Neurology Flashcards

Question

Symptoms of MCA stroke ??

Answer 1

C/L paralysis & Sensory loss of - Lower Face & ULs If Dominant hemisphere involved - Aphasia If Non-dominant hemisphere - Hemineglect Wernicke's is a/w Rt. Superior Quadrant Visual F defect => Temporal lobe involvement - C/L Homonymous Hemianopia

Answer 2

C/L paralysis + Absence of Cortical signs (eg., neglect, aphasia, visual field loss) Pure Motor stroke are MC Common site of Lacunar Infarcts due to Microatheroma & Hyaline arterio-sclerosis (Lipohyalinosis) secondary to unmanaged HTN

Answer 3

MEDIAL CNs - CN 3, 4 : PCA - CN 6 : Basilar - CN 12 : Anterior Spinal LATERAL CNs - CN 5, 7, 8 : Labyrinthine & AICA - CN 9, 10, 11 : Vertebral & PICA

Answer 4

PCA - Occipital lobe. - Supplies CN 3, 4 BASILAR artery - Pons, Medulla, Lower Midbrain - Corticospinal & Corticobulbar tracts - Ocular CN nuclei. - Paramedian Pontine Reticular Formation (PPRF) - Supplies CN 6 ANTERIOR INFERIOR C A - Facial & Vestibular nuclei - Spinothalamic tract, Spinal Trigeminal nucleus - Sympathetic fibres, Middle & Inferior Cerebellar peduncles. - Inner ear POSTERIOR INFERIOR C A - Nucleus ambigus (CN 9, 10) - Vestibular Nucleus, Lateral S T tract, Spinal Trigeminal nucleus - Sympathetic fibres - Inferior Cerebellar Peduncle ANTERIOR SPINAL Artery - Corticospinal tract - Medial leminiscus - Caudal Medulla- Hypoglossal nerve

Answer 5

C/L Hemianopia with Macular Sparing DOMINANT Hemisphere, extending to Splenium of Corpus callosum - Alexia without Agraphia NON-Dominant H involved - Prosopagnosia: difficulty to recognise people face WEBER's Synd. (Midbrain stroke) - Paramedian PCA branch occlusion - I/L CN 3 palsy + C/L Hemiplagia (damage to I/L cerebral peduncle)

Answer 6

Locked-in syndrome Consciousness preserved IF RAS spared Quadriplegia Loss of voluntary - Facial (except blinking); Mouth & Tongue movements - Loss of Horizontal but NOT Vertical eye movements

Answer 7

Lateral Pontine Syndrome - I/L Paralysis of face (UMN lesion in Cortical stroke - Decrease lacrimation, salivation, Taste in anterior 2/3 of tongue - I/L SNHL, vertigo (supplied by labyrinthine A, a branch of AICA) PICA c/f : Decrease in pain & temperature from C/L body, I/L face - I/L Horner's, I/L ataxia & dysmetria

Answer 8

Lateral Medullary/ Wallenberg's - Dysphagia, Hoarseness, Decreased Gag reflex, Hiccups (Nucleus ambigus effects are specific to PICA lesions) AICA c/f - Vomit, Vertigo, Nystagmus- Decrease pain & temp. from C/L body & I/L face - I/L Horner's - I/L Ataxia & Dysmetria

Answer 9

MEDIAL Medullary Syndrome (Paramedian branch of ASA &/or Vertebral artery occlusion) C/L paralysis of ULs & LLs Decreased C/L Proprioception I/L hypoglossal dysfunction (Tongue deviates I/L)

Answer 10

Increased ICP - Mass effect (Haemorrhage) - Cerebral edema (Stroke or Trauma) - Hydrocephalus Divided into 2 categories - Supratentorial - Infratentorial

Answer 11

Cingulate (Subfalcine) H under Falx ceribri - Can compress ACA Central/Downward Transtentorial H - Caudal displacement of Brainstem Uncal Transtentorial H - Uncus= Medial Temporal lobe Cerebellar Tonsillar H into F Magnum - Brainstem compression => Coma & death Upward Cerebellar - Ataxia, Nystagmus

Answer 12

Brainstem Caudal displacement - Rupture of Paramedian Basilar artery branches => DURET Haemorrhages - Decorticate & Decerebrate Posturing - Fatal

Answer 13

Compress 2 key structures - PCA & CN 3 Early H => I/L Down out Blown pupil (U/L CN3 compression) + C/L Hemiparesis Late H => Coma + Kernohan phenomenon (Misleading C/L Blown pupil + I/L Hemiparesis due to C/L compression against Kernohan notch)

Answer 14

Meningitis, Encephalitis SAH, Head injury Sinusitis Glaucoma Tropical illness eg- Malaria Chr. Raised ICP Paget's disease Psychological

Answer 15

Dx. Criteria (ICHD-3) Criterion A: At least 5 attacks fulfilling B to D criterias Criterion B: Severe/ Very severe U/L Orbital, Supraorbital, &/or Temporal Pain lasting 15- 180 min (when not Rx Criterion C: Either or Both of - At least one of the following C/F or Signs, I/L to Headache - Conjunctival injection &/or Lacrimation - Nasal congestion &/or Rhinorrhea - Eyelid Edema - Forehead & Facial Sweating - Miosis &/or Pupils - Sense of Restlessness or Agitation Criterion D: Attacks have a frequency b/w 1 every other day & 8/day Criterion E: Not better accounted for by another ICHD-3 dx.

Answer 16

Represents a grp. of Primary Headache disorders characterised by - Severe U/L Pain in CN-5 distribution - Accompanied by I/L Autonomic C/F This includes - Cluster Headache - Paroxysmal Hemicrania - Short-Lasting U/L Headache attacks (SUNCT & SUNA) - Hemicrania Continua - Other less common variants

Answer 17

Criterion A: At least 20 attacks fulfilling criteria B- E Criterion B: Severe U/L Orbital, Supraorbital, or Temporal pain lasting 2- 30 min Criterion C: At least 1 of the following C/F or Signs, I/L to Headache: - Conjunctival Injection &/or Lacrimation - Nasal Congestion &/or Rhinorrhea - Eyelid Edema - Forehead & Facial Sweating - Miosis &/or Ptosis Criterion D: Attack Frequency or > 5/day for ,ore than 1/2 of the time Criterion. E: Complete response to therapeutic INDOMETHACIN doses

Answer 18

SUNCT: Short-lasting U/L Neuralgiform headache attacks with Conjunctival injection & Tearing SUNA: Short-lasting U/L Neuralgiform headache attacks with cranial Autonomic symptoms - BOTH involve brief attacks of moderate to severe U/L head pain, typically lasting 1- 600 sec. & occurs at a frequency of at least 1/day

Answer 19

A : At least 20 attacks fulfilling B- D B : Moderate or severe U/L Head pain lasting for 1- 600 sec. C : At least 1 of the following C/F or signs, I/L to headache For SUNCT : Conjunctival injection &/or Lacrimation For SUNA: - C injection &/or Lacrimation - Nasal Congestion &/or Rhinorrhoea - Eyelid Edema - Forehead & Facial Sweating - Miosis &/or Ptosis D : Attack Freq.- At least 1/day E : Not better accounted for by another ICHD-3 dx.

Answer 20

A : U/L Headache fulfilling B- D B : Presents for > 3 months, with exacerbations of moderate to severe intensity C : At least 1 of the following C/F & Signs, I/L to headache- - C Injection &/or Lacrimation - Nasal congestion &/or Rhinorrhea - Eyelid Oedema - Forehead & Facial Sweating - Miosis &/or Ptosis D : Complete response to theurapeutic dose of INDOMETHACIN E : Not better accounted by another ICHD-3 dx.

Answer 21

1) 1st line: High-flow O2 (12-15l/min) + SC Sumatriptans 2nd line: Intranasal Zolmitriptan & IM Dihydroergotamine 2) ToC: INDOMETHACIN - Celecoxib/ Meloxicam (if 1st line CI)

Answer 22

Dysfunction in the Hypothalamus & its connections with the CN-5-Autonomic reflex pathways - Neuroimaging: Posterior Hypothalamic Gray matter during attacks - Genetic factors, Neuropeptide signalling & Hormonal influences may also play a role.

Answer 23

1) IV Lidocaine - Lamotrigine & Topiramate (Short-term Rx.) 2) ToC: INDOMETHACIN

Answer 24

1) 1st line: VERAPAMIL - Lithium, Topiramate as alternatives Corticosteroids (Short-term prevention during episode) 2) INDOMETHACIN - Alternatives: Gabapentin/ Topiramate

Answer 25

1) 1st line: Lamotrigine, Topiramate & Gabapentin - Carbamazepine, Oxcarbamazepine can also be considered 2) INDOMATHACIN - Celecoxib, Meloxicam (if 1st line CI)

Answer 26

A : At least 5 attacks fulfilling B- D B : Headache for 4- 72 hrs (untreated or unsuccessfully Rx.) - Children: Shorter lasting + more commonly B/L + GI c/f MC C : Headache has >=2 of - U/L location - Pulsating quality - Moderete or Severe pain - Aggravation by/ Causing avoidance of routine physical activity (walking or climbing stairs) D : During Headache at least 1 of - N & V - Photophobia & Phonophobia E : Not attributed to another disorder

Answer 27

3x more common in Women - Prevelence in Men: 6% & Women: 18% Common TRIGGERS - Tiredness, Stress - Alcohol, - COCPs - Lack of food or Dehydration - Cheese, Chocolate, Red wine, Citrus - Menstruation - Bright lights

Answer 28

Atypical Aura features like - Motor weakness - Double vision - U/L Visual symptoms - Poor Balance - Decreased level of Consciousness

Answer 29

M with Aura (25% cases) is easier to Dx.. a TYPICAL aura is - Progressive in nature -Seen Hours prior to Headache - Visual - Transient Hemianopia disturbance (or) Spreading Scintillating Scotoma (Jagged crescent) - Sensory C/F can also occur Auras are seen +/- Headache & - Fully Reversible - Develop over at least 5 min. - Lasts 5- 60 min

Answer 30

NICE suggests the following along with the International Headache Society Dx. Criteria - Migraines can be U/L or B/L - NICE gives more details about Typical Auras

Answer 31

5-HT r (+) : used for Acute Rx. 5-HT r (-) : used for Prophylaxis

Answer 32

1st line: Oral Triptan + NSAIDs (or) Oral Triptan + PCM - Age 12- 17yrs: Nasal Triptans (Not Oral) 2nd line: Non-Oral preparation of [Metoclopramide/ Prochlorperazine] +/- [NSAIDs or Triptans] NOTE: Acute Dystonic reaction in Young pts.

Answer 33

Given IF >= 2 attacks/ month 1) 1st line: Propranolol or Topiramate Women of Child-bearing age - PROPRANOLOL >> Topiramate (Teratogenic & Reduced Hormonal Contraceptive's effectiveness) 2) 2nd line: course of upto 10 sessions of Acupuncture over 5- 8 wks 3) Riboflavin: Reduces Frequency & Intensity on attacks in some pts.

Answer 34

1) 1st line : PCM 2nd line: NSAIDs (in 1st & 2nd Trimester) - Avoid: Aspirin & Opioids 2) COCPs use is an Absolute CI in pts of M with Aura (Stroke increased risk) 3) SAFE to give HRT for pts. with H/o M but it may worsen the migraines

Answer 35

Acute: Mefanamic acid or [Aspirin + PCM + Caffeine] Start from 2 days before until 3 days after Bleeding start - Frovatriptan (2.5mg PO BD) - Zolmitriptan (2.5mg PO TDS)

Answer 36

MoA- - Blocks Voltage-gated Na+ channels - Increases GABA action - Carbonic Anhydrase (-) : Results in decreased Urine Citrate excretion & forms Alkaline urine & favours CaPO4 stone formation It is a P450 enzyme CYP3A4 inducer - Can cause Hormone Contraceptives being less effective Topiramate + - COCPs & POPs = UKMEC 3 - Implants = UKMEC 2

Answer 37

Depo-Provera Injection Intrauterine System Inducer of P450 enzyme CYP3A4

Answer 38

Reduced appetite & Wt. loss Dizziness Paraesthesia Lethargy & Poor conc. Rare: Acute Myopia & 2ndary Angle Closure Glaucoma Teratogenic (malformations)

Answer 39

One of the MCC of Chr. Daily Headache - Present for >= 15 days/ month - Developed or Worsened while taking regular symptomatic Rx. - Pts. on OPIOIDS & TRIPTANS are at more risk - May be a Psychiatric Co-morbidity

Answer 40

ABRUPT withdrawal of - Simple Analgesics & Triptans (may initially worsen headache) OPIOID Analgesics withdrawn gradually Withdrawal C/F can occur - N & V, Hypotension, Tachycardia, Restlessness, Sleep disturbances & Anxiety

Answer 41

AGONISTS of 5-HT1B & 5-HT1D - Acute Rx. of Migraine - Taken asap AFTER headache starts & NOT after Aura starts S/E - Triptan Sensations: Tingling, heat, Tightness (throat, chest), Heaviness, Pressure CI: IHD or Cerebrovascular Disease - (Previous H/o or At Risk pts.)

Answer 42

U/L severe pain over the distribution of CN-5 - MCC is IDIOPATHIC - Compression of Trigeminal roots by tumour or Vascular probs may occur

Answer 43

- Sensory changes - Deafness or Other ear problems - H/o Skin or Oral lesions that could spread Perineurally - Pain ONLY in the Ophthalmic division of Trigeminal nerve (Eye socket, Nose & Forehead) or B/L - Optic Neuritis - FHx of Multiple Sclerosis - Age of Onset before 40 yrs

Answer 44

U/L disorder characterised by brief Shock-like pain, abrupt in onset & termination, limited to >- 1 division of Trigeminal nerve - Pain is evoked by Light touch (Washing, shaving, talking, brushing of teeth) & frequently occurs spontaneously - Trigger area: Small areas in Naso-Labial fold or chin may be particularly susceptible to the ppt. of pain - Pain usually remits for variable period

Answer 45

1st line: CARBAMAZEPINE Refer to Neurology if failure to respond to Rx. or Atypical features (< 50yrs old)

Answer 46

Seen in 1/3rd pts. Due to leak of CSF following Dural puncture - MC in Young Females + Low BMI Factors that Contribute to Headache - Increased Needle size - Direction of Bevel - Not placing the Stylet - Increased no. of LP attempts

Answer 47

Sudden enlargement of Pituitary tumour (usually Non-Functioning Macroadenoma) - 2ndary to Bleeding or Infarction Precipitating Factors - HTN, - Pregnancy - Trauma, - Anticoagulation Ix.oC : MRI is diagnostic

Answer 48

Develops within 24-48hrs after LP but can occur up to 1 wk later Can last for Several days Worsens with Upright position Improves with Recumbent position Rx.- - Initially Supportive: Analgesia, Rest If pain for > 72hrs: Specific Rx. is indicated to prevent Sub-Dural H - Blood patch, - Epidural saline & IV Caffeine

Answer 49

Increased volume of CSF removed Bed rest following procedures Increased fluid intake post LP Opening pressure of CSF Position of pt.

Answer 50

Parietal Lobe lesion - Sensory Inattention, - Apraxias - Astereognosis (Tactile agnosia) - Inferior Homo. Quadrantanopia - Gerstmann's Syndrome (Dominant P lobe lesion) : Alexia Acalculia, Finger agnosia & Rt.-Lt. Disorientation

Answer 51

Sudden onset Headache (similar to the one seen in SAH) Vomiting Neck Stiffness Extraocular Nerve Palsy Bitemporal Superior Quadrantanopia Features of Pituitary Insufficiency - Hypotension, HypoNa+ (2ndary to Hypoadrenalism)

Answer 52

IoC : MRI is diagnostic Urgent Steroid replacement (due to ACTH loss) Careful Fluid balance Surgery

Answer 53

Homo. Hemianopia with Macular sparing Cortical Blindness Visual Agnosia

Answer 54

1) Wernicke's Aphasia - Forms speech before sending it to Brocas ares - Lesion: Substitution, Neologism, FLUENT Speech 2) Superior Homo. Quadrantanopia 3) Auditory Agnosia 4) Prosopagnosia (difficulty recognising face)

Answer 55

Brocas Aphasia (Expressive) - Site: Posterior aspect of FL in the Inferior gyrus - Broken speech, laboured & halting Disinhibition Perversed Anosmia Inability to generate a list

Answer 56

Midline lesion: Gait & Truncal Ataxia Hemisphere Lesions - Intention tremor, - Nystagmus - Past-pointing - Dysdiadokinesis

Answer 57

Hypersexuality, Hyperorality, Hyperphagia, Visual Agnosia - AMYGDALA is affected

Answer 58

- Subthalamic nucleus of BG - Striatum (Caudate N) of BG - Substantia nigra Pars compacta of BG - Medial Thalamus & Mammillary bodies of HYPOTHALAMUS - Amygdala

Answer 59

Pressure : 10-18 cmH2O (Recumbent) Protein : 0.2- 0.4 g/l Glucose : > 2/3rd BG Cells : RBCs- 0, WBC- < 5/mm3

Answer 60

Viral Meningitis/ Encephalitis TB meningitis Partially treated Bacterial Meningitis Lyme's disease Behcet's SLE Lymphoma, Leukaemia

Answer 61

GBS TB, Fungal & Bacterial Meningitis Viral Encephalitis Froin's Syndrome - Increase in CSF protein below a Spinal canal blockage - eg.- Tumour, Disc, Infection

Answer 62

1) SNHL (MC sequelae) 2) Seizures 3) FND 4) Infective: Sepsis Intracerebral Abscess 5) Pressure: - Brain herniation - Hydrocephalus 6) Meningococcal Meningitis are at risk of Waterhouse-Fridrichsen Synd. (Adrenal insufficiency 2ndary to Adrenal haemorrhage)

Answer 63

1) MRI can be normal but - FLAIR sequence: Deep Subcortical Limbic Str. abnormalities 2) CSF (Normal Initially) - Later: Pleocytosis 3) Anti-MuSK autoantibodies - No Thymoma & No Antibodies against ACh receptors 4) Anti-GM1 autoantibodies - Specific for Acute Inflam. Demyelinating Polyneuropathy (AIDP) variant of GBS

Answer 64

PARANEOPLASTIC Syndrome Features- Prominent Psychiatric C/F - Agitation, Hallucinations - Delusions, Disordered thinking Seizures, Insomnia, Dyskinesia Autonomic instability

Answer 65

Immunosuppression - Steroids, IGs, Cyclophosphamide, Rituximab alone or in combination Plasmapheresis Resection of Teratoma is also therapeutic

Answer 66

Ovarian Teratomes - Detected in upto 1/2 of ALL Female adult pts. More prevalent in AFRO-CARIBBEANS

Answer 67

aka Post-Infectious Encephalomyelitis Autoimmune DEMYELINATING disease of the CNS Cause : Occurs after Bacterial or Viral pathogen - Measles, Mumps, Rubella & Varicella + others Ix.- MRI (Supra- & Infra- Tentorial Demyelination) Rx.- - IV Glucocorticoids - IVIG if this fails

Answer 68

After a gap of Few days to 2 months, there is an Acute onset Multifocal CNS symptom with RAPID deterioration - Headache, Fever, N & V Motor + Sensory deficits Brainstem involvement including Oculomotor defects

Answer 69

1) MRI- FLAIR sequence - Deep Subcortical Limbic Str. abnormalities - Plain MRI head may be normal 2) MRI - Supra- & Infra- Tentorial Demyelination

Answer 70

Causes - Extension of Sepsis from middle ear or sinuses, trauma or surgery to scalp Penetrating head injury & Embolic events from Endocarditis Ix.- Pt assessment & CT Scan Rx.- 1) Surgery (Craniotomy + Abscess cavity debridement) - Abscess can reform as because the head is closed after abscess drainage 2) IV 3rd Gen. Cephalosporins + Metronidazole 3) ICP increased: Dexamethasone

Answer 71

Presenting features depends on the site of abscess - Those in critical areas (eg- Motor complex) will present earlier - Headache (dull, persistent) - Fever (NOT Swinging pyrexia as seen with abscesses at other sites) 2ndary to raised ICP (Mass effect) - FND - Nausea, Papilloedema, Seizures

Answer 72

RAPID Progressive CNS condition caused by PRION Proteins - These proteins induce the formation of Amyloid Folds resulting in tightly packed Beta-pleated sheets resistant to Proteases Ix.- - CSF usually normal - EEG: Biphasic, High Amplitude sharp waves (only in Sporadic CJD) - MRI: Hyperintense signals in BG & Thalamus

Answer 73

85% cases & 10-15% are Familial Mean age onset is 65yrs EEG: Biphasic, High amplitude sharp waves MRI: Hyperintense signals in BG & Thalamus

Answer 74

Young pts. (Average age of onset 25 yrs) Psychological C/F: (MC) - Anxiety, Withdrawal & Dysponea - Prion protein is encoded on Chr.20 Methionine Homozygosity at codon 129 of prion protein is a risk factor for developing CJD- Median survival of 13 months

Answer 75

Kuru Fatal Familial Insomnia Gerstmann Straussler-Scheinker disease

Answer 76

Sporadic - Old age + Rapid Progressive Dementia + Myoclonus - EEG: Biphasic, High amplitude sharp waves New Variant CJD - Young Age (25 yrs) + Psychological C/F (Anxiety, Withdrawal, Dysphonia)

Answer 77

Cerebral A D Arteriopathy with Subcortical Infarcts & Leukoencephalopathy - Rare cause of Multi-Infarct DEMENTIA - Pt. often presents with Migraine

Answer 78

Speech is FLUENT If Comprehension relatively Intact - Conduction Aphasia If Comprehension Impaired - Wernicke's Aphasia Speech is NOT Fluent If Comprehension relatively Intact - Broca's Aphasia If Comprehension Impaired - Global Aphasia

Answer 79

RECEPTIVE Aphasia ['Forms' speech] Lesion: Superior Temporal Gyrus B Supply: Left MCA (Inferior branch) - Forms speech before sending it to Broca's area C/F: Sentences make NO Sense, Word substitution & Neologism but FLUENT speech 'Word salad' - Comprehension IMPAIRED

Answer 80

EXPRESSIVE Aphasia Lesion: Inferior Temporal Gyrus B Supply: Left MCA (Superior Branch) - Broken speech (not fluent), Halting, Laboured - Repetition is IMPAIRED - Comprehension is NORMAL

Answer 81

Stroke affecting Arcuate Fasiculus Connects Wernicke's => Broca's - Speech is FLUENT - Repetition is POOR - Aware of the errors they make - Comprehension is NORMAL

Answer 82

Lesion affecting ALL areas ie. - Wernicke's, A Fasiculus & Broca's - Severe Receptive & Expressive Aphasia - Able to communicate using Gestures

Answer 83

Brief spasms beginning in the 1st few months of life - Salaam attack: Flexion of Head, Trunk, limbs; lasts for 1-2 sec, repeats upto 50 times - Progressive Mental handicap - EEG: Hypsarrhythmia Causes- Idiopathic 2ndary to: Serious CNS probs (T Sclerosis, Encephalitis, Birth asphyxia)

Answer 84

May be an Extension of West's Synd. Onset: 1- 5 yrs Features- - Atypical absences, falls, jerks - 90% Moderate-Severe Mental Handicap - EEG: Slow Spikes

Answer 85

Form of Generalised Epilepsy - MC in Children (3- 10 yrs old) - Girls >> Boys Features - Absences last for few- 30 sec. - No warning + Quick Recovery - Provoked by Hyperventilation or Stress - Child UNAWARE of seizures - Occur Multiple times in a day EEG: B/L Symmetrical 3Hz Spike & Wave pattern

Answer 86

Age: 4- 12 yrs Occurs at Night or On waking up Seizures are Partial (eg Paraesthesia affecting Face) Secondary generalization may occur - Tonic-Clonic movt. EEG: Centro-Temporal Spikes

Answer 87

Typical in Teenage yrs, MC in Girls Features - Infrequent generalised seizures - Often in Morning/ after Sleep deprivation - Daytime Absences - Sudden, shock-like seizures (may develop before seizures)

Answer 88

1) FOCAL Onset Seizures - Motor - Non-Motor 2) GENERALIZED Onset Seizures Motor - Tonic-Clonic (Grand Mal - Tonic, - Clonic, - Atonic Non-Motor Typical Absence 3) FOCAL Onset to B/L Seizure - Starts on 1 side of brain (Specific area) before spreading to Both lobes - Secondary Generalised Seizures 4) UNKNOWN Onset Seizures - Term reserved wen the origin of seizure is unknown

Answer 89

Is based on 3 key features - Where seizures begin in brain - Level of Awareness during Seizures - Other features of Seizures

Answer 90

These engage or involve networks on both sides of brain at the Onset - All pts LOSE Consciousness immediately Divided into - Motor: Tonic-Clinic (Grand-Mal), Tonic, Clonic, Atonic - Non-Motor Typical Absence (Petit Mal)

Answer 91

Focal Onset Seizures Starts at specific area on 1 side of brain; Can be further divided into - Motor: eg- Jacksonian March - Non-Motor: eg- Deja vu, Jamais vu Having other features such as Aura The pt. may be - Aware or Impaired Awareness or Awareness Unknown

Answer 92

1) Rx.- Vigabatrin & Steroids - EEG: Hypsarrhythmia 2) Rx.- Ketogenic diet may help - EEG: Slow Spike 3) Rx.- Na Valproate & Ethosuximide - Good Prognosis: 90-95% are seizyre free by adolescence - EEG: B/L Symmetrical 3Hz Spike & Wave pattern 4) Rx.- Excellent Prognosis, stops by Adolescence - EEG: Centro-Temporal Spike 5) Rx.- Na Valproate

Answer 93

1) Folic Acid 5mg/ day well before conception to minimise NTDs 2) Aim for MONOTHERAPY 3) Least Teratogenic among the Older Antiepileptics : CARBAMAZEPINE 4) Newer agents: LAMOTRIGINE - Dose needs to be Increased 5) Breastfeeding is safe (except with Barbiturates) 6) Pregnant + on Phenytoin - - Vit. K at last month of POG to prevent clotting probs. in foetus

Answer 94

TEMPORAL Lobe ("HEAD") - Hallucinations (Auditory/Gustatory/ Olfactory), - Epigastric rising or Emotional - Automatism (Lip smacking/Grabbing or Plucking) - Deja vu or Dysphasia post-ictal FRONTAL Lobe (Motor) - Head/Leg Movt., Posturing - Post-Ictal Weakness, Jacksonian march

Answer 95

PARIETAL Lobe (Sensory) - Paraesthesia OCCIPITAL Lobe (Visual) - Floaters or Flashes

Answer 96

C/F: Lip Smaking, Involuntary movt. of Hands, Fluttering of Eyelids 1st line: ETHOSUXIMIDE 2nd Line - Males: Sodium Valproate - Females: Lamotri. or Levetira. Carbamezepine may WORSEN absence seizures

Answer 97

1) 1st line: Lamatrigine/ Levitiracetam - 2nd line: Carbamazepine/ Oxcarbamezepine/ Zonisamide 2) Males: Na Valproate - Females: Lamotrigine/ Levetiracetam - Girls < 10yrs + Unlikely to need Rx when old enough (OR) Women who are unable to have Kids : Offer SODIUM VALPROATE as 1st line

Answer 98

Rx. is started following SECOND Epileptic Seizure Start Anti-Epileptics after the 1st episode in the following- - FND - Structural abnormalities on Brain Scans - EEG shows definite Epileptic waves Pt. or their Family or Carers consider the risk of having a further seizure unacceptable

Answer 99

1) Males: Na Valproate - Females: Levetiracetam 2) Males: Na Valproate - Females: Lamotrigine 3) 1st line: Carbamazipine

Answer 100

Single seizure for > 5min (OR) >= 2 seizures within a 5 min. period without the person returning to normal b/w them

Answer 101

Medical Emergency 1) ABC: Airway adjunct, O2, Check BG 2) 1st line: IV BZPs (Dia-/ Lora- zepam) - Prehospital setting: PR Diazepam or Buccal Midazolam - In Hospital: IV Lorazepam, can be repeated once after 10-20 min 3) If Ongoing/ 'Established' Status start- 2nd line: Phenytoin/ Phenobarbital Infusion 4) If NO Response/ 'Refractory' Status within 45 min of Onset - GA Induction

Answer 102

Works by Increasing GABA activity S/E - Teratogenic - Neurodevt. delay

Answer 103

DoC in Absence seizures MoA: Blocks T-type Ca2+ channels in Thalamic neurons

Answer 104

MoA: Binds to Na+ channels Increasing their Refractory period - P450 enzyme Inducer Trough levels needs to be checked immediately before dose should be checked if - Adjustment of Phenytoin dose - Suspected Toxicity - Detection of Non-Adherence

Answer 105

ACUTE - Initially: Dizziness, Diplopia, Nystagmus, Slurred speech, Ataxia - Later: Confusion, Seizures CHRONIC - Common: Gingival Hyperplasia (2ndary to increased PDGF expression), Hirsutism, Coarse Facial features, Drowsiness - Megaloblastic anaemia - Peripheral Neurapathy - LNpathy, - Dyskinesia - Enhanced Vit.D metabolism causing Osteomalacia

Answer 106

IDIOSYNCRATIC - Fever, - Hepatitis - Dupuytren's contracturs - Aplastic anaemia - Drug-induced Lupus - Rashes (including TEN) TERATOGENIC - Cleft Palate & Congenital H Disease

Answer 107

Chemically similar to TCAs MoA: Binds to Na+ channels => Increase Refractory period Uses: Trigeminal N & Bipolar disease Exhibits Autoinduction

Answer 108

P450 inducer Dizziness, Ataxia Drowsiness, Headache Visual disturbances (DIPLOPIA mc) SJS LEUCOPENIA & Agranulocytosis Hypo[Na+]: 2ndary to SIADH

Answer 109

When a pt. starts Carbamazepine, they may see a return of seizures after 3- 4 wks of Rx.

Answer 110

MoA: Na+ channel Blockers S/E: SJS

Answer 111

40% pts. develop visual field defect which may be IRREVERSIBLE - Check Visual Fields every 6 months

Answer 112

Progressive Neurodegenerative condition caused by degeneration of DA Neurons in S Nigra Triad: Bradykinesia, Tremors, Rigidity Symptoms are ASYMMETRICAL - 2x more common in MEN - Mean age of Dx.- 65 yrs

Answer 113

BRADYKINESIA (Hypokinesia) - Poverty of movt. - Short, shuffling steps with reduced arm swinging - Difficulty to INITIATE movt. TREMORS - Most marked at Rest, 3- 5 Hz - Worse: Stressed or Tired - Relieves: VOLUNTARY movt. - 'Pill-Rolling' (Thumb & Index finger) RIGIDITY - Lead-Pipe - COGWHEEL: Rigidity superimposed by Tremors

Answer 114

Mask-like facies Flexed posture Micrographia Drooling of Saliva Psychiatric C/F:DEPRESSION (mc 40%) - Dementia, Sleep disturbance Impaired Olfaction REM Sleep behaviour disorder Fatigue Autonomic: Postural C/F

Answer 115

MOTOR c/f are geberally - RAPID onset - B/L onset - Rigidity & Tremors are Uncommon

Answer 116

Dx. is usually Clinical - Difficult to differentiate b/w Essential tremor & Parkinson's [(123)I-FP-CIT] SPECT - Discolouration of S nigra due to loss of pigmented nerve cells

Answer 117

TIME_Critical Acute Akinesia or Neuroleptic Malignant Synd. is high if- - NOT taken on time (OR) - Not absorbed properly (eg.- GE) Never have 'Drug Holiday' IMPULSE CONTROL Disorders This can occur with any DA therapy but is more common with - DA Agonist Rx. - H/o Previous impulsive behaviour - H/o [-OH] intake or Smoking

Answer 118

EXCESSIVE Sleepiness - If in daytime: Avoid Driving - Use Modafinil if alternative strategy fails (eg.- adjusting dose) ORTHOSTATIC Hypotension - Review medications - MIDODRINE if c/f persists DROOLING of Saliva - Glycopyrronium Bromide

Answer 119

Used in Orthostatic Hypotension due to Parkinson's disease - Acts on Peripheral Alpha-adrenergic receptors => Increase Arterial resistance

Answer 120

Should ONLY be Dx. & Rx. Initiated by a SPECIALIST 1st Line Rx.- - Motor C/F affecting quality of life: LEVODOPA - Motor C/F NOT affecting quality of life: DA agonist (Non-Ergot derived), Levodopa, MAO-B i Excessive Sleepiness, Hallucinations & Impulse Control Disorder

Answer 121

add DA agonist, MAO-B i or COMT i as an adjunct

Answer 122

Almost always combined with - Decarboxylase (-): Carbidopa or Benserazide - This prevents peripheral metabolism of Levodopa to DA outside of brain => Reduces S/E S/E : Dry mouth, Anorexia, Psychosis Palpitations, Postural Hypotension

Answer 123

Ergot derived: Bromocriptine, Cabergoline Ropinirole, Apomorphine Prior to Rx. obtain - Echo, CXR, ESR, Cr. - Pts. should be closely monitored

Answer 124

1) End-of-dose wearing off : C/F worsen towards the end of dosage interval => Decline in Motor activity 2) 'On-off' Phenomenon: Large variation in Motor performance, - 'On': Normal function - 'Off': Weakness & restricted mobility 3) Dyskinesia at Peak dose - Dystonia, Chorea, Athetosis (involuntary writhing movt.) 4) Do NOT acutely Stop LD - If can't take drug PO, give a DA agonist patch (Rotigotine patch) as Rescue drug to prevent Acute DYSTONIA

Answer 125

- Impulse Control Disorder - Excessive daytime Somnolence - Hallucinations in Older pts. (more common than in Levodapa) - Nasal Congestion & Postural Hypotension

Answer 126

1) (-) breakdown of DA secreted by Dopaminergic neurons - Selegiline, Rasageline 2) Increases DA release & (-) its uptake at DA synapses - S/E: Ataxia, Slurred speech, Livido reticularis, Confusion, dizziness,

Answer 127

COMT is an enzyme involved in the breakdown of DA - Used in conjunction with Levodopa in pts. with established PD - Entacapone, Tolcapone

Answer 128

Progressive Supranuclear Palsy - A 'Parkinson Plus' syndrome Features - Postural instability & Falls - Stiff Broad-based gait - IMPAIRED Vertical gaze (Downgaze worse than Up gaze- Difficulty reading or descending stairs) - Parkinsonism: BRADYKINESIA is prominent - COGNITIVE Impairment (Primary FRONTAL Lobe dysfunction) Rx.- Poor response to L-dopa

Answer 129

Blockes Cholinergic r - used in Drug-induced Parkinsonism rather than Idiopathic PD - Helps tremor & rigidity Eg: Procyclidine, Benzotropine, Trihexyphenidyl (Benzhexol)

Answer 130

Usually given with Decarboxylase i (Carbidopa or Benserazide) Reduced effectiveness with time S/E - Reddish discolouration of Urine upon Standing - Psychosis - Dyskinesia - 'On-off' effect, - N & V - Postural Hypotension - Cardiac arrhythmias

Answer 131

PD Drug induced: Anti-Psychotics, Metoclopramide - Domperidone dose not cross BBB, so Extra-Pyramidal S/E NOT seen Progressive Supranuclear Palsy Multiple System Atrophy Wilson's disease Post-Encephalitis Dementia Pugilistica (2ndary to chronic head trauma eg.- Boxing) Toxins: Carbon Monoxide, MPTM

Answer 132

Typically develops after 35yrs of age - Chorea - Personality changes: Irritabile, Apathy, Depression - Intellectual impairment - Dystonia - Saccadic eye movements Ventricles are enlarged

Answer 133

Two types of MSA MSA-P: Parkinsonian predominant c/f MSA-C : Cerebellar predominant C/F Shy-Drager Synd. is a type of MSA C/F Parkinsonism Autonomic disturbance - Erectile dysfunction: EARLY c/f - Postural Hypotension - Atonic Bladder Cerebellar signs

Answer 134

Inherited A D Neurodegenerative condition - CAG repeat disorder - Defect in Huntingtin gene on Chr. 4 - Anticipation: Disease presents at an earlier age in successive generations Causes Degeneration of Cholinergic & GABAergic neurons in STRIATUM of Basal Ganglia

Answer 135

Huntington's, Wilson's, Ataxia Telangiectasia SLE, APLS RF: Sydenham's Chorea OCPs, L-dopa, Antypsychotics NeuroAcanthocytosis Pregnancy: Chorea gravidarum Thyrotoxicosis Polycythaemia Rubra vera Carbon Monoxide Poisoning Cerebrovascular accident

Answer 136

Caused by damage to the - BG specially Caudate nucleus Involuntary, rapid, jerky, movt. which often move from one part of the body to another ATHETOSIS: Slower, sinuous movt. of the limbs

Answer 137

Occurs following damage to the Subthalamic Nucleus - Ballistic movt. are Involuntary, sudden, jerking movt. - Seen C/L to the side of lesion Primarily affects PROXIMAL Limb musculature & Distal muscles may display more Choreiform like movt.

Answer 138

Symptoms may decrease in Sleep Anti-DA agents - HALOPERIDOL

Answer 139

Seen within Hrs- Days of starting Anti-Psychotics - Pyrexia - Muscle Rigidity - Autonomic lability: HTN, Tachycardia & Tachypnoea - Agitated Delirium with Confusion - Normal pupils Raised CK is common => 2ndary AKI Leukocytosis

Answer 140

Seen in pts. on ANTI-PSYCHOTICS - Can also occur in Atypical Anti-P - Seen in PD when L-dopa is suddenly stopped or dose reduced Anti-Psychotics => DA blockade => triggers Massive release of Glutamate => Neurotoxicity & Muscle damage

Answer 141

1) STOP Antipsychotics 2) Transfer to Medical ward if in Psychiatric ward 3) IV Fluid to prevent Renal failure 4) Dantrolene (selected cases) - Binds to Ryanodine r => Decreases Ca2+ release from S reticulum => decreases excitation-contraction coupling in skeletal muscles 5) Bromocriptine, DA agonist may be used

Answer 142

Any Adult who have experienced some Loss of Conscious or Amnesia since the injury with the following - >= 65 yrs old - H/o Bleeding or Clotting disorders including Anti-Coagulants - Dangerous mechanism of injury (pedestrian or cyclist hit by motor vehicle, an occupant ejected by a motor vehicle or a Fall from a height > 1 mt. or 5 stairs - > 30 min of Retrograde amnesia of events immediately before head injury On Warfarin + Head injury + NO other indications for a CT = Do CT head within 8 hrs of injury

Answer 143

GCS < 13 on initial assessment GCS < 15 at 2 hrs post-injury Suspected Open or Depressed skull # Signs of Basal Skull # : Panda eyes, Haemotympanum, CSF leak from Ear or Nose, Battle's sign Post-traumatic seizures FND > 1 episode of vomiting

Answer 144

Primary Brain Injury - Focal (Contusion/ Haematoma) - Diffuse (diffuse axonal injury) Diffuse Axonal Injury - Due to Mechanical Shearing following deceleration, leads to tear & disruption of Axons INTRA-CRANIAL Haematoma's - Extradural/ Subdural/ Intracerebral CONTUSION: Seen adjacent to Coup or C/L (Contre-coup) to the side of impact SECONDARY Brain Injury: Cerebral Oedema, Ischaemia, Infection, Tonsillar or Tentorial herniation exacerbates original injury

Answer 145

Frontal & Parietal lobes Rupture of Small Bridging VEINS in the SD space RF: Old age, Chr. [-OH] => Brain atrophied => Fragile or Taut bridging veins & Anticoagulation

Answer 146

HTN + Bradycardia, often occurs late & is usually a Pre-Terminal event

Answer 147

Temporal region - Skull # cause rupture of MIDDLE MENINGEAL Artery - Lucid Interval is experienced

Answer 148

Fresh blood collection in SD space - MCC: High-impact Trauma => often a/w underlying brain injury C/F Severity depends on - Size of compressive clot - Associated injuries Presentation: Incidental finding in trauma to severe coma & Coning due to herniation Large Acute SDH => Mass effect => Mid-line shift or Herniation

Answer 149

1) Crescentric collection NOT limited by Suture lines - Appears Hyperdense in comparision to brain 2) Very similar to Acute SDH findings BUT- are Hypodense (dark) compared to brain substance 3) Acute blood (Hyperdense) spread in the Basal Cisterns, Sulci & in severe cases- Ventricular system

Answer 150

Small or Incidental Acute SDH - Observed conservatively Sx. options - Monitor ICP - Decompressive Cranieotomy

Answer 151

Blood collection in SD space for wks. to months - Rupture of Small BRIDGING Veins in the SD space Several week to months Progressive H/o Confusion or Reduced Consciousness or FND

Answer 152

Intracranial bleed: presence of blood within the SA space, ie., deep to the SA layer of meninges - MCC: Head Injury called Traumatic SAH - In the absence of Trauma it is called Spontaneous SAH

Answer 153

Incidental finding or Small size + Not a/w CNS deficits - Conservative Rx. Pt. confused + a/w FND or Severe Imaging findings - Surgical Decompression with Burr hole

Answer 154

1) Intracranial Aneurysm (Saccular Berry Aneurysm) : 85% cases Conditions a/w Berry aneurysm are - APKD, Ehlers-Danlos, Coarctation of Aorta - May be 2ndary to Autonomic Neural stimulation from Hypothalamus (OR) 2) Elevated levels of circulating Catecholamines 3) AV Malformations 4) Pituitary Apoplexy 5) Arterial dissection 6) Mycotic (Infective) aneurysm 7) Perimesencephalic (Idiopathic venous bleed)

Answer 155

Re-Bleeding (70% Mortality rate) - In 10% cases & MC in first 12 hrs - If suspected: Repeat CT Head Vasospasm aka Delayed Cerebral Ischaemia : 7- 14 days after onset HYPO[Na+] : MC due to SIADH Seizures Hydrocephalus Death

Answer 156

CT head - Hyperdense at Basal cisterns, Sulci & in Severe cases- Ventricular system - (-)ve in 7% cases 2) LP [Used to confirm when CT (-)ve] - Performed >= 12hrs after C/F onset as this allows Xanthochromia to set in - Xanthochromia helps to distinguish b/w True SAH from Traumatic tap (Blood introduced by LP itself) - Normal/ Raised Opening pressure 3) Refer to NeuroSx. as soon as SAH is confirmed 4) CT intracranial Angiogram (finds the vascular lesion) +/- Digital Subtraction Angiogram (Catheter Angiogram)

Answer 157

1) Spontaneous SAH - Treat the cause 2) Intracranial Aneurysm needs Rx. due to risk of Rebleeding - Maj. cases : Coiling (Interventional Neuroradiologist) - Minority cases: Craniotomy + Clipping by a Neurosurgeon - Until Aneurysm treated, pt. should be in Strict Bed-rest, well-controlled BP & avoid straining 3) Hydrocephalus - External V drain (temporary) - VP Shunt (Long term)

Answer 158

Thunderclap or Baseball bat or Worst of my life HEADACHE - Sudden onset, Severe, OCCIPITAL N & V Meningism (Photophobia, Neck stiffness) Seizures, Coma, Sudden Death ECG: ST elevation

Answer 159

To prevent Vasospasm, - NIMODIPINE for 21 days - CCBs which targets brain vessels Treated with Hypervolaemia, Induced HTN & Haemodilution

Answer 160

Conscious level on Admission Age Amount of Blood seen on CT Head

Answer 161

Can cause Cerebral Infarction (much less common than Arterial causes) Types - Isolated Sagittal Sinus Thromboses (50% cases) - Coexistent Lateral Sinus + Cavernous Sinus thromboses Features - Headache (may be sudden in onset) - Reduced Consciousness - N & V

Answer 162

Gold Std. Ix.- MRI Venogram - CT Venogram (alternative) NCCT is normal in 70% cases D-Dimer may be elevated Rx.- Anti-Coagulation - Acute AC : LMWH - Long term AC : Warfarin

Answer 163

1) Present with Seizures + Hemiplegia 2) Parasagittal biparietal or Bifrontal Haemorrhagic infarction may be seen 3) Venography: EMPTY DELTA Sign 4) CECT: Empty DELTA Sign (look for triangular shaped dural sinus, this should be filled with Contrast => Thrombus fails to enhance & is outlined by Enhanced Collateral channels in Falx

Answer 164

CN- 6 & 7 palsy

Answer 165

Causes : Local infection (eg Sinusitis), Neoplasia, Trauma - Peri-Orbital Edema - Ophthalmoplegia: CN-6 damage before CN- 3 & 4 - CN-5 involvement: Hyperaesethesia of Upper face & Eye pain Central Retinal Vein Thrombosis

Answer 166

Formerly called Benign IC HTN Risk Factors - Obesity - Female Sex, - Young - Pregnancy Drugs: COCPs, Steroids, Tetracyclines, Vit. A, Lithium Features - Headache, Blurred Vision - Papilloedema - Enlarged Blindspot - CN-6 plasy

Answer 167

1) Wt. Loss 2) Diuretics: Acetazolamide 3) Topiramate also used - Added benefit of causing Wt. loss 4) Repeated LP 5) Surgery - Optic N sheath decompression & fenestration (to prevent ON damage) 6) Lumbo-Peritoneal or VP Shunt - To reduce ICP

Answer 168

REVERSIBLE cause of Dementia in Elderly pts. - 2ndary to Reduced CSF absorption at Arachnoid villi Cause: Head injury, SAH or Meningitis TRIAD - Urinary Incontinence - Dementia & Bradyphrenia - Gait abnormality (similar to PD) 60% of pts. have all these features These develop over a few months

Answer 169

Hydrocephalus with Ventriculo-megaly in the absence of, or out of proportion to, sulcal enlargement Rx.- - VP Shunt - 10% with Shunt experience significant complications like: Seizure , Infection & Intracranial Bleed

Answer 170

HSV-1 (95% cases) typically affects the - TEMPORAL Lobes & - Inferior Frontal Lobes Features - Fever, Headache, Psychiatric C/F, Seizures, N & V - Focal features: APHASIA - Peripheral lesions (eg Cold sores) have NO RELATION to the presence of HSV Encephalitis

Answer 171

CSF: Lymphocytosis, Elevated protein PCR for HSV CT : Medial Temporal & Inferior Frontal changes (eg Petechial haemorrhages)- Normal in 1/3rd pts. MRI is Better : Hyperintensity of the affected White matter & Cortex in the Medial Temporal lobes & Insular Cortex EEG : Lateralised Periodic discharges at 2 Hz

Answer 172

IV Acyclovir - Prognosis is dependent on whether Acyclovir is started Early - If Rx. started promptly: Mortality is 10- 20% - Left untreated: Mortality is 80%

Answer 173

Acute onset of Anterograde Amnesia (inability to form NEW memories) - Due to Transient ischaemia to THALAMUS (particularly Amygdala & Hippocampus) Features - Pt. appears Anxious & repeatedly asks the same questions - Episodes are self-limiting & resolve within 24hrs.

Answer 174

Tissue based definition (now used) - A transient episode of neurological dysfunction caused by Focal brain, Spinal C, or Retinal ischaemia without Acute infarction Time based definition (formerly used) - Sudden onset of focal neurological symptom &/or sign lasting , 24hrs, due to a transient decrease in blood flow

Answer 175

Sudden onset FND but rather than persisting, the features resolve within 1 hour - U/L weakness or Sensory loss - Aphasia or Dysarthria - Ataxia, vertigo or loss of balance Visual problems - Sudden transient loss of vision in 1 eye (Amaurosis fugax) - Diplopia - Homonymous hemianopia

Answer 176

1) NEUROIMAGING CT Brain should NOT be done UNLESS there is a clinical suspicion of an alternate dx. that CT could detect MRI (with Diffusion weighted & Blood sensitive sequence) - Preferred to determine Ischaemic Territory or to detect Haemorrhage or alternative pathologies Done on the same day as specialist assessment if possible 2) CAROTID Imaging - Atherosclerosis in carotids may be a source of Emboli in some pts. - ALL pts. must have an URGENT Doppler unless they are not a pt. for Carotid Endarterectomy

Answer 177

Treat TIA urgently Aim: Reduce risk of Recurrent stroke - 10% risk in first 7 days after TIA ASPIRIN 300mg immediately (unless CI) in suspected cases PPIs if dyspepsia a/w aspirin use If Aspirin can't be used (allergic or intolerant) give CLOPIDOGREL Refer the pt. within 24 hrs to Specialist assessment & Ix. to a TIA clinic

Answer 178

If >1 episode of TIA (Crescendo TIA) has occurred (OR) has a suspected Cardio-Embolic source (OR) Severe Carotid Stenosis - Admission or Observation with a Stroke specialist If TIA suspected in last 7 days : - Urgent assessment (in < 24hrs) by a Specialist Stroke physician If TIA suspected to have occurred > 7 days previously - Specialist Assessment within 7 days Advise NOT to drive

Answer 179

ANTI-THROMBITIC Therapy 1) Start DAPT in pts. presenting in < 24hrs of TIA + Low risk of bleeding - [Aspirin + Clopidogrel]*21 days (OR) - [Aspirin + Ticagrelor[*30 days - If pt. NOT appropriate for DAPT, give Clopidogrel loading dose followed by Daily maintenance dose 2) PPIs if risk of GI bleed or Dyspepsia 3) Single Anti-P Rx. should be used with Clopidogrel recommended as std. Rx. :- - After DAPT completion - For long-term prevention of vascular events in people with TIA without paroxysmal or permanent AF - ASPIRIN used if Clopidogrel is not tolerated 4)

Answer 180

4) AC with a Rapid onset action to pts. with Paroxysmal, persistent or permanent AF or A Flutter asap after IC bleed or other CI (severe HTN, >=180/120, should be treated 1st) are Excluded 5) High Intensity STATIN Therapy immediately unless CI - Start in ALL pts irrespective of baseline LDL (2ndary prevention) - If alternate Statin at max. tolerated dose (if high intensity statin not suitable or not tolerated)

Answer 181

Degree of CA Stenosis is reported using NASCET (North American Symptomatic C Endarterectomy Trial) 1) TIA or Acute non-disabling ischaemic stroke + STABLE neuro symptoms + Symptomatic Severe Carotid stenosis 50-99% - Assessed & referred for CAE to be performed in < 7 days of C.F onset - Receive optimal medical Rx.: Control BP, Anti-P Rx., Cholesterol reduction by diet & drugs, lifestyle advice, Smoking cessation 2) TIA or Acute Non-disabling Ischaemic stroke + Mild-moderate carotid stenosis < 50% should: - NOT undergo CAE - Receive optimal drug Rx. as above 3) Meet the CAE criteria + Unsuitable for Open Sx. (inaccessible Carotid bifurcation, Restenosis after CAE, Radiotherapy associated carotid stenosis) - Carotid Angioplasty + Stenting

Answer 182

ROSIER Score Exclude Hypoglycaemia first & then LoC or Syncope : [-1] Seizure activity : [-1] New, Acute Onset of : - Asymmetric Face weakness : [+1] - Asymmetric Arm weakness : [+1] - Asymmetric Leg weakness : [+1] - Speech disturbance ; [+1] - Visual Feild Defect [+1] Stroke is likely if score is > 0

Answer 183

NCCT of Head - Ischaemic or Haemorrhagic Acute Ischaemic Stroke - Areas of low density in Grey or White matter of the territory (These changes may take time to develop) - Hyperdense artery sign corresponds to the responsible Arterial clot- visible immediately Acute Haemorrhagic Stroke - Area of Hyperdense material (Blood) surrounded by low density (oedema)

Answer 184

Oxford Stroke Classification (aka Bamford Classification) classifies stroke based on Initial C/F The follo. criteria is assessed - U/L Hemiparesis &/or Hemisensory loss of the Face, arm & leg - Homonymous Hemianopia - Higher Cognitive dysfunction eg.- Dysphagia

Answer 185

TACI (15% ) - Involves MCA + ACA arteries - All 3 of Bamford criteria (+)ve

Answer 186

PACI (25%) - Involves Smaller arteries of Anterior circulation, eg- Upper or Lower division of MCA - 2 of the 3 Bamford criteria (+)ve

Answer 187

LACI (25% cases) Involves perforating arteries around Internal capsule, Thalamus, BG Presents with one of the following- - U/L weakness (&/or Sensory deficit) of Face & arm, Arm & leg or ALL 3 - Pure Sensory Stroke - Ataxic Hemiparesis

Answer 188

POCI (25% cases) Involves Vertebro-basilar artery Presents with 1 of the following - Cerebellar or Brainstem syndromes - Loss of Consciousness - Isolated Homo. Hemianopia

Answer 189

Lateral Medullary Syndrome [Poste. Inferior Cerebellar Artery] - Ataxia, Nystagmus - I/L : Dysphagia, Facial numbness, CN palsy (Horner's) - C/L : Limb Sensory loss

Answer 190

I/L CN-3 palsy C/L Weakness

Answer 191

Stabilise + Refer to Hyperacute or Acute stroke unit ABC Consider ET Intubation in - Unable to protect airway - GCS <= 8 Give O2 only if sats. < 93% - Target: 96% in acutely ill + not at risk of Hypercapnia - Target: 88-92% If at risk of Hypercapnia

Answer 192

IV Alteplase (Recombinant TPA) - IC Bleed must be excluded before Thrombolysis Window < 4.5 hrs of C/F onset (OR) 4.5 to 9 hrs of known onset or in < 9 hrs of midpoint of sleep when they have woken up with C/F & - Evidence of Potential to salvage brain tissue on CT perfusion or MRI (DWI-FLAIR mismatch) - Whom Mechanical Thrombectomy is either not indicated or not planned IV Tenecteplase is an alternative BUT is NOT recommended in - Ischaemic stroke on awakening from sleep (OR) - Unknown onset who undergo no brain imaging other than CT IV Thrombolysis should not delay Mechanical Thrombectomy

Answer 193

Wake-up stroke - > 4.5 hrs from last seen well, no upper limit - MRI DWI-FLAIR mismatch - DWI lesion + No FLAIR lesion Wake up stroke/ Unknown onset time - > 4.5 hrs from last seen well & < 9hr of the midpoint of sleep (time 1/2way b/w going to bed & waking up) - CT or MRI Core-perfusion mismatch - Mismatch ratio >1.2, mismatch volume > 10ml & Ischaemic core volume < 70ml Known Onset Time (4.5 to 9 hrs) - CT or MRI Core perfusion mismatch - Mm ratio > 1.2, Mm Vol. > 10ml & Ischaemic Core vol < 70ml

Answer 194

Eligible MT pts. should receive prior IV Thrombolysis asap (unless CI) irresepective of if they presented to Acute Strike Unit or Thrombectomy Centre ASAP in < 6 hrs of C/F onset (together with IV Thrombolysis) if not CI to - - With NO previous disability (Mod. Rankin Score 0 or 1) - With confirmed occlusion of the Proximal Anterior Circulation & Proximal IC Large Artery Occlusion causing a disabling neuro deficit (NIHSS of >=6) ASAP in pts. last known to be well b/w 6-24 hrs previously (including wake-up-stroke) & With No Previous Disabilities (Mod. Rankin S 0 or 1) Combined with Thrombolysis, if eligible ------

Answer 195

ASAP in pts. last known to be well b/w 6-24 hrs priorly (including wake-up-stroke) & With no previous disabilities (Mod. Rankin S 0 or 1) Combines with Thrombolysis, if eligible 1) Who have Confirmed Proximal IC Large Artery Occlusion (ICA &/or MI) causing a disabling Neuro. deficit (NIHSS score of >= 6) 2) If there is a Potential to Salvage Brain Tissue, as shown by Perfusion imaging - B/w 6- 12 hrs: ASPECTS Score >= 3, irrespective of the Core Infarct size - B/w 12- 24 hrs: ASPECTS Score >=3 & CT or MRI Perfusion Mismatch of >15 ml irrespective of Core I size Consider MT + IV thrombolysis (IF not CI & within licensed time window) in pts/ with - Confirmed occlusion of Proximal Anterior Circulation (By CTA or MRA) - If there is potential to Salvage brain tissue as shown by perfusion imaging

Answer 196

Pts. who cannot receive Thrombolysis eg.- CI like Recent Sx., Current AC use

Answer 197

Offer ASAP but certainly within 24hrs (unless CI) in Acute Stroke + IC Bleed has been excluded by imaging - In practice, administration of Aspirin (or alternative) is usually delaye 24hrs after Alteplase or Tenecteplase, once further CT scan has excluded significant bleed - Anti-P Rx. is CI or Delayed in pts with active bleeding (eg GI bleed)

Answer 198

ASPIRIN (only) in pts. with Disabling Ischaemic stroke - Continue daily for 2 wks - Then start definitive long-term Anti-Thrombotic Rx. DAPT with either Aspirin & Clopidogrel for 21 days (OR) Aspirin + Ticagrelor for 30 days In pts. presenting within 24hrs of minor stroke & with a low risk of bleeding - PPI to reduce risk of GI Bleed - Minor Ischaemic stroke who are not appropriate for DAPT, give Clopidogrel monotherapy SECONDARY Prevention - After 21 or 30 days, for long term prevention of vascular events in people with Ischaemic stroke without Paroxysmal or Permanent AF, single Anti-Platelet Rx. should be used

Answer 199

Orally (if no Dysphagia) or Rectally or by Enteral tube (for those with dysphagia) Aspirin allergy/ Intolerance/ S/Es - CLOPIDOGREL is used as an alternative - Offer PPIs in addition to Aspirin if any pt. reports dyspepsia a/w Aspirin

Answer 200

Intermittent Pneumatic Compression within 3 days of admission - Do NOT use LMWH or Graduated compression stockings In Practice, LMWH is considered if IPC is CI or not possible Do NOT use AC routinely Indications of AC in stroke include - Cardiac source of Embolism - Cerebral Venous Thrombosis - Some cases of Arterial dissection If already on AC (prosthetic HV) + Disabling Ischaemic stroke + At risk of Haemorrhagic transformation - Stop AC for 7 days + substitute with ASPIRIN

Answer 201

Do NOT start Rx. immediately - Appropriate to start once the pt. can swallow - Consensus states: Safe to start after 48 hrs Moderate or Low intensity statin Rx. at max. tolerated dose if High intensity statin is unsuitable or not tolerated Continue statin if already on it.

Answer 202

Post stroke + Hyperglycaemia = Increased risk of mortality independent of their age & severity of stroke; due to - - Increased Tissue Acidosis from Anaerobic metabolism, - Free radical generation, - Increased BBB permeability BG maintained at 4 to 11 mmol/L - DM: Insulin + Glucose to all adults - Hypoglycaemia (can cause Neuronal injury) Exclude Hyper- or Hypo- glycaemia before Thrombolysis as - Hypo-G : is a Stroke mimic - Hyper-G : a/w IC Bleed & worse clinical outcome

Answer 203

Severe progressive encephalopathy affecting children that is a/w Fatty infiltration of Liver, Kidneys & Pancreas Cause- A/W Aspirin use & Viral cause Peak Incidence at 2 yrs of age - H/o preceding Viral illness - Encephalopathy: Confusion, Seizures, Cerebral Oedema, Coma - Fatty infiltration of .... - Hypoglycaemia Rx.- SUPPORTIVE

Answer 204

1) Lt. Homo. Hemianopia : VFD to left ie. lesion of Rt. Optic tract 2) Homo. Quandrantanopias (PITS) - Parietal-Inferior, Temporal-Superior 3) INCONGROUS defects: Optic tract defect 4) CONGROUS defect: Optic Radiation or Occipital Cortex lesion

Answer 205

Lesion: Inferior Optic Radiations in Temporal lobe (MEYER'S Loop) Lesion: Superior Optic Radiations in Parietal lobe

Answer 206

- Optic TRACT lesion - Optic RADIATION or Occipital Cortex - Occipital CORTEX lesion

Answer 207

Lesion: Optic CHIASM Upper Quadrant defect>>Lower Q D - INFERIOR Chiasmal compression => PITUITARY Tumour Lower Quadrant defect>>Upper Q D - SUPERIOR Chiasmal compression => CRANIOPHARYNGIOMA

Answer 208

INO is caused by MLF Lesion - MLF coordinates eye movt. by linking CN-6 nucleus of one side of brainstem with the CN-3 of opposite side Causes - MS (MCC in younger pts.) - Stroke (common in Older pts.) - Trauma - Tumour & Infections: Less Common cause

Answer 209

INO a/w additional Neuro. deficits 1) WEBINO: Wall-Eyed B/L INO - B/L INO + Wall-Eyed Appearance 2) One & a Half Syndrome - INO + I/L Horizontal gaze palsy 3) Eight & a Half Syndrome - One & a Half synd. + CN-7 palsy 4) Half-&-Half Syndrome - INO + CN-4 Palsy

Answer 210

Adduction on I/L side of MLF lesion - Affected eye shows limited or no movt. towards nose ABDucting Nystagmus. of C/L eye - Opposite eye on looking outwards often exhibits Nystagmus Diplopia

Answer 211

B/L INO with the following C/F - B/L ADDuction deficit - B/L ABDucting Nystagmus - Wall-Eyed appearance: Eyes appear to be turned Outwards (Exotropia) at rest giving a 'Wall-Eyed' look CAUSE: Severe Brainstem lesion due to - MS, Stroke or Trauma affecting both MLFs

Answer 212

I/L Horizontal Gaze Palsy C/L INO : Other eye shows ADDuction deficit Residual movt.- - ONLY remaining Horizontal movt. is ADDuction of C/L eye; hence the term '1.5'

Answer 213

INO + Horizontal gaze palsy Lesion: Affects both MLF + Adjacent Pontine str. such as Paramedian Pontine Reticular Formation (PPRF) (OR) CN-6 nucleus Causes - Stroke in the Pons - MS : Especially in Young pts. - Tumours & Other Brainstem Pathologies: LESS Commonly

Answer 214

1.5 synd. + CN-7 palsy Features - C/F of 1.5 syndrome - CN-6 Palsy: Weakness or Paralysis of the muscles on 1 side of the face CAUSES - Brainstem lesion: Stroke, MS, or other Focal Brainstem pathology - Affects both MLF & CN-7 Nucleus or Fascicle

Answer 215

NMO is a Monophasic or Relapsing-remitting Demyelinating CNS disorder - Distinct disease (Not a part of MS) - MC in Asians Typically involves Optic nerves & Cervical Spine - Vomiting (common presenting c/f)

Answer 216

SMALL Pupils - Horner's syndrome - Argyll-Robertson pupil - SENILE Miosis - PONTINE Haemorrhage - Congenital Drug Causes - Opiates, - OP Toxicity - Parasympathomimetics: Pilocarpine

Answer 217

INO + CN-4 (Trochlear N) palsy Features - INO features - CN-6 Palsy: VERTICAL Diplopia due to SO muscle weakness => UPWARD Deviation of affected Eye CAUSES: Brainstem lesions - Stroke, MS, other Focal Brainstem pathology affecting both the MLF & CN-6 or its Nocleus

Answer 218

UPBEAT Nystagmus - Cerebellar VERMIS Lesions DOWNBEAT Nystagmus - Foramen Magnum Lesion - Arnold-Chiari malformation

Answer 219

B/L Optic Neuritis & Myelitis + 2 of the following 3 criteria - SC lesion involving >= 3 spinal levels - Initially normal MRI brain - AQUAPORIN 4 (+)ve serum Antibody

Answer 220

Chronic Cell mediated Autoimmune disorder characterised by Demyelination of CNS - 3x MC in Women - 20- 40 yrs old - MC in Higher latitudes (5x MC than in Tropics) Monozygotic Twin Concordance: 30% Dizygotic Twins Concordance: 2%

Answer 221

Made on the basis of >= 2 relapses & either objective clinical evidence of >= 2 lesions (OR) objective clinical evidence of 1 lesion together with reasonable historical evidence of a previous relapse VISUAL - Optic Neuritis (MC presenting c/f) - Optic atrophy - Uhthoff's phenomenon: Vision deteriorates on rising body temp. - INO SENSORY - Pins/ Needles, - Numbness - Trigeminal Neuralgia - Lhermitte's Synd.- Limb paraesthesia on neck flexion MOTOR, CEREBELLAR & OTHERS

Answer 222

RELAPSING-REMITTING disease - MC form (83% cases) - Acute attacks (eg, 1-2 months): Followed by period of Remission SECONDARY PROGRESSIVE Disease - Describes R-R type pts. who have deteriorated & have developed neuro signs & c/f b/w relapses - 65% of pts. with R-R type do to develop 2ndary progressive disease within 15yrs of Dx. - GAIT & BLADDER disorders seen PRIMARY PROGRESSIVE Disease - 10% of pts. - Progressive deterioration from start - MC type in Older adults

Answer 223

MOTOR - Spastic weakness: MC seen in legs CEREBELLAR - Ataxia : MC during an Acute Relapse than as a presenting feature - Tremor OTHERS - Urinary Incontinence - Sexual dysfunction - Intellectual deterioration

Answer 224

Dx. requires demonstration of lesions disseminated in Time & Space MRI - High signal T2 lesion - Periventricular plaques - Dawson Finger: Often seen on FLAIR images: Hyperintense lesion perpendicular to C Callosum CSF - Oligoclonal bands (& NOT in serum) - Increased Intrathecal synthesis if IgG Visual Evoked Potentials - Delated, but well-preserved waveform

Answer 225

Aim: Reducing the frequency & duration of relapses. NO cure Acute Relapse - High dose STEROIDS may be given for 5 days to shorten the length of an acute relapse - Steroids SHORTENS the duration of relapse & do NOT alter the degree of recovery (ie. whether a pt. returns to baseline functions)

Answer 226

GOOD Prognosis features - Female sex - Young age of onset (20- 30) - R-R disease - Sensory symptoms ONLY - Long interval b/w first 2 episodes - Complete recovery b/w relapses

Answer 227

FATIGUE - Exclude other causes (anaemia, TFT) - Trial of AMANTIDINE - 2nd line: CBT, Mindfulness training SPASTICITY - 1st line: BACLOFEN & GABAPENTIN - 2nd line: Diazepam, Dantrolene & Tizanidine - Physiotherapy BLADDER DYSFUNCTION - Urgency/ Incontinence/ Overflow - Do an USS first to assess Bladder emptying- Anticholinergics may worsen c/f in some pts. - Significant Residual V: Intermittent Self catheterisation - NO significant Residual V: Anticholinergics OSCILLOPSIA

Answer 228

NATALIZUMAB (1st line) given as IV - Recombinant monoclonal Anti-B - Antagonises Alpha-4-Beta-1-integrin found on Leucocytes surface - (-) Leucocyte migration across the endothelium across BBB - Has the Strongest evidence for PREVENTING Relapse FINGOLIMOD BETA- INTERFERONS GLATIRAMER ACETATE

Answer 229

Visual Field appear to Oscillate 1st line Rx.- GABAPENTIN

Answer 230

Typical Indication of Disease-Modifying Drugs (DMDs) include - R-R disease + 2 relapses in past 2 yrs + able to walk 100m unaided - 2ndary Progressive D + 2 relapses in past 2 yrs + able to walk 10m (aided or unaided)

Answer 231

FINGOLIMOD - Sphingosine 1-phosphate (SIP) receptor modulator - Prevents Lymphocytes from leaving LNs - Oral formulations available BETA-IFN (IM or SC route) - Not considered to be as effective as DMDs

Answer 232

Lethargy Double vision, pain behind eyes, decrease colour vision (red desaturation), INSULAR = Intention tremor, Nystagmus, Slurred speech, Urinary probs, Labile mood, Ataxia, Retrobulbar neuritis

Answer 233

Immunomudulating drug: acts as 'IMMUNE Decoy' Given SC Along with Beta-IFN considered an 'Older drug' with less effectiveness compared to Monoclonal Anti-B & SIP receptor modulators

Answer 234

Eye deviated 'Down & Out' Ptosis Pupil may be dilated (sometimes called a 'surgical' 3rd N palsy) Causes : DM, - Vasculitis (T arteritis, SLE) False Localising sign (due to Uncal herniation through tentorium if raised ICP Poste. Communicating A Aneurysm - Pupils dilated - a/w Pain Cavernous sinus thrombosis Weber's Synd: I/L 3rd N palsy + C/L Hemiplegia (Midbrain stroke) Amyloid, MS

Answer 235

Supplies Superior Oblique (depresses eye, moves inward) SO4 FEATURES - Vertical Diplopia : Classic when reading a book or going downstairs - Torsional Diplopia: Subjecting tilting of objects - Pt. may develop Head tilt (Lt. CN4 palsy => Rt head tilt), which they may or may not be aware of - When looking straight: affected eye Deviates upwards & outwards

Answer 236

U/L cerebellar lesions causes I/L signs "DANISH" - Dysdiadochokinesia, Dysmetria (past-pointing), pt. may appear drunk - Ataxia (limb, truncal) - Nystagmus (Horizontal=I/L Hemisphere) - Intention Tremor - Slurred staccato speech, Scanning dysarthria - Hypotonia

Answer 237

Friedreich's Ataxia, Ataxia telangiectasia Neoplasia: Cerebellar Hemangioma Stroke Alcohol MS Hypothyroidism DRUGS: Phenytoin, Lead poisoning Paraneolpastic: eg.- 2ndary to Lung Cancer

Answer 238

A R Condition : Defect in ATM Gene (encodes DNA repair enzyme) One of the Inherited Combined Immunodeficiency disorders - Early childhood, 1- 5 yrs old with abnormal movt. - Cerebellar ataxia - Telangiectasia - IgA deficiency => Recurrent Chest infection - 10% risk of Malignancy, Lymphoma, Leukaemia - Also Non-Lymphoid tumours

Answer 239

A R condition - GAA repeat disorder [in X25 gene on Chr. 9 (Frataxin)] - Do NOT show anticipation Onset: 10- 15 yrs - MC presenting C/F: Cerebellar ataxia & Kyphoscoliosis - HOCM (90%)- MCC of death - Absent ankle jerks/ Extensor plantar - Optic Atrophy - Spinocerebellar tract degeneration - DM (10-20%) - High-arched palate - Telangiectasia (at 1- 2 yrs)

Answer 240

- HOCM (90% cases) - Telangiectasia

Answer 241

Impotence, Inability to sweat, Postural hypotension (drop of 30/15 mmHg) Loss of decrease in HR following Deep breath Pupils: DILATES after Adrenaline instillation CAUSES - DM, - GBS, - PD - MSA (Shy-Drager's syndrome) - HIV, Chaga's, Neurosyphilis Drugs: Anti-HTN, TCAs - Craniophatyngioma

Answer 242

UMN pattern of weakness in LL Causes - Demyelination (MS) - Cord compression: Trauma, Tumour - Parasagittal Meningioma - Tropical Spastic Paraparesis - Transverse myelitis (eg,- HIV) - Syringomyelia - Hereditary Spastic Paraplegia - Osteoarthritis of Cervical spine

Answer 243

Lateral Hemisection if SC - I/L weakness below lesion - C/L loss of pain & temp. sensation

Answer 244

Inflammation of Myelin, extends transversly across SC - Damages myelin sheath Causes - Virus: VZV, HSV, CMV, EBV, HIV, Influenzae, Echovirus - Bacterial: Syphilis, Lyme's - Post-infectious: Immune mediated - First C/F of MS or Neuromyelitis optica (NMO)

Answer 245

Due to B12 deficiency Dorsal Column + Lateral CS tract affected - Joint position & Vibration sense lost first UMN signs develops in leg, classically- Extensor plantar, brisk knee reflex, Absent ankle jerks In untreated: Stiffness & Weakness persists

Answer 246

Acute onset U/L (occasionally B/L) severe pain - Followed by Shoulder & Scapular weakness several days later - Sensory changes are minimal Rapid wasting of Arm muscles in accordance to the nerve involved RFs : Recent Trauma, Infection, Sx., Vaccination Prognosis: Good except when PHRENIC Nerve is involved => Breathlessness

Answer 247

Degenerative condition of C Spine, essentially OA of Cervical vertebral bodies - Spinal canal narrowed => press on SC => Neuro dysfunction - Seen in 5- 10% of pts. who have cervical spondylosis - Neck pain - UMN weakness in LLs => Increased reflexes, tone & upgoing plantars - Motor weakness, Sensory loss & Bladder/ Bowel dysfunc. - Wide-based, Ataxic or Spastic gait - Bladder: Urgency, retention

Answer 248

Aura : Posterior territory vascular disturbance (Acute-onset vertigo, tinnitus, slurred speech, double vision) lasting for a few hrs Followed by Headache a/w vascular migraine

Answer 249

Typical Behaviour Vocal Tics (Bad language, shouting in class) Motor tics (eg.-involuntary hand movt.) Rx.- Low dose RISPERIDONE High dose can cause tardive dyskinesia

Answer 250

Supplies Anterior 2/3rd of SC - Loss of B/L Motor function - Loss of B/L Pain & Temp. sensation Vibration & Proprioception are preserved