Neurology Flashcards
patient with a stroke AND ecg showing they have atrial fibrilliation
already on aspirin and simvastatin since stroke.
most appropriate long term plan for secondary stroke prevention?
Apixaban!!! (an xa-inhbitor)
or warfarin
as anticoagulation
in acute management of stroke, 300mg of aspirin only given after ct is done to rule out hemorrhagic stroke
- A 65 year old woman has a week of disorientation and dizziness. She also has headaches that are worse when bending over and associated with vomiting. She had a non-small cell lung cancer that was treated with radical radiotherapy two years ago.BP is 178/95 mmHg. She has no focal Neurological signs. What is the diagnosis? UKMLA question.
Cerebral Mets!,
Typical Observations due to intracanial hypertension secondary to cerebral metastases
woman has severe neck chest and back pain after a fall
cxr clear with left sided rib fracture
CT head is clear except orbital fracture
most appropriate next investigation?
CT scan of neck!!!!
history and exam suggests cervical spine fracture
when would a CT scan of head be indicated after a fall?
LOC
OR amnesia
sudden severe headache 4 hours ago. autosomal dominant polycystic kidney disease
neuro exam and CT scan head normal
next step in management?
lumbar puncture!!!
patient most likely had a subarrachnoid hemorrhage
negative CT scan must be followed up with lumbar puncture
Question describing A focal Siezure affecting patients right hemisphere as a result of a previous stroke
spinal stenosis presentation?
neurogenic claudication - eg numbeness and weakness of legs that come on with walking that improve with leaning forward
A 17 year old boy has repeated episodes characterised by a funny ‘racing’
sensation in his abdomen, followed by loss of awareness. His girlfriend
describes that he has a vacant stare and waves his left arm around in a
writhing manner during these attacks.
what is the most likely site origin of these episodes?
right temporal lobe
He has focal onset impaired awareness
seizures, the aura implicates one of the temporal lobes. In the seizure
itself he waves his left arm, suggesting spread to the right frontal lobe (though
the origin is elsewhere).
A 46 year old woman attends the Emergency Department with fever,
headache and confusion, which developed over several hours. She finds it
impossible to lift her head from the pillow and resists the doctor’s attempts to
feel her neck.
Her temperature is 38.1°C, pulse rate 105 bpm and BP 110/60
mmHg. Her GCS score is 14.
A CT scan of her head is normal. A lumbar puncture is performed
High pressure, raised protein, excess neutrophils
TIA management?
management if patient on anticoagulants or has bleeding disorder?
300mg aspirin + specialist review within 24hrs
anticoagulants = immediate non contrast! CT to rule out hemorrhage
TIA may present as amurosis fugax
All TIA patients should have an urgent carotid doppler?
bells palsy management?
oral prednisolone and artificial tears
aciclovir is not given!!
if the paralysis shows no sign of improvement after 3 weeks, refer urgently to ENT
baclofen not helping enough for patient with muscle stiffness in with MS. other first line option?
acute relapse treatment?
gabapentin
oral or IV methylprednisolone
MS baseline investigation?
MRI WITH contrast
other bells palsy symptoms?
post-auricular pain (may precede paralysis)
altered taste
dry eyes
hyperacusis
plasmodium vivax, treated with chloroquine, what other drug needed?
non falcipaurm palsmodium thus primaquine!! also neededd to treat the stores of parasite
loss of foot dorsiflexion/foot drop + sensory loss dorsum of the foot
L5 lesion!!! - can also cause weakness of hip abduction
L3 = Sensory loss over anterior thigh
Weak hip flexion, knee extension and hip adduction
Reduced knee reflex
Positive femoral stretch test
L4 =Sensory loss anterior aspect of knee and medial malleolus
Weak knee extension and hip adduction
Reduced knee reflex
Positive femoral stretch test
L5 = Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
S1 = Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test
*note, no L2. just 3,4,5 + S1
Suspected TIA, normal management is what?
when would you admit to hospital urgently instead for urgent imaging and what type of imaging?
in a TIA clinic, most appropriate next step in management?
normal management = 300mg aspirin + urgent specialist assessment within 24 hours to include imaging choice usually mri w diffusion weighted imaging vs stroke which is ALWAYS non contrast CT
If a patient presents more than 7 days ago they should be seen by a stroke specialist clinician as soon as possible within 7 days + aspirin
hospital admission =
on warfarin doac or has bleeding disorder = urgent admission = CT head!!! as there is a concern about hemorrhage -> contrast MRI which is preferred imaging
A combination of thrombolysis AND thrombectomy is recommend for patients with an acute ischaemic stroke who present within 4.5 hours
at what age is amoxicillin added on to IV cefotaxime/ceftriaxone for meningitis?
> 50
what further investigations done if symptoms of subarachnoid headache, and CT done more than 6 hours from symptom onset and it is negative?
what would be finding of this further investigation?
if CT head is done more than 6 hours after symptom onset and is normal
do a lumber puncture (LP)!!!!
timing wise the LP should be performed at least 12 hours!!! following the onset of symptoms to allow the development of xanthochromia!!!(the result of red blood cell breakdown- bilirubin in CSF).
xanthochromia helps to distinguish true SAH from a ‘traumatic tap’ (blood introduced by the LP procedure).
as well as xanthochromia, CSF findings consistent with subarachnoid haemorrhage include a normal or raised opening pressure
Describe the type of siezures that occur in each lobe of the brain
Temporal lobe - automatisms (e.g. lip smacking/grabbing/plucking) are common
An aura occurs in most patients
typically a rising epigastric sensation
also psychic or experiential phenomena, such as dejà vu, jamais vu
less commonly hallucinations (auditory/gustatory/olfactory)
Frontal lobe (motor) Head/leg movements, posturing, post-ictal weakness, Jacksonian march (clonic movements travelling proximally)
Parietal lobe (sensory) Paraesthesia
Occipital lobe (visual) Floaters/flashes
First line treatment in diabetic neuropathy is with?
amitriptyline, duloxetine, gabapentin or pregabalin
when should a lumbar puncture be delayed in suspected bacterial meningitis?
signs of severe sepsis or a rapidly evolving rash!!!!
severe respiratory/cardiac compromise
significant bleeding risk
signs of raised intracranial pressure:
focal neurological signs
papilloedema
continuous or uncontrolled seizures
GCS ≤ 12
most suitable contraceptivea for a woman with epilepsy on carbamezapine?
copper IUD
mirena coil - preferred if heavy bleeding
or progesterone injection - weight gain so avoid if obese, and less preferred due to effect on bone density
brain abscess treatment?
ceftriaxone and metronidazole
migraine PROPHYLAXIS treatment?
propanolol! - avoid in asthma
topiramate! - but avoid in women of childbearing age¬!
A 23-year-old man is brought to the emergency department after a generalised tonic-clonic seizure. Over the past 4 days, he has had a fever, headaches, drowsiness, and irritability. He is known to have HIV, but his viral load and adherence to antiretroviral therapy are not known.
His pulse is 85 beats per minute, blood pressure is 134/74 mmHg, and oxygen saturation is 97% on room air. He has nuchal rigidity but no rashes are noted. A CT scan of the head shows ill-defined hypodense areas in the bilateral temporal lobes and inferior frontal lobes.
herpes simplex encephalitis!!
ill defined nad not ring enhanced so not toxoplasmosis
not cryptococcal meningitis - would show meningeal enhancement and signs of cerebral edema
which motor neuron disease has worst prognosis?
progressive bulbar palsy
name a medication that can trigger migraines
ocp
A 62-year-old man presents to the emergency department after a fall. He has not lost consciousness, did not hit his head, and was brought in via ambulance after 3 hours as he could not stand up after falling. Over the last few months, he has felt weak. His only history is gastroenteritis 8 months ago.
He has bilateral leg muscle atrophy and reduced power in both the upper and lower limbs, which are worse on the left. Sensation and coordination are intact. The biceps and triceps reflexes are absent, however, the ankle and knee reflexes are brisk. Babinski’s sign is positive.
What is the most likely diagnosis?
ALS !! = Asymmetrical limb weakness, mix of upper and lmn signs
Primary lateral sclerosis = no LMN signs so no fasiculations, weak reflexes or atrophy. only UMN
Acute sinusitis complication, fever headache, nausea (raised icp) difficulty raising right arm and leg(focal neurology - can also present with oculomotor or abducens nerve palsy) ?
differentials?
brain abscess - can also occur with ear infections
cavernous sinus thrombosis = unilateral facial oedema, photophobia, proptosis and palsies of the cranial nerves which pass through it (III, IV, V, VI).
women with painful eye movements and visual disturbance, urinary incontinence and frequency. imaging modality required
MRI WITH contrast. most likely MS -optic neuritis
common stroke territories
essential tremor features?
management?
postural tremor: worse if arms outstretched
improved by alcohol and rest
Propanolol
Investigation for vestibular shwannoma?
MRI of the cerebellopontine angle - CN V, VII, VIII
A woman of childbearing age who presents with generalised tonic-clonic seizures should be offered what seizure medication?
Lamotrigine or levetiracetam
Even if on the contraceptive pill!
In a patient with dizziness and right sided hearing loss, what test would point to a shwannoma?
Absent corneal reflex!
Elbow injury with wrist drop, most likely anatomical site of injury?
Fracture of the shaft of humerus!, = damage to radial nerve
Supracondylar fracture of humerus is most commonly associated with ulnar nerve damage.
Fracture of the proximal humerus is most commonly associated with axillary nerve damage.
