Neurology Flashcards
What triad of symptoms is associated with normal pressure hydrocephalus?
Urinary incontinence
Dementia
Gait abnormality
KNOWN AS HAKIM TRIAD
What is the result of a third nerve palsy?
Down and out eye
Diplopia
Ptosis
Fixed dilated pupil (mydriasis)
What is the result of a fourth nerve palsy?
Defective downward gaze (vertical diplopia)
What is the result of a sixth nerve palsy?
Defective abduction (horizontal diplopia)
What is the management of neuropathic pain?
Monotheraphy with Amitryptiline, pregabalin, gabapentin, or duloxetine
If doesnt work then switch medication
Triad for wernickes encephalopathy?
Gait ataxia
Ophthalmoplegia/Nystagmus
Confusion
What is the result of a common peroneal nerve palsy?
Weakness of foot Doris flexion and foot eversion
What marker can be used to differentiate a seizure form a pseudo seizure?
Prolactin
What is the mainstay treatment for a TIA?
Aspirin 300mg for 2 weeks followed by long term use of clopidogrel 75mg
What is the acute management of a cluster headache?
High flow oxygen + SC/intra nasal triptan
Prophylaxis mix of cluster headache?
Verapamil
What is the management of an acute relapse of ms?
High dose steroids
What medication/s reduce risk of relapse in MS
Natalizumab
Fingolimod
Beta interferon
What is the medical management of myasthenia gravis
Acetylycholinesterase inhibitors- Pyradistigmine
What is the 1st line Ix for MG?
Acetylcholine receptor antibodies
What is syringomeylia?
Collection of CSF in spinal cord
What are the key features of syringomyelia/
Cape like distribution loss of sensation to temperature and pain but preservation of light touch, proprioception and vibration classic- burn hands and don’t notice
Upgoing plantars
Autonomic features e.g. Horner’s
Spastic weakness (predominantly Lower limbs)
What does syringomyelia have a strong association with?
Arnold-Chiari malformations
What is the ix and management for syringomyelia?
Ix- full spine and brain MRI
Ms- dependent on cause - possibly a shunt
What is a fixed dilated pupil and indication of?
Cn 3
What would be the result of Neuro imaging in NPH?
Ventriculomegaly w/o sulcal enlargement
What is the inheritance pattern of neurofibromatosis?
Autosomal dominance
What chr is affected in NF1 and list 3 features?
Chr 17
> =6, 15mm cafe au lair spots
Axillary/groin freckles
Iris hamatomas (Lisch Nodules)
Scoliosis
Phaechromocytoma
What chr is affected in NF2 and list prominent feature?
Chr 22
Bilateral vestibular schwannomas
List 3 Sx of. An acoustic neuroma?
Unilateral hearing loss
Reduced facial sensation
Balance problems
What is the 1st line and GS Ix for acoustic neuromas? Also what sign will be present on GS to be diagnostic?
1st line- Audio gram
GS- gadolinium enhanced MRI scan- will show ‘absence of dural tail’
What is the Rx for prophylaxis of migraines?
Propranolol
Topiramate- avoid in girls of bearing age
Amitryptiline
What nerve is affected in a mid shaft humerus fracture and what happens?
Radial nerve –> Wrist drop and loss of grip strength
What is the mode of inheritance of charcot marie tooth syndrome?
autosomal dominant
What nerve and blood vessel is affected in amurosis fugax?
Optic nerve
retinal/opthalmic artery (branch of ICA)
What is the key diagnostic test in GBS and what does it show?
Lumbar puncture (raised protein, with normal wcc)
How long can a person who suffered from their first unprovoked/isolated seizure with no evidence in imaging/EEG not drive for?
6 months
What is the associated effects of an anterior cerebral artery infarct?
Contralateral hemiparesis
sesnoryt loss lower extremity > upper
What are the associated effects of a middle cerebral artery infarct?
Contralateral hemiparesis
sensory loss greater in upper extremity
contralateral homonymous heminanopia
aphasia
What are the associated effects of a posterior cerebral artery infarct?
Contralateral homonymous hemianopia with macular sparing
Visual agnosia
What is webers syndrome?
Weber’s syndrome is a form of midbrain stroke (posterior cerebral artery) characterised by the an ipsilateral CN III palsy and contralateral hemiparesis
Wha are the characteristics of Progressive supranuclear palsy (PSP)?
postural instability, impairment of vertical gaze, parkinsonism, frontal lobe dysfunction
What is the tx of choice for an essential tremor?
Propranolol or Primidone
What are sx and features of an acoustic neuroma?
vertigo
sensorineural hearing loss
unilateral tinnitus
absent corneal reflex
facial palsy
What classification can be used for an acute ischaemic stroke?
The Oxford stroke (Bamford) classification.
What medication should you give to someone within 4.5 hours of having an ischaemic stroke?
Thrombolysis - Alteplase (IV).
What are the contraindications for alteplase?
Haemorrhage.
Suspected SAH.
Active bleeding.
Recent GI infection or UTI.
Recent surgery.
Malignancy.
List the signs of a ACA infarct?
LL weakness and loss of sensation
Gait apraxia
Incontinence
Drowsiness
Decrease in spontaneous speech
List the signs of a MCA infarct?
UL and LL weakness
Contralteral homonymous hemianopia
Aphasia
Dysphasia
Facial droop
List the signs of PCA infarct?
Speech impairment + dysphagaia
Cerebellar dysfunction
Visual disturbances (contralateral homonymous hemianopia with macular sparing)
visual agnosia
prospagnosia
What are the signs of Weber’s syndrome and what artery is affected?
Branches of posterior cerebral artery that supply midbrian
Ipsilaterla CN3 Palsy
contralkaterla weakness of UL and LL
What is the signs of Wallenberg syndrome/lateral medulalry syndrome and what aretry is affected?
Posterior inferior cerebellar artery
Ipsilateral facial pain and temp loss and Horner’s
Contralateral limb/torso pain and temp loss
Ataxia, Nystagmus
Give 4 signs of UMN weakness.
Increased muscle tone.
Hyperreflexia.
Spasticity.
Minimal muscle atrophy.
Give 5 signs of LMN weakness.
Decreased muscle tone.
Hyporeflexia.
Flaccid.
Muscle atrophy.
Fasciculations.
Give 3 signs of Myasthenia Gravis.
Generalised fatiguability:
Proximal limbs.
Neck/face - head drop, ptosis.
Extra-occular - diplopia.
Speech and swallowing problems.
Risk of other auto-immune disorders.
Peripheral Neuropathy: describe mononeuritis multiplex.
A patchy process where individual nerves are picked off randomly. Often it has an inflammatory or immune mediated cause. Chronic, slow progression.
What are the 3 main components of the Glasgow Coma scale?
Best motor response.
Best vocal response.
Best eye-opening response.
What spinal tract is responsible for motor response?
Corticospianl tract
What signals does the spinothalamic tract carry?
Anterior- Crude touch, light touch, vibration.
Lateral- pain, temperature,
Give 2 population groups who may be at increased risk of a subdural haematoma.
Elderly and alcoholics - due to cerebral atrophy.
Give 3 symptoms of a subarachnoid haemorrhage.
Thunderclap, maximum severity headache within seconds.
Photophobia.
Neck stiffness.
Nausea and vomiting.
What investigations might you do in someone who you suspect has a subarachnoid haemorrhage?
CT head (star shaped).
Cerebral angiography.
Lumbar puncture - xanthochromia.
How do you manage and treat a patient who has had a subarachnoid haemorrhage?
Nimodipine (CCB).
Early intervention, support and close monitoring is essential.
Give 3 symptoms of Cauda Equina syndrome.
Bilateral sciatica - pain radiates down leg to foot.
Saddle anaesthesia.
Bladder/bowel dysfunction.
Erectile dysfunction.
Leg weakness.
Define frailty.
A state of increased vulnerability resulting from an ageing associated decline in function across multiple physiologic systems; the ability to cope with everyday stressors is therefore compromised.
What is relative afferent pupillary defect (RAPD)?
It is observed during the swinging light test. The patient’s pupils constrict when the light is swung from the unaffected to the affected eye. The affected eye still senses the light and produces pupillary sphincter constriction to some degree, albeit reduced.
What is another name for RAPD?
Marcus Gunn pupil.
In what conditions might you see RAPD?
MS.
Glaucoma.
Severe retinal disease.
Optic nerve lesion.
List 5 RF for stroke?
Smoking
Alcohol
HTN
Hyperlipidaemia
obeisty
DM
AF
What is syncope?
A transient loss of conciousness, loss of postural tone
List 5 differentials for blackouts?
Vasovagal syncope
cardiac syncope
migraine w/ aura
Hypoglycaemia
TIAs
non-epileptic seizures
Intermittent hydrocephalus
What ix couold be done for blackouts
12 lead ECG
Brain imaging
EEG
Video telemtery
Tilt Table Test
List 3 features of Multi System Atrophy?
- parkinsonism
- autonomic disturbance
- cerebellar signs
classical history of poor response to levodopa, impotence, urinary retention and age group.
List features of PSP?
impaired balance and therefore being prone to many falls.
vertical gaze palsy.
symmetrical onset and is poorly responsive to levodopa
what should be suspected with a Painful third nerve palsy
Posterior communictaion artery aneurysm
What diagnosis should be suspected in a Obese, young female with headaches / blurred vision
Idiopathic intracranial hypertension
which of the muscles are typically spared in MND
Ocular muscles
What is Brown-Sequard syndrome a result of and list the main feature
BSS is a result of lateral hemisection of the spinal cord
ipsilateral weakness below lesion
ipsilateral loss of proprioception and vibration sensation
contralateral loss of pain and temperature sensation
What is the GS ix for suspected stroke?
Non contrast CT head
List 5 triggers for a migraine?
Chocolate
Hangovers
Orgasms
Cheese
Oral contraceptives
Lie ins
Alcohol
Tumult
Exercise
List the triad associated with Horners syndrome
Ptosis, Miosis and Anhidrosis
What is GCA and list 3 fetaures?
GCA is agrnaulamatous vasuclitis of medium sized arteries
Temporal headaches
Jaw claudication
Sclap tenderness
Amurosis fugax
Aching and stiffness
What is the firts line and GS Ix of GCA?
1st line- Infammmatory markers- Raised ESR
GS- Temporal artery biopsy- granulamatous inflammation
What is the 1st line medication for focal seizures
Lamotrigine or Leviteracetam
What is Charcots Neurological triad and list the 3 features?
Charcot’s neurological triad refers to a set of three classic clinical features associated with the progression of multiple sclerosis (MS)
1) Nystagmus
2) Dysarthria
3) Intention tremor
What is MS?
A chronic cell mediated autoimmune disorder charcterised by demyelination of the CNS (a type 4 hsr)
What cells are reponsible for myelination in
a) CNS
B) PNS
A) Oligodendrocytes
B) Schwann cells
What criteria is used to make a diagnosis of MS
McDonalds criteria of MRI imaging
List 2 signs/phenemenoms found in MS?
Lhermittes phenemenom- Parsatehesia in limbs following neck flexion
Uhertoffs phenemenom- Increase in temp causes worsening of sx (often visual)
List 2 findings in someone with MS
White matter plaques disseminaated in space and time
CSF- oligoclonal bands
What type of lesion if bells palsy
LMN lesion
list the clincial features in Parkinson’s disease
Bradykinesia
Pill rolling resting tremor
Postural instability
Rigidity
Reduced facial expression (hypomimia)
What is Parkinson’s disease?
A neurodegenerative disorder characterised by the loss of dopiminergic neurons in the substantia nigra
Give 2 histopathological signs of Parkinson’s disease.
Lewy bodies.
Loss of dopaminergic neurones in the substantia nigra.
What class of medications are used to treat PD?
Levodopa
Dopmaine agonist e.g. Bromocriptine, ropinerole, Cabergoline
MAO-B Inhibitors- seleglline
COMT inhibitors- entacapone
What lobe of the brain is affected in Alzheimer’s disease?
Temporal lobe
Give histopathological signs of Alzheimer’s disease
Excess intraneuronal Amyloid plaques
Aggregates of TAU proteins– neurofibliray tangles
What medication can be used to manage the sx of alzheimers dementia
Acetylcholinesterase inhibitors e.g Donepezil, Rivastigmine
or Memnatine (NMDA antagonist)
Frontotemporal dementia is characterised by what?
Pick bodies
What is the tx for GBS?
IV Immunoglobulins 5 days and plasma exchange
What is MG?
(T2 Hypersensitivity reaction)
Automimmune disorder resulting in insufficient functioning acetylcholine receptors
What antibodies are associated with MG?
Acetylchloline receptor antibodies
MUSK antibodies
What is the mx of a myasthenic crisis?
Plasmapharesis and IVIG
What other conditions is LEMS asscoaited with?
Small cell lung cancer **
breast and ovarian cancer to a lesser extent
What is LEMS?
Lambert-Eaton myasthenic syndrome is caused by an antibody directed against presynaptic voltage-gated calcium channel in the peripheral nervous system.
What antibody is associated with LEMS
Anti P/Q voltage gated calcium channel
What is the mx of LEMS?
3,4 Diaminopyridine (Amifampridine)
What are the subtypes of MND and list their key sx?
1) Amyotrophic Lateral Sclerosis
UMN and LMN affected
Babinski +ve, Fasiculations on tongue, Dysphagia, Dysarthria
2) Progressive Bulbar plasy
(Bulbar)-> Medulla so CN 9,10,11,12 affected
Carries the WORST PROGNOSIS
3) Progressive Muscle atrophy
4) Primary lateral Sclerosis
What is the 1st line tx for MND?
Riluzole
Then just symptom management: Respiratory care, Nutrition
List the RF for carpal tunnel syndrome and what nerve is repsonsible?
OPRAH
Obesity
Pregnancy
RA
Acromegaly
Hypothyroidism
Median nerve
What is the mx of carpal tunnel?
moderate
1st line- wrist splint
2nd line- corticosteroid injection
severe
1st line- surgical release
What is the GS ix for carpal tunnel?
EMG
List the causes of Cauda equina syndrome
Lumbar disc hernaition (L4/5 AND L5/S1)- Most common cause
Neoplasm
Abscess
Iatrogenic causes
List 5 sx of Cauda equina?
Back pain
Saddle anaesthesia
Loss of senstaion in bladder and rectum
Bilateral sciatica
Bilateral LMN weakness
Sexual dysfunction
Reduced anal tone on PR exam
Absent ankle reflex
GS ix of cauda equina
urgent MRI of spine
WHat is the mx of cauda equina syndrome
Surgical decompression ideally witthin 48 hours
if malignancy- give dexamethasone
What tracts are repsonsible for
a) Temp and pain
b) crude touch
c) sensory info of lower limbs
d) Sensory info of upper limbs
a) Lateral spinothalamic tract
b) Anterior spinothalamic tract
c) DCML- Fasiculus Gracillis (Medial)
d) DCML- Fasiculus Cuneatus (Lateral)
What is Subacute combined degeneration of the spinal cord
A neurological complication associated with vit b12 deficiency
List the causes of vit b12 deficiency that can cause SCDC
prenicious anemia
malabsorbtion syndromes
Dietary deficiencies
Misuse of nitrous oxide (functional rather than true)
list the importance of vit b12 and how a deficiency of b12 may lead to sx of SCDC?
- B12 is essential to the syntheisis of myelin therefore in b12 deificiency the synthesis is compromised and leading to demyelination of nerve fibres
- in the absence of b12, the metabolism of certain amino acids and fatty acids is disrupted thus leading to an acucmulation of HOMOCYSTEINE and METHYLYMALONIC ACID –> toxic metabolites lead to neuro sx of SCDC
What ix can be done for a diagnosis of SCDC?
Folate and B12 levels
Homocysteine levels- rasied level despite normal B12 levels may indicated functional deficiency
MRI of spine to exclude cervical myelopahy
EMG
What is the managemnt of a brain abscess
surgery- abscess cavity is debrided
Abx- 3rd gen cephalosporin + metronidazole
Intracranial pressure mx- dexamethasone