Neurology Flashcards
conductive hearing loss, tinnitus and positive family history - diagnosis?
Otosclerosis
episodic vertigo, tinnitus, and hearing loss - diagnosis?
Meniere’s disease
Why can phenytoin cause bruising in newborn if mother takes it?
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
Caution for those using Natalizumab?
Natalizumab can cause reactivation of the JC virus causing progressive multifocal leukoencephalopathy (PML) - hx of MS with new neurological sx
Mx of focal seizures?
first line: lamotrigine or levetiracetam
second line: carbamazepine, oxcarbazepine or zonisamide
Mx of absence seizures? What is CI and why?
first line: ethosuximide
second line:
male: sodium valproate
female: lamotrigine or levetiracetam
CI = carbamazepine may exacerbate absence seizures
Mx of myoclonic seizures
males: sodium valproate
females: levetiracetam
Mx of tonic / atonic seizures?
males: sodium valproate
females: lamotrigine
Mx of generalised tonic-clinc seizures?
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
What is Waterhouse-Friderichsen syndrome - who is at risk of this?
Waterhouse-Friderichsen syndrome (adrenal insufficiency secondary to adrenal haemorrhage)
Pts with meningococcal meningitis are at risk
Anti-epileptics and breastfeeding?
Safe with most except barbiturates (-barbital suffix)
Mx of cranial abscess?
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
cerebellar signs, contralateral sensory loss & ipsilateral Horner’s
Which stroke syndrome? Vessel affected?
Lateral medullary syndrome - PICA affected
Adverse effects associated with 5HT3 antagonists?
Where do they act? examples?
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)
Important blood test in restless legs syndrome?
Ferritin
What is hemiballism?
Ballisic movements are involuntary, sudden, jerking movements which occur contralateral to the side of the lesion
Cause of hemiballism? Mx?
Hemiballism occurs following damage to the subthalamic nucleus in the basal ganglia
Antidopaminergic agents (e.g. Haloperidol) are the mainstay of treatment
When to perform LP if suspecting SAH?
12 hours post headache
Medication used in MND?
Riluzole - prolongs life by about 3 months (mostly used in ALS)
Which neuro medication can cause SJS?
Lamotrigine
Mx of idiopathic intracranial HTN?
Weight loss - 1st
Acetazolamide - carbonic anhydrase inhibitor
1st line tx for parkinsons?
If motor sx affecting QoL - Levodopa
If motor sx not affecting QoL - Dopamine agonnist, levodopa or MAO-B inhibitor
How to manage drooling in Parkinsons?
Glycopyrronium bromide
dementia (rapid onset)
myoclonus
Suggestive of what condition?
CJD
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
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.
shock-like, irregular jerking movements, usually of the arms suggestive for which type of seizures
Myoclonic seizures
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
Mx of spasticity in MS?
Baclofen + Gabapentin
Best tx for survival benefits in MND?
Riluzole - prolongs life by 3 months
NIV - prolongs life by 7 months
What do assymetric symptoms in Parkinsons suggest?
Idiopathic parkinsons instead of drug induced
First line mx in Restless legs?
Dopamine agonists eg pramipexole and ropinirole
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
combination of falls, alcohol excess, fluctuating episodes of confusion and focal neurology
suggests which diagnosis?
Fluctuating consciousness = subdural haemorrhage
Which CN palsy causes vertical diplopia? which causes horizontal diplopia?
Vertical - Trochlear
Horizontal - Abducens
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
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
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
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
When can carbamazepine be used for neuropathic pain?
Only in trigeminal neuralgia
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)
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
Common peroneal nerve - where is injury normally? characteristic feature?
Injury typically at neck of fibula - leads to foot drop
Sciatic nerve divides into:
Common peroneal nerve
Tibial nerve
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
Which anti-epileptic can lead to increased appetite and weight gain?
Sodium Valproate
Prognosis absence seizures in adolescence?
90-95% seizure free
Speech is fluent but repetition is poor
Comprehension normal
Which aphasia?
Conduction aphasia
Which disease is associated with bilateral vestibular schwannomas?
NF2
EEG - bilateral, symmetrical 3Hz spike and wave pattern
Suggestive of what disorder?
Absence seizures
peripheral neuropathy, lymphadenopathy, and bleeding gums
Can occur with which anti-epileptic
Gingival hyperplasia and the other sx mentioned are most common with phenytoin
Why to be careful giving metaclopramide in mx of migraines to young people and females?
At greater risk of EPSEs / acute dystonic reactions
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
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
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
Best and worst prognosis MND?
Best - Progressive muscular atrophy
Worst - Progressive bulbar palsy
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%
Suspected post-LP headache - mechanism?
Leaking of CSF from dura via puncture site -> ongoing CSF loss
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
Mx of neuroleptic malignant syndrome?
Stop antipsychotic
-> to medical ward (often ICU)
IV fluids - prevent renal failure
Dantrolene - decreases excitation-contraction in skeletal muscle
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
How should paracetamol and triptans be stopped in medication overuse headaches?
Withdrawn abruptly - may initially worsen headaches
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
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
Where is the leison in the Brocas aphasia?
Leison of inferior frontal gyrus supplied by superior division of L MCA
Where is the leison in conduction aphasia?
Arcuate fasiculus - connection between Brocas and Wernicke’s area
Where is the leison in global aphasia?
Large leison affecting inferior, superior temporal gyrus and arcuate fasiculus (all 3)
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
age of onset in friedreichs ataxia and ataxia telangiectasia?
Ataxia telangiectasia = 1-5 years old
Friedrichs ataxia - 10-15 years old
Both autosomally recessive
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
MRI findings in CADASIL?
Multiple widespread hyper intense leisons in white matter, basal ganglia, thalamus and pons
What are some CIs for use of triptans? Triptan MoA?
Triptan MoA - 5HT1B / 5HT1D agonists
CI = hx of significant RFs for IHD / CVD
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
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
Features of occipital lobe leisons?
homonymous hemianopia (with macula sparing)
cortical blindness
visual agnosia
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)
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
What condition do you see bilateral vestibular schwannomas in ?
NF 2
Prophylactic management of cluster headaches?
Verapamil
What can cause gingival hyperplasia?
Phenytoin
Ciclosporin
CCBs
AML
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
What is spastic paraparesis? how can varicella / HIV cause this?
UMN patterns of weakness in lower limbs
Via transverse myelitis in HIV / Varicella
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
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
What nerve palsy can be seen with raised ICP and why?
Third nerve palsy - pupillary dilatation due to herniation
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
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
Which tumours are associated with VHL?
Hemangiomas
Clear cell renal cell carcinoma
Phaeochromocytoma
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
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
NCS in axonal pathology?
Normal conduction velociy
Reduced amplitude
NCS in demyelinating disorders?
Reduced conduction velocity
Normal amplitude
Where is the damage present in GBS?
Myelin sheath
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
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
What are subdural haematomas usually associated with?
luctuating consciousness, often following trivial injury in the elderly or alcoholics
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)
Which AED can cause hypotension?
Phenytoin
Medication overuse headache tx?
Simple analgesia - stop abruptly
Opioid analgesia - withdraw gradually
CT showing temporal lobe changes eg petechial haemorrhages is suggestive of ….
HSV encephalitis
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
Why to be careful using Natalizumab in certain patients for MS?
Can reactivate JC virus -> PML (Progressive multifocal leukoencephalopathy)
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
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
MoA of procyclidine
Anti-muscarinic
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
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
What are the features of CJD?
rapid onset dementia
myoclonus
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)
What is the mx of a myasthenic crisis?
IVIg or plasmapheresis
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
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
What is Gerstmanns syndrome?
Acalculia, right-left disorientation, finger agnosia and agraphia
Due to deficit in dominant parietal lobe (angular and supramarginal gyri)
inability to generate a list
Where is the leison?
Frontal lobe
anosmia
Where is the leison?
Frontal lobe
Where is Brocas area?
Frontal lobe
Where is Wernickes area?
Temporal lobe
What are the features of midline cerebellar leisons?
gait and truncal ataxia
What are the features of hemispheric cerebellar leisons?
intention tremor, past pointing, dysdiadokinesis, nystagmus
Damage to the Medial thalamus and mammillary bodies of the hypothalamus leads to what disorder?
Wernicke and Korsakoff syndrome
Damage to the subthalamic nucleus of the basal ganglia leads to what disorder?
Hemiballism
Damage to the Striatum (caudate nucleus) of the basal ganglia leads to what disorder?
Huntington chorea
Damage to the amygdala leads to what disorder and what are the features of this?
Kluver-Bucy syndrome (hypersexuality, hyperorality, hyperphagia, visual agnosia
What is the pattern of muscle weakness in CMT?
Distal muscular weakness / atrophy
can get stork leg deformity
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
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
Which anti-epileptic is associated with SJS? How can this present?
Lamotrigine
SJS - several, global rash with blistering and peeling of the skin
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
How can you distinguish between Wernickes and Conduction aphasia?
Wernickes - impaired comprehension
Conduction - Comprehension in tact
What may be seen in imaging for someone with hydrocephalus?
hydrocephalus with ventriculomegaly in the absence of, or out of proportion to, sulcal enlargement
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
Which neuropathic analgesic should be used less often if someone has reacted to pregabalin?
Gabapentin
What type of hearing loss in otosclerosis?
Conductive
Which side is the leison in PICA (Lateral medullary) strokes?
Ipsilateral to horners
Contralateral to sensory loss
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
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
delayed, but well preserved waveform in visual EVPs dx?
MS
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)
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
What is a rare but important adverse effect of topiramate?
acute myopia and secondary angle-closure glaucoma
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
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
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)
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
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
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
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
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)
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)
Retinal/ophthalmic artery stroke?
Amaurosis fugax
Basilar artery stroke?
‘Locked-in’ syndrome
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
Mx of otitis externa?
Topical corticosteroid + aminoglycoside
Craniopharyngioma - what part of the hypothalamus may be involved?
The ventromedial area of the hypothalamus is often involved.
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.
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
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
Which side is optic tract leison in comparison to incongruous homonymous hemianopia?
Contralateral side
Mutation in CADASIL?
NOTCH3
Painful third nerve palsy suggests what disorder?
posterior communicating artery aneurysm
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
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
NF chromosome?
NF1: chromosome 17 - as neurofibromatosis has 17 characters
NF2: chromosome 22 - all the 2’s
What causes loss of corneal reflex?
Seen due to CN V palsy in acoustic neuroma (vest schwannoma)
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
Essential tremor mx when BB CI?
Primidone
cause of narcolepsy?
Orexin levels being low (hypocretin)
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)
areflexia, ataxia, ophthalmoplegia
Is the triad of what disorder?
Miller fisher GBS
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
trigger for cluster headache?
alcohol
maybe nocturnal sleep
Causes of miosis (small pupil)
Horner’s syndrome
Argyll-Robertson pupil
senile miosis
pontine haemorrhage
congenital
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
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
Essential tremor inheritance pattern?
Autosomally dominant
HSMN - what type of disease is this?
Lower Motor neuron hence hyporeflexia
Why is COCP CI in migraine w aura?
Significant risk of ischaemic stroke
Can you get diplopia in parkinsons?
No - think of a parkinson plus condition like progressive supranuclear palsy
Which interferon can be used for reducing relapse risk in MS?
b-inteferon
Drug causes of IIH?
combined oral contraceptive pill
steroids
tetracyclines
retinoids (isotretinoin, tretinoin) / vitamin A
lithium
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
Which parkinsonian sx are uncommon in drug induced parkinsons?
rigidity and rest tremor
Causes of predominantly sensory peripheral neuropathy?
diabetes
uraemia - eg ckd
leprosy
alcoholism
vitamin B12 deficiency
amyloidosis
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
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
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
Vigabatrin - adverse effect?
Vigabatrin can cause visual field defects hence requires fields monitoring every 6m
Anti-epileptic
Apomorphine moa?
Dopamine agonist
Which anti epileptic can cause cerebellar syndrome?
Phenytoin
What drugs can cause peripheral neuropathy?
amiodarone
isoniazid
vincristine
nitrofurantoin
metronidazole
How can you distinguish between Parkinsons and MSA?
Presence of ataxia
What is used for drug induced parkinsonianism?
Anti muscarinic drugs eg procyclidine, benzotropine and trihexyphenidyl (benzhexol)
When can AEDs be withdrawn in epilepsy?
Seizure free>2 yr ,AED stop over 2-3 m
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
ECG finding in myotonic dystrophy?
Prolonged PR
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
Paraneoplastic syndromes affecting nervous system - Anti-Hu?
associated with small cell lung carcinoma and neuroblastomas
sensory neuropathy - may be painful
cerebellar syndrome
encephalomyelitis
Paraneoplastic syndromes affecting nervous system - Anti-Yo?
associated with ovarian and breast cancer
cerebellar syndrome
Paraneoplastic syndromes affecting nervous system - Anti-GAD?
associated with breast, colorectal and small cell lung carcinoma
stiff person’s syndrome or diffuse hypertonia
Paraneoplastic syndromes affecting nervous system - Anti-Ri?
associated with breast and small cell lung carcinoma
ocular opsoclonus-myoclonus
Paraneoplastic syndromes affecting nervous system - Anti-purkinje ab?
peripheral neuropathy in breast cancer
Ovarian teratoma ix?
Pelvic USS
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
Phaeochromocytoma, renal cell cancer are seen in which neuro condition?
VHL
Which abx are CI in MG as they can percipitate an attack?
Aminoglycosides eg gentamicin
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
Effect of phenytoin on hair?
Hirsuitism
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.
Peroneal neuropathy mx?
Conservative - avoidance of leg crossing, squatting + kneeling and rv -> should improve in 2-3 months
What are the different types of MSA?
1) MSA-P - Predominant Parkinsonian features
2) MSA-C - Predominant Cerebellar features
Poor response to L-Dopa may be seen in which condition?
MSA
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.
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.)
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
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
Which dopamine agonists in parkinsons are associated w pulmonary retroperitoneal and pericardial fibrosis?
Ergot derived ones eg pergolide, bromocriptine, cabergoline, Pergolide
Why can phenytoin cause anaemia?
Can cause megaloblastic anaemia secondary to altered folate metabolism
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
What condition is characterised by episodic vertigo, tinnitus (often described as a ‘roaring’ sensation), and sensorineural hearing loss?
Menieres
L Dopa advereese effects?
D - Drowsiness, Dry Mouth, Dry mouth
O - On/off effect
P - Postural hypotension, Palpitations, Psychosis
A - Anorexia, Arrythmias
Which drugs can percipitate MG crises?
penicillamine
quinidine, procainamide
beta-blockers
lithium
phenytoin
antibiotics: gentamicin, macrolides, quinolones, tetracyclines
Vertical v Horizontal gaze palsy leison location?
Dorsal Midbrain: vertical gaze palsy
Pons: horizontal gaze palsy
MRI finding in Wenickes encephalopathy?
enhancement of the mamillary bodies due to petechial haemorrhages
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
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
Alexia (cant read ) without agraphia (cant write) - where is the leison?
Corpus callosum
Palatal myoclonus - leison location?
Olivary nucleus
Laughter → fall/collapse is what sign? when may this be seen?
Cataplexy and may be seen with narcolepsy
What is a gelastic seizure?
Laughing outburst is the seizure - caused by brain neoplasms
What to do when focal seizures dont respond to lamotrigine / levetiracetam?
Use the other drug ie lamotrigine / levetiracetam
Ataxic telangiectasia gene?
ATM gene
When for carotid endartectomy?
> 70% stenosis
Entacapone MoA?
Sounds like mascapone, and COMT is also a cheese.
Selegiline MoA?
MAO-B inhibitor
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
When to avoid amitripytilline and why in mx of neuropathic pain?
If pt has hx of glaucoma - anticholinergic effects can exacerbate this
