Neurology 3 Flashcards
What are the symptoms of normal pressure hydrocephalus?
Ataxia
Urinary incontinence
Dementia
*wet wacky and wobbly
How long following a TIA till a patient can drive again?
1 month
Which type of seizures tends to a have postictal Tod’s paralysis?
Focal onset seizures
What are the first line medications for neuralgic pain?
Amitriptyline
Duloxetine
Gabapentin
Pregabalin
Which anti-epileptic medication is most associated with weight gain?
Sodium valproate
What are the side effects of sodium valproate?
VALPORATE:
V- valporate A - appetite L - Liver failure P - Pancreatitis R - reversible hair loss O - Oedema A - Ataxia T - Tremor, telectangestia, tetragenic E - Encephalopathy
or: WHAT Weight gain Hepatoxicity / Hyponatremia Ataxia Thrombocytopenia
What is the motor innervation to the uvula?
Vagus nerve
What quick bedside test can be done to test if rhinorrhoea is CSF?
Glucose test
- CSF has glucose in it.
Beta transferrin -2 is more definitive test
What is an important differential for a headache in a patient on the COCP? and what other condition might this occur?
Cerebral venous sinus thrombosis
- also occurs in nephrotic syndrome
- should be a differential in a child with nephrotic syndrome
What is the disorder which forms cysts over the spinal cord? and how does it present?
Syringomyelia
Causes compression from the centre of the spine leading to loss of spinothalamic tract leading to pain
What are some causes of third nerve palsy?
Diabetes mellites
Uncal herniation due to raised ICP
Posterior communicating artery aneurysm
- usually painful as well
Cavernous sinus thrombosis
Thrombotic occlusion of to the vaso nervorum
In Pancoast tumour causing Horner’s syndrome
- where else might the patient experience neuropathy?
In the ulnar region as it compresses on the brachial plexus
*T1 nerve root compression
Name some sub-types of hydrocephalus and how they present:
Idiopathic intracranial hypertension
- seen in females who are obese and on the COCP
- stop pill, loose weight
- oral tetracyclines make worse
Normal pressure hydrocephalus
- elderly
- urinary incontinence
- ataxia
- dementia
- CT scan
- ventriculi-peritoneal shunt
TB Meningitis / abscess formation
- CXR
- History of TB
What bloods should you do in someone with a seizure?
FBC - infection? U&Es - electrolyte abnormality? Magnesium levels Calcium levels Glucose Lactate - ABG
Anti-epileptic medication levels**
How is a Myasthenia Crisis managed?
- Contact ICU early
- FVC must be measured - for monitoring purposes
- *FVC because it will demonstrate the restrictive nature of it
BiPAP ventilation
Plasma exchange / plasmapheresis to remove antibodies
IV immunoglobulins
What is the investigations for diagnosis of Duchene muscular dystrophy?
Muscle biopsy
EMG
CK levels
What are some causes of neurological muscle weakness in children?
Duchene/ Beckers muscular dystrophy
Spinal muscular atrophy
Myasthenia Gravis
Polio
Dermatomyositis
Name 3 types of cognition you can test along with questions to ask:
Orientation
- where are you, time, date place,
Memory recall
Language
- name these objects
What is a common trigger for cluster headaches?
Alcohol
What is the management for a massive P.E?
Un-fractioned heparin
followed by thrombolysis
How do chronic and acute sub-duras appear on CT scan and what is the management? and what are your differentials for a chonic sub-dura?
Chronic:
- hypodense - appearing dark
Acute:
- hypertense - appearing bright
Management:
Chronic:
- reverse any clotting abnormalities
- Craniotomy and washout of clots
- establish reason for fall or injury **
- anti-epileptic medication if you suspect there will be seizures
Acute:
- Craniotomy/ burr hole
- should be done within 4 hours
Differentials:
- dementia
- stroke
- tumour
What may be the CT finding on a extra-dural haematoma?
Hyperdense - convex lesion with fracture present
What is the management for extra-dural bleed?
Conservative: <30ml and normal GCS
- serial CT scans
Acute:
- ATLS
- IV resuscitation
- Neurosurgery *burr hole, craniotomy
*IV hypersaline or mannitol may be considered if hydrocephalus develops
What is the definition and what are the complications of status epilepticus?
Definition:
>30 mins seizure or >5mins seizures without recovery to consciousness
Complications:
- Permanent neurological damage
- AKI from rhabdomyolysis
- Behaviour problems
What are the headaches associated with prodromal SAH?
Sentile headaches
what percentage of people will have a seizure at some point in their life and what percentage will go on to have further seizures?
1 in 20
40% will go on for further seizures
What type of seizure is a febrile seizure?
Epileptic seizure
*doesn’t mean they have epilepsy but there is generalised overacitivty in the brain which is epilpetic by definition
When giving buccal mizadolam where do you place it in the cheeks?
Side facing the ground
How can you differentiate between a psychogenic and tonic clonic seizure?
Complex movement
Eyes shut
Excessive thrashing of movement
Pelvic flexion
Crying afterwards
What is the treatment for infantile spasms?
Steroids
Anti-epileptic drugs
When doing a GCS, if the patient flexes and extends to pain which do you count?
Flexing - as an abnormal flexion .
You take the best of the actions
What are some symptoms of Parkinson’s disease that might be present prior to the onset of the disease?
Anosmia
- loss of sense of smell
REM
Restless leg syndrome
Hyperactive bladder
How can bradykinesia be tested for clinically?
Asking the patient to open and close their hand rapidly. This will deteriorate in slowing of movement
Contrast stiffness and spasticity:
Stiffness:
- non-velocity dependent. it is stiff throughout passive movement.
Spasticity:
- Velocity dependent: increased catch as movement speeds up
What are some of the late complications of Parkinson’s disease?
Drooling
- which can lead to aspiration pneumonia
Lewy Body Dementia
Falls
Depression
What is the natural history of Parkinson’s disease?
Stage 1.
- loss of sense of smell
- unilateral symptoms - easy to ignore
Stage 2.
- Symptomatic
Stage 3.
- Dementia
- Falls
- Terminal events
What is a positive Hoffman’s sign?
Flicking the middle finger which causes contraction of the fingers, especially the index to the thumb
- sign of UMN
What are the aetiologies of cervical myelopathy and some symptoms?
Disc herniation Osteophyte formation Facet joint degeneration Cervical stenosis Tumour compression Posterior ligamental calcification (common in Asians)
Symptoms:
- Clumsiness of hands (loss of co-ordinated ability)
- Neck pain
- Spastic gait
- Ataxia
- Bladder dysfunction
Signs:
- positive Hoffman’s
- Ankle Clonus
- Spastic lower extremities
- Weakness
What are some differentials for cervical myelopathy and how is it investigated? What is the treatment?
MND
MS (will have cranial nerve signs as well)
Syringomyelia
Spinal cord tumour
Investigations:
- MRI T2 weighted
*if an MRI cannot be done then a CT myelogram
Treatment: - Anterior discectomy or - Posterior laminectomy \+/- Foramotomy
What kind of disc herniation causes cauda equina?
Central disc prolapse
- this is different to posterior lateral which causes sciatic pain.
- remember that nerve root affected is below where the herniation has occurred. I.e. L4/5 disc herniation = L5 symptoms
Name two aetiologies of sciatica:
Intraspinal:
Disc herniation (posterior lateral herniation, L4/5)
Tumours
Spondylolisthesis
Extra-spinal:
Piriformis syndrome
- directly compresses the sciatic nerve
Pregnancy
Define spondylosis, spondylolysis and spondylolisthesis:
Spondylosis: Arthritis of the vertebral joints leading to osteophyte formation and radiculopathy
Spondylolysis: Pars inter-articular breaks
- without slippage
Spondylolisthesis:
- Slippage of the vertebral body over each other
Which position helps spinal stenosis?
Flexion
Pain is made worse by extension
What are the nerve roots of the sciatic nerve?
L4 - S3
List some of the brainstem stroke types:
Lateral Medullary syndrome
- PICA artery
- Ipsilateral loss of pain and temperature
- Nystagmus / vertigo
- Contralateral loss of pain and temperature
- Ataxia
- Ipsilateral Horner’s (sympathetic fibres are involved)
Weber’s syndrome:
- Posterior Cerebral artery
- contralateral weakness
- Ipsilateral Ocular nerve palsy
Lock in syndrome
- basilar artery
- affects the pons damaging the corticospinal and corticobulbar tracts
If someone has a lesion on their right side of their cerebral cortex - what symptoms would you NOT expect?
Speech and language difficulty
- Broca’s area and Wernicke’s area is on the left side
What features in Parkinson’s would make you think it may be drug induced?
Dyskinesia
- this is seen with anti-psychotics and not a feature of the onset of Parkinson’s
Bilateral symptoms
- Parkinson’s tends to develop unilaterally first
Levodopa helps
What are some important differentials for a third nerve palsy and what things in the history would make you suspect a worrying cause and how would you investigate?
Diabetes
Thrombotic inclusion of the vaso- nervorum
Aneurysm
Internal carotid dissection
Things that suggest a more worrisome feature:
- Pupillary defect
- Family history of bleeds
- Pain
- Immediate onset
Tests: - CT angiogram - MRI Angiogram or - Cather angiogram
*can also do a digital subtraction CT to allow only vessel visualisation
What can be a triggering factor for BPPV?
Head injury
What exercises can a patient do at home to help improve symptoms of BPPV?
Cawthorne- Cooksey exercises
What test should be done to assess respiratory function in a patient with a muscle dysfunction and why?
Forced vital capacity
- this can assess restriction
*one might be tempted to say a PEFR but this can only assess restrictive lung disease
What is the definition of epilepsy:
> 2 unprovoked seizures
> 1 with a underlying disorder to cause seizures
> 1 with evidence of structural abnormality i.e. ischemic injury
What are the causes of epilepsy?
VITAMIN-P
Vascular abnormalities (AVMS) Idiopathic Trauma Alzheimer's Metabolic (Na, Ca2+, Mitochondrial disorders) Infection (meningitis) Neoplasm and mass (tubulosclerosis) Primary disorder (Juvenile myoclonic epilepsy)
What are some of the characteristic findings of a simple partial seizure?
Pre-ictal:
- Aura (smells, Deja vu, visual changes)
Ictal:
- localised seizure (Jacksonian motor seizure which may spread called Jacksonain march)
- Heard turning with conjugate gaze (away from source)
Post-ictal:
- little no post ictal phase
*last for 10-20seconds
What are some symptoms of complex partial seizure?
Pre-ictal:
- Aura
- Autonisms
- Loss of consciousness or awareness
Ictal:
- Autonisms (lip smacking, dressing, walking in circles)
- may progress to general tonic Clonic
Post ictal:
- autonisms may continue
- Tired and confused
*last for 1-2 mins
What are some treatment options for epilepsy?
Education
Medication
Surgery:
- corpus collosum dissection
- Removal of source (temporal lobectomy)
Ketogenic diet
Vagal nerve stimulation
Name some chid-hood epilepsy syndromes;
West syndrome
- Salaam attack
- corticosteroid treatment
Lennox- Gastaut
- associated with mental impairment
- regression of milestones
- non-respondent to medication
Juvenile myoclonic epilepsy
- 12-18 years old
- starts with myoclonic jerks and progresses to tonic clonic
- triggers: alcohol, stress, sleep deprivation and strobe lights
Childhood absent seizures:
- 10seconds of absence
- females x2
- not aware
- Ethosuximide
What are some differentials for a stroke?
Hypoglycaemia
Migraine
Post ictal - Todd’s paralysis
Tumour
Encephalopathy
What are the risk factors for MS?
Genetic
Female
North latitude
Low Vitamin D
EBV
Smoking
What is the epidemiology of Myasthenia Gravis?
Bimodal distribution
- younger adults
- elderly population
*elderly population it is more associated with lung cancer
What advice should be given to those starting steroids for Myasthenia Gravis?
Steroids can initially worsen symptoms
- may need to be placed on IVIG to begin with
What physical examinations can be done to help diagnose Myasthenia gravis?
Superior ocular gaze
Abducting one arm up and down
- compare this with other arm
Ice pack over the eye
- theoretically this should improve symptoms
- Uhthoff’s effect
How is triptans delivered for cluster headaches and why?
IM triptans
- due to speed of onset
Clusters tends to last for 15-45mins long therefore need for a quick acting drug
What should triptans be avoided in and why?
Avoided in ischemic heart disease
Ischemic vascular disease
*causes vasoconstriction
