Neurology Flashcards

1
Q

conductive hearing loss, tinnitus and positive family history - diagnosis?

A

Otosclerosis

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2
Q

episodic vertigo, tinnitus, and hearing loss - diagnosis?

A

Meniere’s disease

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3
Q

Why can phenytoin cause bruising in newborn if mother takes it?

A

Phenytoin induces vitamin K metabolism, which can cause a relative vitamin K deficiency, creating the potential for heamorrhagic disease of the newborn

Mothers taking phenytoin advised to have Vit K in last month of pregnancy

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4
Q

Caution for those using Natalizumab?

A

Natalizumab can cause reactivation of the JC virus causing progressive multifocal leukoencephalopathy (PML) - hx of MS with new neurological sx

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5
Q

Mx of focal seizures?

A

first line: lamotrigine or levetiracetam

second line: carbamazepine, oxcarbazepine or zonisamide

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6
Q

Mx of absence seizures? What is CI and why?

A

first line: ethosuximide

second line:
male: sodium valproate
female: lamotrigine or levetiracetam

CI = carbamazepine may exacerbate absence seizures

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7
Q

Mx of myoclonic seizures

A

males: sodium valproate
females: levetiracetam

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8
Q

Mx of tonic / atonic seizures?

A

males: sodium valproate
females: lamotrigine

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9
Q

Mx of generalised tonic-clinc seizures?

A

males: sodium valproate
females: lamotrigine or levetiracetam

girls aged under 10 years and who are unlikely to need treatment when they are old enough to have children or women who are unable to have children may be offered sodium valproate first-line

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10
Q

What is Waterhouse-Friderichsen syndrome - who is at risk of this?

A

Waterhouse-Friderichsen syndrome (adrenal insufficiency secondary to adrenal haemorrhage)

Pts with meningococcal meningitis are at risk

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11
Q

Anti-epileptics and breastfeeding?

A

Safe with most except barbiturates (-barbital suffix)

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12
Q

Mx of cranial abscess?

A

surgery
a craniotomy is performed and the abscess cavity debrided
the abscess may reform because the head is closed following abscess drainage

IV antibiotics: IV 3rd-generation cephalosporin + metronidazole

intracranial pressure management: e.g. dexamethasone

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13
Q

cerebellar signs, contralateral sensory loss & ipsilateral Horner’s

Which stroke syndrome? Vessel affected?

A

Lateral medullary syndrome - PICA affected

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14
Q

Adverse effects associated with 5HT3 antagonists?

Where do they act? examples?

A

Ondansetron - act on chemoreceptor trigger zone in medulla oblongata

Can cause constipation and prolonged QT -> increased risk of polymorphic VT or torsades de pointes (mx = IV MgSO4)

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15
Q

Important blood test in restless legs syndrome?

A

Ferritin

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16
Q

What is hemiballism?

A

Ballisic movements are involuntary, sudden, jerking movements which occur contralateral to the side of the lesion

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17
Q

Cause of hemiballism? Mx?

A

Hemiballism occurs following damage to the subthalamic nucleus in the basal ganglia

Antidopaminergic agents (e.g. Haloperidol) are the mainstay of treatment

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18
Q

When to perform LP if suspecting SAH?

A

12 hours post headache

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19
Q

Medication used in MND?

A

Riluzole - prolongs life by about 3 months (mostly used in ALS)

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20
Q

Which neuro medication can cause SJS?

A

Lamotrigine

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21
Q

Mx of idiopathic intracranial HTN?

A

Weight loss - 1st
Acetazolamide - carbonic anhydrase inhibitor

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22
Q

1st line tx for parkinsons?

A

If motor sx affecting QoL - Levodopa

If motor sx not affecting QoL - Dopamine agonnist, levodopa or MAO-B inhibitor

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23
Q

How to manage drooling in Parkinsons?

A

Glycopyrronium bromide

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24
Q

dementia (rapid onset)
myoclonus

Suggestive of what condition?

A

CJD

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25
What are the most common causes of brain abscesses?
Extension of sepsis from middle ear / sinuses Trauma / surgery to scalp Penetrating head injuries Embolic events from endocarditis
26
What scoring system can be used to quantify the disability in activities of daily living? - In stroke patients
Barthel index i.e. feeding, bathing, grooming, dressing, bowel control, bladder control, toileting, chair transfer, ambulation and stair climbing.
27
shock-like, irregular jerking movements, usually of the arms suggestive for which type of seizures
Myoclonic seizures
28
MoA of Ramsay Hunt? mx?
reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve. mx - oral aciclovir and corticosteroids
29
Mx of spasticity in MS?
Baclofen + Gabapentin
30
Best tx for survival benefits in MND?
Riluzole - prolongs life by 3 months NIV - prolongs life by 7 months
31
What do assymetric symptoms in Parkinsons suggest?
Idiopathic parkinsons instead of drug induced
32
First line mx in Restless legs?
Dopamine agonists eg pramipexole and ropinirole
33
What is impaired in subacute combined degeneration of spinal cord?
Dorsal column - impaired proprioception and vibration sense, distal parasthesia legs>arms Lateral corticospinal tracts - muscle weakness, hyperreflexia and spasticity, UMN signs typically in legs first, brisk knee reflexes, absent ankle, extensor plantars Spinocerebellar tracts - sensory ataxia and +ve Rombergs
34
combination of falls, alcohol excess, fluctuating episodes of confusion and focal neurology suggests which diagnosis?
Fluctuating consciousness = subdural haemorrhage
35
Which CN palsy causes vertical diplopia? which causes horizontal diplopia?
Vertical - Trochlear Horizontal - Abducens
36
What can percipitate subacute degeneration of spinal cord in B12 deficient patients?
Replacing folate before replacing B12 Always do B12 first as B is before F
37
What is anti-NMDA receptor encephalitis? How does it present and what is usually present?
Paraneoplastic syndrome - presents with prominent psychiatric features inc agitation, hallucinations, delusions and disordered thinking Ovarian teratomas in 1/2 of female adults - particularly afro-carribeans
38
What are the features of internuclear ophthalmoplegia? what are some causes?
Impaired adduction of eye - ipsilateral side Horizontal nystagmus of adducting eye - contralateral side Causes - vascular disease and MS
39
Where is the leison present in internuclear ophthalmoplegia?
Leison in medial longitudnal fasciculus (MLF) - paramedian area of midbrain / pons which controls horizontal eye movements by connecting CN III, IV and VI nuclei It is located in paramedian area of midbrain and pons
40
When can carbamazepine be used for neuropathic pain?
Only in trigeminal neuralgia
41
Location of homonymous quadrantanopias and the mneumonic?
superior: lesion of the inferior optic radiations in the temporal lobe (Meyer's loop) inferior: lesion of the superior optic radiations in the parietal lobe mnemonic = PITS (Parietal-Inferior, Temporal-Superior)
42
How can the different aphasias be classified?
Speech is NOT fluent: (laboured and halting) - Comprehension relatively in tact - Brocas (expressive) - Comprehension impaired - Global aphasia Speech is fluent (sentences dont make sense, word substitution + neologisms but speech is fluent) - Comprehension relatively intact - conduction aphasia (poor repetition) - Comprehension impaired - wernickes (receptive) aphasia
43
Common peroneal nerve - where is injury normally? characteristic feature?
Injury typically at neck of fibula - leads to foot drop
44
Sciatic nerve divides into:
Common peroneal nerve Tibial nerve
45
Features of common peroneal nerve leison?
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 peroneal muscles
46
Which anti-epileptic can lead to increased appetite and weight gain?
Sodium Valproate
47
Prognosis absence seizures in adolescence?
90-95% seizure free
48
Speech is fluent but repetition is poor Comprehension normal Which aphasia?
Conduction aphasia
49
Which disease is associated with bilateral vestibular schwannomas?
NF2
50
EEG - bilateral, symmetrical 3Hz spike and wave pattern Suggestive of what disorder?
Absence seizures
51
peripheral neuropathy, lymphadenopathy, and bleeding gums Can occur with which anti-epileptic
Gingival hyperplasia and the other sx mentioned are most common with phenytoin
52
Why to be careful giving metaclopramide in mx of migraines to young people and females?
At greater risk of EPSEs / acute dystonic reactions
53
Why do you get hyperaccusis in CN 7 palsy eg Bells palsy?
CN 7 damage affects stapedius muscle involved in dampening loud sounds -> paralysis of this means this doesn't happen anymore
54
Presentation of peripheral neuropathy in a personal treated with decompressive surgery for degenerative cervical myelopathy Mx? why?
Urgent referral to spinal / neurosurg - pathology can 'recurr' at adjacent spinal levels and require urgent mx
55
What are the different types of MND?
ALS - UMN + LMN Primary lateral sclerosis - UMN only Progressive muscular atrophy - LMN only distal muscles > proximal Progressive bulbar palsy - palsy of tongue, muscles of mastication and facial muscles due to loss of func of brainstem motor nuclei
56
Best and worst prognosis MND?
Best - Progressive muscular atrophy Worst - Progressive bulbar palsy
57
What is Miller Fisher Variant? antibodies present?
Variant of GBS - associated with ophthalmoplegia, areflexia and ataxia - eye muscles typically affected first Descending paralysis usually v ascending Anti-GQ1b antibodies in 90%
58
Suspected post-LP headache - mechanism?
Leaking of CSF from dura via puncture site -> ongoing CSF loss
59
Trigger for neuroleptic malignant syndrome? Features?
Antipsychotics (inc atypicals) + Dopaminergic drugs for Parkinsons (eg Levodopa) - often when drug is suddnely stopped Pyrexia Muscle rigidity Autonomic lability - HTN, tachycardia + tachypnoea Agitated delirium with confusion
60
Mx of neuroleptic malignant syndrome?
Stop antipsychotic -> to medical ward (often ICU) IV fluids - prevent renal failure Dantrolene - decreases excitation-contraction in skeletal muscle
61
Ipsilateral: Weakness (below leison) Loss of proprioception + vibration Contralateral: Loss of pain and temperature sensation Diagnosis and cause?
Brown-Sequard syndrome - caused by lateral hemisection of spinal cord
62
How should paracetamol and triptans be stopped in medication overuse headaches?
Withdrawn abruptly - may initially worsen headaches
63
What does it tell us if there is a visual field defect that is congruous? what if the macula is spared alongside this and why?
Congruous suggests the leison is posterior to optic tract (optic radiation or occipital cortex) Macula sparing tells us this leison is in the occipital cortex due to dual blood supply from MCA and PCA
64
Where is the leison in Wenickes aphasia?
Due to leison in superior temporal gyrus - supplied my inferior division of L MCA (Forms speech before sending to Brocas) -> Word salad Remember by Wernickes is W so 'we up' hence superior temporal gyrus
65
Where is the leison in the Brocas aphasia?
Leison of inferior frontal gyrus supplied by superior division of L MCA
66
Where is the leison in conduction aphasia?
Arcuate fasiculus - connection between Brocas and Wernicke's area
67
Where is the leison in global aphasia?
Large leison affecting inferior, superior temporal gyrus and arcuate fasiculus (all 3)
68
What are the features of ataxia telangiectasia?
Cerebellar ataxia Telangiectasias IgA deficiency -> recurrent chest infection 10% risk of malignancy mostly leukaemia / lymphomaa but also non-lymphoid tumours
69
age of onset in friedreichs ataxia and ataxia telangiectasia?
Ataxia telangiectasia = 1-5 years old Friedrichs ataxia - 10-15 years old Both autosomally recessive
70
What is CADASIL and how does this present
cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy Genetic condition that presents with migraines in middle age -> recurrent TIAs + strokes -> neurocognitive decline, psychiatric problems and dementia
71
MRI findings in CADASIL?
Multiple widespread hyper intense leisons in white matter, basal ganglia, thalamus and pons
72
What are some CIs for use of triptans? Triptan MoA?
Triptan MoA - 5HT1B / 5HT1D agonists CI = hx of significant RFs for IHD / CVD
73
Bitemporal hemianopias: What are the different causes dependent on whether upper or lower quadrants are more greatly affected?
upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma
74
What are the features of parietal lobe lesions?
sensory inattention apraxias astereognosis (tactile agnosia) inferior homonymous quadrantanopia Gerstmann's syndrome (lesion of dominant parietal): alexia, acalculia, finger agnosia and right-left disorientation
75
Features of occipital lobe leisons?
homonymous hemianopia (with macula sparing) cortical blindness visual agnosia
76
Features of temporal lobe leisons?
Wernicke's aphasia: this area 'forms' the speech before 'sending it' to Brocas area. Lesions result in word substituion, neologisms but speech remains fluent superior homonymous quadrantanopia auditory agnosia prosopagnosia (difficulty recognising faces)
77
Which CNs are affected in vestibular schwannomas (acoustic neuromas)
Classically vertigo, hearing loss, tinnitus and absent corneal reflex CN VIII - Vertigo, unilateral sensorineural hearing loss, unilateral tinnitus CN V - Absent corneal reflex CN VII - Facial palsy
78
What condition do you see bilateral vestibular schwannomas in ?
NF 2
79
Prophylactic management of cluster headaches?
Verapamil
80
What can cause gingival hyperplasia?
Phenytoin Ciclosporin CCBs AML
81
What can happen after SAH -> excessive Na loss? How can you distinguish between these?
SIADH and cerebral salt wasting syndrome Both lead to increased urinary sodium Cerebral salt wasting syndrome has low / normal urine osmolality whereas in SIADH (everything urinary is high) hence high osmolality
82
What is spastic paraparesis? how can varicella / HIV cause this?
UMN patterns of weakness in lower limbs Via transverse myelitis in HIV / Varicella
83
Which imaging should be used in MS, strokes / TIAs and which in thyroid eye disease?
MRI FLAIR - MS MRI Diffusion-weighted - Stroke / TIA MRI STIR - Thyroid eye disease
84
What is brachial neuritis?
acute onset of unilateral (occasionally bilateral) severe pain, followed by shoulder and scapular weakness several days later Usually minimal sensory changes Can see muscle wasting depending the nerve involved Good prognosis unless phrenic nerve involved -> significant breathlessness
85
What nerve palsy can be seen with raised ICP and why?
Third nerve palsy - pupillary dilatation due to herniation
86
Which opioid can be trialled in neuropathic pain if failure to respond to classical options and why?
Tramadol - dual MoA Weak opioid agonist Reuptake inhibitor of serotonin and norepinephrine
87
Features of Friedreichs ataxia?
Neurological features - absent ankle jerks/extensor plantars - cerebellar ataxia - optic atrophy - spinocerebellar tract degeneration Other features - HOCM (90%, most common cause of death) - DM (10-20%) - high-arched palate
88
Which tumours are associated with VHL?
Hemangiomas Clear cell renal cell carcinoma Phaeochromocytoma
89
Features of Tuberous Sclerosis?
ASHLEAF A- ash leaf spots S- Shagreen patches H- Heart Rhabdomyomas L- lung lumphanfioleiomyomatosis E- epilepsy A- angiomylolipoma in kidney F- Facial angiofibroma
90
NICE guidelines for starting AEDs after 1st seizure state:
To start AEDs if: the patient has a neurological deficit brain imaging shows a structural abnormality the EEG shows unequivocal epileptic activity the patient or their family or carers consider the risk of having a further seizure unacceptable
91
NCS in axonal pathology?
Normal conduction velociy Reduced amplitude
92
NCS in demyelinating disorders?
Reduced conduction velocity Normal amplitude
93
Where is the damage present in GBS?
Myelin sheath
94
What is Brown Sequard syndrome caused by? What are the features?
Ipsilateral weakness below leison Ipsilateral loss of proprioception and vibration sense Contralateral loss of pain and temp sensation Caused by lateral hemisection of spinal cord
95
What occurs when there is a rupture of MMA due to injury to pterion? what can be seen in some pts
Extradural haematoma Can see lucid interval in some patients - usually after major head injury
96
What are subdural haematomas usually associated with?
luctuating consciousness, often following trivial injury in the elderly or alcoholics
97
How can you distinguish between carpal tunnel syndrome and degenerative cervical myelopathy?
Both can present similarly but DCM will also have +ve hoffmans (thumb and index finger coming together when you flick the middle finger down)
98
Which AED can cause hypotension?
Phenytoin
99
Medication overuse headache tx?
Simple analgesia - stop abruptly Opioid analgesia - withdraw gradually
100
CT showing temporal lobe changes eg petechial haemorrhages is suggestive of ....
HSV encephalitis
101
Facioscapulohumeral muscular dystrophy - what is it? who does it affect? What other features can be present?
AD muscular dystrophy that affects face, scapula and upper arms 1st typically presents by 20y Can also involve high frequency-hearing loss and abnormality of the retinal arteries
102
Why to be careful using Natalizumab in certain patients for MS?
Can reactivate JC virus -> PML (Progressive multifocal leukoencephalopathy)
103
What is HSMN? What are the main types and how are they distinguished?
Hereditary sensorimotor neuropathy (HSMN) is a relatively new term which encompasses Charcot-Marie-Tooth disease 7 but 2 main clinically: HSMN type I: primarily due to demyelinating pathology HSMN type II: primarily due to axonal pathology
104
What can happen 3-4 weeks after starting Carbemazepine tx and why?
Can become less effective and more rapidly metabolised This is due to autoinduction of the enzyme that metabolises it
105
MoA of procyclidine
Anti-muscarinic
105
MRI: hyperintense signals in the basal ganglia and thalamus pulvinar region and dorsomedial thalamus are hyperintense on T2-weighted imaging What is this sign called and when is it seen?
Seen in CJD known as hockey stick sign
105
Mneumonic for cerebellar signs? what if its unilateral?
D - Dysdiadochokinesia, Dysmetria (past-pointing), patients may appear 'Drunk' A - Ataxia (limb, truncal) N - Nystamus (horizontal = ipsilateral hemisphere) I - Intention tremour S - Slurred staccato speech, Scanning dysarthria H - Hypotonia Signs will occur in ipsilateral side
106
What are the features of CJD?
rapid onset dementia myoclonus
107
What is PICA stroke called? What are the features?
Lateral medullary syndrome (Wallenbergs) due to occlusion of PICA Cerebellar signs - ataxia, nystagmus Brainstem signs - ipsilateral (dysphagia, facial numbness, CN palsy eg Horners) + contralateral (limb sensory loss)
108
What is the mx of a myasthenic crisis?
IVIg or plasmapheresis
109
What are the features of Wenickes encephalopathy and Korsakoffs syndrome?
Wernickes: - Nystagmus - Ophthalmoplegia inc nystagmus - Ataxia If untreated develops into Korsakoff's which includes above and also: - Amnesia (anterograde + retrograde) - Confabulation
110
What are the features of transient global amnesia?
clinical syndrome of uncertain aetiology, characterised by a discrete episode lasting for a few hours (always less than 24 hours) of anterograde amnesia, retrograde amnesia, repetitive questioning with an absence of other cognitive or neurological impairments There has to be a reliable witness, absence of trauma / LOC, preserved personal identity and absence of epileptic features
111
What is Gerstmanns syndrome?
Acalculia, right-left disorientation, finger agnosia and agraphia Due to deficit in dominant parietal lobe (angular and supramarginal gyri)
112
inability to generate a list Where is the leison?
Frontal lobe
113
anosmia Where is the leison?
Frontal lobe
114
Where is Brocas area?
Frontal lobe
115
Where is Wernickes area?
Temporal lobe
116
What are the features of midline cerebellar leisons?
gait and truncal ataxia
117
What are the features of hemispheric cerebellar leisons?
intention tremor, past pointing, dysdiadokinesis, nystagmus
118
Damage to the Medial thalamus and mammillary bodies of the hypothalamus leads to what disorder?
Wernicke and Korsakoff syndrome
119
Damage to the subthalamic nucleus of the basal ganglia leads to what disorder?
Hemiballism
120
Damage to the Striatum (caudate nucleus) of the basal ganglia leads to what disorder?
Huntington chorea
121
Damage to the amygdala leads to what disorder and what are the features of this?
Kluver-Bucy syndrome (hypersexuality, hyperorality, hyperphagia, visual agnosia
122
What is the pattern of muscle weakness in CMT?
Distal muscular weakness / atrophy can get stork leg deformity
123
What are the features of Juvenile myoclonic epilepsy (Jans syndrome)? tx?
infrequent generalized seizures, often in morning//following sleep deprivation daytime absences sudden, shock-like myoclonic seizure (these may develop before seizures) treatment: usually good response to sodium valproate
124
How can you distinguish NPH from MSA?
The presence of dementia and absence of cerebellar signs point away from a diagnosis of multiple system atrophy
125
Which anti-epileptic is associated with SJS? How can this present?
Lamotrigine SJS - several, global rash with blistering and peeling of the skin
126
symptoms of progressive ataxia, dysarthria, cognitive impairment and generalised weakness In someone with MS being treated - what is the likely diagnosis, organisms and implicated drug?
progressive multifocal leukoencephalopathy (PML) due to reactivation of JC virus Med - Natalizumab
127
How can you distinguish between Wernickes and Conduction aphasia?
Wernickes - impaired comprehension Conduction - Comprehension in tact
128
What may be seen in imaging for someone with hydrocephalus?
hydrocephalus with ventriculomegaly in the absence of, or out of proportion to, sulcal enlargement
129
Distal sensory loss, tingling + absent ankle jerks/extensor plantars + gait abnormalities/Romberg's positive Is suggestive of what?
Subacute combined degeneration of the spinal cord
130
Which neuropathic analgesic should be used less often if someone has reacted to pregabalin?
Gabapentin
131
What type of hearing loss in otosclerosis?
Conductive
132
Which side is the leison in PICA (Lateral medullary) strokes?
Ipsilateral to horners Contralateral to sensory loss
133
MRI finding shape in extradural v subdural - how to distinguish between acute / chronic?
Extradural = convex / limited by suture lines Subdural = Concave / not limited by suture lines Acute = Hyperintense Chronic = Hypointense
134
Progressive supranuclear palsy - features? (4)
postural instability, supranuclear ophtalmoplegia - typcially impairment of vertical gaze (patients may complain of difficultly reading or descending stairs) parkinsonism, frontal lobe dysfunction
135
delayed, but well preserved waveform in visual EVPs dx?
MS
136
Bladder dysfunction in MS - ix and mx?
guidelines stress the importance of getting an ultrasound first to assess bladder emptying - anticholinergics may worsen symptoms in some patients if significant residual volume → intermittent self-catheterisation if no significant residual volume → anticholinergics may improve urinary frequency (eg oxybutinin and tolterodine)
137
Features of dystonic myotonica ?
Dystrophia myotonica - DM1 Distal weakness initially autosomal Dominant Diabetes Dysarthria Cataract +- loss of red reflex Hear conduction defects Testicular atrophy - secondary to hormone issues
138
What is a rare but important adverse effect of topiramate?
acute myopia and secondary angle-closure glaucoma
139
What are the localising features of temporal lobe seizures?
May occur with or without impairment of consciousness or awareness 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) Seizures typically last around one minute automatisms (e.g. lip smacking/grabbing/plucking) are common
140
Features of frontal, parietal and occipital lobe focal seizures?
Frontal lobe (motor) Head/leg movements, posturing, post-ictal weakness, Jacksonian march Parietal lobe (sensory) Paraesthesia Occipital lobe (visual) Floaters/flashes
141
Cause of upbeat nystagmus v downbeat?
Upbeat nystagmus cerebellar vermis lesions (top of cerebellum) Downbeat nystagmus - foramen magnum lesions -> Arnold-Chiari malformation (low cerebellar tonsils)
142
Prognostic features of MS?
Good prognosis features female sex age: young age of onset (i.e. 20s or 30s) relapsing-remitting disease sensory symptoms only long interval between first two relapses complete recovery between relapses Ways of remembering prognostic features the typical patient carries a better prognosis than an atypical presentation
143
Causes of Parkinsonianism?
Parkinson's disease drug-induced e.g. antipsychotics, metoclopramide* progressive supranuclear palsy multiple system atrophy Wilson's disease post-encephalitis dementia pugilistica (secondary to chronic head trauma e.g. boxing) toxins: carbon monoxide, MPTP
144
BP control in ischaemic strokes?
blood pressure should not be lowered in the acute phase of ischaemic stroke unless there are complications e.g. Hypertensive encephalopathy or they are being considered for thrombolysis (see below) blood pressure control should be considered for patients who present with an acute ischaemic stroke, if they present within 6 hours and have a systolic blood pressure > 150 mmHg
145
Features of ACA, MCA and PCA strokes?
ACA - Contralateral hemiparesis and sensory loss, lower extremity > upper MCA - Contralateral hemiparesis and sensory loss, upper extremity > lower, Contralateral homonymous hemianopia, Aphasia PCA - Contralateral homonymous hemianopia with macular sparing, Visual agnosia
146
Ipsilateral CN III palsy Contralateral weakness of upper and lower extremity Suggest what stroke?
Weber's syndrome (branches of the posterior cerebral artery that supply the midbrain)
147
Ipsilateral: facial pain and temperature loss Contralateral: limb/torso pain and temperature loss Ataxia, nystagmus + Ipsilateral: facial paralysis and deafness Which type of stroke?
Anterior inferior cerebellar artery (lateral pontine syndrome)
148
Retinal/ophthalmic artery stroke?
Amaurosis fugax
149
Basilar artery stroke?
'Locked-in' syndrome
150
Lacunar strokes features?
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
151
Mx of otitis externa?
Topical corticosteroid + aminoglycoside
152
Craniopharyngioma - what part of the hypothalamus may be involved?
The ventromedial area of the hypothalamus is often involved.
153
how to distinguish between TIA and Migraine?
Stroke and TIA are associated with sudden-onset 'negative' symptoms, migraine is more commonly associated with 'positive' symptoms Negative Symptoms: These refer to deficits or losses in neurological function. In strokes and TIAs, patients may experience: Hemiparesis: Weakness on one side of the body. Aphasia: Difficulty with speech or language comprehension. Visual Field Deficits: Loss of vision in part of the visual field. Positive Symptoms: These involve the presence of abnormal sensations or experiences. In migraines, particularly during the aura phase, patients may report: Visual Disturbances: Such as scintillating scotomas or zigzag lines. Sensory Changes: Including tingling or numbness, often unilateral. Aura Symptoms: Can include auditory hallucinations or olfactory changes. This differentiation is essential for timely intervention; while migraines are typically self-limiting, strokes require immediate medical attention to prevent long-term disability.
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Movement disorders in order of least speed to fastest?
Dystonia - fixated position Athetosis - Snake-like writhing (slow) Choreiform - Like a dance choreographer Ballistic/Ballismus/Hemiballismus - Fast flinging movements, can injure themselves or others 'like a ballistic missile' (memorisation method) DACB
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The following conditions are associated with raised lymphocytes in CSF?
viral meningitis/encephalitis TB meningitis partially treated bacterial meningitis Lyme disease Behcet's, SLE lymphoma, leukaemia
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Which side is optic tract leison in comparison to incongruous homonymous hemianopia?
Contralateral side
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Mutation in CADASIL?
NOTCH3
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Painful third nerve palsy suggests what disorder?
posterior communicating artery aneurysm
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Causes of demyelinating v axonal peripheral neuropathy?
Demyelinating pathology Guillain-Barre syndrome chronic inflammatory demyelinating polyneuropathy (CIDP) amiodarone hereditary sensorimotor neuropathies (HSMN) type I paraprotein neuropathy Axonal pathology alcohol diabetes mellitus* - can also be demyelinating vasculitis vitamin B12 deficiency* - can also be demyelinating hereditary sensorimotor neuropathies (HSMN) type II
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Typical presentation of syringiomyelia?
cape-like loss of pain and temperature sensation due to compression of the spinothalamic tract fibres decussating in the anterior white commissure of the spine
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NF chromosome?
NF1: chromosome 17 - as neurofibromatosis has 17 characters NF2: chromosome 22 - all the 2's
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What causes loss of corneal reflex?
Seen due to CN V palsy in acoustic neuroma (vest schwannoma)
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Which NF is associated w Phaeo? what else can you see
NF1 can also see: Cafe-au-lait spots (>= 6, 15 mm in diameter) Axillary/groin freckles Peripheral neurofibromas Iris hamatomas (Lisch nodules) in > 90% Scoliosis Pheochromocytomas Nb NF2 has other CNS tumours present
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Essential tremor mx when BB CI?
Primidone
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cause of narcolepsy?
Orexin levels being low (hypocretin)
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Which patients should be offered thrombectomy?
Offer thrombectomy as soon as possible to people who were last known to be well between 6 hours and 24 hours previously (including wake-up strokes): - confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA and - if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume Offer thrombectomy as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if within 4.5 hours), to people who have: acute ischaemic stroke and - confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA)
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areflexia, ataxia, ophthalmoplegia Is the triad of what disorder?
Miller fisher GBS
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What are some trinucleotide repeat disorders and their nucleotides?
CAG: Huntingtons - like hunting animals in a cage GAA: Friedrich Ataxia - Friedrich is a baby, goo goo gaa gaa CTG: Myotonic dystrophy - if youre in myotonic dystrophy you need a CT, G CGG: Fragile X syndrome - Comme Garcos gay, if you have this you have a fragile X
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trigger for cluster headache?
alcohol maybe nocturnal sleep
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Causes of miosis (small pupil)
Horner's syndrome Argyll-Robertson pupil senile miosis pontine haemorrhage congenital
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Poor prognostic features of GBS?
age > 40 years poor upper extremity muscle strength previous history of a diarrhoeal illness (specifically Campylobacter jejuni) high anti-GM1 antibody titre need for ventilatory support
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SPASTIC PARAPARESIS causes ?
S=syringiomyelia p=parasagittal meningioma a=arthritis of the cervical spine s=spastic paraplegia hereditary t=tropical spastic paraparesis t=transverse myelitis i=infection..HIV / VZV C=cord compression trauma, tumour
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Essential tremor inheritance pattern?
Autosomally dominant
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HSMN - what type of disease is this?
Lower Motor neuron hence hyporeflexia
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Why is COCP CI in migraine w aura?
Significant risk of ischaemic stroke
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Can you get diplopia in parkinsons?
No - think of a parkinson plus condition like progressive supranuclear palsy
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Which interferon can be used for reducing relapse risk in MS?
b-inteferon
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Drug causes of IIH?
combined oral contraceptive pill steroids tetracyclines retinoids (isotretinoin, tretinoin) / vitamin A lithium
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Mx of migraines in pregnancy? and menstruation?
Pregnancy: > paracetamol 1g is first-line > NSAIDs can be used second-line in the first and second trimester > avoid aspirin and opioids such as codeine during pregnancy Menstruation related: > mefanamic acid or a combination of aspirin, paracetamol and caffeine. > Triptans are also recommended in the acute situation
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Which parkinsonian sx are uncommon in drug induced parkinsons?
rigidity and rest tremor
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Causes of predominantly sensory peripheral neuropathy?
diabetes uraemia - eg ckd leprosy alcoholism vitamin B12 deficiency amyloidosis
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Causes of predominantly motor peripheral neuropathy?
Guillain-Barre syndrome porphyria lead poisoning hereditary sensorimotor neuropathies (HSMN) - Charcot-Marie-Tooth chronic inflammatory demyelinating polyneuropathy (CIDP) diphtheria
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Stroke / TIA driving advice?
stroke or TIA: 1 month off driving, may not need to inform DVLA if no residual neurological deficit multiple TIAs over short period of times: 3 months off driving and inform DVLA
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Seizures DVLA advice?
1st / isolated seizure: > 6 months off if there are no relevant structural abnormalities on brain imaging and no definite epileptiform activity on EEG. > If these conditions are not met then this is increased to 12 months for patients with established epilepsy or those with multiple unprovoked seizures: > Drive if seizure free for 12m > If no seizures for 5y +- meds - til 70 licence restored withdrawal of meds: > should not drive whilst anti-epilepsy medication is being withdrawn and for 6 months after the last dose
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Vigabatrin - adverse effect?
Vigabatrin can cause visual field defects hence requires fields monitoring every 6m Anti-epileptic
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Apomorphine moa?
Dopamine agonist
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Which anti epileptic can cause cerebellar syndrome?
Phenytoin
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What drugs can cause peripheral neuropathy?
amiodarone isoniazid vincristine nitrofurantoin metronidazole
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How can you distinguish between Parkinsons and MSA?
Presence of ataxia
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What is used for drug induced parkinsonianism?
Anti muscarinic drugs eg procyclidine, benzotropine and trihexyphenidyl (benzhexol)
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When can AEDs be withdrawn in epilepsy?
Seizure free>2 yr ,AED stop over 2-3 m
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presents with a combination of cranial nerve (CN) palsies involving the 3rd and 6th nerves, which are both involved in eye movement. Additionally, there is hyperaesthesia of the upper face on the left side, suggesting involvement of the trigeminal nerve (CN V) Location of Leison?
Cavernous sinus
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ECG finding in myotonic dystrophy?
Prolonged PR
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Presentation of vestibular neuronitis and viral labyrinthitis?
Vestibular neuronitis: self-limiting condition characterised by acute onset vertigo with nausea and horizontal nystagmus, but crucially without auditory symptoms following a viral illness Viral labyrinthitis: Commonly follows viral infection, presents w vertigo + involves vestibular and cochlear part of inner ear -> hearing loss and / or tinnitus
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Paraneoplastic syndromes affecting nervous system - Anti-Hu?
associated with small cell lung carcinoma and neuroblastomas sensory neuropathy - may be painful cerebellar syndrome encephalomyelitis
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Paraneoplastic syndromes affecting nervous system - Anti-Yo?
associated with ovarian and breast cancer cerebellar syndrome
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Paraneoplastic syndromes affecting nervous system - Anti-GAD?
associated with breast, colorectal and small cell lung carcinoma stiff person's syndrome or diffuse hypertonia
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Paraneoplastic syndromes affecting nervous system - Anti-Ri?
associated with breast and small cell lung carcinoma ocular opsoclonus-myoclonus
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Paraneoplastic syndromes affecting nervous system - Anti-purkinje ab?
peripheral neuropathy in breast cancer
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Ovarian teratoma ix?
Pelvic USS
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irregular, flowing, non-rhythmic involuntary movements that appear to move from one body part to another Describes what neuro feature? where is the damage?
Chorea - caused by damage of the caudate nucleus of the basal ganglia
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Phaeochromocytoma, renal cell cancer are seen in which neuro condition?
VHL
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Which abx are CI in MG as they can percipitate an attack?
Aminoglycosides eg gentamicin
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Tachycardia, lower limb hyporeflexia and flaccid paralysis are seen in which condition? hyperreflexia is seen in which condition?
GBS - Absent or depressed deep tendon reflexes, paralysis is flaccid and autonomic sx are rare but most commonly tachycardia + urinary retention hyperreflexia seen in GBS variant - Bickerstaffs encephalitis
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Effect of phenytoin on hair?
Hirsuitism
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Indications for specialist referral in a patient with foot drop?
Bilateral symptoms, fasiculations or other abnormal neurological findings (e.g. hyperreflexia) are indications for specialist referral.
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Peroneal neuropathy mx?
Conservative - avoidance of leg crossing, squatting + kneeling and rv -> should improve in 2-3 months
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What are the different types of MSA?
1) MSA-P - Predominant Parkinsonian features 2) MSA-C - Predominant Cerebellar features
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Poor response to L-Dopa may be seen in which condition?
MSA
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What is neuromyelitis optica?
Neuromyelitis optica (NMO) is a monophasic or relapsing-remitting demyelinating CNS disorder More common in asians ypically involves the optic nerves and cervical spine, with imaging of the brain frequently normal. Vomiting is also a common presenting complaint.
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Criteria for dx of neuromyelitis optica?
Diagnosis requires bilateral optic neuritis, myelitis and 2 of the following 3 criteria: 1. Spinal cord lesion involving 3 or more spinal levels 2. Initially normal MRI brain 3. Aquaporin 4 positive serum antibody - NMO-IgG seropositive status (The NMO-IgG test checks the existence of antibodies against the aquaporin 4 antigen.)
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Motor weakness, encephalopathy, seizures and coma Is a neurological condition which occurs typically a few weeks following a viral illness or vaccination ix? and mx?
Ix T2-weighted MRI imaging which reveals poorly-defined hyperintensities in the subcortical white matter. These lesions can develop throughout the course of the illness and hence serial MRIs may be required. Dx:Acute disseminated encephalomyelitis
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Mx of Post-lumbar puncture headache?
supportive initially (analgesia, rest) if pain continues for more than 72 hours then specific treatment is indicated, to prevent subdural haematoma treatment options include: blood patch, epidural saline and intravenous caffeine
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Which dopamine agonists in parkinsons are associated w pulmonary retroperitoneal and pericardial fibrosis?
Ergot derived ones eg pergolide, bromocriptine, cabergoline, Pergolide
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Why can phenytoin cause anaemia?
Can cause megaloblastic anaemia secondary to altered folate metabolism
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Mx and prevention of menieres?
acute attacks: buccal or intramuscular prochlorperazine. Admission is sometimes required prevention: betahistine and vestibular rehabilitation exercises may be of benefit
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What condition is characterised by episodic vertigo, tinnitus (often described as a 'roaring' sensation), and sensorineural hearing loss?
Menieres
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L Dopa advereese effects?
D - Drowsiness, Dry Mouth, Dry mouth O - On/off effect P - Postural hypotension, Palpitations, Psychosis A - Anorexia, Arrythmias
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Which drugs can percipitate MG crises?
penicillamine quinidine, procainamide beta-blockers lithium phenytoin antibiotics: gentamicin, macrolides, quinolones, tetracyclines
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Vertical v Horizontal gaze palsy leison location?
Dorsal Midbrain: vertical gaze palsy Pons: horizontal gaze palsy
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MRI finding in Wenickes encephalopathy?
enhancement of the mamillary bodies due to petechial haemorrhages
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What is Foster kennedy syndrome?
which is an anterior intracranial mass directly compresses the ipsilateral optic nerve -----> causing atrophy and Increases intracranial pressure -----> causing contralateral papilledema. Leison is in frontal lobe
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Why are analgesics often given with prokinetic agents in migraine?
Patients with migraine experience delayed gastric emptying during acute attacks Hence prokinetic agents can help
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Alexia (cant read ) without agraphia (cant write) - where is the leison?
Corpus callosum
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Palatal myoclonus - leison location?
Olivary nucleus
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Laughter → fall/collapse is what sign? when may this be seen?
Cataplexy and may be seen with narcolepsy
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What is a gelastic seizure?
Laughing outburst is the seizure - caused by brain neoplasms
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What to do when focal seizures dont respond to lamotrigine / levetiracetam?
Use the other drug ie lamotrigine / levetiracetam
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Ataxic telangiectasia gene?
ATM gene
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When for carotid endartectomy?
>70% stenosis
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Entacapone MoA?
Sounds like mascapone, and COMT is also a cheese.
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Selegiline MoA?
MAO-B inhibitor
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In subacute combined degeneration of the spinal cord What is affecgted?
Dorsal columns - Loss of proprioception + vibration sense Lateral corticospinal tracts - Leads to UMN signs
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When to avoid amitripytilline and why in mx of neuropathic pain?
If pt has hx of glaucoma - anticholinergic effects can exacerbate this