neurology 2 Flashcards
work up post stroke
long term ECG + 24 hour tape - AF HTN lipids HbA1c carotid dopplers cardiac echo for thrombus
most common cause of peripheral neuropathy
diabetes
peripheral neuropathy causes
Alcohol B12/folate CKD Diabetes Everything else eg. drugs (chemo, isoniazid) syphillis
down and out eye
3rd nerve (oculomotor) palsy
pupil dilated (parasympathetic fibres) - surgical cause eg. tumours, aneurysms
pupil not dilated - medical cause eg. diabetes, vascular disease
6th nerve palsy cause
raised ICP - 6th nerve has longest intracranial path (false localising sign)
Multiple sclerosis
forhead sparing 7th nerve palsy
stroke, multiple sclerosis ie. upper motor neurone
NOT forhead sparing 7th nerve palsy
bell's palsy ramsy hunt Guillain barre syndrome Lyme disease local malignancy eg. parotid
shen do you start parkinsons treatment
when symptoms are affecting quality of life
acute multiple sclerosis first line
methylprednisolone
Cerebellum signs
Dysdiadokinesia Ataxia (broad based) Nystagmus Intention tremor Slurred speech Hypotonia
Dysarthia
Causes of cerebellar syndrome
MS Stroke Tumour Drugs (phenytoin) Alcohol Paraneoplastic syndrome — treat underlying cancer Hypothyroidism
Causes of motor neurone disease
Sporadic disease of anterior horn cells of the motor pathway
Genetic forms - SOD1 mutation (A Dom)
Mx MOtor neurone disease
Riluzole - increases life expectancy for 3 years
Supportive MDT - SALT Communication aids Dietician - gastrostomy due to loss of swallowing Psychology
Ventilation —- life threatening resp failure
Proximal myopathy
Causes
Signs
shoulder girdle/ hip and thigh muscle weakness
Causes
Inherited:
- duchennes, beckers (pseudo calf hypertrophy)
- muscular dystrophy type 1&2
Acquired: Infection - hiv, influenza Inflammation - RA, dermato/polymositis, sarcoidosis Endocrine - addisons, Cushing Diseas Autoimmune - thyroid disease, SLE Drugs - alcohol, steroids
Signs
- walking aids
- muscle mass is normal, symmetrical proximal muscle wasting is late sign
- underlying cause
- muscle tenderness!!!!!! – disorder of blood vessels
- difficult standing without arms
Normal sensation, reflexes
dermato vs poymysositis definition causes investigations treatment
inflammatory myositis - dermatomyositis involves the skin
polymyositis is a diagnosis of exclusion of other causes of inherited and acquired myopathies
causes of polymyositis: autoimmune, connective, drugs (statins), infections (HIV), idiopathic
causes of dermatomyositis: cancer (ovary, GI, breast)
signs
inspection: normal/ symmetrical proximal muscle wasting, skin (heliotrope rash, gottren’s papules)
palpation: muscle tenderness
facial weakness +/- dysphagia
power: proximal muscle weakness (unable to stand from a squatting position, difficulty lifting things, difficulty walking up stairs
normal reflexes or reduced if severe muscle atrophy
normal sensation
Ix. Drug history, elevated CK, EMG , muscle biopsy is diagnostic
Mx. steroids, steroid sparing agents (azathioprine, methotrexate)
causes of drug induced parkinsonism
dopamine antagonists such as antixpsychotics
essential/dystonic tremor vs parkinsons tremor
essential tremor:
- improves with alcohol
- symmetrical tremor
parkinsons tremor
- asymmetrical
- pill rolling
- worse at rest
what sleep issue may preceed parkinsons disease
rapid eye movement sleep disorder: poor sleep, acting out dreams
what roportion of patients with parkinsons disease have depression
one third
examination findings for parkinsons
inspection:
- walking aids
- mask like face
- stooped posture
- shuffling gait, small steps, loss of arm swing on one side, difficulty turning, unsteadiness, difficulty initiating gait
tone - assymmetrical cogwheeling, tremor, rigidity
power function - repetitive hand movements like walking the thumb along the fingers
subacute combined degeneration of the cord
examination findings
UMN (myelopathy) + distal LMNs (length dependent neuropathy)
inspection
- walking aids
- normal/ proximal muscle mass wasting
- anaemia
tone normal
power normal
reflexes: brisk, extensor plantar responses
sensation: vibration and proprioception loss, paraesthesia, loss of sensation disttally
coordination: limb incoordination
gait: ataxic, romberg’s sign positive
special test in subacute combined degeneration of the spinal cord
romberg test - cant stay balanced with eyes closed
Lhermitte’s phenomenon
intrinsic lesion of cervical cord
passive flexion of the neck gives electric shock sensation down the back
multiple sclerosis and subacute combined degenereation of the spinal cord
signs of B12 deficiency
megaloblastic anaemia neuropathy myelopathy optic atrophy pyschiatric/ cognitive impairment glossitis autonomic neuropathy
Charcot marie tooth disease
- cause
- diagnostic investigations
- features of disease
autosomal dominant chr 17 - sensorimotor neuropathies
patients present before age 20 - progressive
peripheral nerves DESTRUCTION
Ix. genetic desting
classic type 1A disease
- distal > upper limb muscle wasting
- inverted champagne bottle appearance – preserves thigh muscles
- foot deformities: toe clawing, hammer toes, charcot joints, pes cavus (high arch)
- wasting of small muscles in hand – ulnar nerve damage
- tremor
- scoliosis
tone normal/ reduced
distal weakness
absent reflexes
sensation lost distally in all modalities
high stepping gait due to bilateral foot drop (popliteal nerve)
Carotid endartectomh
75% stenosis symptomatic
Heels and toes walking
Which nerves regions
Heels L4/5
Toes S1/2
Triceps reflex root
C7/8
Biceps reflex root
C5/6
Brachioradialis root
C6
Knee reflex root
L3/4
Ankle reflex root
S1/2
Tuning fork nerves
128Hz
causes of small pupil
miosis
anisocoria (different sizes) - degree of anisocoria is worse in the dark
- physiological: no more than 1mm difference in diameter between the eyes and equal in light
- pilocarpine (pharmacological)
- Horners (ptosis, miosis, anhidrosis)
- Argyll Robertson pupil - tertiary syphilis, sudden constriction on accomdation, both pupils miosis but to different degress. do not react to light
- opiate use (bilateral)
- multiple sclerosis
topical cocaine solution
- if equal dilation = physiological
- if anisocoria = horner’s
horner’s where is the lesion
hydroxy amphetamine 1% solution
pupils dilate equally = central lesion
anisocoria remains = post ganglionic lesion
mx syphilis
penicilin G IV –> IM for a total of 3 weeks
HIV serology
congenital syphilis
Hutchinson triad
- interstitial keratitis - inflammation of the cornea
- hutchinson’s incisors - widly spaced teeth
- Cranial 8 deafness
internuclear opthalmoplegia findings
cause: interruption of the medial longitudinal fasciculus that connects the nuclei of cranial nerves 3 and 6 to coordinate them
unilateral - ipislateral failure to adduct on contralateral gaze + nystagmus in other eye
* horizontal diplopia
bilateral - exotropic eyes (eyes look out away from nose), vertical nystagmus
– Multiple sclerosis
bulbar palsy
- definition
- where is the lesion
- causes
- signs
lower motor neuron syndrome involving the lower cranial nerves 11, 12
lesions can be anywhere from the nuclei in the medulla to the lower motor neuron
causes: stroke (nerve bodies in the brainstem), motor neurone disease, medullary infarction, brainstem tumours, guillain barre, lyme disease, congenital
signs:
- NG tube for feeding
- saliva at side of mouth
- tongue fascivulations (but can move rapidly from side to side)
- say ahhh (failure of soft palate to elevate)
- dysphagia
- lip, tongue, palatal weakness
- note and quality of speech – nasal
- absent gag reflex/ jaw jerk
pseudobulbar palsy
BILATERAL UPPER motor neurone syndrome involving 11, 12
lesions from the cortex to the nuclei in the medulla
causes: motor neuron disease, bilateral hemispheric infarction, high brainstem tumour, multiple sclerosis, trauma
signs:
- signs:
- NG tube for feeding
- saliva at side of mouth
- spastic tongues (do not fasciculate) + slow/spastic when moved from side to side
- say ahhh (failure of soft palate to elevate)
- dysphagia
- lip, tongue, palatal weakness
- note and quality of speech – high pitched, dysarthria
- absent gag reflex
- brisk jaw jerkjaw jerk
MND and bulbar palsy
typicall mixed bulbar/pseudobulbar palsy
- fasciculating tongue with brisk jaw jerk
where does the spinal cord end
L1/2 at the conus
cauda equina syndrome symptoms
pain in lower back
variable paralysis/ sensory disturbance of lower limbs
saddle anaesthesia
bladder/bowel/sexual disturbance
LMN signs
cauess of cauda equina syndrome
***lumbar disc prolapse
traumatic
infective abscess ankylosing spondylitis vascular (epidural haematoma) neoplastic iatrogenic (spinal anesthesia)
mx cauda equina
urgent decompression by neuro surgeons
pilocarpine uses
reduce pressure inside the eye and treat dry mouth
angle closure glaucoma until surgery can be performed, ocular hypertension, primary open angle glaucoma, and to bring about constriction of the pupil following its dilation.
signs and symptoms of myasthenia gravis
bilateral ptosis
diplopia at extremes of gaze
fatiguable ptosis (ask patient to look up)
facial weakness
dysphagia
painless fatiguable muscle weakness - check power, raise arms up and down then re-check power
normal reflexes, sensation
tenilon test
myasthenia gravis
IV edrophonium temporarily improves weakness but not done in elderly due to cardiac side effects
cervical myelopathy
progressive compression of the spinal cord at the cervical lesion - denegerative, neoplastic, infective, trauma
LMN at the level of the lesion
UMN signs below
walking aid increased tone, clonus pyramidal weakness brisk reflexes loss of sensation (vibration, proprioception)
spastic stiff legs and foot drop
hoffman sign
finger flick the middle nail
index finger and thumb flex in response
multiple sclerosis, cervical myopathy
pyramidal weakness
UMN weakness
upper limb flexors stronger than extensors
lower limb extensors stronger than flexors
foot drop nerve involved
peroneal nerve injury
spinal cord stroke
rare
usually anterior spinal arteries –> loss of pain and temperature, preservation of proprioception and vibration (dorsal medial lemniscus supplied by posterior spinal arteries)
transverse myelitis
inflammation of the spinal cord
can be isolated or occur with MS
can occur following bacterial/ viral infections (especially where there is a rash)
ascending weakness, sensory disturbances are common
carotid stenosis
> 70% stenosis of at least one carotid endartectomy – mx. endartectomy or stenting
> 50% surgical if symptomatic
<70% stenosis - antiplatelets, statins, lifestyle changes
optic neuritis
pain in one eye on movement
blurred vision
worsened with heat - hot shower/ exercise *Urthoff’s sign)
pale optic disc
Multiple sclerosis vs Guilain barre as CSF analysis
MS – oligoclonal bands only in the CSF (not in serum)
GBS – systemic so the oligoclonal bands are in the CSF & serum
think where does the inflammation start
Sub arachnoid haemorrhage imaging
CT scan – may not show anything initially, takes 6hrs
CSF — xanthochromia 4-12 hours after
normal CSF opening pressure
10-18 cm H20
what does blood, oedema and ischaemia look like on CT
blood = white
oedema (ischaemia/infarct) = grey
normally infarcts dont show anthing on CT
work up for first seizure in adult life
space-ocupying lesions - malignancy, neurocysticercosis
cerebral bleeds
metabolic disturbancs
immunocompromised (HIV): cryptococcus neoformns, TB, toxoplasmosis
