Neurology 2 Flashcards
What is essential tremor?
What makes it worse? What makes it better?
an autosomal dominant condition which usually affects both upper limbs
Symmetrical fine tremor (6-12 Hz)
postural: worse if arms outstretched
worse with tiredness, caffeine and stress
improved by alcohol and rest, completely absent during sleep
Other than the hands, where may be affected by essential tremor?
head tremor, jaw tremor and vocal tremor
most common cause of titubation (head tremor)
How can essential tremor be managed?
propranolol is first-line
Give some ddx for a patient with tremor?
Essential tremor
Parkinson’s disease
Dopamine antagonists (e.g. antipsychotics)
Multiple sclerosis
Huntington’s chorea
Hyperthyroidism
Fever
Anxiety
What is Horner’s syndrome?
Triad of:
miosis (small pupil)
ptosis
anhidrosis (loss of sweating one side)
May include enophthalmos (sunken eye)
Caused by damage to the sympathetic nervous system supplying the face
How can you distinguish between causes of Horner’s syndrome based on clinical signs alone?
heterochromia (difference in iris colour) is seen in congenital Horner’s
Anhidrosis of the face, arm and trunk = central lesion
Anhidrosis of the face = pre-ganglionic lesion
No anhidrosis = post ganglionic lesion
How can you test for Horner’s syndrome pharmacologically?
apraclonidine drops (an alpha-adrenergic agonist) can be used: causes pupillary dilation in Horner’s syndrome but produces mild pupillary constriction in the normal pupil
What is the classical history of an acoustic neuroma?
a combination of vertigo, hearing loss, tinnitus and an absent corneal reflex
What may cause bilateral acoustic neuromas?
neurofibromatosis type 2
How should patients with a suspected acoustic neuroma be investigated and managed?
referred urgently to ENT
MRI of the cerebellopontine angle
Audiometry: only 5% of patients will have a normal audiogram.
Mx = surgery, radiotherapy or observation
What can be seen on this MRI?
vestibular schwannoma (acoustic neuroma) of the right cerebellopontine angle
What is Subacute combined degeneration of the spinal cord?
impairment of the lateral corticospinal tracts, dorsal columns and spinocerebellar tracts due to vitamin B12 deficiency
What sxs may dorsal column involvement in subacute combined degeneration of the cord present with?
distal tingling/burning/sensory loss is symmetrical and tends to affect the legs more than the arms
impaired proprioception and vibration sense
What sxs may lateral corticospinal tract involvement in subacute combined degeneration of the cord present with?
muscle weakness, hyperreflexia, and spasticity
upper motor neuron signs typically develop in the legs first
brisk knee reflexes
absent ankle jerks
extensor plantars
What sxs may spinocerebellar tract involvement in subacute combined degeneration of the cord present with?
sensory ataxia → gait abnormalities
positive Romberg’s sign
How can subacute combined degeneration of the spinal cord be managed?
high-dose vitamin B12 supplementation
can help to reverse the neurological symptoms and prevent further damage
Cavernous sinus thrombosis (CST) refers to the formation of a clot within the cavernous sinus.
What causes this?
most common cause of CST is infection
typically spreads from an extracranial location such as the orbit, paranasal sinuses, or the ‘danger zone’ of the face
Infection is able to spread due to the anastomosis between the facial vein and superior ophthalmic veins
How may cavernous sinus thrombosis present?
headache, unilateral periorbital oedema, proptosis (eye bulging), photophobia and cranial nerve palsies
the abducens nerve (CN VI) is most commonly affected
If it is due to infection, it can rapidly progress to meningitis, so requires prompt tx with abx
A pituitary adenoma is a benign tumour of the pituitary gland. They account for around 10% of adult brain tumours.
How may they be classified?
Pituitary adenomas can be classified according to:
size (a microadenoma is <1cm and a macroadenoma is ≥1cm)
hormonal status (a secretory/functioning adenoma produces an excess of a particular hormone and a non-secretory/functioning adenoma does not)
What is the most common type of pituitary tumour?
Prolactinomas are the most common type
After prolactinomas, non-secreting adenomas are the next most common, then GH-secreting and then ACTH-secreting adenomas.
How may pituitary tumours present?
excess of a hormone (e.g. Cushing’s disease due to excess ACTH, acromegaly due to excess GH or amenorrhea and galactorrhea due to excess prolactin)
depletion of a hormon / generalised hypopituiatrism (due to compression of the normal functioning pituitary gland)
stretching of the dura around the pituitary fossa (causing headaches)
compression of the optic chiasm (causing a bitemporal hemianopia due to crossing nasal fibers)
How may pituitary adenomas be investigated?
a pituitary blood profile (including GH, prolactin, ACTH, FSH, LSH and TFTs)
formal visual field testing
MRI brain with contrast
Give some ddx for a pituitary adenoma
pituitary hyperplasia
craniopharyngioma
meningioma
brain metastases
lymphoma
hypophysitis
vascular malformation (e.g. aneurysm)
How may pituitary adenomas be managed?
medical therapy:
prolactinomas = dopamine agonists (cabergoline or bromocriptine)
GH-secreting adenomas= somatostatin analogues (e.g. octreotide)
transsphenoidal surgery:
non-functioning adenomas are generally diagnosed due to their compressive symptoms - surgery is therefore the first-line treatment
radiotherapy: for residual or recurrent tumours post-surgery