Neurology Flashcards
Cord compression:
Management
Malignant cause - dexamethasone 4mg/IV, then treatment
Epidural abcess - surgically decompressed and ABx
Carotid sinus syncope
Hypersensitive barorecptors, eg turning head, shaving
Stokes-Adams attack
Transient arrhythmia/bradycardia
Collapses with slow/absent pulse, pulse speeds up and regains consciousness
Causes of cord compression
Disc prolapse
Haematoma
Tumor
Atlanto-axial subluxations
MRI definitive Ix
CN I Palsy
Can’t smell
CNII Palsy
Optic
Blind
CNIII Palsy
Oculomotor
Ptosis
Down and out
Dilated fixed pupil
CNIV Palsy
Trochlear
Vertical diplopia
CNV Palsy
Trigeminal Neuralgia Loss of corneal reflex Loss of facial sensation Paralysis of mastication muscles Deviation of jaw to weak side
CNVI Palsy
Horizontal diplopia (defective abduction)
CNVII Palsy
Flaccid paralysis of face
Loss of corneal reflex (efferent)
Loss of taste
Hyperascusis
CNVIII Palsy
Vesticulocochlear
Hearing loss
Vertigo nystagmus
CNIX
Glossopharyngeal
Loss of gag reflex
CNX Palsy
Vagus
Uvula deviates away from site of patient
Loss of gag
CNXI Palsy
Can’t shrug
CNXII palsy
Hypoglossal
Tongue deviates towards side of lesion
Temporal lobe lesion visual field defect
Homonymous hemianopia with macula sparing
Wernickes encephalopathy
Thiamine deficiency Nystagmus Opthalmoplegia Ataxia Confusion Peripheral sensory
Subclavian Steal Syndrome
Stenosis proximal to vertebral artery
When you use arm it steals blood from vertebral artery causing LOC, dizziness
Suspect if BP difference in arms >20
Giant cell arteritis
Tender, thickened pulseless temporal
Jaw claudication
ESR >40
Prompt steroids
Medication overuse headache
From mixing, eg paracetamol + codiene/opiates, ergos, triptans
Can use analgesia/naproxen for rebound
Cluster headache
Rapid onset Excruciating on eye Watery, bloodshot, lacrimal ion, flushing, rhinorrhea, miosis, ptosis Often nocturnal Give 02 and sumatriptan
Trigeminal neuralgia
Sharp stabbing pain over trigeminal nerve
Unilateral
Triggered by eating, washing, shaving
Can be from nerve compression so needs MRI
Migraine
Unilateral, throbbing, with aura
Nausea, vom, allodynia, photophobia
Can have produce for dats before
Acute migraine treatment
NSAID
triptan
Ergot as it starts
Migraine prevention
Propanalol
Amytriptiline
Conus medullaris
Mixed UMN/LMN
Let weakness, urinary retention, constipation, back pain, altered sensation
Cauda Equina
Back pain Shooting leg pain Asymmetrical areflexic Atrophi. Paralysis LMN only
Spastic gait
Stiff
Circumducting legs
Scuffing toes
Extrapyramidal gait
Flexed posture Shuffling feet Slow to start Postural instability Eg Parkinson's
Apraxia gait
Wide based
Unsteady gait
Tendency to fall
E.g normal pressure hydrocephalus
Ataxic gait
Wide based
Can’t heel to toe
Falls worse with eyes closed
Eg cerebellae lesion
Myopathic gait
Can’t stand from sit
Waddle gait from hip girdle weakness
Chorea
Jerky purposeless
Eg huntingtons
Athetosis
Slow confluent
Eg Cerebral palsy
Tics
Brief repeated stereotyped
Eg Tourette’s
Myoclonus
Focal involuntary jerk
Tardive dyskinesia
Eg chewing grimacing
From chronic dopamine use
Immediate stroke management
Pulse, ECG - AF Only treat low BP BM 4-11 Urgent CT/MRI only if \: considering thrombolysis, cerebellae stroke or unusual presentation Thrombolysis if
When can you thrombolyse in stroke?
Less than 1.7)
Facilitates and doctors available
Refer for urgent tPa eg late please
CT 24hr after thrombolysis
Prevention of next stroke
Reduce risk factors
Clopidogrel (2nd line aspirin+dipyridamole)
If any AF start warfarin only 2weeks after
Later Ix for stroke
CXR - heart failure
ECG - AF
Echo - ideally TOE for thrombus
Carotid Doppler
SAH typical presentation
Sign of berry aneurysm
Devastating headache
Collapse, seizure, coma, stiff neck, focal neuro
SAH management
CT (invades into fissures). If negative
LP >12h shows bloody/yellow CSF
Aim for BP >160 to maintain perfusion
Nimodipine
SDH typical presentation
From trauma, even minor, up to months ago
Elderly more common
Fluctuating consciousness
ICP gradually increases and structures shift to one side
Sleepy headache, gradual slowing
Personality change or unsteadiness
Seizures local Neuro
SDH management
CT/MRI shows clot +- midline shift, crescent shift
Irrigate and evacuate
EDH typical presentation
Lucid interval
From fractured temporal or parietal bone causing tear of middle meningeal
Increasing ICP
Headache vom, confusion, UMNL
Limb weakness, resp depression, blown pupil
EDH management
CT - lens/circle shaped X-RAYS could be fracture NO LP!!! Evacuate and ligamen Good prognosis if found early
Lewy body dementia
Fluctuating cognitive impairment
Detailed visual hallucination
Late parkisonism
Fronts-temporal dementia
Behavioral/personality changes
Disinhibition
Emotional unconcern
Alzheimers presentation
Progressive global impairment (other dementias affect one at a time)
Role of b amyloid
Some family history
Alzheimer’s treatment
Acetycholinesterase inhibitors
Antigultaminergics
Folic acid and vit b supplements
Shows beta amyloid senilie plaques on CT
Parkinsonism triad
Tremor
Rigidity
Bradykinesia
Parkisonism features
Resting/pill roll tremor Increased tone/rigidity - lead pipe/cogwheel Poor supination and pronation Bradykinesia - slow to initiate, montonic quiet speech Micrographics Reduced arm swing Festinance Freezing Hypomimia (mask face)
Parkinson’s management
MDT
Asses cognition and disability
Incurable and progressive but responds well to other measures
Discuss benefits in delaying treatment and wearing off
Complications: depression, dementia, psychosis
Parkinson’s meds
Levodopa - cause dyskinesia, psychosis, delay alap
Dopamine agonists - mono therapy to avoid above
Apomorphine - rescue pen for freezing
Anticholinergics - for tremor
MAOB inhibitors - alternative to dopamine ags in early PD
COMT - lessen off time
MS pathology
Demyelination plaques throughout CNS
Relapsing remitting pattern, but repeated relapse leads to progressive atonal loss
More common in women and vit D deficiency
MS typical presentation
Unilateral optic neuritis Numbness/tingling Diplopia, dystaxia Stress/heart induced Women 30ish Diagnosis made on McDonald's criteria
MS management
MRI - plaques LP - igG oligoclonal Steroids - for relapses but not prognosis Interferon - reduces relapse rate Monoclonal antibodies Azothiaprine
Parkisonism Plus Syndromes
1) progressive supranuclear palsy
2) multiple systems atrophy
3) Lewy body dementia
4) corticobasal degeneration
5) vascular Parkinsonism
More severe and Les responsive to PD drugs
Progressive supranuclear palsy
Early postural instability Loss of vertical gaze Rigid trunk>limbs Symmetrical Speech and swallowing problems Not much tremor
Multiple systems atrophy
Early autonomic features e,g impotence, incontinence
Postural hypotension
Cerebellar and pyramidal signs
Rigidity>tremor
Lewy body dementia
Fluctuating cognition
early dementia
Visual hallucination
Corticobasal degeneration
Rigidity in one limb
Cortical sensory loss (higher sensory function)
Apraxia
Alien limb
Vascular Parkinsonism
Pyramidal
Gait
Ataxia
Carpal tunnel
Aching pain and tingling in hand worse at night Relieving hanging over bed/shaking Sensory loss Thumb middle index Weakness of abductor pollis brevis- wasting of thenar eminence Ax w/ RA preg Phalens/tinels Tx: - splint, steroids, surgery
Motor neurons disease
Loss of upper and lower motor neurons
No sensory loss
4 types: ALS, PBP, PMA, PLS
Awful prognosis
Pseudobulbar palsy
UMNL
More common than bulbar palsy
Same slow movement but increased jaw jerk, pharyngeal/palatial reflexes
Cervical spondylosis
Can compress cord causing spastic paraparesis
Painful limited neck movement, crepitus
Lhermittes - neck flexion causes tingling down spine
Radiculopathy: pain, electrical tingling down fingers at levels, dull reflexes, sensory disturbance, UMN signs below weakness level
Needs laminectimy
Myasthenia gravis
Autoimmune from anti acetylcholine
Sx: increasing muscle fatigue, ptosis, diplopia, myasthenic snarl, fading voice
Ax w/ thymus pathology
Myasthenia gravis management
Test for anti aCH antibodies, MUSK
CT thymus
Tx: anticholinesterases, steroids, thymectomy
If mysasthenic crisis: vent support, plasmophoresis, IV Ig
Lambert Eaton syndrome
Not enough pre synaptic relapse of ACH
Paraneoplastic eg SCLC or autoimmune
Gait difficulty followed by eyes signs ( unlike MG), autonomic involvement, hyporeflexia
Do CT in case of cancer
Syringomyelia
Cyst of CSF in spinal cord
From tumor, infection, blocked CSF
Loss of pain and temp but other ok, at level of syrinx
Wasting/weakness of hand, claw
Syringobulbia is brain stem so involves tongue atrophy, nystagmus
Neurofibromatosis type 1
Autosomal dominant Cafe au lait Freckling in skin folds Lisch nodes - in eye slit lamp Learning disability
Neurfibromatosis type 2
Autosomal dominant/de novo
Lass cafe au lait
Bilateral vestibular schwannomas
Tuberous sclerosis
Ash leaf spots Shagreen patches on lumbar sound Developmental delay Epilepsy Intellectual impairment
Myotonic dystrophy
20-30 Balding Ptosis Myotonic facies Cataracts Dysarthria
Subacute combined degeneration of the cord
From low b12
Triad: extensor plantar + absent knee jerk + absent ankle jerk
Fine touch/proprioception+motor (dorsal +corticospinal)
Ataxia, decreasing vision, bilateral spastic paresis
Brown-sequard syndrome
Damage to spinal cord cussing loss of proprioception and paralysis on ipsilateral side with loss of pain and temp on contra lateral side
Charcot Marie tooth
Inherited peripheral neuropathy Distal Muscle wasting and sensory loss Autosomal dominant (but can be others) 4 types Wasting of intrinsic muscles of hands and feet Pets cavys, hammer toes, pets planus, spinal deformities Tremors, cramp, acrocyanosis Inverted champagne bottle sign
