Neurology 2 Flashcards
Motor neuron disease
Upper/lower
Age of onset
Features (4)
Both upper and lower motor neuron signs
>40yo
Fasciculations
Absence of sensory signs
Mixture of upper and lower signs
Wasting of small hand muscles
Features NOT seen in motor neuron disease (3)
No cerebellar signs
Doesn’t impact external ocular muscles
No sensory signs
Examples of motor neuron disease (3)
Amyotrophic lateral sclerosis
Progressive muscular atrophy
Bulbar palsy
Diagnosis of MS
Two or more relapses
OR
Two or more lesions
OR
One lesion with reasonable historical evidence of prev relapse
What is Uhthoff’s phenomenon
Worsening of vision following a rise in body temperature
Acute relapse of MS mx
High dose steroids 5/7 (PO or IV methylpred)
Mx for reducing the risk of relapse in MS (1)
Give five examples
DMARDS
1. natalizumab
2. ocrelizumab
3. fingolimod
4. beta-interferon
5. glatiramer acetate
MS symptomatic management
Fatigue (2)
- Amantadine
- CBT/ mindfulness
MS symptomatic management
Spasticity
1st line (2)
2nd line (3)
3rd line (1)
- Baclofen/ gabapentin
- Diazepam/ dantrolene/ tizanidine
- PT
MS symptomatic management
Bladder dysfunction
Ix (1)
If sig residual volume (1)
If not (1)
US
If significant residual volume –> intermittent self catheterisation
If no significant residual volume –> anticholinergics
MS symptomatic management
Oscillopsia
Mx (1)
Gabapentin
Good prognosis features for MS (6)
Female
Young age of onset
Relapsing remitting
Sensory sx only
Long interval between first two relapses
Complete recovery between relapses
Multiple system atrophy
Features (3)
Parkinsonism
Autonomic dysfunction e.g erectile dysfunction, postural hypotension, atonic bladder
Cerebellar signs
Myasthenia gravis
What is it?
Autoimmune disorder resulting in antibodies to acetylcholine receptors
Myasthenia gravis features (4)
- Extraocular + proximal muscle weakness
- Ptosis
- Dysphagia
- Diplopia
Myasthenia gravis
Associations (3)
Thymomas
Pernicious anaemia
Autoimmune thyroid disorders
Myasthenia gravis
Ix (4)
EMG
CT thorax to exclude thymoma
CK normal
Autoantibodies
Myasthenia gravis mx (3)
- Pyridostigmine
- Prednisolone, AZT, cyclosporin
- Thymectomy
Myasthenia crisis mx (2)
Plasmapheresis
IV immunoglobulins
Drugs that can exacerbate myasthenia gravis (4)
BB
Lithium
Phenytoin
Gent, macrolides, tetracyclines, quinolones, penicillamine
Triad for Wernicke’s encephalopathy
Ataxia
Encephalopathy
Ophthalmoplegia/nystagmus
Korsakoff’s extra symptoms (2)
Antero+retrograde amnesia
Confabulation
What is Von Hippel Lindau syndrome?
AD condition characterised by cysts/ benign tumours with potential for malignant transformation
Cerebellar haemangiomas
Extra-renal cysts
Retinal haemorrhages
Renal cysts
Phaeo
= which condition?
Von Hippel Lindau
Restless legs
Associations (4)
IDA
Uraemia
DM
Pregnancy
Restless legs mx (4)
- Walking/stretching/massaging
- Pramipexole/ ropinirole (dopamine agonists)
- Benzos
- Gabapentin
What is Reye’s syndrome?
Age
Features (4)
Severe, progressive encephalopathy affecting children
2yo
Preceding viral illness
Encephalopathy
Fatty infiltration of liver, kidney, pancreas
Hypoglycaemia
Management of acute seizures
1 month-1year
2year-11year
12-17years
Adult
Elderly
When can you repeat?
Rectal diazepam
1 month-1year 5mg
2year-11year 5-10mg
12-17years 10mg
Adult 10-20mg
Elderly 10mg
Once more, after 10-15 minutes
IV benzo if in hospital
Adverse effects of sodium valproate (5)
Teratogenic
Alopecia
Hepatotoxicity
Pancreatitis
Hyponatraemia
Define status epilepticus
Seizure lasting >5 minutes
OR
>= 2 seizures within a 5 minute period without the person returning to normal in between
Acute subdural haematoma is most commonly caused by?
What will the CT show? (2)
High impact trauma
Crescentic collection, not limited by suture lines
Hyperdense +/- midline shift
Chronic subdural haematoma
Who is at risk? (2)
How will the patient present?
CT
Elderly and alcoholics
Several week to month progressive history of confusion and reduced consciousness or neurological deficit
Crescentic shape not limited by suture lines but appear hypodense
Syringomyelia what is it?
Features (5)
Ix
Collection of CSF within the spinal cord
- Cape like (neck, shoulder arms) loss of sensation to temperature e.g pt burns hands without realising
- Spastic weakness
- Neuropathic pain
- Upgoing plantars
- Horner’s syndrome
MRI spine + brain
Causes of syringomyelia (3)
Trauma
Tumours
Chiari malformation (strong association)
Tension type headache
First line mx (3)
Prophylaxis (1)
First line: aspirin, paracetamol, NSAID
Prophylaxis 10 sessions of acupuncture over 5-8 weeks
Down and out, ptosis + dilated pupil
Causes (4)
Third nerve palsy
- DM
- Vasculitis
- Cavernous sinus thrombosis
- Weber’s syndrome
What is Weber’s syndrome?
Ipsilateral third nerve palsy, contralateral hemiplegia (caused by midbrain strokes)
Thoracic outlet syndrome what is it?
Typical patient
Age
Usually precipitated by?
Disorder involving compression of brachial plexus, subclavian artery or vein
Thin, young woman, long neck and drooping shoulders
30-40
Trauma
Features of neurogenic thoracic outlet syndrome (3)
- Painless muscle wasting of hand
- Nubmness and tingling of arm
- Cold hands, blanching or swellling
Features of vascular TOS (2)
- Diffuse arm swelling with distended veins
- Painful arm secondary to artery compression (claudication), ulceration, gangrene
Thoracic outlet syndrome Ix (6)
XR cervical spine/ CXR
CT/MR
Venography/ angiography
Neurofibromatosis
NF1 chrm?
NF2 chrm?
NF1 chrm 17
NF2 chrm 22
NF1 features (5)
Cafe au lai spots
Axillary groin freckles
Iris haematomas (lisch nodules)
Scoliosis
Pheochromo
NF2 features (2)
Bilateral vestibular schwannomas
Multiple intracranial schwannomas
Ash leaf spots
Shagreen patches
Epilepsy
Developmental problems + intellectual impairment
Adenoma sebaceum (angiofibromas) butterfly distribution over nose
= which condition?
Tuberous sclerosis
Myotonic dystrophy what is it?
Age
Distal or proximal weakness more prominent in each?
DM1 chrm?
DM2 chrm?
Inherited myopathy affecting skeletal, cardiac and smooth muscle
20-30yo
DM1 chrm 19 distal weakness more prominent
DM2 chrm 3 proximal weakness more prominent
Myotonic dystrophy features (5)
Myotonic facies (long haggard appearance)
Frontal balding
Bilateral ptosis
Cataracts
Dysarthria
Long haggard appearance
Frontal balding
Bilateral ptosis
Cataracts
Dysarthria
= which condition?
Myotonic dystrophy
Mild mental impairment
DM
Testicular atrophy
Heart block/ cardiomyopathy
Dysphagia
= which condition
Myotonic dystrophy
Neuroleptic malignant syndrome
Occurs when?
Features (4)
Hours to days of starting an antipsychotic
Pryexia
Muscle rigidity
Autonomic lability (HTN, tachycardia, tachypnoea)
Delirium
Neuroleptic malignant syndrome
Ix (3) (all bloods findings)
Raised CK
AKI
Leukocytosis
Neuroleptic malignant syndrome
Mx (2)
Stop antipsychotic
IVF
Differences between neuroleptic malignant syndrome and serotonin syndrome
Reflexes
Pupils
Onset
Other feature
Serotonin syndrome
Increased reflexes
Clonus
Dilated pupils
Faster onset (hours)
Neuroleptic malignant syndrome
Reduced reflexes
Lead pipe rigidity
Normal pupils
Hours to days onset
Neuropathic pain mx
1st line (4)
- Amitriptyline
- Duloxetine
- Gabapentin
- Pregabalin
Neuropathic pain
Rescue therapy (1)
Localised neuropathic pain (1)
Tramadol
Topical capsaicin
Normal pressure hydrocephalus
Triad of symptoms
Mx (1)
Urinary incontinence
Dementia
Gait abnormality
Mx shunting
Parkinson’s disease classic triad of features
Drug induced parkinsonism features (2)
Which two of the triad are not usually present?
Bradykinesia
Tremor
Rigidity
Motor symptoms are generally rapid onset and bilateral
Rigidity and rest tremor are uncommon
Parkinson’s mx
1st line management (2)
If motor sx are affecting the patient’s QOL = levodopa
Otherwise DA, levodopa or MAO-B inhib
Levodopa should always be combined with?
SE (5)
Decarboxylase inhibitor
Dry mouth
Anorexia
Palpitations
Postural hypotension
Psychosis
Dopamine agonists
Examples (2)
SE (4)
Bromocriptine
Cabergoline
SE
Pulmonary/ retroperitoneal/ cardiac fibrosis
Excessive daytime somnolence
Hallucinations
Nasal congestion
MAO-B inhibitors
Example (1)
Selegiline
Amantadine
SE (4)
Ataxia
Slurred speech
Confusion
Livedo reticularis
COMT inhibitors
Examples (2)
When is it used?
Entacapone, tolcapone
In conjunction with levodopa
Mx of drug induced Parkinsonism (2)
Anti-muscarinics e.g procyclidine & benzotropine
Mx of drooling in PD?
Glycopyronium
Orthostatic hypotension in PD mx (1)
Midodrine
Causes of peripheral neuropathy sensory (4)
Alcoholism
B12 deficiency
DM
Uraemia
Peripheral neuropathy motor loss causes (4)
Guillian Barre
Porphyria
Lead poisoning
Charcot Marie Tooth
When to check trough levels of phenytoin?
ignore
Dose change
Suspected toxicity
Detection of non adherence
Phenytoin SE (6)
- Teratogenic (cleft palate, congenital heart disease)
- Diplopia
- Nystagmus
- Gingival hyperplasia
- Megaloblastic anaemia
- Peripheral neuropathy
Reflexes nerve roots
Ankle
Knee
Biceps
Triceps
S1-S2
L3-L4
C5-C6
C7-C8
Reflexes nerve roots
Ankle
Knee
Biceps
Triceps
S1-S2
L3-L4
C5-C6
Ct-C8
Topiramate
COCP UKMEC
Implant UKMEC
Depot
IUS
3
2
Depot + IUS not affected by topiramate
Topiramate
SE (4)
Acute myopia/ secondary angle closure glaucoma
Reduced appetite and weight loss
Paraesthesia
Foetal malformations
TIA
Who should get a specialist review?
When to admit (1)
When to get an assessment within 24 hours
When to get an assessment within 7 days
> 1 TIA (e.g crescendo TIA) - admit
If suspected TIA in the last 7 days - arrange urgent assessment within 24 hours
If >1 week ago for specialist assessment within 7 days
TIA mx (2)
- Aspirin 300mg immediately + clopi
OR - Aspirin + dipyridamole (if clopi not tolerated)
Trigeminal neuralgia mx (2)
- Carbamazepine
If not effective - refer to neurology
Features of acoustic neuromas (4)
Mx (2)
Vertigo
Tinnitus
Hearing loss
Absent corneal reflex
Urgent referral to ENT
Surgery/ RT
Left hemianopia means visual field defect to the left which means a lesion where?
Right optic tract
Homonymous quadrantanopias
PITS
Parietal - inferior
Temporal - superior
