Neurology Flashcards
Which HLA is associated with MG ?
HLADR2 and HLADR3
Which Type of Voltage Gated Pre-synaptic calcium channels are affected in LEMS ?
P/Q Calcium Channels
When Dyskinesia from Levodopa –> add COMT
Reduce Levadopa/ add Amantadine / duodopa –> Treat Dyskinesia
‘end-of-dose fluctuations’ –> Adjunct with MOAI
Anti-Muscarinic ( procyclidine, benztropine, trihexyphenidyl (benzhexol) —> Treat Drug induced PD vs Idiopathic PD
Add Apomorphine –> when ‘OFF’ effects precipitate
What is the side effect of Natalizumab in Multiple Sclerosis ?
JC Virus reactivation causing Progressive Multifocal Leukoencephalopathy
Wernicke’s vs Broca’s
Wernicke (Brodmann area 22 at Superior Temporal Gyrus) = Word Salad
Random Words
Comprehension IMPAIRED
Inferior division of L MCA
Broca’s (Brodmann Area 44 and 45) at Inferior Frontal Gyrus
Stutters and Word Finding Difficulty
Comprehension is PRESERVED
Superior Division of L MCA
Conductive Aphasia (Arcuate Fasciculus)
Fluent Speech but cant REPEAT
Third Nerve Palsy
Down and Out
Dilated
Ptosis
Painful and Dilated in Surgical
Causes of Facial Nerve Palsy
Upper Motor Neuron
Stroke
Lower motor neuron
1) Bell’s palsy
2) Ramsay-Hunt syndrome (due to herpes zoster)
3) Acoustic neuroma
4) Parotid Tumors
5) HIV
multiple sclerosis* (may be also UMN)
6) DM
B/L Facial Nerve Palsy
1) Sarcoidosis
2) GBS
3) Lyme disease
4) Bilateral acoustic neuromas (NF2)
as Bell’s palsy is relatively common it accounts for up to 25% of cases of bilateral palsy, but this represents only 1% of total Bell’s palsy cases
Path of Cranial Nerve 7
Transient Global Amnesia Treatment ?
Sudden Anterograde Amnesia –> Reassure as self limiting
False Localizing Lesion of CN6 seen when ?
Raised ICP and presents as B/L CN6 Palsy
Tuberous Sclerosis
1) Inheritance , Which Genes and Chromosomes and Proteins affected
2) Tumors where ?
3) Presentation
3) Treatment
Autosomal Dominant with Variable Expressivity and Incomplete Penetrance
TSC 1 - Chromosome 9 - Hamartin
TSC 2 - Chromosome 16 - Tuberin - Co-exists with PCKD as PKD 1 gene on Chromosome 16
2) Hamartia
Hamartoma
Giant Cell Astrocytoma’s
Retinal Nodular Hartoma’s - White Patches on Retina (Phakoma)
Adenoma Sebaceum (angiofibromas) - Butterfly distribution
Rhabdomyosarcoma
Angiomyolipoma of Kidney
Subungual Fibroma
Shagreen Patches and Ashleaf Spots
LAM in Lungs (Lymphangioleiomyomatosis)
3) Infantile Spasms - Vigabatrin and ACTH
Intellectual Disability
Astrocytoma - Evorilomus
Angiomyolipoma
Neurofibromatosis Type 1 and Type 2 Facts
1) Inheritance
2) Protein
3) Presentations
1) Autosomal Dominant
2) NF1 coding for Neurofibromin in Chromosome 17
NF2 coding for Merlin in Chromosome 22
3)
NF1
Cafe - Au - Lait Spots
Cutaneous Neurofibromas
Pigmented Iris Hartomas (Lisch Nodules)
Phaeochromocytoma
NF2 (2 Ears , 2 Eyes and 2 parts of Brain)
Bilateral Acoustic Neuroma
Juvenile Cataracts
Mengiomas and Ependymoma
Von Hipple Lindau Syndrome
MRCP
M: Mutation in VLH suppressor gene on chromosome 3
R: Retinal haemangiomata presenting as vitreous hemangioma, Renal cyst, Clear Renal cell carcinoma
C: CNS haemangioblastoma
P: Pheochromocytoma, Pancreatic cyst
Endolymphatic Sac Tumors
Causes of Chorea
HITING ME
Hemochromatosis and Rheumatic Heart Disease DONT cause Chorea
Hereditary -
1. Wilsons
2. Huntingtons
3. Neuroacanthocytosis
Infection -
1. Streptococcus Pyogenes - Sydenham Chorea
2. SLE & APLS
Toxins
1. LDOPA
2. Neuroleptics (Dopamine Agonists)
3. CO poisoning
Ischemia
Neoplasia
Gynecological - Pregnancy, Chorea Gravidum
Myeloproliferative - Polycythemia Rubra Vera
Endocrine - Thyrotoxicosis
Causes of Action / Postural Tremor
BEATINGS
Benign Essential Tremor
Hypoglycemia
Hyperthyroidism
Alcohol Withdrawal
Infection - Syphilis
Toxins - Lithium, SV, Salbutamol, TCA, Hatter’s Shakes (Lead Mercury Arsenic)
Enhanced Physiological Tremor
What is Autoinduction ?
Drug induces the enzymes that break it down
CARBAMEZAPINE
Side Effects of Carbamazepine
-SJS
-Diplopia
- Cytochrome 450 INDUCER
-Agranulocytosis/leucopenia
-SIADH and Hyponatremia
Neuropathic Pain Control in Diabetics ?
Duloxetine
Neuropathic Pain
Change drug
DONT ADD
Amitriptyline Duloxetine
Gabapentin Pregabalin
MOA of Pregabalin / GABApentin
Gabapentin and Pregabalin bind to alpha2Gamma subunit of Voltage Gated Calcium Channels at Presynaptic Neurons
Inhibiting depolarization and release of Neurotransmitters like Glutamate or Substance P
Thrmobolysis and Thrombectomy Guidance ______________
Benign Intracranial Hypertension
Obese Young Women
Drugs -
COCP
Steroids
Tetracyclines
Tetinoids (Isotretinoin, tretinoin) / vitamin A
lithium
Carbonic Anhydrase Inhibitors like Acetazolamide
Add on Topiramate
Optic nerve sheath decompression
VP Shunt
Guidance
CMTD Freidriehs
Migraine Treatment
Acute -
Triptan + NSAID OR Triptan + PCM
If not working then
Non Oral Metoclopramide or Prochlorperazine
Consider adding Non Oral Triptan or Nsaid
Prophylactic -
Topiramate
Propranolol
Amitriptyline
Riboflavin 400mg/day
If Predictable Menstrual Migraine - Frovatriptan or Zolmitriptan
DMD vs Beckers vs Myotonic vs FSH Dystonia
DMD (X linked Recessive)
Proximal Muscles
Gowers Maneuver
Waddling Gait
Dilated CDM
Weak Reflexes
Becker’s Muscular Dystrophy
Myotonic Dystrophy Inheritance ,
Features and Associations
Myotonic Dystrophy (Autosomal Dominant - CTG Trinucleotide Repeat)
DM1 - CTG Trinucleotide Repeat at end of DMPK gene on Chromosome 19 (Distal First)
DM2 - Repeat Expansion of ZNF9 gene on Chromosome 3 (Proximal First)
LMN
Distal Muscle Weakness
Loss of Ankle Reflex
Face
Bilateral Ptosis
Mastication Weakness
Frontotemporal Balding
Myotonia
Slow Release Hand Shake
Percussion Myotonia
Slow to Open eyes after Shutting tight
Christmas Tree Cataracts
Hypertrophic Cardiomyopathy & HB
Dysphagia
Testicular Atrophy
3T 3D
- 3T: Toupee (balding), ticker (cardiomyopathy), testicles (atrophy)
- 3D: diabetes, dysarthria, learning disability
Internuclear Ophthalmoplegia explain pathophysiology and how to differentiate from a Oculomotor Palsy ?
Demyelination of MLF
Located in Paramedian area of Midbrain and Pons
Features
- Unable to ADDUCT of the eye on the same side as the lesion
- Horizontal nystagmus of the ABDUCT TING eye on the contralateral side
Test of Convergence to help INO>Oculomotor Nuclear Palsy
Drugs causing Peripheral Neuropathy
I AM Very Peripherally Numb
Isoniazid
Amiodarone
Metronidazole
Vincristine
Phenytoin
Nitrofurantoin
Ataxia Telangiectasia
1) Inheritance
2) Features
Autosomal Recessive
ATM Gene
1-5 y/o VS FA
Spider Nevi
IgA Deficiency - Recurrent Chest Infection
Cerebellar Ataxia
Risk of Leukemia or Lymphoma (NH)
Friedrichs Ataxia
Trinucleotide Repeat (GAA)
Chromosome 9
10-15y/o vs AT
Ataxia + DANISH
Loss of Reflexes
Optic Atrophy
Kyphoscoliosis
HOCM / T1DM
What is the MOST COMMON INHERITED Peripheral Neuropathy ?
What do you see on biopsy of neurons in this disease ?
Charcot Marie Tooth Disease
Autosomal Dominant
PMP22 gene
T1 - Demyelination
T2 - Axonal
Intrinsic Feet Muscles (Frequent Ankle Sprains)
Sensory Loss
High Arch Feet
Champagne Inverted Feet
Loss of Reflexes
Onion Skin Peel Appearance on Neuronal Biopsy
Decreased Velocity on EMG
Anti Hu
Anti Ri
Anti GAD
Anti Yo
Anti Hu -
Painful Peripheral Neuropathy
Cerebellar
Neuroblastoma SCLC and Encephalomyelitis
Anti Ri - Ocular opsoclonus-myoclonus
Anti GAD -
Breast , Colorectal and SCLC
Stiff Person Syndrome
Anti Yo -
Cerebellar
Ovarian Breast
Purkinje Fibers
Peripheral Neuropathy in Breast Cancer
Syringomyelia Presentation ?
Cape Like
1) Loss of Pain and Temperature
2) Hypersensitive to Vibration and Touch
3) Upgoing Plantar
4) Spastic (Immobile)
5) Sometimes , Rarely , Bladder and Bowel Involvement
Klumke’s vs Erbs Palsy
Klumpke’s Palsy (CLAW HAND)
C8-T1
Erbs (WAITERS TIP)
C5-C6
Restless Leg Syndrome Treatment ?
Massage
Treat Iron Deficiency
Dopamine Agonist - Ropinirole, Pramipexole
Benzodiazepine
Gabapentin
Nucleotide Repeats
GAA - Friedreich Ataxia
CTG - Myotonic Dystrophy
CAG - Huntington’s
CGG - Fragile X Syndrome
Huntington’s Disease
Ix and Tx
Ix -
MRI - increase in size of Frontal Horn of Lateral Ventricles
Gordon Reflex Phenomenon
NO CURE BUT for CHOREA
Tetrabenazine
Reversible inhibitor of VMAT 2
Impaired packaging of Monoamines into vesicles (esp Dopamine)
Reduced Release
Huntington Disease Gene and Inheritance
HTT gene Chromosome 4
Autosomal Dominant
Huntington Disease pathophysiology
Cholinergic and GABAergic neurons in the striatum of the basal ganglia
Low ACh
Low GABA but HIGH Dopamine
Multiple Sclerosis DMARD Criteria
- Relapsing and Remitting + 2 relapses in 2 years + able to walk 100m UNAIDED
- Secondary Relapsing + 2 relapses in 2 years + able to walk 10m (AIDED or UNAIDED)
DMARD’s
Natalizumab (Antibodies against alpha-4 beta-1-integrin) - JC Virus reactivation
B interferon (reduce relapse NOT progression)
Fingolimod (Sphingosine-1-phosphate receptor modulator )
Daclizumab (Antibody against CD25 part of the IL12R )
Alemtuzumab (Antibodies against Alpha 4 integrin)
Fatigue - r/o obvious causes - Trial Amantadine
Spasticity - Gabapentin / Baclofen
Bladder Dysfunction -
Get USS first
Significant Residual Volume –> ISC
If not –> Antimuscarinic
Oscillopsia - Gabapentin
Miller Fisher vs GBS
Presentation
Antibodies
Anti GM1 in GBS
Anti GQ1b in MFS
Ondansetron MOA
5HT3 antagonist
Depress Vomit Centre in Medulla Oblangata
Sodium Valproate Side Effects
Teratogenic
INHIBITOR OF P450
Alopecia
Weight Gain
Hepatotoxic
Tremor
Thrombocytopenia
Hyponatremia
Hyperammonemic Encephalopathy - L Carnitine as treatment
When is Vitamin B12 Levels Falsely Normal ?
When you inhale Nitric Oxide
Phenytoin Side Effects
Acutely
Nystagmus,
Slurred Speech
Diplopia
Ataxia
Chronically
Gingival Hyperplasia
Coarsening of Facial Features
Megaloblastic Anaemia (Folate NOT Vit B12)
Peripheral neuropathy
Osteomalacia (increased Vit D metabolism)
Idiosyncratic
Fever
TEN
Hepatitis
Dupuytren’s contracture*
Aplastic anaemia
Drug Induced Lupus
Phenytoin when to check levels ?
Usually no need to
But Trough Levels immediately before dose if
1. Toxicity
2. Dose adjustment
3. Non adherence
Phenytoin MOA ?
Binds to Na channels increasing refractory period
Benign Idiopathic Hypertension Treatment ?
Carbonic Anhydrase Inhibitor
How to treat Medication Overuse Headaches?
Opoids- Withdraw gradually
Triptans and Simple Analgesia - Abruptly
Subarachnoid Hemorrhage Investigation
Do CT Head within 6 hours and if NAD –> Alternative Dx
If CT Head > 6 hours and if NAD –> LP done after 12 hours of symptom onset (Xanthochromia)
Once SAH confirmed
CT Angiogram –> if CI then MRA or Digital Subtraction Angiogram
Repeat CT if worsening Neurology
Complications of SAH
- Rebleed
- Hydrocephalus (external ventricular drain)
- Vasospasm (7-14 days post) - ensure euvolemia
- SIADH
Side effect of Ondansetron ?
Constipation
Homonymous quadrantanopia’s
Superior: lesion of the inferior optic radiations in the temporal lobe (Meyer’s loop)
Inferior: lesion of the superior optic radiations in the parietal lobe (Barums Loop)
Mnemonic = PITS (Parietal-Inferior, Temporal-Superior)
Knights Templars !!!!!
Bitemporal Hemianopia
Optic Chiasm
upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour
lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma
CJD Features
VCJD mnemonic
V-vertical upgaze palsy
C-clonus….myoclonus, cerebellar signs (ataxia, nystagmus)
J- Just rigidity
D- Dementia
SIGN= hockey stick sign on MRI
Peadiatric Epilepsy Syndromes Facts
Infantile Spasm (West Syndrome)
Months of life
Salaam Attack
Intellectual disability
Vigabatrin and Steroids
EEG - Hypsarrhythmia
Lennox Gastaut Syndrome
1-5 years
Atypical absences, falls, jerks
Intellectual disability
EEG: slow spike
Ketogenic Diet
Juvenile myoclonic epilepsy (Janz syndrome) - Dropping Breakfast
1) Teenage Girls
2) Generalized Seizures in Morning or after sleep deprivation
3) Myoclonic Jerks before
4) Daytime Absences
EEG - Generalised spike and wave or polyspike and slow-wave discharges
Sodium Valproate
Benign Rolandic epilepsy
Paraesthesia on Unilateral face on waking up
Homonymous Hemianopia Lesions
Optic Tract or Optic Radiation
ALWAYS CONTRALATERAL !!!
C(ongruous) = Radiation lesion.
I(ncongruous) = Tract lesion.
DVLA guidance for Seizure, Syncope and TIA
First unprovoked Seizure - 6 months (all tests NAD)
Known Epileptic or Multiple Provoked - 12 months (if EEG abnormal or brain imaging)
No driving whilst Anti-Epileptic Meds being withdrawn and for 6 months last dose
TIA - 1 month - (No DVLA)
Multiple TIA - 3 months (DVLA)
Syncope
simple faint: no restriction
single episode, explained and treated: 4 weeks off
single episode, unexplained: 6 months off
two or more episodes: 12 months off
Craniotomy for Meningioma - 1 year
Narcolepsy/cataplexy: cease driving on diagnosis, can restart once ‘satisfactory control of symptoms’
Cluster Headache
Acutely - O2 AND Subcutaneous Sumatriptan
Prophylaxis - Verapamil
MRI with Gadolium - Investigation of Choice
Triggered by Alcohol
Treatment of MG ?
Baclofen MOA
GABA Agonist
Vigabatrin Side Effect
GABA Transaminase inhibitor —> Increasing GABA levels
Visual Field Defects
6 monthly checks
Migraines Treatment
1) When Pregnant ?
2) Can given when on HRT ?
3) When Menstruation ?
1) PCM 1st Line
NSAID’s 2nd line in 1st & 2nd Trimester cuz in 3rd Trimester (Closure of PDA)
2) Yes but make it worse
3) Mefenamic Acid OR combination of aspirin, paracetamol and caffeine
MFS Plantar Up or Down going ?
Down going
Up is abnormal
Cholesteatoma pathognomic
Foul Smelling Discharge
Cyproheptadine vs Datrolene MOA
Datrolene - Ryanodine receptor binder and reduce calcium release from SR
Cyproheptadine - 5HT2A receptor antagonist and also H1 blocker
NMS features
Serotonin Syndrome distinguishing features
Fever
Autonomic Dysfunction
Rigidity
Mental State
Mydriasis
Diahorrea
Hyperreflexia (vs decreased reflexes in NMS)
Gold Standard for Intracranial Venous Thrombosis
MRI Venogram
Phenytoin what to give in the last trimester of Pregnancy ?
Vitamin K to prevent Hemorrhagic Disease of Newborn
When to give Folate 5 mg ?
If
BMI≥30
Diabetes
Coeliac disease
Anti epileptic medication
Neural tube defect in either partners
Thalassemia
Pre-conception till 12th week of Pregnancy
Polyneuropathies Which Ones are Predominantly Motor vs Sensory
PREDOMINANTLY MOTOR:
CLD Has Poor proGnosis.
C- CIDP
L- lead poisoning
D- DIPHTHERIA
H- HSMN (CMTD)
P- PORPHYRIA
G- GBS
PREDOMINANTLY SENSORY:
VALUED:
V- Vitamin B12 deficiency
A- Amyloidosis
L- Leprosy
U- Ureamia
E- Ethanol
D- Diabetes
Parts of the Hypothalamus and their functions
All the nuclei of the hypothalamus along with their functions:
Suprachiasmatic - Circadian rhythm
Anterior - Cooling
Posterior - Heating
Ventrolateral - Secretes orexin => wakefulness and feeding
Medial - Satiety
Arcuate - Satiety
Paraventricular - Oxytocin
Supraoptic - ADH
Preoptic - VL => Sleep; VM => GnRH
Mamillary - Memory
Dorsomedial - Behavior
Topiramate MOA
1) blocks voltage-gated Na+ channels
2) increases GABA action
3) carbonic anhydrase inhibition -
Decrease Urinary citrate excretion
Formation of alkaline urine that favours the creation of calcium phosphate stone
INDUCER
Causes Acute Close Angle Glaucoma
AICA vs PICA Presentation
Facial PAIN in PICA (Lateral Medullary or Wallenburg)
For Wallenburg =
Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, Nystagmus
AS ABOVE + Ipsilateral Facial PARALYSIS and Deafness in AICA (Lateral Pontine)
Wallenburg
- Ipsilateral facial loss of pain and temperature (CN V spinal nucleus)
- Contralateral loss of pain and temperature
- Ipsilateral CN 9-12 palsies (dysphagia, hoarseness, hiccups)
- Ipsilateral cerebellar signs (ataxia, nystagmus, vertigo)
- Ipsilateral Horner’s syndrome
- No UMN weakness
Webers Syndrome
Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity
Paramedian Branches of PCA
Subacute Degeneration of Spinal Cord
Absent Ankle Reflex
Brisk Knee Reflex
Positive Rhomberg
Lateral CST and Dorsal and Spinocerebellar
Which Antiepileptic given IV causes Hypotension ?
Phenytoin
Proximal MCA infarct = large vessel occlusion = thrombectomy
Rinnes and Webers interpretation
If Conductive Hearing Loss on Rinnes then Webers Lateralizes to AFFECTED Ear
If Sensineural Hearing Loss on Rinne then Weber Lateralizes to UNAFFECTED ear
What is associated with BIH ?
Cranial Nerve 3 due to Uncal Herniation via the Tentorium
Causes of Parkinsomism
Parkinson’s disease
drug-induced e.g. antipsychotics, metoclopramide*
progressive supranuclear palsy
multiple system atrophy
Wilson’s disease
post-encephalitis
dementia pugilistica (secondary to chronic head trauma e.g. boxing)
toxins: carbon monoxide, MPTP
Causes of Spastic Paraparesis
Spastic paraparesis
mnemonic: COMPACTS HD
- Cord compression (trauma, tumor)
- Osteoarthritis of the cervical spine
- Multiple sclerosis (demyelination)
- Parasagittal meningioma
- AIDS (HIV causing transverse myelitis)
- Cervical osteoarthritis
- Tropical spastic paraparesis
- Syringomyelia
- Hereditary spastic paraplegia
- Disc compression (alternative term for cord compression)
Wernicke’s Encephalopathy Triad
Ataxia (Broad Based Stomping)
Encephalopathy
Oculomotor Dysfunction
1. Lateral Rectus Palsy
2. Sluggish Pupils
3. Anisocoria
4. NYSTAGMUS (Most Common)
5. Conjugate Gaze Palsy
What feature suggests more of an idiopathic Parkinson’s
Asymmetrical Tremor
Pheochromocytoma associated with which conditions
Phaeochromocytoma is associated with 1,2,3
NF-1, MEN 2(a,b), VHL (chromosome 3)
Focal Seizures Antiepileptic Drugs 1st and 2nd Line
First Line - Lamotrigine or levetiracetam
Second Line = carbamazepine, oxcarbazepine or zonisamide
ALS Genetic Mutation ?
90% Sporadic
10% Familial
C9orf72
SOD1 - More Important
Treatment for ALS
Riluzole (Glutamate Antagonist)
Edaravone (Decrease Physical Deterioration)
Baclofen , Clonazepam, Tizanidine (Spasticity)
Antidepressants (Pseudobulbar Effect)
NIV - Better for Survival - When FVC < 80%
PEG feeding recommended
MOA for
Baclofen
Clonazepam
Tizanidine
Baclofen - GABA B Agonist in the spinal cord
Clonzepam - GABA A Agonist
Tizanidine - agonism at central α2 receptors
Chronic Subdural Hemorrhage on CT
Acute Subdural Hemorrhage on CT
HYPODENSE (dark) compared to the substance of the brain.
HYPERDENSE
Conditions with elevated protein in CSF ?
Guillain-Barre syndrome
TB and Fungal Meningitis
Froin’s syndrome*
Viral Encephalitis
Whats Froin Syndrome
Increase in CSF protein below a certain blockage
Tumour , Prolapse etc ….
MRI Sequences
MRI FLAIR - MS
MRI STIR - Thyroid Eye Disease
MRI Susceptibility Weighted - Microhemorrhages and Iron Deposits
TIA Treatment guidelines
Aspirin 300mg STAT
Aspirin + Clopidogrel for 21 days OR Aspirin + Ticagrelor for 30 days
Then Monotherapy !!!!
Statins 80mg to reduce non HDL by 40%
Carotid Endarterectomy only if >50%
Brain Abscess Treatment
IV Ceftriaxone + Metronidazole
Causes of Autonomic Neuropathy
DM
GBS
MSA aka Shy-Drager syndrome
PD
Infections: HIV, Chagas’ disease, neurosyphilis
drugs: antihypertensives, tricyclics
craniopharyngioma
Treatment for Bells
Give Oral Pred in 72 hours
Eye protection from keratopathy
Degenerative Cervical Myelopathy Treatment
MRI
ALWAYS Spinal and Neurosurgical Referral
Ideally within 6 months
Post Op Recurrence
Refer to Spinal and Neurosurgery (Not Analgesia)
LEMS vs MG
Hyporeflexia
Autonomic Dysfunction Present
vs MG
Drug for Restless Leg Syndrome
Ropinirole
Anti NMDA receptor encephalitis features
Associated with Ovarian Teratomas
AfroCarribean
Psychiatric Disturbance
MRI Normal but FLAIR shows abnormalities
Anti GM1 (AIDP of GBS) and Anti MUSK
What’s the treatment for Post Lumbar Puncture Headache
Blood Patch
Complex Regional Pain Syndrome Diagnostic Criteria is called ?
BUDAPEST Diagnostic Criteria
