Neurology Flashcards
Features of essential tremor
Essential tremor (previously called benign essential tremor) is an autosomal dominant condition which usually affects both upper limbs
Features
➡️5-10hz (Parkinson’s 3-5hz)
➡️Always bilat
➡️postural tremor: worse if arms outstretched
➡️improved by alcohol and rest
➡️most common cause of titubation (head tremor)
➡️No micrographia
Management
➡️propranolol is first-line
➡️primidone is sometimes used
Scoring system if previous TIA to predict stroke risk
Age >= 60 --------->1
BP >=140/90 ------> 1
Clinical features
Speech disturbance, no weakness --->1
Unilat weakness ---->2
Duration 10-59min ---->1
>60min ------>2
Diabetes --------------->1
0-7
>4 is high risk
Management from abcd2 scores
High risk >4 300mg aspirin daily immediately Specialist assessment and investigation within 24hr below 4 assessment within 1wk
but if 2 TIAs or more in a week, then HIGH RISK
OSCES description of Parkinson’s
Parkinson’s disease is a progressive neurodegenerative condition caused by degeneration of dopaminergic neurons in the substantia nigra.. This results in a classic triad of features: bradykinesia, tremor and rigidity. The symptoms of Parkinson’s disease are characteristically asymmetrical.
Drug induced Parkinson’s vs Parkinson’s disease
Drug-induced parkinsonism has slightly different features to Parkinson’s disease:
➡️motor symptoms are generally rapid onset and bilateral
➡️rigidity and resting tremor are uncommon
Symptom presentation of Parkinson’s disease indicating prognosis (from Majeed teaching)
PD has a Better prognosis if in a woman (about twice as common in men), or if presents with tremor symptoms first
There is a Worse prognosis if presents with rigidity first
Presenting symptoms of MS
Commonest presenting symptoms (nearly all have fatigue too)
➡️Limb weakness 40%
➡️Optic neuritis 22% (classically greying monocular visual loss with colour desaturation and painful eye movements -this often precedes visual loss)
➡️Parasethesia 21%
➡️Diplopia 12%
➡️Vertigo 5%
➡️Trigeminal neuralgia 2% (rarely presenting complaint but is seen more in MS patients)
What is Uhthoff’s
Seen in MS. Specifically visual loss after exercise (but often just referred to as after any heat, eg hot bath)
Previous optic neuritis causing heat dependent visual loss
What is L’Hermittes?
Symptom seen in MS
➡️Electrical shock paraesthesia down limbs when stretch
➡️Due to previous demyelination of cervical cord, so they become mechano-sensitive
Definition of relapse in MS
(?check)
New neurological disturbance which lasts longer than 24 hrs (they usually last 6wk)
Diagnosis of MS
At least TWO neurological events separated by time and space
So➡️ exclude mimics (sarcoidosis, hiv, lupus)
➡️ MRI looking for dawsons fingers, ventricular dilation, cerebral atrophy
➡️ LP with inflam, oligoclonal bands (positive in95%, not specific)
➡️ visually evoked potential, look for delay
Signs of cerebellar damage
Dysdiadochokinesia Ataxia Nystagmus Intention tremor Slurred speech Hypotonia
Peripheral neuropathy
Alcohol B12 Chronic renal failure Diabetes and drugs (tb meds etc) Every vasculitis Cancer (paraneoplastic), lymes and Charcot Marie tooth
Who needs ct head after head injury?
If any of the following are present, a CT is required immediately:
➡️GCS once
Loss of consciousness AND any of the following:
➡️Age ≥65
➡️Coagulopathy
➡️’Dangerous mechanism of injury’, eg car crash or fall from great height
➡️Anterograde amnesia of >30min
When might you get ‘claw hand’? And what other signs?
Ulnar nerve palsy (claw hand is due to loss of lumbrical innervation)
Weak pincer grip
Loss of sensation on fifth finger and ulnar half of fourth finger
Wasting of first dorsal interosseous muscle
Causes of carpal tunnel syndrome…
Rheumatoid arthritis Acromegaly Pregnancy Idiopathic Diabetes Trauma Tenosynovitis of flexor tendons Thyroid (hypo)
Upper limb nerve roots for movements
Shoulder abduction C5 Elbow flexion C6 Wrist extension C7 (cock wrist back) Finger extension C8 (fingers back) Finger abduction T1 (spread fingers)
Drugs that are associated with idiopathic intracranial hypertension
tetracycline antibiotics isotretinoin contraceptives steroids levothyroxine lithium cimetidine
Features of Parkinsonial gait
Shuffling Hesitancy Festinating (Latin for hurry) Reduced arm swing Flat foot strikes (instead of heel to toe) Freezing of gait
Causes of SAH
80% are rupture of berry aneurysm (assx with PKD, ehlers danlos, coarctation)
Rest are AV malformations
Trauma
Tumour
Investigation for SAH
CT negative in 5% So LP (but wait 12hr for xanthochromia to develop)
Management of cerebral oedema
Hyperventilation
- the decreased CO2 reduces cerebral blood flow
Reversible cause of dementia to rule out
Normal pressure hydrocephalus
Thought to be secondary to decreased CSF absorption in arachnoid villi
- enlarged fourth ventricle
Triad of normal pressure hydrocephalus
Gait abnormalities (like PD)
Urinary incontinence
Dementia / bradyphrenia (slowness of thought)
Management of normal pressure hydrocephalus
Ventriculoperitoneal shunting
Causes of carpal tunnel
Myxoedema Edema HF Diabetes Idiopathic Acromegaly Neoplasm Trauma RA Amyloidosis Pregnancy
Contraindications to LP
Raised ICP (unless just idiopathic intracranial hypertension)
Coagulopathy
Infection at needle site
…no consent!
Complications for LP
Headache….common, lie down for two hours afterwards
Parasthesia
Permanent nerve damage is very rare
CSF analysis - bacterial vs TB
Both will have low glucose, high protein
Bacterial is cloudy (tb may be slightly)
Bacterial will have polymorphs (tb will be lymphocytes)
International migraine criteria
At least 5 of Between 4 and 72hr Characteristic (unilat, puls, mod/severe, worse with activity) During get: N/V, Photo/phonophobia Exclude other causes
Features of neurofibromatosis type 1
Lack of neurofibromin (tumour suppressor)
Over 6 cafe au lait (over 15mm)
Axillary or inguinal freckles
Two or more neurofibromas
Two or more Iris harmatomas (Lische nodules)
First degree relative
(Also may have scoliosis)
Managment of mild moderate alzheimer’s
NICE now recommend the three acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) as options for managing mild to moderate Alzheimer’s disease
Drugs that cause Parkinsons
Atypical antipsychotics Calcium channel blockers Amiodarone Typical antipsychotics Lithium metoclopramide
Management of GBS
Immunoglobulins, monitor FVC every 4 hours and ventilate if under 1.5 or if O2 under 10
Diagnosis of GBS
Suggestive hx, (progressive weakness of all 4 limbs, areflexia, Mild sensory involvement, Absence of fever, no other diagnosis (MG, botulism, poliomyelitis etc))
CSF with HIGH protein and low WCC (under 10)
Predominantly motor polyneuropathies
GBS, lead poisoning, Charcot Marie tooth
Young patient with acute neck pain and hemiplegia.. Diagnosis
Carotid artery dissection (remember, tunica intima and tunica media split making false lumen). Common cause of stroke in young patients, may have neck pain or headache
Antibiotic contraindicated in myasthenia gravis
Aminoglycosides (Gentamicin)
Presentation of venous sinus thrombosis
Young patient headache seizure paresis papilloedema
Ct string sign
Mx heparin
What vitamin deficiency causes dermatitis, diarrhoea and dementia?,
Vitamin B3, aka Niacin deficiency (diagnosis is Pellagra)
