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MRCP PACES > Neurology > Flashcards

Neurology Flashcards

1
Q

What are the features of spastic paraparesis?

A

Increased tone bilaterally
Pyramidal weakness bilaterally
Increased reflexes
Upgoing plantars and clonus
Spastic scissoring gait

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2
Q

What extra things would you look for in spastic paraparesis (if doing LL exam)? - not in normal LL exam

A

Eyes - INO, nystagmus, RAPD

Mouth - fasciculations

Hands/arms - small muscle wasting, fasciculations, co-ordination, tone, power, reflexes

UL - sensory level

Back - spinal surgery scars, tenderness

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3
Q

Spastic paraparesis + cerebellar signs + dorsal column involvement?

A

Friedreich’s Ataxia

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4
Q

Completing Lower Limb Exam

A

PR - anal tone + saddle anaesthesia
Examine UL and Cranial nerves
Take Hx

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5
Q

What are the main causes of spastic paraparesis?

A

Demyelination

Cord Compression

Trauma

Anterior Horn Cell Disease

Cerebral Palsy

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6
Q

Spastic paraparesis + sensory level

A

Cord compression
- disc disease - spinal stenosis
- tumour
- trauma
- infection - epidural abscess, TB
- Vascular issue - haematoma/haemorrhage

Cord infarction

Transverse myelitis

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7
Q

What are the causes of transverse myelitis?

A

Infection - HSV, VZV, HIV
Autoimmune
Paraneoplastic
Sarcoid
Neuromyelitis optica

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8
Q

Spastic Paraparesis and dorsal column loss?

A

Demyelination
Friedrich’s ataxia
Subacute combined degeneration of cord
Syphilis
Parasagittal meningioma
Cervical myelopathy

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9
Q

Spastic paraparesis and spinothalamic loss

A

Syringomyelia
Anterior spinal artery infarction

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10
Q

Spastic paraparesis and cerebellar signs

A

Demyelination
Friedrichs ataxia
Spinocerebellar ataxi
Arnold Chiari malformation
Syringomyelia

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11
Q

Spastic paraparesis and small hand muscle wasting

A

Cervical myelopathy
Anterior horn cell disease
Syringomyelia

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12
Q

Spastic paraparesis and UMN signs

A

Cervical myelopathy
Bilateral strokes

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13
Q

Spastic paraparesis and absent ankle jerk

A

MND
Friedrich’s ataxia
Subacute combined degeneration of cord
Syphilis
Cervical myelopathy and peripheral neuropathy
Conus medullaris

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14
Q

Other causes of spastic paraparesis

A

Hereditary spastic paraparesis
Tropical - HTLV1
Cerebral Palsy

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15
Q

Spastic paraparesis without any sensory involvement

A

Consider MND and HSP

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16
Q

Classic case for cerebral palsy?

A

Birth injury/illness in neonatal period
Intellectual impairment
Spastic paraparesis
Brisk reflexes
Upgoing plantars

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17
Q

Classic case for hereditary spastic paraparesis

A

Spastic paraparesis
Upgoing plantars
Brisk reflexes

ABSENT sensory signs

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18
Q

Classic case for Friedrich’s ataxia

A

Pes cavus
Cerebellar signs
Wasting
Spastic paraparesis
?Absent reflexes
Dorsal column loss
Peripheral sensory neuropathy

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19
Q

Classical case for MS

A

Spastic paraparesis
Brisk reflexes
Upping plantars
Cerebellar signs
Hx of visual or sphincter disturbance

Poss sensory - dorsal column >spinothalamic

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20
Q

Classical case for anterior spinal artery occlusion

A

Spastic paraplegia
Brisk reflexes
Upgoing plantars
Loss of pain and temperature with sensory level
Dorsal columns spared

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21
Q

Classical case for MND

A

Spastic paraparesis
Brisk reflexes
Upgoing plantars
Wasting
Fasciculations
No sensory signs

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22
Q

Demyelinating causes for spastic paraparesis

A

MS
Neuromyelitis optica
Subacute degeneration of cord
Transverse myelitis

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23
Q

Asymmetric spastic paraparesis

A

Think Brown-Sequard

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24
Q

Compressive causes of myelopathy

A

Disk herniation
Tumours
Spinal stenosis

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25
Q

Autoimmune causes of myelopathy

A

MS
Lupus
Sarcoid

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26
Q

Infectious causes of myelopathy

A

HIV
Varicella

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27
Q

Nutritional causes of myelopathy

A

Vitamin deficiency - B12
Copper deficiency

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28
Q

Genetic causes of myelopathy

A

Hereditary spastic paraparesis

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29
Q

Acute causes of spastic paraparesis (minutes to 1-2 days)

A

Minutes - Likely vascular cause

1-2 days
- Trauma
- Disc herniation

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30
Q

Subacute causes of spastic paraparesis - days to weeks

A

Autoimmune:
- Lupus
- Demyelination

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31
Q

Causes of spastic paraparesis that occur over weeks to months

A

Nutritional deficiencies - B12, copper
Slow growing tumour

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32
Q

Chronic causes of spastic paraparesis - month to years

A

Genetic causes

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33
Q

How would you investigate spastic paraparesis?

A

Bedside
- Blood pressure (autonomic involvement)
- Vital capacity - resp muscle involvement

Bloods
- Bone profile
- LFT
- Immunoglobulin and protein electrophoresis
- FBC, CRP, ESR - malignancy, infection, inflammation
- Virology - HIV, HTLV1, syphilis
- Anti NMO, AMA - autoimmune
- Haematinics - B12

Imaging
- MRI spine - help find cause, localise lesion and assess for intervention
- MRI brain - ?MS

Special
- Visual evoked potentials - ?MS
- LP - ?oligoclonal bands
- EMG - fibrillation and fasciculation in MND

34
Q

How is spastic paraparesis managed?

A

Non pharmacological:
- Education
- PT/OT
- Orthotics
- Social services
- DVLA

Medical
- steroids - IV methylpred/PO dex
- Radiotherapy

Surgical
- Decompress/fix depending on cause

35
Q

Which malignancies commonly metastasise to bone?

A

Solid organ - Breast, Prostate, Lung, Kidney, Thyroid

Haem - myeloma

36
Q

What are differentials for flaccid paraparesis?

A

Myopathies - inflammatory, toxic, inherited

NMJ disorder - botulism, myasthenia

Neuropathy - Hereditary sensory motor neuropathy, alcohol, lead poisoning, porphyria

Anterior horn cells - MND

37
Q

How is MS defined

A

Demyelinating disease of the CNS which is disseminated in time and space

Doesn’t affect peripheral nerves

38
Q

What investigation findings are seen in MS?

A

Visual evoked potentials - reduced - slow conduction

CSF - increased proteins and lymphocytes. Unmatched oligoclonal bands

MRI - active inflammation, hyperintense on T2 imaging. Periventricular white matter lesions, corpus callosum, brainstem, cerebellar, spinal cord and optic nerve

39
Q

Stocking distribution of sensation loss with reduced/absent reflexes?

A

Peripheral polyneuropathy

Usually soft touch
± pin prick
± vibration

40
Q

How do you test for sensory ataxia?

A

If UL - do finger nose with eyes closed
LL - Rhombergs positive only with eyes closed = sensory

41
Q

If thinking peripheral polyneuropathy, what should you look for on examination?

A

Pes cavus/charcot joint

High stepping gate - foot drop

Thickened nerves - leprosy, Charcot Marie tooth, amyloidosis, neurofibromatosis

Arms - fistula

Abdo - renal, insulin injection sites

Thyroid

Conjunctival pallor

Hands - Dupeytrens contracture, finger prick marks, clubbing, vasculitic signs, muscle wasting

42
Q

When you have detected a peripheral neuropathy, what should you try to work out?

A

Sensory, motor or sensorymotor

Distal or proxima

Small or large fibre

Focal, multifocal or polyneuropathy

43
Q

Motor causes of peripheral neuropathy?

A

CIDP
GBS
Hereditary sensorimotor polyneuropathy
Multifocal motor neuropathy and conduction block
Porphyria
Lead/Dapsone
Anterior Horn Cell - Progressive muscular atrophy
Botulism
Muscle issues - inclusion body myositis

44
Q

Predominant sensory peripheral neuropathy?

A

B12, B1, B6
Alcohol
Diabetes
Isoniazid
Vincristine
Vasculitis
Uraemia

45
Q

Splitting sensory peripheral neuropathy Ddx into categories:

A

Metabolic:
- Diabetes
- Hypothyroidism

Nutritional deficiency:
- B1, B6, B12

Toxic:
- Alcohol
- Drugs - chemo, antibiotics, antivirals - TB drugs, phenytoin, metronidazole, gold, amiodarone, ciclosporin, hydralazine

Immune mediated:
- RA
- GPA
- CIDP
- GBS

Others:
- Genetic
- Infection - HIV, Lyme

46
Q

How would you investigate a patient with suspected diabetic neuropathy?

A

Bedside:
- LS BP - ?autonomic dysfunction
- Fundoscopy
- Urinalysis

Bloods
- Renal function
- Hb1AC

47
Q

How would you investigate sensory polyneuropathy

A

Bedside - fundoscopy, finger prick glucose, urinalysis

Bloods:
- FBC - anaemia, WCC, macrocytosis
- B12
- U&E - uraemia
- Hb1AC
- TFT
- LFT
- ESR/CRP
- Can do connective tissue screen - ANA, ccp, RF, ANCA, Ig, ACE, paraneoplastic
- Virology

Imaging/Special - if req.
- nerve conduction studies ?demyelinating ?axonal
- EMG
- Nerve biopsy
- LP - raised protein + normal cell in GBS. cytology if ?lymphoma
- Genetic testing - Charcot Marie Tooth

48
Q

How can you interpret nerve conduction studies?

A

Reduced amplitude = axonal pathology

Slower conduction = demyelinating pathology

49
Q

What are the non-pharmacological management options for peripheral neuropathy?

A

OT/PT
Orthotics
Social needs assessment
DVLA considerations
CBT - chronic pain
TENS machine
Stop drinking - if contributing
DSN/Podiatry if diabetic
Dietician

50
Q

What is the pharmacological management of peripheral neuropathy?

A

Pain management
- Amitriptyline, Duloxetine
- Gabapentin/Pregablin
- Consider topical capsaicin
- Chronic pain team input

Tight glycaemic control

51
Q

What is Charcot joint?

A

A neuropathic joint where impaired joint position sense and sensation of pain leads to chronic damage to joints such as the ankle and mid-foot, often accompanied by poor healing responses related to peripheral vascular changes or autonomic neuropathies.

52
Q

How would you clinically distinguish between neuropathy and myopathy?

A

Myopathy
- Proximal muscle weakness
- No fasciculations + reflexes preserved until late in disease course
- Contractures

Neuropathy
- Distal
- Fasiculations and reflexes lost early
- No contractures
- Sensory signs

If myopathy - consider cardiac involvement

53
Q

What medications cause neuropathy - consider type of neuropathy too

A

Sensory - Isoniazid

Sensorymotor - Vincristine, amiodarone

Motor - Dapsone

54
Q

What is Charcot Marie Tooth Disease?

A

Hereditary Sensory Motor Neuropathy

Inherited - typically autosomal dominant

55
Q

What would you look for on inspection in Charcot Marie Tooth?

A
  • B/L Pes Cavus
  • Muscle wasting - more prominent distally
  • Inverted Champagne Bottle
  • B/L Clawed hands/toes
  • High steppage gait
  • Scoliosis
56
Q

What examination features would make you think Charcot Marie Tooth?

A

LMN signs:
- Reduced Tone
- Reduced reflexes

Reduced Power - distal>proximal
Normal co-ordination

Mildly impaired sensation - all modalities.

Positive Romberg’s
Can palpate thicker nerves

57
Q

What are the main differentials for Charcot Marie Tooth disease?

A
  • Diabetes
  • Alcohol
  • Vasculitis with mononeuritis multiplex
58
Q

Acquired neuropathies which are differentials for Charcot Marie Tooth?

A

Immune - CIDP, multifocal motor neuropathy with conduction block

Metabolic - diabetes

Toxic - alcohol, meds

Nutrition - B12

Paraneoplastic

Amyloidosis

59
Q

Investigations to consider in Charcot Marie Tooth

A

Bedside
- Basic jobs - L/S for autonomic involvement
- Blood glucose
- Urine dip - glucose/amyloid
- Fundoscopy - CMT types 6 - optic atrophy

Bloods - r/o alternatives - inflammatory markers, deficiency, Diabetes etc.

Special
- Genetic testing
- Nerve conduction studies
- Nerve biopsy

60
Q

How is Charcot Marie Tooth managed?

A

MDT Approach:
- PT
- OT
- Genetic counselling
- Support groups

Med - analgesia

Sure - orthopaedic procedures

61
Q

Types of Charcot Marie Tooth?

A

Based on clinical findings, inheritance, nerve conduction studies and genetic testing:

Thickened peripheral nerves T1/3

Weak arm>leg = T2D

Pyramidal tract signs - T5

Optic atrophy - T6

62
Q

What are some pyramidal tract signs

A

Hyperreflexia
Spasticity
Upgoing plantars
Slowed alternating movements

63
Q

Thrombolysis contraindications

A

Significant head trauma within 3months
Ischaemic stroke within 3 months
Intracranial malignancy
Bleeding: active, disorders, recent
Recent surgery - esp brain/spine
HTN 200/100
Pregnancy

64
Q

Inflammatory causes of motor neuropathy

A

Guillian Barre
Chronic Inflammatory Demyelinating Polyneuropathy
Multifocal motor neuropathy
Sarcoid
Vasculitis
Paraprotein
Amyloidosis

65
Q

Infectious causes of motor neuropathy

A

HIV
Diptheria
Lyme disease
HTLV-1
West nile virus
Rabies
Enteroviruses

66
Q

Toxin causes of motor neuropathy

A

Lead
Arsenic
Thallium
Mercury
Shellfish poisoning

67
Q

Metabolic causes of motor neuropathy?

A

Diabetic amyotrophy
Porphyria

68
Q

Drug causes of motor neuropathy?

A

Penicillamine
Gold
Ciclosporin

69
Q

Congenital causes of motor neuropathy

A

Charcot-Marie Tooth

70
Q

Neuromuscular junction disorders associated with flaccid paraparesis?

A

Myasthenia gravis
Lambert Eaton Syndrome
Botulism
Organophosphate poisoning
Tick paralysis
Snake venom

71
Q

Features of Guillian Barre Syndrome

A

Acute inflammatory demyelinating neuropathy

Ascending paralysis

Onset over days - weeks, typically after an infection - chest (Mycoplasma) or GI - Campylobacter

72
Q

Symptoms of Guillain Barre

A

Spine pain
Distal paraesthesia - sensory loss is patchy
Fatigue
Ascending flaccid paralysis
Absent reflexes

73
Q

What are the other features of Guillian Barre (apart from flaccid paralysis)

A

Cranial nerves - ptosis, ophthalmoplegia, facial nerve and bulbar weakness

Autonomic - tachycardia, labile BP, arrhythmia, bladder/bowels

Resp - SOB, fatigue

74
Q

What is Miller Fischer Syndrome?

A

Proximal variant of GBS

Ataxia
Ophthalmoplegia
Areflexia

anti-GQ1b antibodies

75
Q

How would you investigate Guillian Barre

A

CSF Cytology - raised protein, normal WCC

Nerve conduction study - reduced velocity + conduction block

Anti GM1 antibodies

FVC

ECG

76
Q

How is Guillian Barre managed?

A

IVIG

Methylpred

Plasma exchange

ITU - if FVC <1.3L or Bulbar dysfunction - may need tracheostomy/ventilationW

77
Q

What is spina bifida

A

Neural tube defect with incomplete closure of the vertebral canal

78
Q

How does spina bifida present?

A

Asymmetrical flaccid paraparesis with sensory loss (usually L5/S1)

Bladder and bowel involvement

Cutaneous - tufts of here/dimples

79
Q

What would you expect with old polio?

A

Flaccid mononeuropathy

Often associated limb shortening

Limb hypoplasia and wasting
Reduced reflexes

No sensory loss

80
Q

What is a differential for old polio?

A

Infantile hemiplegia
Motor neurone disease

81
Q

What is polio, how is it transmitted?

A

Enterovirus transmitted via faecal oral route

Causes predilection of anterior horn cells

MRCP PACES (6 decks)

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