investigation of choice for a subdural haemorrhage and what are the findings ?
CT imaging
crescentic collection not limited by suture lines
353
what is the management of subdural haemorrhages ?
if small can be observed and managed conservatively
surgical - decompressive craniectomy
354
what causes a chronic subdural haemorrhage ?
rupture of the small bridging veins within the subdural space and cause slow bleeding
355
who are most at risk of developing a chronic subdural haemorrhage ?
elderly and alcoholic patients
due to brain atrophy and fragile taut veins
356
how does a chronic subdural haematoma present ?
typically several week to month progressive history of either confusion, reduced consciousness or neurological deficit.
357
what is the management chronic subdural haematoma ?
if no neurological deficit - conservatively
if there is a neurological deficit - decompression with burr holes
358
what is syringomyelia ?
describes a collection of cerebrospinal fluid within the spinal cord.
359
what are some causes of syringomyelia ?
chiari malformation
trauma
tumours
idiopathic
360
what are some features of syringomyelia ?
loss of sensation to temperature but preservation of light touch, proprioception and vibration
spastic weakness
neuropathic pain
ungoing plantars
361
what investigations should be performed when suspecting syringomyelia ?
full spine MRI with contrast - exclude a tumour
brain MRI - exclude chiari malformation
362
what is the management of syringomyelia ?
treat the cause of the syrinx
a shunt into the syrinx can be placed if persistent
363
what are the characteristic features of a tension headache ?
tight band around the head
bilateral
lower intensity than a migraine
may be related to stress
364
what is chronic tension type headache defined as ?
15 or more days per month
365
what is the management of a tension headache ?
acute - aspirin, NSAIDs, paracetamol
prophylaxis - amitriptylline
366
what are some features of a third nerve palsy ?
eyes deviated down and out
ptosis
pupil may be dilated
367
what are some causes of third nerve palsy ?
DM
vasculitis - temporal arteritis, SLE
PCA aneursym
cavernous sinus thrombosis
368
what is a TIA ?
a brief period of neurological deficit due to a vascular cause typically lasting less than an hour.
369
what are some features of TIA ?
sudden onset
unilateral weakness or sensory loss
aphasia or dysarthria
ataxia, vertigo or loss of balance
visual problems - amaurosis fugax, diplopia and homonymous hemianopia
370
what is amaurosis fugax ?
sudden transient loss of vision in one eye
371
what is the immediate management of TIA ?
give aspirin 300mg immediately
372
what is the secondary prevention of a TIA ?
clopidogrel is first line
aspirin + dipyridamole - second line
high intensity statin - atorvastatin 20-80
373
what investigations are performed for a TIA ?
MRI
carotid imaging - urgent carotid doppler
374
what tremor is present in Parkinson's disease ?
resting, pill rolling tremor
375
how is the tremor described in essential tremor ?
postural tremor - worse if arms are outstretched
improved by rest and alcohol
376
what is trigeminal neuralgia ?
a pain syndrome characterised by severe unilateral pain. usually idiopathic
377
what is the management of trigeminal neuralgia ?
carbamazepine is first line
failure to respond to treatment should prompt referral to neurology
378
what are some adverse effects of triptans ?
triptan sensation - tingling, heat, tightness, heaviness and pressure
379
what is the classical history of vestibular schwannoma ?
a combination of vertigo, hearing loss, tinnitus and absent corneal reflex.
facial palsy
380
what investigations should be performed for vestibular schwannoma ?
MRI of the cerebellopontine angle
381
what is the management of vestibular schwannoma ?
surgery
radiotherapy
observation
382
what is an incongruous defect + example?
incomplete or asymmetric visual field loss
optic tract lesion
383
what is a congruous defect + example ?
complete or symmetrical visual field loss
optic lesion or occipital cortex lesion
384
where is the lesion in a bitemporal hemianopia ?
lesion of the optic chiasm
385
where is the lesion in a superior homonymous quadrantanopia ?
inferior optic radiation in the temporal lobe - Meyer's loop
386
where is the lesion in a inferior homonymous quadrantanopia ?
superior optic radiations in the parietal lobe
387
if there is macular sparing in homonymous hemianopia where is the lesion ?
lesion of the occipital cortex
388
what is von Hippel-Lindau syndrome ?
an autosomal dominant condition predisposing to neoplasia.
it is due to an abnormality in the VHL gene located on short arm of chromosome 3.
389
what are some features of von Hippel-Lindau syndrome ?
cerebellar haemangioma
retinal cyst
phaechromocytoma
extra-renal cysts
endolymphatic sac tumours
clear cell renal cell carcinoma
390
what is wernicke's encephalopathy ?
a neuropsychiatric disorder caused by thiamine deficiency which is most commonly seen in alcoholics.
391
what is the classic triad of wernicke's encephalopathy ?
ophthalmoplegia/nystagmus
ataxia
encephalopathy
392
what are some features of wernicke's encephalopathy ?
oculomotor dysfunction - nystagmus
gait ataxia
encephalopathy - confusion, disorientation
peripheral neuropathy
393
what investigations should be performed when suspecting wernicke's encephalopathy ?
decreased red cell transketolase
MRI
394
what is the management of wernicke's encephalopathy ?
urgent replacement of thiamine
395
if wernicke's encephalopathy isn't treated what can develop ?
korsakoff syndrome
396
how does korsakoff syndrome present ?
antero and retrograde amnesia
confabulation
397
