neurology Flashcards
how can you differentiate surgical and medical 3rd nerve palsy
surgical = painful and causes fixed dilated pupil, can be caused by posterior communicating artery aneurysm
medical = pupil sparing, common cause is diabetes
describe symptoms of midbrain infarct (weber’s syndrome)
n ipsilateral third nerve palsy (due to involvement of oculomotor nerve fibres originating in the midbrain)
and contralateral hemiparesis (due to involvement of corticospinal fibres as they pass through the midbrain)
what is chemosis
swelling of the tissue that lines the eyelids and surface of the eye
describe symptoms of cavernous sinus thrombosis
unilateral ptosis and chemosis
oedema
headache
photophobia
what does the triad of urinary incontinence, dementia and gait abnormality indicate
normal pressure hydrocephalus
what is the definitive management for normal pressure hydrocephalus
Ventriculo-peritoneal shunting
what does bilateral medial temporal lobe involvement on an MRI indicate
encephalitis
what mediation is given to reduce the long term neurological symptoms of meningitis
IV dexamethasone
what mediation is given to relatives/close contacts to a pt with meningitis
oral ciprofloxacin or rifampicin
what bacteria does an India ink stain show
Cryptococcal meningitis
likely cause of meningitis in an immunocompromised pt eg with HIV, who has fibrin web CSF, high protein, normal glucose ad high lymphocytes, but normal CXR and no haemoptysis
Cryptococcal meningoencephalitis
(normal CXR and no haemoptysis indicate that its not TB)
Tx for meningitis in a pt with penicillin allergy
IV Chloramphenicol
(cefriaxoen is C/I due to cross-reactivity between cephalosporins and penicillin)
what is the common gram positive rod shaped bacteria that causes meningitis
listeria monocytogenes
what type of encephalitis do IgM or IgG antibodies in the CSF suggest
tick-borne encephalitis
what can be given for status epileptics in the community if IV route can’t be established
PR diazepam or Bucal midazolam
pt had stomach upset 2 weeks ago and now has rapidly progressing ascending weakness
diagnosis?
guillain barre syndrome
what is used to monitor respiratory muscle involvement in Guillain barre syndrome
FVC
which anti epileptic causes gingival hypertrophy, hirsutism and coarsening facial features
phenytoin
side effects of levetiracetam
drowsiness
headaches
irritation
nausea and vomiting
side effects of carbamazepine
drowsiness
ataxia
headache
hyponatraemia
rarely, Stevens-Johnson syndrome
how can temporal lobe epilepsy cause long term memory loss
can cause damage to medial temporal lobe structures eg hippocampus - causes long term memory loss
what is west syndrome
infantile spasms, which usually start between 4-8 months of age and involve myoclonic jerking (or ‘jack-knife’ spasms) that occur in clusters
preceded by an aura followed by automatisms, including fidgeting of the hands, chewing, lip smacking or swallowing
These episodes would usually be accompanied with altered awareness and subsequent amnesia.
which type of focal epilepsy is this
temporal lobe epilepsy
which juvenile epilepsy occurs exclusively in sleep
benign Rolandic seizures
cause of tremor on movement but nothing at rest
essential tremor
facial weakness, unilateral ear pain and vesicles seen in the ear canal
diagnosis?
Ramsay hunt syndrome due to VZV infection (causes inflammation of the geniculate ganglion of the facial nerve)
Tx for Ramsay hunt syndrome due to VZV infection
oral antiviral and steroids
first line tx for GBS
Iv immunoglobulin and supportive treatment
what is the most important thing to monitor regarding pt prognosis in a pt with GBS
FVC
what does an isolated rise in CSF protein indicate
GBS
name 5 drugs which cause idiopathic inter cranial HTN
Oral contraceptive pill
Steroids
Tetracycline
Vitamin A
Lithium
first line Tx for atonic seizures in women of reproductive age
lamotrigine (or levetiracetam)
(sodium valproate is first line for generalised seizures but not for women of reproductive age)
what type of hydrocephalus is caused by problems in the subarachnoid space, often stemming from complications like subarachnoid haemorrhage and infective meningitis.
communicating hydrocephalus
where are the common causes of obstruction in obstructive hydrocephalus
foramen of Monro (e.g. due to colloid cysts), cerebral aqueduct (e.g. due to aqueduct stenosis), or fourth ventricle (e.g. due to posterior fossa tumour).
dilated lateral ventricles and third ventricle
normal fourth ventricles
headache, no other history
diagnosis?
obstructive hydrocephalus due to lesion/obstruction in cerebral aqueduct (aqueduct stenosis)
(obstructive hydrocephalus can affect all the ventricles)
but communicating hydrocephalus would be after meningitis or subarachnoid haemorrhage
what is a secondary generalised seizure
secondary to preceding focal seizure
tx for Ramsey hunt syndrome
prednisolone and oral acyclovir
LMN facial nerve palsy
ringing noise
vesicles in ear
diagnosis?
ramsay hunt syndrome
what is scintillating scotoma
visual phenomenon described in patients suffering from migrainous headache
visual hallucination of zigzags starting in centre and moving out to peripheries of vision
what type of lesion does babinskis sign suggest
UMN lesion
what is the difference between the movements of the foot that are impaired in peroneal/common fibular nerve palsy and L5 root lesion
peroneal/common fibular nerve palsy
= loss of
ankle eversion
ankle dorsiflexion
L5 root lesion
= loss of
ankle eversion
ankle dorsiflexion
ankle inversion
(also causes weakness of hip abduction)
which disorder causes an ascending pattern of weakness that improves on exertion/repetition
LEMS (Lambert-eaton syndrome)
which disorder causes descending weakness that fatigues on repletion/sustained action
myasthenia gravis
effects of autonomic neuropathy
postural hypotension
gastroparesis
effects of spinothalamic tract damage
contralateral loss of coarse touch/pain and temperature sensation
effects of peripheral sensory neuropathy
glove-and-stocking distribution of sensory loss or paraesthesiae
effects of dorsal column damage
ipsilateral loss of fine touch, vibration sense, and proprioception
effects of corticospinal tract damage
ipsilateral weakness below the level of the medulla
contralateral weakness above the level of the medulla
what is raised on bloods in an epileptic seizure
prolactin
what is the difference between a true epileptic seizure and non epileptic attack disorder
true epileptic seizure
- caused by abnormal brain activity
- head remains fixed
- eyes remain open
- post octal confusion / tongue biting / incontinence
- raised prolactin
non epileptic attack disorder
- caused by psychological stress
- pelvic thrusting
- head movements
- eyes closed
- Postictal crying
- normal prolactin
pelvic thrusting, head movements, eyes closed, postictal crying
what kind of seizure/disorder is this
non epileptic attack disorder
what is Todds paresis/palsy
when there is persistent weakness or paralysis in a part of the body following a seizure
what medication can be given through a cannula for a patient who is in status epilepticus
lorazepam
(lorazepam given IV, diazepam given PR)
which nerve is often damaged in fractures of head of fibula
common fibular/peroneal nerve
which seizure involves crazy movements and jerking of limbs but no loss consciousness
myoclonic
what does reflex anoxic seizure involve
faint, causing a brief twitching episode
tx for GBS
IV Ig
or plasma exhcnage if they have vit A deficiciency or renal failure
which epilepsy is seen in children 1-2 hours after waking up, triggered by lack of sleep, and which is seen in children during sleep
juvenile myoclonic epilepsy
- after waking up
- triggered by lack of sleep
- myoclonic
benign Rolandic seizures
- during sleep
- tonic clonic
what is the cause of a fine bilateral tremor associated with anxiety, hair loss, palpitations and breathlessness
thyrotoxicosis
cause of intention tremor, reduced coordination and dysarthria
cerebellar ataxia
which tremor starts following a stressful life event
psychogenic tremor
what is vital to monitor in GBS and why
FVC, the ascending muscle weakness could affect diaphragm which could then cause resp arrest
what is a coryzal illness
inflammation of mucous membranes of nasal cavities
what is the triad for normal pressure hydrocephalus
urinary incontinence
dementia
gait abnormality
what medication can be given through cannula for status epilepticus
IV lorazepam
(diazepam given PR)
which nerve is damaged in a neck of fibula fracture
Common fibular nerve (common peroneal nerve)
which seizure is a faint followed by twitching
reflex anoxic seizure
describe consciousness in a myoclonic seizure
not affected
which child epilepsy occurs after waking up, and which one occurs during sleep
juvenile myoclonic epilepsy
- after waking up
- triggered by lack of sleep
- myoclonic
benign Rolandic seizures
- during sleep
- tonic clonic
what is the cause of a bine bilateral tremor associated with anxiety, hair loss, palpitations, breathlessness
thyrotoxicosis
what is the cause of an intention tremor, associated with reduced coordination and dysarthria
cerebellar ataxia
which tremor starts after stressful life event
psychogenic tremor
why should FVC be monitored in GBS
the weakness may spread to diaphragm which causes resp arrest
first line manager t for idiopathic inter cranial hypertension
weight loss and close monitoring
how do LMN and UMN lessons affect forehead
UMN - forehead sparing
LMN - non forehead sparing
is bells palsy UMN or LMN lesion
LMN
give a cause of acute onset unilateral facial drooping with forehead sparing
acute stroke
cause of unilateral facial weakness with hypersensitivity to loud sounds
Ramsay hunt syndrome
what is the cause of foot drop that involves loss of foot inversion as well as eversion
L5 radiculopathy
what is the cause of foot drop that involves loss of sensation over the big toe
L5 radiculopathy
what is the cause of foot drop that involves loss of sensation over the lateral calf
common perineal nerve palsy
LMN facial palsy with ear pain, hearing loss and vertigo
diagnosis?
Ramsay hunt syndrome
what is the likely diagnosis of a hiker that had illness (fever, fatigue muscle/joint pain) and later developed monoarthiritis or facial nerve palsy or neuropathic pain or palpitations
Lyme disease
what is the diagnostic sign for GBS
albumin-cytologic dissociation
ie raised protein, normal white cell count
(raised WCC would indicate infection, but GBS is usually para-infectious)
pt has urinary incontinence, dementia and gait abnormality
diagnosis?
normal pressure hydrocephalus
tx for normal pressure hydrocephalus
ventriculo-peritoneal shunting
ix for cauda equina due to metatstases
spine MRI (cauda equina due to all causes)
do whole spine MRI rather than just lumbar spine MRI if you think the cause is metastases as you can check the whole spine and pick up multiple lesions if there are some
which seizure involves
Swearing / screaming / laughing
Urinary incontinence
Weakness after the seizure
frontal lobe seizure
pt has a seizure which involves repetitively pulling at his shirt
what kind of seizure is this
temporal lobe
what is this feature and what type of seizure does it present in
twitching in one area of body, that progresses to involve another area of the body as well
Jacksonian march
frontal lobe seizure
CSF: very high proton. normal WCC, normal glucose, normal appearance
diagnosis
GBS
pt was complaining of numbness in his fingers and arm, before he lost consciousness and his arms and legs starting jerking.
type of seizure ?
Generalised seizure secondary to parietal lobe seizure
tx for Ramsay hunt syndrome
acyclovir
what is todds paresis
focal unilateral weakness after a seizure - usually frontal lobe seizure
which antiepileptic can cause hepatic dysfunction
sodium valproate
which condition can the Tensilon Test diagnose
myasthenia gravis
which test confirms Idiopathic inter cranial hypertsenion
lumbar puncture - will have high opening pressure
(do imaging of brain first to rule out a space occupying lesion ads that would contraindicate lumbar puncture)
management of pt with IIH that has new onset visual loss
optic nerve fenestrations - try to relieve the pressure and improve sight
which type of hydrocephalus is after subarachnoid haemorrhage
communicating hydrocephalus
which type of hydrocephalus results from problems with the arachnoid granulations
communicating hydrocephalus
(CSF can exit the ventricular system but there is a problem with CSF absorption at the arachnoid granulations)
what is opthalmoplegia
paralysis of eye muscles
which condition has a prodrome pf gastroenteritis and presents with a triad of ataxia, areflexia and opthalmoplegia
miller fisher syndrome
(Remember that Guillain-Barre starts distally (polyneuropathy) and makes it way up. Miller-Fisher starts proximally i.e. with the eyes)
which antiepileptic can cause renal stones
topiramate
which anti epileptic can cause skin rash, ataxia, dysarthria and nystagmus
carbamezapine
which anti epileptic can cause Acne, anorexia, constipation, dizziness, gingival hypertrophy, hirsutism, insomnia, rash, tremor.
phenytoin
proteinuria
oedema
enlarged kidneys
palpitations
cardiomegaly
carpal tunnel syndrome
likely diagnosis?
Amyloidosis
what is the cause of “violet wide-amplitude flinging movements of the proximal limb” after a stroke
Hemiballismus due to stroke in the contralateral side of the brain
which lobe is affected in receptive aphasia
left temporal lobe
- wernickes area is in the the left temporal lobe
which lobe is affected in expressive aphasia
left frontal lobe
- broca’s area is in the left frontal lobe
pt has stroke and CT head is normal
what does that mean
it is a thrombotic stroke not hemorrhagic
which syndrome presents with
hoarse voice
difficulty swallowing
changes in taste
ipsilateral constructed pupil and drooping eyelid
ipsilateral loss of pain and temp sensation on face
contralateral loss of pain and temp sensation on limbs
Wallenbergs syndrome - infarct/ischaemia of the posterior inferior cerebellar artery (PICA)
which 3 features constitute a TACI (Total Anterior Circulation Infarct
Contralateral hemiparesis and / or sensory loss
Contralateral homonymous hemianopia that is non-macular sparing
Higher cerebral dysfunction (eg aphasia, neglect)
( If only 2 of these features are present (or there is higher cortical dysfunction alone) the stroke is called a PACI-)
aphasia vs dysarthria
Aphasia occurs due to brain damage that affects the ability to express and understand speech.
Dysarthria, on the other hand, is a condition that affects the muscles necessary for speech
is the basilar artery anterior or posterior circulation
posterior
symptoms of basillar artery stroke
prodromal symptoms 2 weeks before: vertigo, nausea, headaches
what is hypocusis
partial or total loss of hearing acuity (clarity/clearness)
symptoms of basilar artery stroke
hemiparesis or quadriparesis, and facial palsies, dizziness, headache, and speech abnormalities
locked in syndrome
what is bruising over the mastoid process known as, and what does it indicate
Battle sign
suggestive of a skull fracture
what is a hemotympanum and what does it indicate
presence of blood in the middle ear
clinical feature of a skull fracture
what is CSF otorrhea and what does it indicate
leakage of CSF from the ear (seen as clear fluid)
clinical feature of a skull fracture.
head injury causing an initial loss of consciousness, followed by a lucid interval where the patient appears to have recovered which is then followed by a deterioration in GCS
what type of stroke is this
extradural
which vessel is the most common cause of an extradural haemorrhage
middle meningeal artery
what scoring system can be used in someone with AF to assess their risk of a stroke
CHA2DS2VASc
what scoring system can be used in someone who had a TIA to assess their risk of stroke
ABCD2
what hereditary condition causes recurrent sprains and joint dislocations and which stroke does it increase the risk of
Ehlers dances syndrome
increases risk of Subarachnoid haemorrhage
what type of visual loss does a left parietal lobe lesion cause
right sided inferior homonymous quadrantanopia
what type of visual loss does a left occipital lobe lesion cause
right sided homonymous hemianopia with macular sparing
what type of visual loss does a left temporal lobe lesion cause
right sided superior homonymous hemianopia
what should be given to a pt on warfarin after a hemorrhagic stroke
stop warfarin
give
IV vitamin K
and
Prothrombin complex concentrate
what type of stroke causes
ipsilateral cranial nerve three palsy
and contralateral weakness
webers syndrome - midbrain stroke syndrome
what are the symptoms of Wallenberg syndrome (lateral medullary syndrome)
“DANVAH”
Dysphagia,
ipsilateral Ataxia,
ipsilateral Nystagmus,
Vertigo,
Anaesthesia (Ipsilateral facial numbness and contralateral pain loss on the body)
ipsilateral Horner’s syndrome
pt had severe headache and CT head was normal, had LP 12 hours later which showed xanthochromia. what’s the next step
CT angiogram
what is the difference in symptoms between anterior inferior cerebellar artery stroke and posterior inferior cerebellar artery stroke
posterior inferior cerebellar artery stroke (Wallenberg’s ie lateral medullary syndrome)
-“DANVAH”
Dysphagia,
ipsilateral Ataxia,
ipsilateral Nystagmus,
Vertigo,
Anaesthesia (Ipsilateral facial numbness and contralateral pain loss on the body)
ipsilateral Horner’s syndrome
anterior inferior cerebellar artery syndrome
- same as Wallenbergs with the addition of
- ipsilateral facial paralysis
- hearing loss
which stroke is almost always due to trauma
extradural haemorrhage
what is the characteristic clinical course of an extradural haemorrhage
Initial brief loss of consciousness following the trauma
A period of regained consciousness and apparent recovery (the lucid interval)
Subsequent deterioration of consciousness and the onset of a headache
are extradural haematomas arterial or venous
arterial
are subdural haematomas arterial or venous
venous
which vessel is the typical source of bleeding for an extradural haematoma
middle meningeal artery
are extradural haematomas infratentorial or supratentorial
supratentorial
typical presentation of subarachnoid haemorrhage on CT scan
white area in the centre of the brain that expands bilaterally
typical presentation of subdural haemorrhage on CT scan
crescent shaped haematoma - not limited by sutures of the skull
typical presentation of subarachnoid haemorrhage on CT scan
biconvex haematoma which is limited to the skull sutures where the dura adheres to the skull.
contrast subarachnoid haemorrhage and intracerebral haemorrhage symptoms
Subarachnoid haemorrhage: Characterised by a sudden, severe headache (often described as a ‘thunderclap’ headache), nausea, vomiting, and neck stiffness
(severe headache + meningism)
Intracerebral haemorrhage: Presents with sudden onset severe headache, vomiting, high blood pressure, and signs of increased intracranial pressure
(severe headaches + raised ICP)
which surgical procedure can be done for extradural haemorrhage
ligation of the bleeding artery
what is a lentiform shape and which type of haemtaoma is shaped like this
like a lens - convex
extradural haematoma
what level do you want co2 to be at during raised ICP
normal, so if try to get pt to hyperventilate
bc high Co2 causes vasodilation in the cerebral vessels which increases blood flow to the brain and therefore further increases ICP, you don’t want that
what colour is CSf from LP 12 hours after a confirm subarachnoid haemorrhage
yellow (or sometime pink)
what is a Amaurosis fugax
temporary painless loss if vision in eye which returns to normal after - its like a TIA in the eye
ipsilateral cranial nerve 3 palsy
and contralateral weakness
diagnosis
webers syndrome
which scoring system is used to recognise stroke in the acute setting of the emergency department
ROSIER
what is conductive aphasia
there is an isolated inability to repeat
different from Broca or wernicke aphasia
what is nominal aphasia
inability to correctly name objects
what is mannitol used for
raised ICP
what is contrast vs non contrast Ct head scans used for
contrast enhanced CT head
- intracerebral infections
- tumours
non-contrast CT scan
- haemorrhage (stroke)
what does tetraplegic mean
paralysed in the upper and lower body
lesion in which artery can cause tetraplegia with preserved consciousness and only preserved vertical eye movements
basillar artery (locked in syndrome)
mechanical thrombectomy id most beneficial in thrombi in which 2 arteries
proximal middle cerebral artery thrombus
or
internal carotid artery thrombus
what is enoxaparin
anticoagulant
what should the target bp be in a haemorrhagic stroke
<140 mmHg
when do you start aspirin 300mg in a pt who has been thrombolysed with Iv atleplase
24 hrs after thrombolysis
when do you start aspirin 300mg in a pt who has presented >4.5 hrs from stroke onset
immediately
what type os stroke is cerebral amyloid antipathy associated with
hemorrhagic stroke
what scoring system can be used to assess functional independence of patients after a stroke
Barthel Index
what is the modified SOAR score used for
looks at the short-term mortality of patients after an ischaemic stroke and is measured on a scale of 0–9
what is the NIH stroke scale used for
to measure the severity of neurology after a stroke. It can be used when patients first present to establish the extent and severity of focal neurology with higher scores indicating higher levels of neurological impairment. It is often used to help clinicians decide whether the severity of the stroke outweighs the risks of giving a patient thrombolysis.
what is the DRAGON score used for
is used for patients with ischaemic stroke to predict their 3-month prognosis if they are to be thrombolysed with alteplase
pt is unable to abduct their right eye
where is the lesion
unable to abduct right eye –> lateral rectus muscle doesn’t work –> damage to the abducens nerve which innervates it –> abducens nucleus come out of pons –> lesion in right pons
(Cranial nerve lesions are ipsilateral, except trochlear)
which CN come out of midbrain, pons and medulla
mid brain: CN 3, 4
pons: CN 5, 6, 7, 8
medulla: CN 9, 10, 11, 12
what does loss of grey-white matter differentiation on a CT scan indicate
‘loss of grey-white matter differentiation’ = cytotoxic oedema = ischaemia –> ischaemeic stroke
best ix for MS
MRI brain and spine
what phenomena of MS can checking visual evoked potentials reveal
optic neuritis
which Parkinson’s meds are c/I in pts with impulse control disorders eg gambling addiction
dopmine agonists eg ropinerole, pramipexole, apomorphine
weakness in legs, patches of sensory loss that come and go, middle aged female pt
likely diagnosis
MS
progressive weakness with mixed UMN and LMN signs
diagnosis
MND
what is the parkinsonian triad of symptoms
tremor
hypertonia
bradykinesia
tremor
hypertonia
bradykinesia
vertical gaze palsy
progressive supra nuclear palsy
tremor
hypertonia
bradykinesia
fluctuating cognitive impairment and hallucinations
Lewy body dementia
describe the gait in parkinsons
festinating and shuffling gait
causes of unilateral and bilateral high stepping gait
LMN lesions
Bilateral
- cauda equina
- peripheral neuropathy
- Guillain barre / charocot-maire-tooth
Unilateral
- radiculopathy of L5 root
- neuropathy of the sciatic nerve or common peroneal nerve
- polio at the anterior horn
causes of Spastic and circumducting gait
MS
space occupying lesions
tumours
causes of Spastic and scissoring gait
Cord lesions
- due to trauma, compression, syringomyelia or transverse myelitis
Bihemispheric brain lesions
- due to cerebral palsy or multiple sclerosis
what type of tremor is worse of resting, and reduced on action, can be assymetrical
parksions tremor
(essential tremor is usually bilateral/symmetrical, worse on resting, associated with family history, received by alcohol consumption)
which medication for MS can reduce duration and severity of attacks
IV methylprednisolone
what medication for MS can reduce relapse rate in the long term
IV beta interferon
what do periventricular lesions on MRI indicate
MS
factors associated with worse prognosis in MS
Older, male, motor signs at onset, early relapses, many MRI lesions and axonal loss
which condition is micrographia (abnormally small cramped handwriting) associated with
parkinsons
tremor
hypertonia
bradykinesia
spontaneous activity or akinetic rigidity of a limb
diagnosis
Parkinson plus syndrome –> cortico-basal degeneration
what is sporadic MND
occurs with no family history
what do SOD1mutations cause
familial ALS –> MND
what is hyperemesis gravidarum
persistent severe vomiting leading to weight loss and dehydration, as a condition occurring during pregnancy
what could be the cause of wernickes encephalopathy in a pregnant woman
hyperemesis gravidarum
what should be prescribed to a parksinons pt on levodopa who is experiencing on-off symptoms (motor fluctuations)
MAO-B inhibitor eg rasagiline
or OCMT inhibitor
or dopamine agonist eg ropinerole, pramipexole, apomorphine
classic cause of raised CSF protein
GBS
worsening unilateral neck pain
constricted pupil
ptosis
diagnosis?
internal carotid dissection, causing horners syndrome
which medications can cause acute dystonic reactions
dopamine antagonists eg metoclopramide
how does lesion in the primary visual cortex affect vision
contralateral homonymous hemianopia with macular sparing
how does lesion in the lateral geniculate nucleus affect vision
contralateral homonymous hemianopia
how does lesion in the optic tract affect vision
incongruous homonymous hemianopia
eg lesion in left optic tract causes right homonymous hemianopia
where is the lesion in optic neuritis
optic nerve
what is the gene and inheritance pattern of Huntingtons
autosomal dominant, defect in HTT gene
triad of Huntingtons
movement disorder
psychiatric features
depression
what is an oculogyric crisis (OGC), common causes and treatment
acute dystonic reaction - upward deviation of eyes, sometimes neck extended backwards and mouth fixed in open wide position
commonly caused by use of metoclopramide or haloperidol
tx = procyclidine, benzatropine
what is malingering
the deliberate faking of symptoms in order to obtain secondary gain
pt has difficulty hearing for 6 months, vertigo, reduced sensation of the opthalmic, maxillary, and mandibular divisions of the left trigeminal nerve, reduced taste sensation of the posterior left side of the tongue; and deviation of the uvula to the right
diagnosis?
acoustic neuroma
back pain associated with leg or buttock pain
relieved by flexion and worse with extension
may have weakness or reduced sensation in certain areas
diagnosis
spinal stenosis (which causes spinal claudication)
describe onset fo cluster headache vs migraine
cluster - sudden onset
migraine - gradual onset
where is the lesion in left upper quadrantinopia
right temporal lobe
where is the lesion in left homonymous hemianopia with macular sparing
right occipital lobe
sudden intense headache pain when shaving / brushing teeth / touching face / eating ice cream
diagnosis?
trigeminal neuralgia
unilateral sudden headache pain around eye
profuse eye watering and nasal secretions
diagnosis?
cluster headache
which conditions is sumatriptan (migraine med) C/I in
ischaemic heart disease, hypertension, peripheral vascular disease, previous strokes, and previous myocardial infarctions
(bc sumatriptan causes vasoconstriction)
which medications are used first line for neuropathic pain
Gabapentin, Pregabalin, Amitriptyline and Duloxetine
most common cause of LEMS
Small cell lung cancer
what is LEMS
autoimmune, usually due to underlying malignancy eg SCLC
limb weakness
worse in mornings
dry mouth / impotence / orthostatic hypotension
reduced / absent reflexes
what med can be used as symptoms management for LEMS
amifampridine
LEMS investigations
serology for anti-voltage-gated calcium channel antibodies
nerve condition studies - show a doubling of muscle action potential amplitude following exercise
imaging for SCLC
LEMS vs myasthenia gravis
LEMS
- weakness worse in mornings
- limb weakness
- absent or reduced reflexes
- small response to edrophonium
myasthenia gravis
- fatiguable mucles weakness
- starts with ocular muscle weakness
- persevered reflexes
- proper repose to edrophonium (improves in repose to acetylecholinsterase inhibitors)
when exactly should sumatriptan be taken for a migraine
should be taken once the headache starts, but not during the aura phase
pt presents with severe sudden onset headache and has history of recurrent sprains and shoulder dislocations like her father
diagnosis and explain what’s going on
she has Ehlers danlos syndrome
and is experiencing a subarachnoid haemorrhage due to rupture of a berry aneuryrsm (Ehlers danlos causes aneurysms)
diminished vibration sensation and proprioception
symmetrical sensory symptoms
some exaggerated and some diminished reflexes
diagnosis
subacute combined degeneration of the spinal cord
cause of subacute combined degeneration of the spinal cord
vit B12 deficiency
which tracts are degenerated in subacute combined degeneration of the spinal cord
degeneration of the dorsal column and the corticospinal tract
tx for subacute combined degeneration of the spinal cord
vt b12 replacement
function of spinothalamic tract
only sensory
- Pain
- Temp
sPinoThalamic
function of corticospinal tracts
sensory
- proprioception
light touch
vibration
motor
- lateral corticocpinal tract
voluntary movement of contralateral limbs
- anterior corticospinal tract
voluntary movement of the trunk
function of the dorsal column
only sensory
- fine touch
- 2 point discrimination
- proprioception
- vibration
what do Kayser-Fleischer rings in eye suggest
Wilsons disease
which condition is the ATP7B gene linked to
Wilsons disease
what is Wilsons disease, what are the signs an symptoms, investigations and treatments
defective copper metabolism
leads to copper accumulation esp in liver and brain
ATP7B gene mutation
signs/symptoms
- psychiatric / neurological symptoms
- hepatic dysfunction
- kayser-fleischer rings in the eye
investigations
- serum ceruloplasmin (low)
- serum copper levels (low)
- 24hr urinary copper collection (high)
- genetic testing
treatment
- chelators
–> D-penicillamine
–> Trientine
–> Zinc salts
crampy leg pain that radiates down the back of legs, is brought on by exercise but improves on bending over our walking uphill
diagnosis
spinal claudication
what are the antibodies against in LEMS
Autoantibodies against presynaptic voltage-gated calcium channel
in which condition are Anti-acetylcholine receptor antibodies found
myasthenia gravis
first line prophylaxis in migraine
propanolol
(if asthmatic give topiramate - but don’t give to pregnant or child brawling age)
first line prophylaxis for cluster headaches
verapamil
tx for cluster headaches
high flow oxygen or sumatriptan (subcut or intranasal)
tx for migraine
sumatriptan (oral) + NSAIDs
tiredness
weakness in limbs
numbness
increased tone and spasticity in legs
absent angle jerks
macrocytic megaloblastic anaemia
diagnosis
subacute combine degeneration of the spinal cord
what is a classic cause of surgical third nerve palsy
posterior communicating artery aneurysm
pt: suddenly feeling very dizzy, losing her sense of balance and has been choking on her food. On examination there is reduced left facial sensation, absent pain sensation throughout the right arms and legs, a droopy left eyelid and a constricted left pupil
diagnosis
Lateral medullary syndrome aka Wallenberg syndrome
(“DANVAH” - Dysphagia, ipsilateral Ataxia, ipsilateral Nystagmus, Vertigo, Anaesthesia, ipsilateral Horners syndrome)
sudden onset of vertigo
recent viral illness
vertigo not triggered by head movements
no hearing loss or tinnitus
diagnosis
vestibular neuritis
what are the paraneoplastic syndromes of small cell lung cancer
can be remembered by the “SCLC” mnemonic which stands for
SIADH,
Cushing’s,
LEMS
Cerebellar degeneration.
contrast horners syndrome caused by pan coats tumour vs carotid artery dissection
pancoast tumour
- miosis, ptosis, anhidrosis
- also shoulder pain, cough etc
carotid artery dissection
- miosis, ptosis
- no anhidrosis
- neck pain
patient is unable to adduct her left eye and nystagmus is noted in the right eye on abduction
diagnosis
left intranuclear opthalmoplegia (caused by lesion affecting left medial longitdinal fasciculus)
features of cerebellar dysfunction
DANISH:
Dysdiadochokinesia (inability to perform rapid alternating movements)
Ataxia
Nystagmus (typically multidirectional)
Intention tremor (tremor during voluntary movement illustrated by the finger-nose test)
Slurred speech
Hypotonia
which can best visualises spinal claudication
non contrast spine MRI
when can you use dexamethasone for raised ICP
only used for raised ICP resulting from malignancy
if have raised ICP due to cerebral oedema give mannitol
which medication can be used for raised ICP due to cerebral oedema
mannitol
which headache is COCP C/I in
migraine with aura
right-sided inferior quandrantanopia
where is the lesion
left parietal lobe
which medication can be used to manage choreoathetosis
tetrabenazine
what is sensory ataxia
ataxia due to impairment of sensory feedback signals eg when vision is removed -> rombergs test
what type of visual loss is most common due to optic neuritis
central scotoma
instability
night time falls
jeans no longer fit
pmh of diabetes
diagnosis
diabetic amyotrophy (symmetric wasting of the thighs in diabetes)
pt has infectious signs, siezure, and lateralising signs eg right sided increases tone and hypereflexia
diagnosis?
cerebral abscess - meningitis would not present with focal neurological signs
what does a ring enhancing lesion indicate on CT
abscess
which medication can be given for migraine prophylaxis to an asthmatic young woman
amytriptyline
MRI shows atrophy of the caudate nucleus and putamen
which condition has this
huntigntons
which genetic condition causes choreoathetosis and dementia
Huntingtons
confused, nausea, headache, non contrast CT shows hyper density in a sinus
diagnosis and first lien tx
intracranial venous thrombosis
LMWH
medical vs surgical 3rd nerve palsy, and causes
medical
- doesn’t affect pupil
- problem from inside of nerve: ischaemia of the nerve
surgical
- does affect pupil: dilation
- problem from outside of nerve compressing on it and the parasympathetic fibres which runs along its surface (parasympathetic constructs the pupil): PCA aneurysm - in circle of willis
