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Phase 4 > Neurology > Flashcards

Neurology Flashcards

1
Q

Describe the management of epilepsy

A

Most neurologists now start antiepileptics following a second epileptic seizure.

NICE guidelines suggest starting antiepileptics after the first seizure if:
> neurological deficit
> brain imaging: structural abnormality
> EEG: unequivocal epileptic activity
> patient / family / carers seizure risk unacceptable

Drug treatment

  • Generalised tonic-clonic seizures
    > males: sodium valproate
    > females: lamotrigine or levetiracetam
    » sodium valproate if under 10 or women unable to have children
    » sodium valproate causes weight gain
  • Focal seizures
    > first line: lamotrigine or levetiracetam
    > second line: carbamazepine, oxcarbazepine or zonisamide
  • Absence seizures (Petit mal)
    > first line: ethosuximide
    > second line:
    male: sodium valproate
    female: lamotrigine or levetiracetam
    carbamazepine may exacerbate absence seizures
  • Myoclonic seizures
    > males: sodium valproate
    > females: levetiracetam
  • Tonic or atonic seizures
    > males: sodium valproate
    > females: lamotrigine
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2
Q

describe autonomic dysreflexia

A

caused by excessive sympathetic response below level of injury without coordinated parasympathetic counter response

can only occur if spinal cord injury is above T6

features
- severe hypertension
- flushing and sweating above level of injury
- reflex bradycardia

causes
- urinary retention / catheter blockage
- faecal impaction / loading

complications: stroke

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3
Q

describe Guillain-Barré syndrome

A

immune-mediated demyelination of peripheral nervous system usually post-diarrhoeal illness e.g. Campylobacter jejuni

clinical features
- back/leg pain
- progressive symmetrical ascending weakness (starting in legs)
- reflexes are reduced or absent
- sensory symptoms usually mild

other features
- respiratory muscle weakness
- cranial nerve involvement: diplopia, bilateral facial nerve palsy, oropharyngeal weakness
- autonomic involvement: urinary retention, diarrhoea

investigations
- LP: rise in CSF protein with normal WCC
> gold-standard investigation
- anti-ganglioside antibodies
- Nerve conduction studies: decreased motor nerve conduction velocity

treatment - plasma exchange, IV immunoglobulins

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4
Q

Which medications can be given for the following problems in MS?

  • fatigue
  • spasticity
  • oscillopsia
  • bladder dysfunction
A

fatigue: amantadine

spasticity: baclofen, gabapentin

oscillopsia: gabapentin

bladder dysfunction: anticholinergics

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5
Q

which medications can be given to reduce the risk of relapse in MS?

A

indications
> relapsing-remitting disease + 2 relapses in past 2 years + able to walk 100m unaided
secondary progressive disease + 2 relapses in past 2 years + able to walk 10m (aided or unaided)

medications
- natalizumab: first-line

  • ocrelizumab: another first-line option
  • fingolimod
  • beta-interferon: less effective
  • glatiramer acetate: less effective
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6
Q

describe hereditary sensorimotor neuropathy (HSMN) aka Charcot-Marie-Tooth

A

encompasses Charcot-Marie-Tooth disease (aka peroneal muscular atrophy)

2 common types in clinical practice
- type I: demyelinating
- type II: axonal pathology

HSMN type I
- Autosomal dominant
- due to defect in myelin-coding gene
- features start at puberty
- motor symptoms predominate
- distal muscle wasting, pes cavus, clawed toes
- foot drop and leg weakness often first features

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7
Q

when can anti-epileptic drugs (AED) be stopped?

A

can be considered if seizure free for >2 years with AEDs being stopped over 2-3 months

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8
Q

describe localising features of focal seizures

A

temporal lobe
- with/without impairment of consciousness or awareness

  • aura
    > rising epigastric sensation
    > psychic/experiential phenomena e.g. deja vu, jamais vu
  • less commonly hallucinations (auditory/gustatory/olfactory)
  • seizures typically last around one minute
  • automatisms (lip smacking/grabbing/plucking of clothes)
  • post-ictal dysphasia
  • Todd’s paralysis

frontal lobe (motor)
- head/leg movements
- posturing
- post-ictal weakness
- Jacksonian march

parietal lobe (sensory)
- paraesthesia

occipital lobe (visual)
- floaters/flashes

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9
Q

describe subacute combined degeneration of the cord

A

SCD: spinocerebellar tract, corticospinal tract, dorsal columns

causes
- vitamin B12 & E deficiency
- can result from replacing folate before b12 if b12 deficient (BeFore)
- nitrous oxide inhalation

features
- bilateral spastic paresis: weakness, spasticity
- bilateral loss of proprioception and vibration
- distal tingling, burning and/or sensory loss
- bilateral limb ataxia
- hyperreflexia
- positive Babinski sign

positive Romberg’s test due to sensory ataxia

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10
Q

list driving restrictions for individuals with epilepsy

A

first unprovoked/isolated seizure: 6 months off if no structural brain abnormalities on imaging or epileptiform activity on EEG

established epilepsy / multiple unprovoked seizures:
> qualify for driving license if they have been seizure free for 12 months
> if no seizures for 5 years, a til 70 license is restored

withdrawal of epilepsy medication: cannot drive whilst being withdrawn and for 6 months after

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11
Q

describe spinal muscular atrophy (SMA)

A

rare autosomal recessive condition which causes a progressive loss of lower motor neurones leading to progressive muscular weakness

features
- fasciculations
- reduced muscle bulk
- reduced tone
- reduced power
- reduced / absent reflexes

management: supportive

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12
Q

describe myotonic dystrophy

A

genetic disorder usually presenting in adulthood

features
- progressive muscle weakness
- prolonged muscle contractions
- cataracts
- cardiac arrhythmias

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13
Q

describe the features, investigations and management of a TIA

A

brief period of neurological deficit due to a vascular cause, typically lasting less than an hour (always <24h)

Clinical features
- unilateral weakness or sensory loss
- aphasia or dysarthria
- ataxia, vertigo, or loss of balance
- visual problems
- sudden transient loss of vision in one eye (amaurosis fugax)
- diplopia
- homonymous hemianopia

ABCD2: prognostic score to risk stratify patients

Management
- immediate antithrombotic therapy: > aspirin 300 mg immediately

unless:
1. bleeding disorder / anticoagulated (needs immediate admission for imaging to exclude a haemorrhage)
2. already taking low-dose aspirin regularly: continue the current dose of aspirin until reviewed by a specialist
3. Aspirin is contraindicated: discuss management urgently with the specialist team

Advise the person not to drive until they have been seen by a specialist

Investigations
- diffusion-weighted MRI first-line

  • Carotid imaging
    > all patients should have an urgent carotid doppler unless they are not a candidate for carotid endarterectomy

Further management
> Secondary prevention
- clopidogrel is recommended first-line (as for patients who’ve had a stroke)
- aspirin + dipyridamole should be given to patients who cannot tolerate clopidogrel
- lipid modification
- high-intensity statin (such as atorvastatin 20–80 mg daily)

carotid artery endarterectomy if carotid stenosis > 70%

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14
Q

Describe the symptoms of stroke depending on the affected vessel

A

ACA
> contralateral hemiparesis and sensory loss
> lower extremity > upper

MCA
> contralateral hemiparesis and sensory loss
> upper extremity > lower extremity
> aphasia
> contralateral homonymous hemianopia

PCA
> Contralateral homonymous hemianopia with macular sparing
> Visual agnosia

Weber’s syndrome (branches of PCA supplying midbrain)
> contralateral upper and lower limb weakness
> ipsilateral CN III palsy

PICA (lateral medullary syndrome, Wallenberg syndrome)
> ipsilateral facial pain and temperature loss
> contralateral limb/torso pain and temperature loss
> ataxia, nystagmus
> ipsilateral Horner’s syndrome

AICA (lateral pontine syndrome)
> similar to Wallenberg’s but ipsilateral facial paralysis and deafness also
> reduced GCS, paralysis, bilateral pinpoint pupils

Retinal/ophthalmic artery: amaurosis fugax

Basilar artery: locked in syndrome

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

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15
Q

Describe bacterial meningitis and its management

A

Clinical features
- meningism: neck stiffness, photophobia
- nausea / vomiting
- reduced GCS
- non-blanching rash
- fever
- tachycardia, tachypnoea, hypotension
- Brudzinski / kernig’s sign +ve

attempt LP unless
- severe sepsis / rapidly evolving rash
- severe respiratory / cardiac compromise
- significant bleeding risk
- signs of raised ICP (focal neurological signs, papilloedema, continuous/uncontrolled seizures)

CT head prior to LP ONLY if risk of evolving SOL / signs of increased ICP

Management
- IV antibiotics
> <3 months: IV cefotaxime + amoxicillin
> 3 months-50 years: cefotaxime or ceftriaxone
> >50 years: cefotaxime (or ceftriaxone) + amoxicillin (increased risk of Listeria meningitis)

  • IV dexamethasone 0.15mg/kg QDS for 4 days
    > avoid in septic shock, meningococcal septicaemia, immunocompromised or meningitis following surgery
  • if allergic to penicillin / cephalosporins, use chloramphenicol
  • if Listeria monocytogenes: IV amoxicillin + gentamicin
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16
Q

Describe a post-LP headache and its management

A

Low pressure headache

can occur up to a week later from when the LP was taken

alleviated by lying down
> if headache lasts more than 3 days, consider subdural haematoma

management
- supportive analgesia - analgesia, rest
- consider blood patch, epidural saline and IV caffeine

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17
Q

Describe the diagnostic criteria for migraine

A
  • headache attacks lasting 4-72h
  • at least 2 of the following characteristics
    > unilateral location but may be bilateral
    > pulsating quality
    > moderate or severe pain
    > aggravation by routine physical activity
  • during headache at least one of the following
    > nausea or vomiting
    > photophobia, phonophobia
  • not attributed to another disorder

in children, attacks may be shorter-lasting, headache is bilateral and GI disturbance is more prominent

migraine with aura
> aura is progressive in nature and occurs hours prior to headache
> typical aura: transient hemianopic disturbance / spreading scintillating scotoma (jagged crescent)
> sensory symptom

auras may occur with/without headache and are fully reversible, develop over at least 5 minutes and last 5-60 minutes

atypical symptoms
> motor weakness
> double vision
> visual symptoms affecting only one eye
> poor balance / decreased GCS

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18
Q

Name the most common cause of
- bacterial meningitis <60
- viral meningitis
- viral encephalitis

A

bacterial meningitis <60: Neisseria meningitidis, streptococcus pneumoniae

Viral meningitis: enterovirus
> Coxsackie, Echovirus

Viral encephalitis: HSV

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19
Q

Describe viral meningitis and its management

A

Presents similarly to bacterial meningitis
> less likely to have a non-blanching purpuric rash
> less severe than bacterial meningitis

management
- supportive, usually self-limiting course of 7-14 days
- aciclovir if thought to be caused by HSV
- IV aciclovir if concern regarding encephalitis

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20
Q

in the context of meningitis, under which circumstances should LP be delayed?

A
  • signs of severe sepsis
  • rapidly evolving rash
  • severe respiratory / cardiac compromise
  • significant bleeding risk
  • signs of increased ICP
    > focal neurology
    > GCS <=12
    > Papilloedema
    > seizures
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21
Q

describe CSF results depending on the cause of meningitis

A

bacterial
- appearance: cloudy
- glucose: low (<1/2 plasma)
- protein: high (>1g/l)
- WCC: 10-5000 polymorphs/mm3

viral
- appearance: clear/cloudy
- glucose: 60-80% of plasma glucose
- protein: normal/raised
- WCC: 15-1000 lymphocytes/mm3

TB
- appearance: slight cloudy, fibrin web
- glucose: low (<1/2 plasma)
- protein: high (>1 g/l)
- WCC: 30-300 lymphocytes/mm3

fungal
- appearance: cloudy
- glucose: low
- protein: high
- WCC: 20-200 lymphocytes/mm3

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22
Q

describe the management of status epilepticus

A
  • ABCDE assessment
  • airway: lateral decubitus, nasal trumpets, O2, suction
  • IV access

0-5 mins (give benzos at 5 mins)
> lorazepam 0.1mg/kg IV, max 4mg, repeat once in 4min
> OR midazolam 10mg IM once

10-15 mins
> levetiracetam 60mg/kg IV
> OR fosphenytoin or phenytoin 20mg/kg IV
> OR valproate 40mg/kg IV

> advanced airway management
> RSI
> Preoxygenation
> Induction: propofol or ketofol
> paralytics: rocuronium, succinylcholine

15-20 mins: refractory medications
- propofol
- midazolam
- ketamine
- lacosamide
- phenobarbital

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23
Q

describe herpes simplex encephalitis

A

infection of brain parenchyma

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

investigations
- LP
> elevated protein
> lymphocytosis
> PCR for HSV, VZV, enterovirus

  • CT head: temporal lobe changes e.g. asymmetrical low density areas
  • EEG

management
- start aciclovir promptly in all suspected cases of viral encephalitis
> treats HSV and VZV
> ganciclovir is needed for CMV

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24
Q

how would you check if fluid is truly CSF?

A

check a glucose level: bedside test

beta-2-transferrin level: gold standard

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25
describe the different types of aphasia
Wernicke's (receptive) aphasia > lesion of superior temporal gyrus > usually supplied by inferior division of left MCA > features - sentences that make no sense - word substitution - neologism - speech remains fluent - "word salad" - comprehension is impaired Broca's (expressive) aphasia > lesion of inferior frontal gyrus > usually supplied by superior division of left MCA > speech is non-fluent, laboured and halting > repetition is impaired > comprehension is normal Conduction aphasia > usually due to stroke affecting arcuate fasciculus > speech is fluent but repetition is poor > aware of errors being made > comprehension is normal Global aphasia > severe expressive and receptive aphasia > may still be able to communicate using gestures
26
describe chronic fatigue syndrome
aka myalgic encephalomyelitis (ME) diagnosed after at least 3 months of disabling fatigue affecting mental and physical function >50% of the time in the absence of other disease which can explain symptoms features - fatigue - sleep problems - muscle/joint pains - headaches - painful lymph nodes - cognitive dysfunction - physical or mental exertion makes symptoms worse management - energy management - CBT
27
What is the mechanism of controlled hyperventilation in raised ICP?
Reduced blood carbon dioxide to induce cerebral vasoconstriction
28
describe the Barthel index
measure of disability or dependence in activities of daily living in stroke patients
29
describe neurogenic shock
causes - trauma e.g. spinal cord transection features - bradycardia - hypotension management - vasopressors
30
Describe the management of migraines
Acute: - analgesia NSAIDs or paracetamol + triptans > avoid opioids - antiemetic: metoclopramide > prokinetic agent that helps to relieve gastric stasis that occurs during acute migraine attack > consider even in cases without nausea Prophylaxis: - topiramate (teratogenic) or propranolol
31
What are the antibiotics of choice for contacts of patients with meningococcal meningitis
PO ciprofloxacin or rifampicin > one dose for close contacts within last 7 days
32
Describe idiopathic intracranial hypertension
classically seen in young overweight females features - headache - blurred vision - papilloedema - enlarged blind spot - sixth nerve palsy - high pressure features: worse on coughing/sneezing/lying flat/leaning forwards associated with tetracycline antibiotics investigations - lumbar puncture: opening pressure values >25 cmH2O - CT brain: enlarged arachnoid outpouchings, prominent perivascular spaces management - weight loss - semaglutide and topiramate - carbonic anhydrase inhibitors e.g. acetazolamide - repeated LP - temporary measure - surgery: > optic nerve sheath decompression and fenestration > lumboperitoneal / ventriculoperitoneal shunt
33
Describe an Arnold-Chiari malformation
downward displacement or herniation of cerebellar tonsils through foramen magnum malformation may be congenital or acquired through trauma features - non-communicating hydrocephalus may occur as a result of obstruction of CSF flow - headache - syringomyelia
34
describe essential tremor
autosomal dominant condition which usually affects both upper limbs Features - postural tremor: worse if arms outstretched - improved by alcohol and rest - most common cause of titubation (head tremor) Management - propranolol is first-line - primidone is sometimes used
35
describe a myasthenic crisis and its management
myasthenic crisis - acute respiratory failure characterised by FVC <1L - accessory muscle use Management > plasmapheresis > intravenous immunoglobulins > ventilatory support: low threshold for intubation
36
Describe myasthenia gravis and its management (as well as exacerbating factors)
autoimmune disorder due to autoantibodies against ACh receptors Features - muscle fatiguability - muscles become progressively weaker during periods of activity and slowly improve after periods of rest - extraocular muscle weakness: diplopia - proximal muscle weakness: face, neck, limb girdle - ptosis - dysphagia Associations > thymomas in 15% > autoimmune disorders: pernicious anaemia, autoimmune thyroid disorders, rheumatoid, SLE > thymic hyperplasia in 50-70% Exacerbating factors > penicillamine > beta-blockers > lithium > phenytoin > antibiotics: gentamicin, macrolides, quinolones, tetracyclines > quinidine, procainamide Investigations > single fibre electromyography > CT thorax - exclude thymoma > antibodies to acetylcholine receptors > Tensilon test: IV edrophonium reduces muscle weakness temporarily Management > long-acting acetylcholinesterase inhibitors: pyridostigmine is first-line > immunosuppression: prednisolone initially > azathioprine, cyclosporine, mycophenolate mofetil > thymectomy
37
Describe Wernicke's encephalopathy and its management
Wernicke's encephalopathy is a neuropsychiatric disorder caused by thiamine deficiency which is most commonly seen in alcoholics Rarer causes; persistent vomiting, stomach cancer, and dietary deficiency Classic triad: ophthalmoplegia/nystagmus, ataxia and encephalopathy Features > oculomotor dysfunction > nystagmus (the most common ocular sign) > ophthalmoplegia: lateral rectus palsy, conjugate gaze palsy > gait ataxia > encephalopathy: confusion, disorientation, indifference, and inattentiveness > peripheral sensory neuropathy Investigations > decreased red cell transketolase > MRI Treatment: urgent replacement of thiamine > IV Pabrinex (vitamin B/C) If not treated Korsakoff's syndrome may develop > antero- and retrograde amnesia > confabulation
38
Describe cluster headaches and their management
occur in clusters lasting 4-12 weeks > clusters typically occur once a year More common in men, smokers and alcohol drinkers Features -intense sharp, stabbing pain around one eye - pain once or twice a day, each episode lasting 15 mins - 2 hours - restless / agitatated during attack - clusters typically last 4-12 weeks - ipsilateral autonomic features > conjunctival injection (redness) > orbital oedema > lacrimation > miosis and ptosis > nasal congestion > facial sweating Investigations - neuroimaging - underlying brain lesions are sometimes found > MRI with gadolinium contrast: investigation of choice Management - acute: > 100% oxygen > subcutaneous triptan - prophylaxis: verapamil
39
list the components of the Glasgow Coma Scale (GCS)
Eye-opening > eyes open spontaneously (4) > eyes open to voice (3) > eyes open to pain (2) > no eye-opening (1) Verbal response > orientated (5) > confused (4) > words (3) > incomprehensible sounds (2) > no verbal response (1) Motor resopnse > obeys commands (6) > localises pain (5) > normal flexion (4) > abnormal flexion (3) > abnormal extension (2) > no motor response (1)
40
describe cerebral venous sinus thrombosis (CVST)
clinical features - headache (insidious or sudden onset) - signs of increased ICP > vomiting > papilloedema > focal / generalised seizures risk factors: thrombophilia, female, pregnancy, COCP, infections (mastoiditis, otitis, sinusitis) diagnosis: MR venogram management - anticoagulation: heparin or warfarin - treat underlying cause if possible
41
List contraindications to thrombolysis
Absolute - Previous intracranial haemorrhage - Seizure at onset of stroke - Intracranial neoplasm - Suspected subarachnoid haemorrhage - Stroke / traumatic brain injury in preceding 3 months - LP in preceding 7 days - GI bleed in preceding 3 weeks - Active bleeding - Pregnancy - Oesophageal varices - Uncontrolled hypertension Relative - Concurrent anticoagulation - Active diabetic haemorrhagic retinopathy - Suspected intracardiac thrombus - Major surgery / trauma in the preceding 2 weeks
42
Describe the secondary prevention of stroke
clopidogrel 75mg daily lifelong (first-line) aspirin plus MR dipyridamole (if clopidogrel is contraindicated) Carotid artery endarterectomy if patient has suffered stroke / TIA in the carotid territory and is not severely disabled
43
Describe the management of ischaemic stroke
aspirin 300mg orally or rectally - once haemorrhagic stroke has been excluded > continue aspirin 300mg daily for 2 weeks then clopidogrel 75mg daily long-term If AF - anticoagulants should not be started until 14 days have passed from the onset of an ischaemic stroke if cholesterol is > 3.5 mmol/l - commence statin > delay treatment until after 48 hours due to risk of haemorrhagic transformation Thrombolysis with alteplase for acute ischaemic stroke > if within 4.5 hours of onset of stroke symptoms and haemorrhage definitively excluded Thrombectomy for acute ischaemic stroke > within 6 hours of symptom onset, PLUS intravenous thrombolysis (if within 4.5 hours) > consider extended 6-24h if potential to salvage tissue as shown by CT perfusion or diffusion-weighted MRI showing limited infarct core volume ROSIER score used in medical settings
44
List causes of subarachnoid haemorrhage and describe its diagnosis and management
Clinical features - thunderclap headache > maximal intensity <5mins > sudden onset severe occipital headache - meningism (photophobia, neck stiffness) - nausea and vomiting - coma - seizures - neurological symptoms: visual changes, dysphasia, focal weakness, reduced consciousness - ECG changes - ST elevation risk factors: female sex, smoker, hypertension, black ethnic origin, excessive alcohol Diagnosis - Non-contrast CT head <6h after onset: if negative, consider alternative diagnosis - if CT >6h after onset is negative do LP after 12h (confirm xanthochromia) - after spontaneous SAH is confirmed > CT intracranial angiogram +/- digital subtraction angiogram Management > supportive: bed rest, analgesia, VTE prophylaxis, discontinuation of antithrombotics > nimodipine for prevention of vasospasm - neurosurgical referral due to risk of aneurysm rebleeding > endovascular coiling by interventional neuroradiologist (most common) > if severe, neurosurgical clipping or craniotomy
45
list complications of subarachnoid haemorrhage
- Re-bleeding - hydrocephalus (treat with LP, external ventricular drain or long-term ventriculoperitoneal shunt) - vasopasm > prevention with nimodipine - hyponatraemia (due to SIADH) - Seizures > treat with anti-epileptics - Torsades de Pointes
46
describe the management of Parkinson's disease
- Levodopa (co-careldopa contains levodopa and carbidopa) > reduced effectiveness with time - Carbidopa: DOPA decarboxylase inhibitor - dopamine receptor agonists e.g. bromocriptine, cabergoline, apomorphine > highest chance of inhibition disorders - COMT inhibitors e.g. entacapone - MAO-B inhibitors e.g. selegiline - amantadine
47
List side-effects of levodopa
- dry mouth - anorexia - CVS: palpitations, postural hypotension, arrhythmias - psychosis, hallucinations - on-off phenomenon - end-of-dose dyskinesia
48
describe the features of Parkinson's disease
clinical features - Bradykinesia > test with finger-tap test and pronation-supination test - Unilateral pill-rolling tremor > asymmetrical, 4-6 Hz, enhanced by anxiety - shuffling gait with reduced arm swing - Postural instability - Leadpipe rigidity or cogwheeling Neuropsychiatric - Anxiety, depression - Hallucinations - REM sleep disorders - Cognitive impairment (Parkinson's disease dementia) > motor symptoms ongoing at least a year before the emergence of dementia Autonomic - Altered sense of smell (hyposmia) - Constipation Genitourinary - Incontinence - Nocturia, frequency - Erectile dysfunction Myalgia Hyperhidrosis (sweating) Hypomimia Infrequency of eye blinking Hypophonia
49
List lower motor neurone signs
- Reduced tone - Hyporeflexia - Fasciculations - Paresis - Weakness in a root innervated pattern - muscle atrophy
50
Describe medication overuse headaches and their treatment
Features - present for 15 days or more per month - developed or worsened whilst taking regular symptomatic medication - patients using opioids and triptans are at most risk - may be psychiatric co-morbidity Management - simple analgesics and triptans should be withdrawn abruptly (may initially worsen headaches) - opioid analgesics should be gradually withdrawn
51
which medications can lead to drug-induced parkinsonism?
typical antipsychotics e.g. haloperidol antiemetics e.g. metoclopramide, prochlorperazine > symptoms are likely to be bilateral in drug-induced parkinsonism
52
describe the management of acute confusional state
treat the underlying cause and modify environment if not working then haloperidol / olanzapine can be used if Parkinson's use atypical antipsychotics like quetiapine or clozapine
53
describe vertebrobasilar ischaemia
features - vertigo upon neck extension (looking up) - exacerbated by changes in head position - falls in elderly patients risk factors - CVD, atherosclerosis
54
in a painful third nerve palsy where would the lesion be located?
posterior communicating artery aneurysm after trauma an oculomotor nerve palsy + hemiparesis can be a sign of transtentorial / uncal herniation (medial aspect of temporal lobe compressing CN III and cerebral peduncle)
55
describe the following conditions affecting the spinal cord - Brown-Sequard syndrome - friedrich's ataxia - anterior spinal artery occlusion - neurosyphilis
Brown-Sequard syndrome - aka spinal cord lateral hemisection - ipsilateral spastic paresis below lesion - ipsilateral loss of proprioception and vibration sensatoin - contralateral loss of pain and temperatures sensation friedrich's ataxia - same as above + cerebellar ataxia, intention tremor anterior spinal artery occlusion - bilateral spastic paresis - bilateral loss of pain and temperature sensation neurosyphilis (tabes dorsalis) - loss of proprioception and vibration sense as dorsal columns are affected
56
which diet is used in children with epilepsy which is unresponsive to treatment?
ketogenic diet
57
describe the diagnosis of multiple sclerosis
diagnosis requires dissemination of demyelinating lesions in time and space - MRI brain + spinal cord with contrast > high signal T2 lesions > periventricular plaques > Dawson fingers - +ve Hoffman's sign - CSF > oligoclonal bands > increased intrathecal synthesis of IgG - Visual evoked potentials > delayed but well-preserved waveform risk factors: EBV infection, multiple genes, low vitamin D, smoking, obesity
58
Describe the symptoms of stroke depending on the affected vessel
ACA > contralateral hemiparesis and sensory loss > lower extremity > upper MCA > contralateral hemiparesis and sensory loss > upper extremity > lower extremity > aphasia > contralateral homonymous hemianopia PCA > Contralateral homonymous hemianopia with macular sparing > Visual agnosia Weber's syndrome (branches of PCA supplying midbrain) > contralateral upper and lower limb weakness > ipsilateral CN III palsy PICA (lateral medullary syndrome, Wallenberg syndrome) > ipsilateral facial pain and temperature loss > contralateral limb/torso pain and temperature loss > ataxia, nystagmus > ipsilateral Horner's syndrome AICA (lateral pontine syndrome) > similar to Wallenberg's but ipsilateral facial paralysis and deafness also > reduced GCS, paralysis, bilateral pinpoint pupils Retinal/ophthalmic artery: amaurosis fugax Basilar artery: locked in syndrome Lacunar strokes present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia > strong association with hypertension > common sites include the basal ganglia, thalamus and internal capsule
59
describe multiple sclerosis and its clinical features
Idiopathic inflammatory demyelinating disease of the CNS Acute episodes of inflammation are associated with focal neurological deficits visual symptoms - optic neuritis - optic atrophy - Uhthoff's phenomenon: worsening of vision following rise in body temperature - internuclear ophthalmoplegia sensory symptoms - pins/needles - numbness - trigeminal neuralgia - Lhermitte's syndrome: paraesthesiae in limbs on neck flexion motor symptoms - spastic weakness (most commonly in legs) cerebellar symptoms - ataxia - tremor others symptoms - urinary incontinence - sexual dysfunction - intellectual deterioration
60
describe Miller Fisher syndrome
subtype of Guillain-Barré syndrome (GBS) characterised by areflexia, ataxia and ophthalmoplegia descending weakness is a classic features as opposed to ascending weakness in more common forms of GBS anti-GQ1b antibodies present in most cases
61
describe osmotic demyelination syndrome
aka central pontine myelinolysis - can occur due to overcorrection of severe hyponatraemia - Na levels should only be raised by 4-6 mmol/l in 24h symptoms usually occur after 2 days and are irreversible - dysarthria - dysphagia - paraparesis or quadriparesis - seizures - confusion - coma patients are awake but unable to move or verbally communicate - locked-in syndrome from high to low your brain will blow - cerebral oedema from low to high your pons will die - central pontine myelinolysis
62
Describe the subtypes of multiple sclerosis
- Relapsing remitting Multiple Sclerosis (RRMS) > Unpredictable attacks which may or may not leave permanent deficits followed by periods of remission - Primary progressive multiple sclerosis (PPMS) > At least 1 year of disease progression > Steady increase in disability without attacks - Secondary progressive multiple sclerosis (SPMS) > Initial relapsing-remitting multiple sclerosis > Suddenly begins to decline without periods of remission - Benign multiple sclerosis (BMS)
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describe the management of multiple sclerosis
- disease-modifying therapies e.g. natalizumab for RRMS or ocrelizumab for PPMS - relapses: high dose steroids e.g. IV methylprednisolone - symptomatic > strength: exercise > fatigue: amantadine, modafinil, SSRIs > neuropathic pain: amitriptyline, gabapentin > depression: SSRIs > urge incontinence: solifenacin > spasticity: baclofen, gabapentin > oscillopsia: gabapentin, memantine
64
describe the diagnosis of motor neurone disease (MND)
diagnosis is clinical - features > asymmetric limb weakness > mixture of LMN and UMN signs > wasting of small hand muscles / tibialis anterior > fasciculations > emotional lability > absence of sensory signs/symptoms > sparing of eye movements > nerve conduction studies: normal motor conduction, exclude neuropathy > electromyography: reduced number of action potentials with increased amplitude > MRI - exclude cervical cord compression and myelopathy usually pathological TDP-43 proteins
65
describe the different types of motor neurone disease (MND) and their management
- amyotrophic lateral sclerosis (ALS) > most common - progressive bulbar palsy > second most common > affects talking/swallowing > causes tongue wasting and fasciculations - progressive muscular atrophy - primary lateral sclerosis management - riluzole: slow progression of disease - symptomatic > spasticity: baclofen > antimuscarinics: excessive salivation > NIV to support breathing - advanced directives, end-of-life care
66
describe Lambert-Eaton myasthenic syndrome
usually a paraneoplastic syndrome occurring alongside small-cell lung cancer (SCLC) > can occur as a primary autoimmune disorder caused by antibodies against voltage-gated calcium channels clinical features - proximal muscle weakness (difficulty climbing stairs/rising from chair) - autonomic dysfunction (dry mouth, blurred vision, impotence, dizziness) - reduced / absent tendon reflexes symptoms IMPROVE after periods of muscle contraction, as opposed to myasthenia gravis (fatiguability) management - exclude malignancy - amifampridine: voltage-gated potassium channel blocker - pyridostigmine, immunosuppressants - IV immunoglobulins, plasmapheresis
67
describe Huntington's disease
aka Huntington's chorea AD trinucleotide repeat disorder > demonstrates anticipation: successive generations have earlier age of onset / increased severity of disease clinical features - chorea: involuntary, random, irregular and abnormal body movements - dystonia: abnormal muscle tone leading to abnormal postures - rigidity - eye movement disorders - dysarthria, dysphagia - cognitive, psychiatric or mood problems investigations > genetic testing > MRI: caudate atrophy management - genetic counselling - SSRIs if depressed - tetrabenazine for chorea - supportive: physio, SALT, advanced directives, end-of-life care
68
describe tuberous sclerosis
AD condition cutaneous features - depigmented ash-leaf spots which fluoresce under UV light - roughened patches of skin over lumbar spine (Shagreen patches) - adenoma sebaceum (angiofibromas): butterfly distribution over nose - subungal fibromata - cafe-au-lait spots may be seen - angiomyolipomas neuro features - developmental delay - epilepsy (infantile spasms or partial) - intellectual impairment also: retinal hamartomas, rhabdomyomas of the heart, gliomatous changes in brain lesions, polycystic kidneys, lymphangioleiomyomatosis
69
describe neurofibromatosis
2 types: neurofibromatosis type 1 is more common > NF2 is associated with BILATERAL acoustic neuromas AD inheritance clinical features: CRABBING - cafe au lait spots - relative with NF1 - axillary or inguinal freckling - bony dysplasia e.g. bowing of a long bone - iris hamartomas (Lisch nodules) - neurofibromas: skin-coloured raised nodules - glioma of optic pathway management: monitor for complications complications - migraines - epilepsy - renal artery stenosis - multiple tumours (e.g. spinal cord, GIST...) - vision loss due to optic nerve glioma
70
describe a generalised tonic clonic seizure
clinical features - body stiff, rigid, crashes to the ground - from rigid to rhythmical jerking (not tremor) - may have urinary incontinence / lateral tongue biting - cyanotic - eyes often open (rolled back) usually last 1-2 minutes post-seizure - non-responsive - heavy breathing/snoring - post-ictal confusion - patient may: not remember events, have headache, myalgia, and go to sleep it off
71
describe seizure classification
generalised - tonic - clonic - atonic - tonic-clonic - myoclonic - absence focal - depends on origin of seizure - +/- impaired consciousness - +/- becoming generalised
72
Describe spontaneous intracranial hypotension
Low CSF headaches caused by spontaneous intracranial hypotension > worse on standing, improved lying flat more common in connective tissue disorder e.g. Marfan's syndrome Conservative management. Epidural blood patch if this fails.
73
Describe trigeminal neuralgia
Trigeminal neuralgia: pain syndrome characterised by severe unilateral pain in trigeminal distribution > brief electric shock-like pains, abrupt in onset and termination with a refractory period triggers > light touch, washing, shaving, smoking, talking, and brushing the teeth (trigger factors), and frequently occurs spontaneously idiopathic but compression of trigeminal roots by tumours or vascular problems may occur Management - carbamazepine is first-line - failure to respond to treatment or atypical features (e.g. < 50 years old) should prompt referral to neurology > surgery: microvascular decompression
74
Describe the diagnosis of creutzfeldt jakob disease
Rapidly progressive neurodegenerative prion disorder, usually sporadic but can be inherited clinical features - rapid cognitive decline - myoclonic jerks - behavioural change - visual disturbance - ataxia Key investigations - MRI - lumbar puncture - EEG > bi- or tri-phasic periodic sharp wave complexes appearing with a frequency of around 1-2 per second. Definitive diagnosis: post-mortem biopsy
75
describe the investigations used in stroke
- ROSIER score: asymmetric weakness, speech disturbance, visual disturbance - Non-contrast CT head: > acute ischaemic strokes >> areas of low density in the grey and white matter; changes may take time to develop >> other signs include the 'hyperdense artery' sign corresponding with the responsible arterial clot - this tends to visible immediately > acute haemorrhagic strokes >>hyperdense material (blood) surrounded by low density (oedema)
76
describe chronic traumatic encephalopathy (CTE)
sequelae of chronic repeated head injury usually in athletes e.g. rugby / boxing clinical features - behavioural change - cognitive difficulties - mood disturbance
77
explain the use of prolactin in seizures
Rise in serum prolactin can help to differentiate a seizure from a pseudoseizure pseudoseizures also tend to have a gradual onset while true seizures have sudden onset Other features suggestive of seizure > Tongue biting > Urinary incontinence > Post-ictal phase > Memory loss > Todd's paresis (post-ictal weakness)
78
Describe the clinical presentation of subdural haemorrhage
caused by rupture of bridging veins risk factors: elderly, alcoholism, anticoagulation Clinical presentation - fluctuating consciousness - altered mental state - focal neurology - falls - can be triggered by alcohol excess management - acute subdural haematoma: neurosurgical referral for evacuation of haematoma e.g. decompressive craniectomy - chronic subdural haematoma: > asymptomatic: conservative > symptomatic: burr hole drainage
79
describe Wilson's disease
AR disorder characterised by excessive copper deposition in tissues Features - Liver: hepatitis, cirrhosis - Neurological: speech, behavioural and psychiatric problems - Kayser-Fleischer rings: green-brown rings in the periphery of the iris - Renal tubular acidosis - Haemolysis - Blue nails Lab - Reduced serum caeruloplasmin - Reduced total serum copper - Increased 24h urinary copper excretion Management - penicillamine (chelates copper)
80
describe an extradural haematoma
pathophysiology > mostly trauma, low-impact head injury > especially over temporal region due to the pterion overlying the middle meningeal artery patients may experience a lucid interval > briefly regain consciousness after injury before progressing into coma imaging - biconvex or lentiform hyperdense collection limited by suture lines of skull management - no neurological deficit: cautious clinical and radiological observation - definitive treatment: craniotomy and evacuation of haematoma
81
describe Bell's palsy and its management
acute, unilateral, idiopathic, facial nerve paralysis. risk factors - age 20-40 years - pregnant women Features > lower motor neuron facial nerve palsy → forehead affected > post-auricular pain (may precede paralysis) > altered taste > dry eyes > hyperacusis Management - oral prednisolone within 72 hours of onset of Bell's palsy - eye care to prevent exposure keratopathy: prescribe artificial tears and eye lubricants, taping at night
82
describe syringomyelia
due to development of syrinx (CSF-filled cyst) in the anterior white commisure of the spinal cord Presentation - cape-like loss of pain and temperature sensation due to compression of spinothalamic tract fibres decussating in centre of spinal cord - preserved light touch, proprioception and vibration - spastic weakness - neuropathic pain - upgoing plantars - autonomic features > Horner's syndrome due to compression of sympathetic chain > scoliosis can develop if untreated causes - congenital e.g. Arnold-Chiari malformation - acquired: trauma e.g haemorrhage, tumour - idiopathic investigations - full spine MRI with contrast - exclude tumour / tethered cord - brain MRI - exclude Chiari malformation Treatment - manage underlying cause - shunt into syrinx
83
describe a brain abscess and its management
causes - extension of sepsis from middle ear or sinuses - trauma or surgery to the scalp - penetrating head injuries - embolic events from endocarditis clinical features - depends on the site of the abscess - headache (dull, persistent) - fever - focal neurology e.g. oculomotor nerve palsy - other features of raised ICP: nausea, papilloedema, seizures investigations - CT head management - surgery > craniotomy and debridement of abscess cavity - IV Abx: IV 3rd generation cephalosporin + metronidazole - Intracranial pressure management: e.g. dexamethasone
84
describe Cheyne Stokes breathing
abnormal breathing pattern characterised by periods of hyperventilation alternating with apnoea occurs due to compression of brainstem
85
describe juvenile myoclonic epilepsy
typically affects teenage girls - infrequent generalised seizures often in the morning / following sleep deprivation - daytime absences - sudden shock-like myoclonic seizure
86
describe the management of haemorrhagic transformation in ischaemic stroke
- stop antiplatelets / anticoagulants - control BP (target 140 mmHg)
87
describe cavernous sinus syndrome
usually caused by cavernous sinus tumours features - pain - ophthalmoplegia - proptosis - trigeminal nerve lesion (ophthalmic branch) - Horner's syndrome
88
describe degenerative cervical myelopathy
presentation - pain (neck, upper or lower limbs) - loss of motor function (loss of digital dexterity, arm or leg weakness/stiffness leading to impaired gait and balance) - loss of sensory function causing numbness - loss of autonomic function (urinary or faecal incontinence / impotence) - Hoffman's sign: exaggerated flexion of terminal phalanx of thumb after flicking DIP joint of middle finger > UMN sign MRI - gold standard management - urgent referral for assessment by specialist spinal services - decompressive surgery
89
describe driving guidelines after TIA
can start driving if symptom free after 1 month - no need to inform DVLA
90
describe pituitary apoplexy
clinical features - headache - vomiting - neck stiffness - visual field defects: bitemporal superior quadrantic defect - extraocular nerve palsies - features of pituitary insufficiency > hypotension, hyponatraemia secondary to hypoadrenalism investigation: MRI management - urgent steroids due to loss of ACTH - careful fluid balance - surgery
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Phase 4 (14 decks)

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