Neurology Flashcards
Causes of a predominantly sensory motor polyneuropathy?
MTV I DID IT!
Metabolic: diabetes, hypothyroidism, uraemia
Tumour: paraneoplastic
Vitamin: B12
Inherited: CMT
Demyelination: CIDP/GBS
Inflammatory: sarcoidosis or vasculitis
Drugs: isoniazid, cisplatin, vincristine, nitrofurantoin, amiodarone
Infection: treponemal or retroviral
Toxins: alcohol
Causes of a predominantly motor neuropathy?
MTV I DID IT!
Metabolic: porphyria
Tumour: paraneoplastic
V:
Inherited: CMT
Demyelination: CIDP/GBS (AMAN variant)
I:
Drugs: dapsone
Infection: diptheria, retroviral
Toxins: lead
Myopathy versus neuropathy? (LITFL)
Myopathy: usually proximal, no sensory deficit
Neuropathy the opposite
Causes of an autonomic neuropathy?
Metabolic: diabetes or porphyria
Tumour: paraneoplastic
V
I
Demyelination: GBS
Inflammatory: amyloidosis
D
Infection: Chagas, HIV
Toxins: botulism
What does ‘small fibre neuropathy’ mean?
Subtype of peripheral neuropathies in which there is impairment of small calibre sensory nerve fibres (myelinated A-delta fibres (cold, pain) and unmyelinated C fibres (warmth))
Vibration sense and proprioception preserved
What are the causes of demyelinating polyneuropathies?
CIPD
Multiple myeloma
Hereditary causes e.g. Refsum’s disease
HIV
Features of CIPD? (M)
Relapsing-remitting AIDP
Symmetrical weakness
Areflexia
Predominantly motor
CSF high protein (if high lymphocytes exclude infection e.g. HIV)
Treat with immunosuppression (IVIg or PLEX acutely)
Drugs causing neuropathy?
Sensory: isoniazid, metronidazole, hydralazine
Motor: dapsone
Sensorimotor: vincristine, cisplatin, nitrofurantoin, amiodarone
What does the Romberg test look at? (M)
If positive, it suggests a sensory ataxia e.g. in peripheral neuropathy
What is mononeuritis multiplex?
Impaired sensation and/or power in more than one peripheral nerve
Causes of mononeuritis multiplex? (BMJ)
MTV I DID IT!
Metabolic: diabetes
Tumour: paraneoplastic
Vitamin: -
Inherited: -
Demyelination: some CIPD variants
Inflammatory: vasculitis (eGPA, PAN, SLE, RA, Sjogren’s), sarcoid
Drugs: sulfonamides
Infection: retroviral, leprosy, Lyme
Toxins: -
How would you investigate a patient with peripheral neuropathy?
Urine for glycosuria and fundoscopy
FBC, ESR, U+E, LFT, glucose and HbA1c, thyroid, B12 and folate, protein electrophoresis, autoimmune profile (ANA, ENA, ANCA) i.e. metabolic, paraneoplastic, autoimmune causes
Nerve conduction studies (to determine if axonal or demyelinating) and EMG
Consider LP if ?CIDP or genetic studies if ?CMT
N.B. Axonal = reduced Amplitude
Demyelinating = slow conDuction velocity (usually immune-mediated)
Management of peripheral neuropathy?
MDT (PT, OT, podiatry)
Treat underlying cause
Stop drugs
Reduce risk factors (ETOH, diabetes, vasculitis)
Neuropathic analgesia e.g. pregabalin
Management of GBS?
Ix:
-NCS
-LP
-PFTs (VC)
-Look for underlying cause e.g. testing for Campylobacter, CMV, EBV
-Consider neuroimaging (spine MRI) if diagnostic uncertainty
Mx:
-IVIg or PLEX
-I+V if bulbar dysfunction or PFTs concerning
-pLMWH and analgesia
-Rehab (MDT)
Management of CIDP?
Ix:
-NCS
-LP
-Consider neuroimaging (spine MRI) if diagnostic uncertainty
Mx:
-IVIg or PLEX or IS
-MDT
-Analgesia
What is Charcot joint?
People with peripheral neuropathy
Characterised by inflammation and structural damage to the bones, joints, and soft tissue of the foot
Can lead to permanent bone and joint deformities, including collapse of the arches of the foot
Charcot Marie Tooth findings?*
Wasting of distal LL with preservation of thigh muscle (inverted champagne)
Pes cavus (imbalance between anterior and posterior tibialis)
Weakness of distal muscles
Glove and stocking sensory loss (mild)
High stepping gait (foot drop)
Palpable lateral popliteal nerve in 1A
N.B. Pain and temperature usually not affected in CMT as these fibres are not myelinated
Subtypes of CMT?*
Divided according to neurophysiological findings (axonal versus demyelinating) and inheritance pattern
Type 1A most common (autosomal dominant demyelinating)
How would you manage a CMT patient?
MDT (neurologists, orthopoedic surgeons, physiotherapists for aids, OTs, orthotics for foot drop)
Analgesia for MSK/neuropathic pain
Orthopoedic surgery to correct deformities
Genetic counselling
HNPP features? (M)
AD condition affecting peripheral nerves
Weakness and sensory loss
Susceptible to nerve injury from trivial pressure
Difference between stroke and TIA??*
Rapid onset focal neurological deficit due to a vascular lesion lasting >24 hours versus <24 hours (typically <30 minutes)
How would you investigate a stroke?*
If if within the thrombolysis window, I would calculate their NIHSS, request urgent CT and CTA and call the hyper-acute team stroke team for consideration of thrombolysis
Otherwise:
CT head infarct or bleed, territory
Consider MR if diagnosis remains uncertain
Consider perfusion imaging if considering thrombectomy (salvageable tissue)
FBC, CRP/ESR, U+Es, glucose (stroke mimics), HbA1c and lipids
Urine, ECG and consider CXR
Swallow screen
Holter, echo and carotid doppler
Consider thrombophilia, vasculitis screen, bubble echo in young stroke (<55)
Management of stroke?*
Thrombolysis within 4.5 hours and no ICH
Consider thrombectomy up to 24 hours of acute ischaemic stroke if CTA shows proximal occlusion
Aspirin 300mg for first two weeks then lifelong clopidogrel
Referral to specialist stroke unit for MDT (mobility, nutrition, swallowing)
IPCs for DVT prophylaxis
Address cause:
-Refer for carotid endarterectomy if anterior circulation stroke and >70% stenosis of ipsilateral internal carotid
-Anticoagulation if AF (not in acute phase)
-Address CV risk factors
DVLA advice
Complications of stroke? (PPP)
-Oedema secondary to malignant MCA syndrome
-Haemorrhagic transformation
-Repeat infarcts
-Seizures
-Hydrocephalus in bleeds
-Aspiration pneumonia
-Incontinence
-VTE
-GI bleeds
-Motor: spasticity and falls
-Mood: delirium and depression
Thrombectomy eligbility? (NICE)
Up to 24 hours of acute ischaemic stroke if CTA shows proximal occlusion and salvageable brain tissue
Take into account:
The patient’s overall clinical status
NIHSS (score >5)
Pre-stroke Rankin Scale (score <3, measure of disability)
CI for thrombolysis? (MDCalc)
-Intracranial hemorrhage or history of
-Known structural cerebral vascular lesion or neoplasm
-Ischemic stroke, neurosurgery or HI within 3 months
-Low platelet count
-Active bleeding
-Uncontrolled HTN
Bamford classification of stroke?*
TACS
Hemiplegia, Homonymous hemianopia, Higher cortical dysfunction (dysphasia, dyspraxia, neglect)
PACS
2/3 above
LACS
Pure hemi-motor or/and hemi-sensory loss
POCS
One needs to be present:
-CN palsy and a contralateral motor/sensory deficit
-Bilateral motor/sensory deficit
-Cerebellar dysfunction
-Homonymous hemianopia
Differentials for a patient with hemiparesis? (M)
Stroke
SOL
Cerebral palsy
MS
Brown-Sequard syndrome
In addition:
Stroke mimic
How to assess speech in stroke? (PT)
Speech:
-Comprehension by asking simple instructions (1, 2, 3 stage commands, receptive aphasia)
-Repetition (baby hippopotamus) (conduction aphasia and expressive aphasia)
-Confrontation naming (anomia)
-Spontaneous speech (dysarthria, agrammatism, word retrival, hestitancy)
-Reading and writing
-In most patients speech is L lateralised, so always offer to check if R hemiparesis/hemisensory loss
-Broca’s (non-fluent, agrammatism) L MCA infarct affceting PIF cortex
-Wernicke’s (fluent but meaningless) L MCA affecting PST cortex
-Conduction aphasia (impaired repition) inferior parietal
-Also anomic (word finding) and global aphasia
Stroke mimics?
-SOL
-Seizure +/- Todd’s paralysis
-Metabolic (hypoNa, hypoglycaemia, Wernicke’s)
-Hemiplegic migraine
-Functional
-CNS infection e.g. abscess
-MS
What is the NIHSS? (M)
The NIHSS is a stroke severity scale, a systematic assessment to measure the neurological deficits seen with acute stroke
Assessing speech in stroke?
Expressive dysphasia: “I knew what I wanted to say, but I couldn’t get it out”
Receptive dysphasia: “I wasn’t able to understand anyone, they were speaking gibberish”
Dysarthria: “My speech was really slurred, it sounded like I was drunk”
Lateral medullary syndrome?*
(PICA stroke)
Vertigo, vomiting
Ipsilateral ataxia (fall towards side of lesion)
Also:
Ipsilateral Horner’s, ipsilateral facial loss of pain and temperature
Contralateral loss of pain and temperature sensation
Visual field defects and how to localise? (OSCE stop)
-Monocular: ipsilateral retinal or optic nerve lesion
-Bitemporal hemianopia: optic chiasm
-HH: means lesion is retro-chiasmal, contralateral optic tract or optic radiation
-Homonymous superior quadrantanopia: contralateral temporal optic radiation lesion
-Homonymous inferior quadrantanopia: contralateral pituirary optic radiation lesion
-HH with macular sparing: occipital cortex
Causes of a proximal myopathy?*
Inherited: muscular dystrophy or myotonic dystrophy
Endocrine: Cushing’s, thyrotoxicosis, hyperparathyroidism, diabetic amyotrophy
Inflammatory: polymyositis or MG (if fatiguable)
Metabolic: osteomalacia
Malignancy: paraneoplastic, LEMS
Signs of MS?*
Wheelchair
Catheter if spinal plaques
INO, RAPD/optic atrophy/reduced VA
Sensory and UMN signs
DANISH
Other features:
Fatigue depression cognitive
Autonomic (urinary, impotence, bowel problems)
Uthoff’s (heat-induced condution block of partially demyelinated fibres)
Lhermitte’s (neck flexion results in electric shock sensation, indicates dorsal column involvement or cervical cord)
Diagnostic criteria for MS?
Requires dissemination in time and space
McDonald criteria allows MS to be diagnosed after a single attack using paraclinical tests
Subtypes of MS?*
RRMS 85%, can progress to secondary progressive with a median age of 15 years
PPMS 15%
Devic’s disease?
Investigation of MS?*
Clinical diagnosis plus:
-CSF oligoclonal bands
-MRI lesions in brain or spinal cord (typical T2 hyperintense lesions in periventricular white matter)
-Visual evoked potentials delayed velocity but normal amplitude (optic neuritis)
Treatment of MS?*
MDT (specialist nurses, PT, OT, orthotics team, social worker, neuropsychologist, SLT)
Disease modifying drugs e.g. natalizumab, interferon-beta, glatiramer
Vitamin D replacement
Symptomatic drugs:
-Methylprednisolone shortens relapses but doesn’t alter prognosis
-Anti-spasmodics e.g. baclofen or botox injections
-Gabapentin, pregabalin, amitriptyline for neuropathic pain
-Laxatives and intermittent catheterisation/oxybutynin
-SSRIs for depression
-Amantadine for fatigue
In pregnancy:
Reduced relapse rate during pregnancy but increased in post-partum period
Safe for foetus
2% risk of MS in children
Pathophysiology of MS?*
Idiopathic demyelinating disorder of the CNS characterised by demyelinating plaques separated in both space and time
Characterised as an autoimmune disease but aetiology incompletely understood
Thought to be both genetic and environmental factors at play (EBV, smoking, vitamin D deficiency)
What is an INO?*
Impairment of ipsilateral adduction
Normal abduction in contralateral eye with nystagmus
Results from medial longitudinal fasciculus
Causes of an INO? (Radiopedia)
-Demyelination (MS)
-Infarction (of midbrain or pons)
Less commonly infection (Lyme), inflammation (sarcoid), trauma, SOL
Signs of myotonic dystrophy?*
-Myopathic facies
-Bilateral ptosis
-Frontal balding
-Dysarthria
-Myotonia ‘grip my hand and let go’ or ‘screw eyes up then open’
-Wasting and weakness of distal muscles
-Percussion myotonia
-Areflexia
-Cataracts
-PPM scar
-Diabetes
N.B. Differentials would be myotonia congenita or channelopaties (the familial periodic paralyses)
Diagnosis of myotonic dystrophy?*
Clinical features
‘Dive-bomber’ potentials on EMG
Genetic testing for DM1 (or DM2 if negative)
Also ECG (+/- echo), HbA1c and opthalmology assessment
N.B. CK may be normal or mildly evelated
No indication for muscle biopsy
Genetics of myotonic dystophy? (BMJ paper)
DM1 is trinucleotide repeat disorder affecting DMPK gene on chromosome 19, demonsrates genetic anticipation, presents younger
DM2 is tetranucleotide repeat disorder affecting chromosome 3, presents later
Autosomal dominant
Management of myotonic dystrophy?*
-MDT (PT/OT, orthotics, SLT)
-No treatment for weakness
-Mexiletine may help myotonia (often not needed)
-Advise against GA
-Genetic counselling
Follow-up:
-Yearly ECG and low threshold for cardiology referral
-Investigate OSA symptoms
-Investigate if suspicion of diabetes
-Yearly assessment for cataracts
How to investigate a mononeuropathy? (M)
FBC, ESR, CRP, U+Es, LFTs, HbA1C, TFTs, complement
EMG (axonal or demyelinating) and nerve conduction
MRI cervical spine (to rule out radiculopathy)
How to treat neuropathic pain? (NICE)
Amitriptyline, duloxetine, gabapentin, or pregabalin
Causes of ptosis?*
Bilateral: autoimmune (MG), genetic (myotonic dystrophy), congenital, infection (treponemal), mitochondrial disorder (CPEO)
Investigations: ice or edrophonium test, ACh and MUSK antibodies, CT thorax, treponemal antibodies, muscle biopsy for ragged red fibres (CPEO)
Unilateral: 3rd nerve palsy (see causes), Horner’s (pupil small, see causes)
Investigations: HbA1c, ESR, ANA, ENA, ANCA, MRI brain/cord, CT thorax, angiography
CN3 findings? (GM)
Ptosis
‘Down and out’ eye
Pupil enlarged if surgical or compressive, normal if medical or ischaemic
Causes of CN3 palsy? (180)
Surgical causes often impinge on superficially located papillary fibres:
-PCOM aneurysm
-SOL
-Trauma
-Raised ICP (false localising sign)
Medical causes (ALL THE Ms):
-Microvascular ischaemia secondary to diabetes or HTN
Also:
-Congenital
-Other causes of complex opthalmoplegia but this would not cause an isolated CN3 palsy
How to investigate an ocular palsy? (M)
Bedside:
BP and BM
Bloods:
-HbA1c and lipids
-AChR antibodies and anti-MUSK and TFTs
-ESR +/- autoimmmune screen to look for vasculitis
-Lyme serology
Imaging:
MRI
N.B. In CN3 need urgent MR-A or CT-A to look for PCA which would need urgent neurosurgical input
Management of opthalmoplegia? (PPP)
Treat cause
Eye patch or prism glasses
DVLA
CN4 findings? (GM)
N.B. Depresses the aDducted eye
-Affected eye will look a bit higher and more outwards
-Head tilt towards unaffected side
-Vertical diplopia when looking down
-When eye aDducted it won’t depress
CN6 findings? (GM)
N.B. LR aBducts
-Convergent squint (eye deviates a little more medially as unopposed action of medial rectus)
-Affected eye can’t move out
-Horizontal diplopia which is worsened when they attempt to look towards the affected side
Causes of a complex opthalmoplegia? (M)
-MG or thyroid
-Stroke (especially brainstem)
-Inflammation (MS, sarcoidosis or vasculitis)
-Infection (e.g. Lyme)
-Opthalmoplegic migraine
-Miller Fisher (if ataxia and areflexia)
-Mitochondrial disease with CPEO (symmetrical so no diplopia)
-Cavernous sinus pathology (3, 4, 6)
Clinic signs of cerebellar syndrome?*
DANISH
N.B. Cerebellar hemisphere lesions produce ipsilateral limb signs
Midline lesions cause truncal ataxia
In cerebellar nystagmus, fast phase direction changes with changing of gaze (not the case for vestibular lesions, where fast phase is always away from side of lesion)
Causes of cerebellar syndrome?*
-Paraneoplastic
-Alcohol (Wernicke’s subacute or degeneration chronic)
-Sclerosis (MS or Miller Fisher syndrome)
-Tumour/trauma
-Recessive (Friedrich’s, ataxia telangiectasia) or dominant (spinocerebellar ataxia)
-Iatrogenic (phenytoin toxicity)/infective (VZV or Lyme or cerebellitis)
-Endocrine (hypothyroidism)
-Stroke (cerebellar or brainstem vascular event)
STS = lesions of the ipsilateral cerebellar hemisphere
Remaining = lesions of the vermis or global cerebellar degeneration
Investigations for cerebellar syndrome (180)
Bloods:
FBC (MCV), B12 and folate, TFTs
Consider anti-TTG, anti-GAD and viral serology
MRI brain
Or CT if acute
Consider: LP (MS) or genetic testing (FA) or paraneoplastic screen
Myotomes and dermatomes?
Syringomyelia clinical signs?*
-Weakness and wasting of small muscles of hand
-Loss of reflexes in upper limbs
-Loss of pain and temperature sensation cape-like (preserved of joint position and vibration sense)
-Signs may be asymmetrical
Differentials for syringomyelia? (180)
Arnold-Chiari malformation
Spinal cord SOL
Cervical spondylosis
Trauma
Clinical signs MND?*
Combination of LMN and UMN with preserved sensation
What is MND?*?
Progressive disease of unknown aetiology
Axonal degeneration of U and LMN
Divided into 4 types:
-ALS most common (combined upper and lower, spastic weakness in legs)
-PLS (just UMN)
-Progressive spinal muscular atrophy (only LMN)
-Progressive bulbar palsy (LMN brainstem signs)
Differentials for patient with pure motor involvement (LMN)? (LearnHaem)
Muscle
Inherited: muscular/myotonic dystrophy, spinal muscular atrophy or spinobulbar muscular atrophy (Kennedy’s)
Inflammatory myositis: polymyositis/dermatomyositis (proximal, anti-Mi2 and ANA, CK)
Inclusion body myositis (proximal UL, distal LL needs biopsy)
Endocrine: Cushing’s, thyroid disease, acromegaly
Metabolic: osteomalacia, ion channelopathies
NMJ
Autoimmune: MG (proximal, fatiguable)
Neuropathy:
Demyelinating: CIDP or MMN
Paraneoplastic
AHC
Infection: post-polio
MND (some subtypes)
How to investigate MND?*
-Clinical diagnosis
-VGKC (Isaac’s) and GM1 (MMN with CB) antibodies
-EMG shows denervation (rules out NMJ or demyelination)
-MRI brain spinal cord to exclude lesions which may mimic
Treatment of MND?*
-MDT as treatment is largely supportive (PT, OT, orthotics, specialist nurses, dietician, SLT, nutrition, palliative care depending on disease stage)
-Riluzole slows disease progression by 3 months but doesn’t improve function or QoL
-Regularly screen for speech, swallow, weight, development of FTD and IMPORTANTLY respiratory complications (FVC and early morning gas)
-May need communication aids, PEG and NIPPV
-Baclofen (spasticity), anti-cholinergic (salivation)
Signs of PD?*
‘BRT’
-Hypomimia and reduced movements
-Coarse pill-rolling 2-5Kz tremor
-Bradykinesia
-Cogwheel rigidity
-Gait is shuffling and festinant, reduced arm swinging
-Speech hypophonic and monotonous
Also do:
-Ataxia (MSA)
-Vertical eye movements and axial rigidity (PSNP)
Say you would do:
-L/S BP and bladder scan (MSA)
-Cognitive impairment (LBD, PSNP, NPH)
-Pulse and carotids (vascular Parkinsonism which is normally LL and bilateral affecting gait)
-Ask about medication history (secondary Parkinsonism)
Causes of parkinsonism?*
-PD
-Parkinson’s plus (MSA, PSNP (both symmetrical), corticobasal degeneration (asymmetrical))
-Drug-induced (prochloperazine, metoclopramide, antipsychotics)
-Vascular (acute basal ganglia stroke or diffuse SVD)
-Lewy body dementia
-Wilson’s disease
-Post-encephalitis
MSA?*
MSA-P: tremor, rigidity, bradykinesia
MSA-C: cerebellar and autonomic dysfunction causing collapse, incontinence, dry mouth, swallow problems, urinary retention or incontinence etc.
Investigations for PD? (180)
History (anosmia, constipation, cognition, hallucinations, mood, sleep, drugs, atherosclerotic RF)
Formally assess cognition, L/S BP and bladder scan
Clinical diagnosis, can be aided by a trial of dopaminergic agent
Bloods:
If <40 years, do copper and caeruloplasmin (Wilson’s disease)
Imaging:
MRI brain (vascular changes, atropghy in certain areas may point towards certain differentials, ventricular enalrgement NPH)
DaT scan (differentiates PD from drug-induced, will show decreased dopamine uptake)
Treatment of PD?*
MDT (SN, PT, OT, SLT)
Levo-dopa with peripheral dopa-decarboxylase inhibitor e.g. co-beneldopa (nausea, later wearing off and peak-dose dyskinesias)
Dopamine agonists e.g. ropinirole sometimes used in younger patients (slightly less effective and higher risk of impulsivity)
Also: MAO-B inhibitors (occasionally), anticholinergics (tremor-predominant)
Also: COMT-inhibitors (for Levodopa wearing off)
More advanced therapies which would be started under specialist guidance include:
DBS, apomorphine infusions/rescue injections
In addition, we should:
Manage constipation, mood disorders and sleep disorders
How to deal with wearing off?*
-More frequent dosing
-Drugs to reduce dopamine breakdown (COMT inhibitor)
-Add MAO-B or dopamine agonist
Consider MR dosing
N.B. Consider amantadine or DBS in refractory tremor or bothersome dyskinesias
Pathophysiology of PD?
Loss of dopaminergic neurons in the substantia nigra
Causes of tremor?*
Resting (Parkinsonism)
Action tremor:
Postural: BET, dystonic tremor, alcohol
Kinetic: ipsilateral cerebellar lesion
Signs of FA?*
-Bilateral cerebellar signs
-Combined UMN and LMN signs (leg wasting, reduced power, and absent reflexes due to peripheral neuropathy with upgoing plantars due to corticospinal tract degeneration)
-Posterior column signs (loss of joint vibration and proprioception)
Also:
-Kyphoscoliosis
-Optic atrophy
-High-arched palate
-SN deafness
-Murmur of HOCM
-Diabetes
FA differentials? (M)
Mixed upper and lower MN signs e.g. absent ankle jerks but upgoing plantars:
-SCD
-MND
-Conus medullaris lesion
-Treponemal
-Dual pathology e.g. cervical myelopathy and peripheral neuropathy of any cause
Other causes of ataxia
How to investigate a ?FA? (PT)
-B12 and vitamin E
-Brain and spinal cord imaging (to rule out alternative pathology)
-NCS and EMG (peripheral nerve involvement)
-Genetic testing for hereditary ataxias
-For complications, ECG, echo and HbA1c
Tell me about FA?*
-Autosomal recessive neurodegenerative disorder
-Frataxin gene
-Trinucleotide repeat
-Onset during teens
-Survival rarely exceeds 20 years from diagnosis
-Association between HOCM and dementia
Horner’s pupil signs and causes?*
Ptosis
Miosis
Anhydrosis
Central causes:
Brain stem causes: MS, Wallenberg’s
Pre-ganglionic causes:
Neck: branchial plexus lesion, Pancoast’s tumour
Post-ganglionic:
Carotid artery dissection, cavernous sinus mass
Holme’s Adie pupil signs and causes?*
Dilated pupil with poor response to light and sluggish response to accommodation
With absent or diminished ankle reflexes
Benign condition
Argyll Robertson signs and cause?*
Small irregular pupil, which accommodates but doesn’t react to light
Atrophied and depigmented iris
Usually a manifestation of quaternary syphilis but can also be caused by DM
Optic neuropathy causes?*
-Ischaemic optic neuropathy (arteritic i.e. GCA or non-arteritic i.e. microvascular ischaemia, long-sighted, usually bilateral) if OLDER
-Demyelination (MS, NMO) if YOUNGER
-Glaucoma
-A SOL e.g. optic glioma
-Inflammatory (SLE, sarcoidosis) and infection (Lyme and treponemal)
-Hereditary (Leber’s or RP)
-Compressive e.g. thyroid eye disease, pituitary tumour
-Drugs e.g. ethambutol
-Nutritional (B12, folate)
Interpret RAPD with caution as whilst it suggests an optic neuropathy, can also be present in retinal disease (reflects the difference in optic nerve signal input between the eyes)
So can also be positive in:
-Retinal detachment
-Central retinal artery occlusion
Stages of damage:
If normal, this means retro-bulbar optic neuritis
If swollen, damaged around optic nerve head
Pale optic disc in optic atrophy
Always ask for:
-Full neurological examination
-Slit lamp
-Visual fields
Neurofibromatosis clinical signs?*
-2 or more cutaneous neurofibromas
-Cafe-au-lait 6 or more
-Axillary freckling
-Lisch nodules
-Hypertension
-Neuropathy with palpable nerves
-Optic glioma
Tuberous sclerosis signs?*
-Angiofibromata
-Periungal fibromas
-Shagreen patch
-Ash leaf macules
Other associations:
-Cystic lung disease
-Polycystic kidneys or renal angiomyolipomata or RCC
-Retinal phakomas
-LD
Myasthenia gravis signs?*
-Bilateral ptosis
-Complicated bilateral extra-ocular palsies
-Myasthenic snarl
-Nasal speech, poor swallow
-Proximal muscle weakness with fatiguability
-Sternotomy scars (thymectomy)
-FVC
N.B. Can either be generalised or ocular MG
Associations with MG?*
Thyrotoxicosis
Thymomas
DM
RA
SLE
Tests for MG?*
-Ice/edrophonium test
-FVC is the most important bedside test
-Anti-AChR antibodies in 80%
-Anti-MuSK often positive if above negative
-Consider VGCC antibodies if ?LEMS
-TFTs
-EMG decrement with repetitive stimulation and ‘jitter’ is characteristic
-Also CT/MRI of the mediastinum (thymoma in 10%)
Treatment of MG?*
-MDT (SLT, OT, PT, opthalmology)
-Treat as per Sussman protocol with pyridostigmine and steroids +/- steroid sparing agent
-Consider admission when initiating steroids for observation of ‘steroid dip’
-Thymectomy
-Consider PLEX or IVIg in severe or refractory disease
-Avoid medications e.g. aminoglycosides, quinolones, beta blockers
-Counsel on risk factors for crisis including infections, volume depletion, aspiration, and drugs
-Monitor for swallow and respiratory compromise
Myasthenic crisis:
-ITU for I+V if FVC 15 mL/kg or less
-PLEX or IVIg
N.B. Pyridostigmine not used in crisis as increases secretions
N.B. If oMG and no generalised symptoms within 2 years, can more confidently diagnose oMG
N.B. ‘Steroid dip’ can be observed when starting steroids, especially with large doses (admit for observation if starting higher doses in more severe cases)
LEMS?*
-Pelvic then pectoral weakness plus autonomic (dry mouth and sphincter) with ptosis later
-Diminished reflexes that become brisker after exercise
-70% paraneoplastic (SCC)
To investigate:
-VGCC antibodies and EMG (increment on repetitive stimulation)
-EMG reduced CAMP amplutide with supramaximal stimulus which increases after exercise, jitter
-Investigate for underlying neoplasia
Treatment:
-Treat cause (immunosuppress if no cancer)
-Potentiate synaptic transmission with 3,4-diaminopyridine for symptom control
How to distinguish between UMN and LMN facial weakness?*
UMN weakness spares the forehead and eye closure
LMN involves the forehead and eye closure
Bell’s phenomenon: eyeball normally rolls up on attempted eye closure (visible if orbicularis oculi weakness)
Bell’s palsy?*
-Rapid onset 1-2 days
-HSV-1 implicated
-Induced swelling and compression of the nerve within the facial canal causes demyelination and temporary conduction block
-Prednisolone within 72 hours onset plus aciclovir if severe
-Remember eye protection (artificial tears, tape eye closed at night)
-80% full recovery
-More common in pregnancy, and outcome may be worse
Causes of bilateral LMN facial weakness?*
Myopathy
Inclusion body myositis
Muscular dystrophy
NMJ
MG
Peripheral nerve
Bilateral Bell’s i.e. post HSV
Bilateral Ramsey Hunt i.e. post-VZV
Lyme
GBS
AHC
-MND
Brainstem
-Sarcoidosis
-Malignant
-Infective
-With VI pontine demyelination or CVA
-With V, VI, VIII and DANISH, suspect CP angle e.g. acoustic neuroma
-With VIII suspect auditory canal e.g. cholesteatoma
IIH?
Presents with headaches:
-Postural, valsalva, vomiting
-Visual obscurations (blurring, field loss)
-Pulsatile tinnitus
-Can get diplopia from CN VI false localising sign
Investigations:
-Formal visual field assessment and fundoscopy
-MRI (+/- MRV)
-LP with opening pressure (normal CSF)
Exclude secondary causes raised ICP:
-Venous obstruction
-AV malformations
-Addison’s
-Drugs (vitamin A, anabolic steroids)
Treatment:
-If no visual loss, acetazolamide and weight loss
-If visual loss, LP, optic nerve fenestration, VP shunt
Conductive versus SNHL? (180)
CHL:
-Cerumen
-Otitis externa/media
-Cholesteatoma
-SOL
-Trauma
-Otosclorosis
SNHL:
-Presbycusis or noise-induced
-Labrinthitis or Meniere’s
-Ototoxic drugs
-Infection e.g. CMV
-SOL affecting cerebellopontine angle e.g. acoustic neuroma
-Demyelination
Retinal pathology?*
Chorea differentials? (PT) (Investigations as per differentials)
Acute:
-Stroke (asymmetrical)
-Hyperglycaemia
-Polycythaemia
More chronic:
-Sydenham’s chorea (post-infective, rare)
-SLE
-Huntington’s (trinucleotide repeat disorder, anticipation)
Movement disorders how to categorise?
Hypokinetic (bradykinesia, akinesia)
Hyperkinetic (chorea, dystonia, tremor, myoclonus, tics)
HD management? (PT)
MDT (neurologists for symptom management, neuropsychiatrists, neuropsychologists, dieticians as increased BMR, OT and PT)
Genetic counselling
Acute monocular blindness differentials? (180)
Painless:
-Ischaemic optic neuropathy (GCA (transient) versus non-arteritic ischaemic ON)
-Retinal ischaemia (amaurosis fugax) (transient)
-Retinal artery or vein occlusion
-Retinal detatchment
-Vitreous haemorrhage or PVD
-Papilloedema (transient)
Painful:
-Optic neuritis (pain on eye movement) (e.g. MS/NMO)
-Uveitis
-Acute angle closure glaucoma
-Corneal ulceration or keratitis
-Trauma
-Leber’s
-Migraine (transient)
See causes of optic neuropathy below
Investigations for acute monocular blindness? (180)
-Opthalmologist or neurology
If GCA:
-Inflammatory markers (GCA)
-Urgent rheumatology review with USS temporal artery +/- biopsy
If amaurosis fugax:
-HbA1c and lipids
-Urgent TIA clinic with carotid dopplers and Holter
If thinking optic neuritis:
-B12 and folate
-Anti-MOG and aquaporin 4 antibodies
-MRI brain and spinal cord +/- orbit
-LP
-VEP to evaluate optic nerve function
-If ?inflammatory autoimmune screen and ACE
-If ?infective consider treponemal screen
Homonymous hemianopia differentials? (180)
Stroke
SOL
N.B. PITS
Bitemporal hemianopia differentials? (180)
-Pituitary adenoma (galactorrhoea, acromegaly, Cushing’s)
Causes bitemporal superior quadrantanopia
-Craniopharyngioma
Causes bitemporal inferior quadrantanopia
C(h)IPS
CN6 differentials? (PPP)
-Congenital
-Trauma
-Microvascular ischaemia (associated with DM, HTN)
-Raised ICP causing false localising sign e.g. IIH
N.B. CN6 long route
CN4 differentials? (PPP)
-Congenital
-Traumatic (susceptible as thin nerve and long intracranial course)
-Microvascular ischaemia (diabetes or hypertension)
CN 5 7 8 differentials? (180)
Lesions affecting CP angle:
Usually an acoustic neuroma
Meningioma
Arachnoid cyst
Bulbar palsy? (180)
MND
GBS
Syringobulbia
MG
Poliomyelitis
N.B. Due to diseases affecting nuclei of 9-12 (LMN lesion)
Pseudobulbar is due to lesions affecting corticobulbar tracts (UMN lesion)
Post-polio syndrome signs? (M)
++wasting and LMN signs
++fasciculations (if no fasciculations, just say ‘old polio’)
Shortened limbs
Preserved sensation
What is poliomyelitis? (M)
Infects CNS and destroys anterior horn cells
This causes paralysis, an asymmetrical weakness which affects LLs more than ULs
What is post-polio syndrome? (M)
After a period of prolonged stability following infection, individuals who have been infected and recovered begin to experience new signs and symptoms: muscle atrophy, weakness, pain, fatigue
Jugular foramen syndrome differentials? (180)
CN 9-11
SOL
Lymphoma, TB, sarcoid
Cervical myelopathy findings? (BMJ)
Pyramidal weakness (weakness more distal in upper limbs)
Hyper-reflexia
Spasticity
Sensory loss
May be unilateral or bilateral
N.B. Would be LMN signs in cervical radiculopathy
Brown-Sequard syndrome? (Paper)
Half spinal cord
Paralysis and proprioceptive deficits ipsilateral
Loss of pain and temperature sensation on the contralateral side
As spinothalamic tract ducussates right away in the spinal cord
Brachial neuritis findings? (NP)
Pain followed by flaccid, areflexic paralysis (patchy involvement of muscles supplied by C5-C6)
Peri-scapular wasting
NCS/EMG: sensory motor loss of amplutide with normal velocities, dennervation in muscles after 2 weeks
Differentials: adhesive capsulitis, cervical radiculopathy, neoplastic plexopathy, mononeuritis multiplex
Treatment: prednisolone and PT
Types of muscular dystrophy? (NP)
-Duchenne’s (x-linked, calf hypertrophy, CM, CK >10,000)
-Becker’s (x-linked, milder, CK >10,000)
-Facioscapulohumeral (AD, face and shoulder, can’t whistle or close eyes, winged scapula)
-Limb-girdle (shoulders and pelvis)
-Myotonic
-Oculopharyngeal
Tell me about Duchenne’s? (NP)
X-linked
Translocation results in absence of dystrophin
Spasticity versus rigidity?
Rigidity is not velocity dependent
Spasticity is velocity dependent
Causes of a spastic paraparesis? (M)
Spinal cord compression e.g. due to neoplasia or trauma or disc disease
Spinal cord ischaemia
Demyelination: MS
Nutritional deficiencies (vitamin B12, E, copper)
Inflammatory: neuromyelitis optica, SLE
Infection: retroviral, treponemal
Inherited such as HSP or SCAs or Friedrich’s (if also cerebellar signs and peripheral neuropathy)
MND (PLS variant)
How to investigate spastic paraparesis?
Bloods (B12 and copper)
MRI brain and spinal cord
Urgency determined by speed of onset of symptoms
Condier LP (MS) and genetic studies (HSP)
Tell me about Kennedy’s disease? (PT)
X linked spinobulbar muscular atrophy
LMN
X-linked recessive
Perioral fasciculations pathognomic
Androgen insensitivity
Slow progression
Lesion in brain:
Pure UMN signs, hemiparesis or hermisensory, cerebellar signs
Lesion in brainstem:
Mixed UMN signs and CN palsies and crossed signs
Lesion in spinal cord:
Sensory level, LMN signs at level of lesion, UMN signs below, bowel or bladder dysfunction, isolated dorsal column or spinothalamic tract signs, Brown-Sequard
AHC lesion?
Purely motor signs, mixed UMN and LMN signs with fasciculations
Root lesion?
LMN and sensory signs attributable to one or more roots
Plexus lesion?
LMN and sensory signs affecting more than one root e.g. whole limb
Peripheral nerve lesion?
Either:
Glove and stocking sensory > LMN signs i.e. length dependent
OR:
Sensory and LMN signs attributable to one peripheral nerve e.g. radial, ulnar, peroneal
NMJ lesion?
Fatiguable weakness
No sensory features
Muscular?
No fatigability
No sensory features
Types of gait?
-Cerebellar: broad-based, fall towards side of lesion (DANISH)
-Extra-pyramidal: shuffling, festinant, slow turning circle and axial rigidity, reduced arm swing, stooped (bradykinesia, bradyphrenia, resting tremor)
-Sensory: stamping, Romberg’s +ve
-Proximal weakness: difficulty rising from chair
-Foot drop: high-stepping gait, cannot stand on heels
-Hemiplegia: spastic arm flexion and leg extension, circumduction of leg, toe walking
-Paraplegia: ‘like walking through mud’, spastic leg extension
-Antalgic: due to pain
Foot drop differentials?
L5/S1 lesion
Peroneal nerve
Peripheral neuropathy
Muscular
Explanations:
Common peroneal nerve palsy: wasting of tibialis anterior, weak ankle dorsiflexion (L4/5), eversion (L5/S1) +/- sensory loss on outside of leg and across foot
Causes: fracture or pressure on the neck of fibula
L4, L5 root lesion: weakness of ankle dorsiflexion and inversion (eversion can be preserved (L5/S1) +/- weakness of hip abduction, reflexes normal, sensory signs in the L4, L5 dermatomes
Causes: prolapsed intervertebral disc
Peripheral neuropathy: unilateral or bilateral foot drop, weakness of all muscles in foot (including plantar flexion), normal movements at hip, and knees are flexible, stocking sensory loss
Causes: Guillain-Barre syndrome, chronic inflammatory demyelinating polyradiculopathy (CIDP), lead toxicity, porphyria, drugs, congenital (Charcot Marie Tooth)
Sciatic nerve lesion: (ask about hip trauma or surgery) or lumbrosacral plexus lesion (obstetric injury)
Hyperkinetic movement disorders?
Chorea (jerky and fleeting)
Athetosis (writhing and sinuous)
Hemiballismus (ballistic and unilateral)
Types of nystagmus?
Pendular
Jerk (fast phase towards lesion in central and away in peripheral)
Present peripheral neuropathy, PD, CMT disease, abnormal gait, spastic paraparesis, cerebellar syndrome, myotonic dystrophy, MG, post-polio syndrome, acromegaly.
CSF results? (PT)
Bacterial meningitis
WCC (neutrophils)
Raised protein
Low CSF to serum glucose ratio
Viral meningitis:
WCC (leukocytes)
Normal or raised protein
CSF to serum glucose ratio normal
N.B.
Bacterial:
Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae type b (Hib)
Viral:
Enteroviruses
Complications of bacterial meningitis:
Shock, raised ICP, hydrocephalus
Seizures
Hearing loss
Cognitive
Spina bifida (BMJ)
Variable paralysis and sensory loss in the legs, orthopaedic deformities, neurogenic bowel and bladder, hydrocephalus, and Chiari II malformation
Prevented with folic acid
RF:
Poor maternal diet, maternal diabetes, teratogens e.g. MTX or Na valproate
