Neurology Flashcards
1
Q
What conditions are associated with SAH?
A
PKD
Ehlers-Danlos
Coarctation of the aorta
2
Q
What is Kernig’s sign?
A
Hip and knee bent to 90 degrees and positive if pain is caused by straightening the knee.
Demonstrates meningeal irritation.
3
Q
Where is the blood found in SAH on CT?
A
Interhemispheric fissure
Basal cisterns
Ventricles.
4
Q
What is looked for on LP for SAH?
A
Xanthochromia.
5
Q
What four bones meet at the pterion?
A
Frontal
Temporal
Sphenoid
Parietal
6
Q
What signs on CT may suggest extradural haemorrhage?
A
Midline shift
Compression of the ventricles
7
Q
What are risk factors for stroke?
A
Diabetes
AF
Valvular
Peripheral vascular disease
Previous TIA
Polycythaemia rubra vera
Carotid artery disease
Hyperlipidaemia
Clotting disorders
COCP
Excess alcohol
8
Q
What is the visual field defect in stroke?
A
Homonyous hemaniopia
9
Q
What is Todd’s palsy?
A
Temporary weakness following a seizure (usually of affected limb)
10
Q
What is a partial seizure?
A
Features focal to one hemisphere e.g. motor region
11
Q
What airway adjunct would you use in epilepsy?
A
Nasopharyngeal
12
Q
What are immediate management steps for epileptic fit?
A
Roll patient into recovery position
Move any items away that could cause harm
Call for senior help
Place pillow under head
Oxygen if required.
13
Q
Is the lateral or medial portion of the retinal field likely to be affected in bitemporal hemaniopia?
A
Medial
14
Q
How would you assess cranial nerves II, III, IV and VI?
A
Visual acuity
Visual fields
Fundoscopy
Pupillary light reflexes (direct and consensual)
Pupillary accommodation
Eye movements.
15
Q
What structures are damaged in homonymous hemaniopia?
A
Unilateral damage to optic radiation or visual cortex
16
Q
What is the mechanism of action of triptans?
A
5-HT receptor agonists which bind to and stimulate serotonin receptors
17
Q
What is the management of cluster headaches?
A
100% oxygen and subcutaneous/intranasal sumatriptan
18
Q
What are the pupil changes in cluster headache?
A
Miosis, ptosis, lacrimation
19
Q
How and when do you treat sinusitis?
A
Post 10 days with steroid nasal spray
Or antibiotics (phenoxymethylpenicillin)
20
Q
What can trigger trigeminal neuralgia?
A
Touch
Talking
Eating
Shaving
Cold
21
Q
What are the findings of GCA on biopsy?
A
Multinucleated giant cells
22
Q
What blood test is characteristically raised in GCA?
A
ESR
23
Q
When do you use IV medication for GCA as opposed to oral?
A
High dose IV methylprednisolone used when there is eye involvement
24
Q
What does the artery feel like in GCA?
A
Tender, thickened, pulseless
25
What medication is given with Levoodpa?
Peripheral decarboxylase inhibitor
26
What is the management for essential tremor?
Propranolol
Primidone (barbiturate anti-epileptic)
27
What medications are used in Parkinson's?
Levodopa + peripheral decarboxylase (e.g. carbidopa, benserazide)
COMT inhibitor (inhibitor of catecholomethyltransferase) e.g. entacapone
Dopamine agonist e.g. bromocriptine, cabergoline, pergolide
Monoamine oxidase-B inhibitors e.g. selegiline, rasagiline
28
What is the main side effect of Levodopa?
Dyskinesia:
Dystonia
Chorea
Athetosis
29
How is the dyskinesia caused my Levodopa managed?
Amantadine (glutamate antagonist)
30
What is the mechanism of action of COMT inhibitors?
Inhibit the enzyme which metabolises Levodopa in the brain so Levodopa has a longer effective duration
31
What is a notable SE of dopamine agonists?
Pulmonary fibrosis
32
Why are MOAI used in PD?
Reduce end of dose worsening of symptoms
33
What are the Parkinson's plus syndromes?
Multi system atrophy (autonomic dysfunction)
Lewy body dementia (associated with visual hallucinations, delusions, REM sleep disorders, sexual dysfunction, cerebellar dysfunction)
Progressive supranuclear palsy
Corticobasal degeneration (movement disorders in limbs)
34
Where is CSF contained?
Meninges and sucbarachnoid space
35
What are the most common causes of bacterial meningitis?
Neisseria meningitidis (gram negative diplococcus)
Streptococcus pneumonia
Haemophilus pneumoniae
Group B streptococcus (most common in neonates)
Listeria monocytogenes (common in neonates)
36
What are the viral causes of meningitis?
Enteroviruses e.g. coxsackie
Herpes simplex virus
Varicella zoster virus
37
What are the two tests for meningitis?
Kernig's
Brudzinski's (lie flat and flex head, positive if patient flexes their hips and knees involuntarily)
38
What is a faster way to test for meningococcal DNA than blood culture?
Meningococcal PCR
39
Where is a LP inserted?
L3/L4 level in the subarachnoid space
40
What is the management of bacterial meningitis for < 3 months?
IV cefotaxime + amoxicillin (covers Listeria)
41
What is the management of bacterial meningitis for > 3 months?
IV ceftriaxone
42
What is given to reduce the frequency and severity of hearing loss and neurological complications in meningitis?
Dexamethasone
43
What are notifiable diseases
Bacterial meningitis and meningococcal septicaemia
44
What is given as post exposure prophylaxis for meningitis?
Single dose ciprofloxacin
45
What are complications of meningitis?
Hearing loss
Seizures
Cognitive impairment
Memory loss
Focal neurological deficits e.g. limb weakness or spasticity
46
Where does HSV typically infect in encephalitis?
Temporal lobes and inferior frontal lobes
47
Which type of HSV is most common in neonatal encephalitis?
Type 2 due to genital herpes contracted during birth
48
What does a LP show in encephalitis?
Lymphocytosis
Elevated protein
49
What is Todd's palsy?
Temporary weakness, usually of the affected limb, following a seizure
50
What are infantile spasms known as?
West syndrome
51
What is the characteristic finding of West syndrome on en EEG?
Hypsarrhythmia
52
How is West syndrome treated?
ACTH and vigabatrin
53
What features are suggestive of a pseudo seizure vs a seizure?
Pelvic thrusting
Crying after
Don't occur when the patient is alone
Gradual onset
More common in females
54
What is a ketogenic diet?
Increased fat
Low carbohydrate
Controlled protein
55
What are the investigations for epilepsy?
EEG: electroencephalogram
MRI brain
56
What are the DVLA rules for epilepsy?
6 months no driving if partial seizure or seizure with no changes on imagine
Otherwise 1 year seizure free
57
What are non-medical management options in epilepsy?
Take showers rather than baths
Caution with swimming, heights, traffic, dangerous equipment
58
What is the management for a tonic clonic seizure?
Male: sodium valproate
Female: lamotrigine or levetiracetam
59
What is the management for a partial seizure?
Male: lamotrigine or levetiracetam
Female: lamotrigine or levetiracetam
60
What is the management for a myoclonic seizure?
Male: sodium valproate
Female: levetiracetam
61
What is the management for a tonic or atonic seizure?
Male: sodium valproate
Female: lamotrigine
62
What is the management for an absence seizure?
Male: ethosuximide
Female: ethosuximide
63
Which anti epileptic medication can exacerbate absence seizures?
Carbamazepine
64
Which anti epileptic medication can cause peripheral neuropathy?
Phenytoin
65
What is the mechanism of action of sodium valproate?
Increases the activity of GABA (gamma-aminobutyric acid)
66
What are the notable side effects of sodium valproate?
Teratogenic
Liver damage and hepatitis
Hair loss
Tremor
Reduce fertility
67
What are the rules for taking sodium valproate in regards to pregnancy?
The Valproate Pregnancy Prevention Programme (contraception and annual risk acknowledgement form) as it can cause neural tube defects and developmental delay
68
How many times is a benzopdiazepine given in status epilepticus?
Twice
69
What are the second line options in status epilepticus?
IV phenytoin
IV sodium valproate
IV levetiracetam
70
What are the third line options in status epilepticus?
Phenobarbital
General anaesthesia
71
What are the doses for medication in status epilepticus?
Buccal midazolam (10mg)
Rectal diazepam (10mg)
IV lorazepam (4mg)
72
What is the pathophysiology of MS?
Chronic and progressive autoimmune condition involving demyelination in the CNS. The immune system attacks the myelin sheath of the myelinated neurones (myelin is provided by oligodendoryctes in the CNS).
Inflammation and immune cell infiltration cause damage to the myelin, affecting the electrical signals moving along the neurones
73
Why do symptoms become gradually more permanent in MS?
Re-myelination is incomplete
74
What is needed for a diagnosis of MS?
Demyelinated lesions disseminated in time and space
75
What are the patterns of disease in MS?
Clinically isolated syndrome: first presentation (lesions on MRI suggest they will progress to MS)
Relapsing-remitting
Secondary progressive (used to be relapsing-remitting and now progressive)
Primary progressive
76
What are risk factors for MS?
Genes
EBV
Low vitamin D
Smoking
Obesity
77
How is optic neuritis investigated?
MRI with contrast
78
What is the pathophysiology of optic neuritis?
Demyelination of the optic nerve
79
What are the key features of optic neuritis?
Central scotoma
Pain with eye movement
Impaired colour vision
Relative afferent pupillary defect (affected eye has a decreased response when shining light into it but a normal response when shining light into other eye)
80
What is an eye movement disorder in MS?
Internuclear ophthalmoplegia
Caused by a lesion in the medial longitudinal fasciculus
Impaired adduction of the same side as the lesion and nystagmus in the contralateral eye
81
What type of limb weakness is in MS?
Spastic weakness
82
What is a sign of MS?
Lhermitte's sign: electric shock sensation that travels down the spine and into the limbs when flexing the neck (indicating disease in the cervical spinal cord in the dorsal column caused by stretching the demyelinated dorsal column)
83
What is transverse myelitis?
A site of inflammation in the spinal cord which results in sensory and motor symptoms below the level of inflammation
84
What is Romberg's testing for?
Sensory ataxia (could be cause by a lesion in the dorsal columns)
85
What is the criteria used for MS?
McDonald
86
What is shown on LP for MS?
Oligoclonal bands in the CSF
87
What are the investigations for MS?
MRI
LP
88
What is an example of a medication used long term in MS?
Betaferon
89
How are acute episodes of MS treated?
Methylprednisolone
90
Where does demyelination occur in GBS?
Peripheral nervous system
91
What is the pathophysiology of GBS?
Autoimmune
"Molecular mimicry"
92
What are the infective triggers of GBS?
Campylobacter jejuni
EBV
CMV
93
What are the signs of GBS on examination?
Loss of reflexes
Flaccid paresis
94
What are the CSF findings in GBS?
Elevated protein
Normal glucose
Normal WCC
95
What is the management of GBS?
IV immunoglobulins
Plasmapheresis
96
How is GBS investigated?
EMG nerve conduction studies
CSF
Monitor FVC serially for respiratory depression
97
What are the antibodies in myasthenia graves?
Acetylcholine receptor antibodies (bind to post synaptic membrane to block receptors. The more they are used, the more they become blocked)
Muscle specific kinase antibodies (MuSK)
Low density lipoprotein receptor-related protein 4 antibodies
All of these also activate the complement system, leading to cell damage and worsening symptoms
98
Where does myasthenia graves affect?
Neuromuscular junction
99
Where are the autoantibodies produced in myasthenia gravis?
Thymus
100
What test can confirm if doubt in diagnosis for myasthenia graves?
Tensilon/ Edrophonium test:
Give IV edrophonium chloride which blocks cholinesterase inhibitors and should temporarily relieve weakness
101
What is the management for myasthenia gravis?
Anti-cholinesterases: pyridostigmine or rivastigmine
Immunosuppression to decrease production of antibodies: steroids, azathioprine
Thymoma
Plasmapheresis for severe relapsing cases
Rituximab (monoclonal antibody against B cells) when other treatment fails
102
Which medications worsen myasthenia graves?
Antibiotics
CCBs
BB
Lithium
Statin
103
What is the management of myasthenic crisis?
IV Immunglobulins
Plasmapheresis
NIV e.g. BIPAP
Mechanical ventilation
Serial FVC measurements
104
What is the pathophysiology of MND?
Progressive degeneration of UMN and LMN
Relentless and unexplained destruction of upper motor neurones and anterior horn cells in the brain and spinal cord
105
What are the types of MND?
Amyotrophic lateral sclerosis
Progressive bulbar palsy
Progressive muscular atrophy
Primary lateral sclerosis
106
Does MND have sensory symptoms?
No
107
Does MND have visual symptoms?
No
108
What is the diagnostic tool for MND?
El-Escorial diagnostic criteria
109
What is the medication used in MND?
Riluzole (aims to slow progression and increase survival by 2-3 months)
110
What is the management of MND?
Riluzole
Baclofen for muscle spasticity
Antimuscarinic for excess saliva
Benzodiazepines for breathlessness worsened by anxiety
Advanced directives
111
Which condition is MND associated with?
Pick's disease (frontotemporal dementia)
112
What do most patients die of in MND?
Respiratory failure or pneumonia as a result of bulbar palsy (impairment of CN 9, 10, 11 and 12)
113
What are the microscopic changes in Alzheimer's?
Cortical plaques due to deposition of type A-beta amyloid protein and intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein
Hyperphoshorylation of the tau protein
114
What is the macroscopic change in Alzheimer's?
Widespread cerebral atrophy involving the cortex and hippocampus
115
What are the biochemical changes in Alzheimer's?
Deficit of acetylcholine
116
What are cognitive assessment tools?
6 item cognitive impairment test (6CIT)
10 point cognitive screener (10-CS)
Mini mental state examination <24/30
117
What medications are used in Alzheimer's?
Acetylcholinesterase inhibitors: donepezil, galantamine and rivastigmine (mild or moderate)
Memantine (second line or mono therapy in severe)
118
When is donepezil CI?
Relatively in bradycardia
119
What is the SE of donepezil?
Insomnia
120
What does the facial nerve supply parasympathetic supply to?
Submandibular and sublingual salivary glands
Lacrimal glands
121
What causes bilateral UMN lesions?
Rare:
Pseudobulbar palsies
MND
122
What are common causes of facial nerve palsy?
Bell's palsy
Ramsay Hunt syndrome
Otitis media
Otitis externa
HIV
Diabetes
Sarcoidosis
MS
GBS
Acoustic neuroma
Parotid tumour
Cholesteatoma
Basal skull fracture
123
Who is given Aciclovir in shingles?
If presenting within 72 hours to reduce risk of post hepatic neuralgia
124
Who is eligible for the shingles vaccination?
>70
125
What is the most malignant brain tumour?
Glioblastoma multiforme
126
What do meningiomas cause?
"Mass effect"
127
Which cancers most commonly spread to the brain?
Lung
Breast
Renal cell carcinoma
Melanoma
128
How does raised ICP cause papilloedema?
The sheath around the optic nerve is connected with the subarachnoid space
The raised CSF pressure flows into the optic nerve sheath, increasing the pressure around the optic nerve behind the optic disc, causing the optic disc to bulge forwards
129
What does papilloedema show on fundoscopy?
Blurring of the optic disc margin
Elevated optic disc
Loss of venous pulsation
Engorged retinal veins
Haemorrhages around the optic disc
Paton's lines (creases or folds in the retina around the optic disc)
130
What is Cushing's reflex?
1. Bradycardia
2. Hypertension
3. Irregular respirations
131
What is the management of raised ICP?
Mannitol or hypertonic saline
Intubation/hyperventilation (decreased CO2)
132
What is coning?
Herniation of cerebellar tonsils through the foramen mangnum leads to compression of the brainstem and respiratory arrest
133
What is the management of a brain abscess?
Surgery: craniotomy and the abscess cavity is debrided
IV abx 3rd generation cepahlosporin (ceftriaxone) + metronidazole
Intracranial pressure management: dexamethasone
134
What is shown on a CT head in a brain abscess?
Ring enhancing lesion
135
What causes congenital hydrocephalus?
Spina bifida
Infection during pregnancy e.g. mumps, rubella
136
What causes acquired hydrocephalus?
Illness
Injury e.g. head injury or brain tumour
137
What is the triad of normal pressure hydrocephalus?
1. Abnormal gait
2. Urinary incontinence
3. Dementia
Symptoms come on gradually
138
What shows on imaging for normal pressure hydrocephalus?
Ventriculomegaly in the absence of or out of proportion to sulcal enlargement
139
What is the management of hydrocephalus?
Ventriculo-peritoneal shunt
Endoscopic third ventriculostomy
140
What causes idiopathic intracranial hypertension?
Unknown
Secondary to venous sinus thrombosis
Drugs: tetracyclines, nitrofurantoin, vitamin A, isotretionoin, danazol, somatropin.
141
What is a sixth nerve palsy?
Abducens controls lateral rectus so abducens palsy causes esotropia (eye deviated inwards)
142
What are the investigations for idiopathic intracranial hypertension?
CT: shows no SOL
LP: increased opening pressure
143
What is the management of idiopathic intracranial hypertension?
Weight loss
Acetozolamide
Topiramate
Therapeutic LP
Surgery: optic nerve sheath decompression and fenestration to prevent optic nerve damage
Lumboperitoneal or ventriculoperitoneal shunt
144
What visual field defect does a pituitary tumour cause?
Bitemporal hemianopia due to compression of optic chiasm
145
What is the management of pituitary tumours?
Trans sphenoidal surgery
Radiotherapy
Bromocriptine to block excess prolactin
Somatostatin analogues e.g. octreotide to block excess growth hormone
146
Where is the Huntington's generation found?
Huntington protein chromosome 4
147
How does Huntington's present?
Begins with cognitive, psychiatric or mood problems followed by movement disorders:
Chorea
Dystonia
Rigidity
Eye movement disorders
Dysarthria
Dysphagia
148
What medication is used for chorea symptoms in Huntington's?
Tetrabenazine
149
What is the most common cause of death in Huntington's?
Aspiration pneumonia
Suicide
150
What are the SE of NSAIDs?
Gastritis with dyspepsia
Stomach ulcers
Exacerbation of asthma
Hypertension
Renal impairment
CAD, HF, strokes
151
How do you convert oral morphine to oral codeine/tramadol?
x10
152
How do you convert oral morphine to oxycodone?
x0.6666666
153
How do you convert oral morphine to diamorphine?
x0.3
154
What is a buprenorphine 5mcg patch equivalent to in morphine?
12mg
155
What is a 12cmg fentanyl patch equivalent to in morphine?
30mg
156
What questionnaire is used to determine the likelihood of neuropathic pain?
The DN4 questionnaire >4=likely
157
What types of medication are gabapentin and pregablin?
Anticonvulsant
158
What is the terminal end of the spinal cord called?
Conus medullaris
159
What is the most common primary cancer to metastasise to brain?
Lung
160
What are the ascending spinal tracts?
Spinothalamic tracts
Dorsal column
161
What is the descending spinal tract?
Corticospinal
162
What do the spinothalamic tracts carry?
Anterior: crude touch
Lateral: pain and temperature
163
Do dorsal roots carry afferent or efferent?
Afferent (away from stimulus towards CNS and brain)
164
Do dorsal roots carry sensory or motor?
Sensory
165
Where do the spinothalamic tracts decussate?
At the spinal cord level
166
Where do the dorsal columns decussate?
Brainstem (medulla)
167
What do the dorsal columns carry?
Fine touch, vibration, proprioception
168
Where do the corticospinal tracts decussate?
Lateral: brainstem (medulla oblangata)
Anterior
169
What do corticospinal tracts carry?
Motor
170
How does a complete cord lesion present?
Complete loss of function (motor/sensory) below the level of the lesion
171
How does Brown Sequard syndrome present?
Ipsilateral weakness (UMN signs below the lesion (spastic paralysis) and LMN weakness (flaccid paralysis) at the level of the lesion): corticospinal tracts cross at the brainstem
Ipsilateral proprioception/vibration loss: dorsal columns cross at the medulla
Contralateral pain/temperature loss: spinothalamic cross at the level of the spinal cord
Horner's syndrome is the lesion is above T1
172
What is ventral cord syndrome also known as?
Anterior cord syndrome
Damage to the anterior 2/3 of the spinal cord
173
How does anterior cord syndrome present?
Bilateral weakness
Bilateral loss of pain and temperature
Autonomic dysfunction (abnormal BP)
Bladder dysfunction
174
What causes anterior cord syndrome?
Ischaemia of the anterior spinal artery:
Thromboembolism
Truama
Hypotension
Aortic disease as damaging the arterial supply to the anterior spinal artery e.g. aortic aneurysm, thrombosis, dissection
175
What is dorsal cord syndrome also known as?
Posterior cord syndrome
176
What is mainly carried in the dorsal/posterior cord?
Ascending tracts
177
How does posterior cord syndrome present?
Gait ataxia
Abnormal vibration sense and paraesthesia
If large, may involve the lateral and corticospinal tracts leading to weakness
178
What are the causes of posterior cord syndrome?
Inflammatory e.g. MS
Syphilis
Ischaemia e.g. posterior cord syndrome
Malignancy
Metabolic e.g. subacute degeneration of the cord due to Vitamin B12 deficiency
Hereditary e.g. Friedreich ataxia
179
What often causes central cord syndrome?
Hyperextension injury of the neck within the cervical spine
Most commonly a trauma, caused by a fall in the elderly where there is simultaneous compression of the anterior and posterior cord
180
Which cords does central cord syndrome affect?
Medial aspect of the corticospinal and the crossing fibres of the spinothalamic
181
How does central cord syndrome present?
Weakness: upper extremities > lower extremities
Pain and temperature loss: usually located at the level of the lesion in a cape like distribution affecting the upper back and upper extremities
Neck pain: commonly due to mechanism of injury
Normal vibration and proprioception (dorsal columns)
Urinary retention may occur.
182
What is a syringomyelia?
Fluid filled cyst within the spinal cord
183
What is a radiculopathy?
A narrowing where the nerve root exits the spine
184
What causes a radiculopathy?
Stenosis
Bone spurs
Disc herniation
Disc degeneration
Age related spondylosis (cervical)
185
Where does cervical radiculopathy most commonly affect?
C5-C7
186
What is sciatica also known as?
Lumbar radiculopathy
187
Which nerve root is biceps jerk?
C6
188
Which nerve root is triceps jerk?
C7
189
Which nerve root is ankle jerk?
S1
190
Which nerve root is sensation for thumb?
C6
191
Which nerve root is sensation for middle finger?
C7
192
Which nerve root is sensation for dorsum of foot/big toe?
L5
193
Which nerve root is sensation for ankle, lateral aspect of foot, sole and little toe?
S1
194
Which nerve root is myotome for biceps?
C6
195
Which nerve root is myotome for triceps?
C7
196
Which nerve root is myotome for dorsiflexion (stand on heels)?
L5
197
Which nerve root is myotome for plantar flexion (stand on toes)?
S1
198
In which nerve roots is the knee reflex affected?
L3-L4
199
In which nerve roots is there a positive femoral stretch test?
L3-L4
200
In which nerve roots is there a positive sciatic stretch test?
L5-S1
201
Which nerve root is sensation for anterior thigh?
L3
202
Which nerve root will cause weak hip flexion, knee extension and hip adduction?
L3
203
Which nerve root is sensation for anterior aspect of knee and medial malleolus?
L4
204
Which nerve root will cause weak knee extension and hip adduction?
L4
205
What are the nerve roots of the spinal cord?
C1-C7
T1-T12
L1-L5
S1-S5
206
Which nerve root is upper cervical flexion?
C1
207
Which nerve root is upper cervical extension?
C2
208
Which nerve root is cervical lateral flexion?
C3
209
Which nerve root is shoulder girdle elevation?
C4
210
Which nerve root is shoulder abduction?
C5
211
Which nerve root is elbow flexion?
C6
212
Which nerve root is elbow extension (biceps)?
C7
213
Which nerve root is thumb extension (triceps)?
C8
214
Which nerve root is finger adduction?
T1
215
Which nerve root is hip flexion?
L1/L2
216
Which nerve root is knee extension?
L3
217
Which nerve root is ankle dorsiflexion?
L4/L5
218
Which nerve root is great toe extension?
L5
219
Which nerve root is ankle plantar flexion?
S1
220
Which nerve root is bladder and rectum motor supply?
S4
221
Which nerve root is sensation to heel?
S1
222
Which nerve root is sensation to top of foot?
L5
223
Which nerve root is sensation to medial malleolus?
L4
224
Which nerve root is sensation to inguinal ligament?
L1
225
How does a common perineal nerve lesion present?
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 perineal muscles
226
What does the sciatic nerve divide into?
Tibial and common perineal nerves
227
What are examples of brachial plexus injury?
Erb-Duchenne paralysis: C5,C6
Winged scapula
May be caused by breech presentation
Klumpke's paralysis: T1
Loss of intrinsic hand muscles
Due to traction
228
Which roots does the radial nerve supply?
C5-T1 (continuation of posterior cord of brachial plexus)
229
How does a radial nerve lesion present?
Wrist drop (Saturday night palsy)
Sensory loss to small area between the dorsal aspect of the 1st and 2nd metacarpals
Paralysis of tricep (loss of elbow extension)
230
Which nerve roots are the ulnar nerve?
C8-T1
231
How does an ulnar nerve lesion present?
Motor to the adductor pollicis and hypothenar muscles
Wasting and paralysis of intrinsic hand muscles
Sensory to the medial 1.5 fingers (palmar and dorsal aspect)
"Claw hand": hyperextension of the metacarpophalangeal joints and flexion at the distal and proximal interphalangeal joints of the 4th and 5th digits
Radial deviation of the wrist
232
How do you treat normal pressure hydrocephalus?
Ventriculoperitoneal shunting
233
What causes normal pressure hydrocephalus?
Reduced CSF absorption at the arachnoid villi
234
What are the risk factors for carpal tunnel?
Idiopathic
Pregnancy
Oedema e.g. heart failure
Lunate fracture
Rheumatoid arthritis
235
What are the symptoms of carpal tunnel?
Pain/pins and needles in thumb, index, middle finger
Unusually the symptoms may 'ascend' proximally
Patient shakes his hand to obtain relief, classically at night.
236
What are the signs of carpal tunnel?
Weakness of thumb abduction (abductor pollicis brevis)
Wasting of thenar eminence (not hypothenar)
Tinel's sign: tapping causes paraesthesia
Phalen's sign: flexion of wrist causes symptoms.
237
What is the management of carpal tunnel?
6 week trial of conservative:
Wrist splints at night
Corticosteroid injection.
If persistent:
Surgical decompression: flexor retinaculum division.
238
What are the verbal points in GCS?
Orientated in time/place/person
Confused
Inappropriate words
Incomprehensible sounds
None
239
What are the motor points in GCS?
Obeys command
Localises pain
Normal flexion to pain (withdraws)
Abnormal flexion to pain (decorticate response)
Extends to pain (decerebrate response)
None
240
What is dysphonia?
Difficulty with speech volume
241
What are tests for cognitive state?
AVPU
AMT 0-10 (abbreviated mental test)
MMSE 0-30
MOCA (Montreal cognitive assessment)
ACE-R 0-100 (Addenbrooke's cognitive examination)
242
Which cranial nerve supplies lateral rectus?
Abducens
243
Which cranial nerve supplies superior oblique?
Trochlear
244
What is the motor component of trigeminal nerve?
Muscles of mastication and jaw jerk
245
Which muscles does the accessory nerve supply?
Sternocleidomastoid and trapezius
246
Which nerve root level is the clavicle?
C3/C4
247
Which are the phrenic nerve roots?
C3,4,5
248
Which nerve root is the sternum?
T8
249
What is the neurotransmitter from UMN to LMN?
Glutamate
250
What are UMN?
Neurones with originate in the cerebral cortex and terminate in the brainstem/spinal cord when it synapses with LMN
250
251
Where does the corticospinal tract terminate?
Ventral horn
252
Which of the corticospinal tracts decussates in the medulla and which remained ipsilateral descending into the spinal cord?
Lateral decussates
Anterior remains ipsilateral
253
What are the two corticospinal tracts?
Lateral
Anterior
254
What are LMN?
Cell body lies within the ventral horn of the brainstem nuclei of the cranial nerves. Terminate on the muscle fibres
255
What is a motor unit?
LMN + muscle fibre
256
What causes mononeuritis multiplex?
Vasculitis (Wegener's, polyarteritis nodosa, RA)
Inflammation
Sarcoidosis
257
How do the antibodies in Lambert-Eaton myasthenia syndrome work?
Against voltage gated sodium channels
Less acetylcholine across the synapse
258
Which malignancy is Lambert-Eaton myasthenia syndrome associated with?
Small cell lung cancer
259
How does Lambert-Eaton myasthenia syndrome present?
Proximal muscle weakness
Autonomic dysfunction (dry mouth, blurred vision, impotence, dizziness)
Reduced or absent tendon reflexes
260
How do you differentiate Lambert-Eaton myasthenia syndrome from myasthenia graves?
In Lambert-Eaton myasthenia syndrome, symptoms improve after periods of muscle contraction
261
How is Lambert-Eaton myasthenia syndrome treated?
Amifampridine blocks voltage gated potassium channels in the presynaptic membrane which prolonged the depolarisation of the cell membrane and assist calcium channels in carrying out their action
Other:
Pyridostigmine
Immunosuppressant (prednisolone)
IV immunoglobulins
Plasmapheresis
262
How is Charcot-Marie-Tooth disease inherited?
Autosomal dominant
263
What are the causes of peripheral neuropathy?
A lcohol
B 12 deficiency
C cancer e.g. myeloma and CKD
D diabetes and drugs (isoniazid, amiodarone, leflunomide, cisplatin)
E very vasculitis
264
What is a characteristic feature of Charcot-Marie-Tooth disease?
Peripheral neuropathy
Inverted champagne bottle legs
265
How is neurofibromatosis type 1 inherited?
Autosomal dominant
Chromosome 17, codes for a protein called neurofibromin which is a tumour suppressor gene
266
What is the diagnostic criteria for neurofibromatosis type 1?
"CRABBING"
C afe au last spots (>15mm is significant)
R elative with the condition
A xillary or inguinal freckling
BB bony dysplasia such as bowing of a long bone or sphenoid wing dysplasia
I ris hamaatomas (Lisch nodules, yellow-brown spots on the iris)
N eurofibromas
G lioma of the optic pathway
267
Which neurofibromas are significant?
2 or more
A single plexiform neurofibroma
268
What GI malignancy can neurofibromatosis type 1 cause?
GI stromal tumour (type of sarcoma)
269
270
How is neurofibromatosis type 2 inherited?
Autosomal dominant
Chromosome 22, codes for a protein called merlin which is a tumour suppressor protein important in Schwann cells
271
What is the key feature of neurofibromatosis type 2?
Bilateral acoustic neuromas
272
What signs are present in complex regional pain syndrome?
Intermittent swelling
Colour changes
Temperature changes
Skin flushing
Abnormal sweating
273
What type of pain is complex regional pain syndrome?
Neuropathic
274
What is needed for a diagnosis of chronic fatigue syndrome?
3 months of disabling fatigue affecting mental and physical function >50% of the time in the absence of other disease which may explain symptoms
275
What brain chemical is lacking in narcolepsy?
Hypocretin (orexin) that regulates wakefulness
Immune system thought to attack the cells that produce it
276
How is narcolepsy managed?
Stimulant: modafininl, dexamphetamine, methylphenidate, pitolisant
277
What can trigger narcolepsy?
Hormones e.g. puberty, menopause
Stress
Infection
278
What is cataplexy?
The sudden loss of muscle tone while a person is awake
279
What are types of myopathy?
Steroid myopathy
Statin myopathy
Metabolic and endocrine myopathies
Myotonic dystrophy (myotonia = prolonged muscle contractions after use)
280
What sign is positive in myopathies?
Gower's sign: use their hands and arms to "walk" up their own body from a squatting position due to lack of hip and thigh muscle
281
What is Becker's muscular dystrophy?
Milder form of Duchenne's
282
How is Duchenne's muscular dystrophy inherited?
X-linked recessive
Females are carriers but not affected
No male to male transmission
283
What are symptoms of Duchenne's muscular dystrophy?
Proximal muscle weakness
Often have very bulky muscles at first (psuedohypertrophy) and then muscle wasting later on
Scoliosis later on
284
How is Duchenne's muscular dystrophy diagnosed?
Genetic testing
285
How is Duchenne's muscular dystrophy managed?
Supportive: physiotherapy, wheelchair
Corticosteroids are best treatment (prednisolone): prolong life
Manage congestive HF and arrhythmias
NIV for respiratory failure
286
Which cranial nerves does a pseudobulbar palsy affect?
UMN CN 4, 5, 7
287
Which cranial nerves does a bulbar palsy affect?
LMN CN 9, 10, 11, 12
288
What causes a bulbar palsy?
Brainstem stroke
Tumour
MND
Neurosyphilis
289
What causes a psuedobulbar palsy?
Cerebral stroke or haemorrhage involving both hemispheres
290
What are symptoms of bulbar and psuedobulbar palsy?
Difficulty swallowing (dysphagia)
Vocal cord muscle spasms that change your voice (dysphonia)
Slowed, slurred speech (dysarthria)
291
How do you differentiate between psuedobulbar and bulbar palsy?
Bulbar is LMN, psueodbulbar is UMN
In bulbar palsy, emotions are not affected.
292
What are causes of dysphagia?
Neurological:
Myasthenia gravis
Bulbar palsy
Pseudobulbar palsy
Syringobulbia
Wilson's
PD
Stroke
Non-neurological:
Cancer
Benign stricture
Pharyngeal pouch
Achalasia
Oesophageal spasm
Systemic sclerosis
293
What is suggestive of a motility disorder e.g. achalasia/CNS?
Difficulty swallowing both solids and liquids from the start
294
What makes you suspect a bulbar palsy cause for dysphagia?
Difficulty to make the swallowing movement, especially if they cough on swallowing
295
How do you investigate dysphagia?
CXR
Barium swallow
Upper GI endoscopy
296
What does DANISH stand for?
Dysdiadokinesia, dysmetria (past pointing)
Ataxia
Nystagmus (horizontal = ipsilateral)
Intention tremor
Slurred speech
Hypotonia
297
Who can confirm brain death?
Two doctors at two separate times
Must have 5 years post grad experience
One must be a consultant
Neither can be from transplant team
298
How is brain death confirmed?
Fixed, unresponsive pupils
No corneal reflex
Absent oculi-vestibular reflex (caloric test where there is no eye movement when ice cold water injected to the ear)
No response to supraorbital pressure
No cough or gag reflex
No observed respiratory effort in response to disconnection from ventilator for 5 minutes
299
When can brain death be confirmed?
Deep coma of known aetiology
Reversible causes excluded
No sedation
Normal electrolytes
300
What are the types of cerebral palsy?
Spastic (70%): UMN affected in the periventricular white matter (pyramidal or corticospinal). Can be hemiplegic, quadriplegic or diplegic
Ataxic hypotonic (10%): cerebellum affected
Dyskinetic (10%): basal ganglia and substantia nigra are affected (extrapyramidal)
Mixed (10%)
301
What causes cerebral palsy?
Antenatal (80%): genetic syndromes, rubella, CMV
hypo-ischaemic injury at birth (10%)
Postnatal (10%): intraventricular haemorrhage in prems, trauma, NAI, hydrocephalus, kernicterus due to hyperbilirubinaemia
302
What is the pathophysiology of cerebral palsy?
Non-progressive lesion of motor pathways in the developing brain
303
What are symptoms of cerebral palsy?
Movement issues
Posture trouble
Epilepsy (30%)
Squints (30%)
Visual impairment
Speech and language disorders due to hearing problems
Behaviour problems
Learning difficulties
Feeding problems
Joint contractures
Hip subluxation
Scoliosis
304
Which limb is usually worse in hemiplegic CP?
Arm
305
What is diplegia spastic CP?
All four limbs affected
Legs worse so arm function appears relatively normal
Walking is abnormal
306
What is a developmental sign for CP?
Hand preference before 12 months
Persistent primitive reflexes beyond 6 months
307
What are signs of spastic CP?
Increased limb tone
Brisk deep tendon reflexes
Extensor plantar response (positive Babinski)
Increased tone may suddenly yield under pressure (clasp knife)
308
How is tuberous sclerosis inherited?
Autosomal dominant
TSC1 gene on chromosome 9 which codes for hamartin
TSC2 gene on chromosome 16 which codes for tuberin
Hamartin and tubers interact with each other to control the size and growth of cells
309
What is the characteristic sign of tuberous sclerosis?
Hamartomas (benign tissue growths) affecting:
Skin
Brain
Lungs
Heart
Kidneys
Eyes
310
What are the skin features of tuberous sclerosis?
Ash leaf spots (depigmented areas)
Shagreen patches (thickened, dimpled, pigmented patches of skin)
Angiofibromas (small skin-coloured or pigmented papule that occur over the nose and cheeks)
Ungual fibromas: circular painless lumps that slowly grow from the nail bed and displace the nail
Cafe-au-lait spots
Poliosis: isolated patch of white hair on the head, eyebrows, eyelashes or beard
311
What are the neurological features of tuberous sclerosis?
Epilepsy
Learning disability
Brain tumours
312
What are the signs of CP?
Abnormal limb tone (head and trunk hypo and limbs hyper)
Abnormal limb and trunk posture
Delayed motor milestones
Feeding difficulties: slow, gagging, vomiting, promoter incoordination
Abnormal gait
313
What are the signs of ataxic CP?
Symmetrical
Early trunk and limb hypotonia
Poor balance
Delayed motor development
Ataxic gait
Intention tremor
Cerebellar signs
314
What is quadriplegic CP?
All 4 limbs affected
Arms usually worse
Trunk involved: extensor posturing, poor head control, low central tone
Seizures
Microcephaly
Learning difficulties
315
What is hemiplegic CP?
Bad side
Unilateral involvement of arm and leg
Arm usually worse
Face spared
Tip toe walking
Fisting and flexion of the affected arm
316
What are signs of dyskinetic CP?
Athetoid movements: slow, involuntary, writhing movements, dystonia, choreoathetosis
Oromotor problems
Fluctuating tone
Involuntary movements
Intellect unimpaired
317
Does the dorsal column run posteriorly or anteriorly in the spinal cord?
Posteriorly
