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Specialities > Neurology 5 > Flashcards

Neurology 5 Flashcards

1
Q

What is the most common cause of a SAH?

A

Trauma

Other causes are spontaneous

  • Berry Aneurysm
  • AVM
  • Arterial dissection
  • Pituitary apoplexy
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2
Q

What changes may you see on ECG with a SAH?

A

ST elevation

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3
Q

What are some of the complications that can occur with SAH?

A

Re-bleeding

Cerebral ischemia
- vasospastic action *Nimodipine given to counter act

Hydrocephalus
- arachnoid granulation and blood obstruction

SIADH

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4
Q

Which system is involved causing pain in a migraine?

A

Trigeminovascular system

  • spreading cortical depression
  • Release of CGRP
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5
Q

What are some triggers for migraines?

A

Sleep (too much to little)

Hormone changes
- menstrual cycle

Stress
- includes a let down period after intense stress

Eating
- alcohol

Weather changes

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6
Q

What features can help differentiate a Aura migraine from a TIA?

A

Positive symptoms

  • scotoma
  • tingling
  • TIA tend to have complete vision loss as oppossed to distorted vision

Onset time
- migraines tend to build up

Migraine typically has pain associated

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7
Q

What are the duration of times of antibiotic therapy for meningitis?

A

N. meningitides: 5 days

S. Pneumonia: 10-14 days

L. Monocytogenes: 21 days

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8
Q

What are some poor prognostic indicators in meningitis?

A

> 60 years old

S. Pneumonia infection

Low GCS

Focal neurology

Bleeding

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9
Q

What is the ABCD2 score?

A

Score used to assess if a patient needs to be managed as in patient (seen within 24 hours) or outpatient Due to risk of further risk of stroke.
>4 need to be admitted and seen within 24 hours

A- Age >60 
B - Blood pressure >140
C - Clinical condition (weakness?) 
D - Duration of symptoms 
D - Diabetes
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10
Q

When is the best time to give Alteplase?

A

within first 90mins is best but can be given within 4.5 hour window

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11
Q

What scoring system can be used to assess severity of strokes?

A

NIH Stroke Scale

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12
Q

Why is an extensive stroke not treated with thrombolysis even if within the 4.5hours?

A

Extensive stroke demonstrates large necrosis which is a big risk factor for haemorrhage

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13
Q

When treated with thrombolysis how many will benefit and how many will ?

A

1/3rd will improve

1% will have worse outcomes

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14
Q

What is the criteria for endarterectomy following a stroke?

A

Males: >50% stenosis

Females: >70% stenosis

  • has to be symptomatic (i.e. had a stroke)
  • done within 2 weeks of the event
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15
Q

Why is anti-coagulation not started straight away in patients with an embolic stroke?

A

Anti-coagulation increases the risk of bleeding

- in a similar way thrombolysis increases risk

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16
Q

If someone has signs of a posterior circulatory stroke but no findings on CT what should be done next?

A

MRI scan

CT scan can’t rule out posterior stroke

**any Brainstem signs you need an MRI

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17
Q

What type of nystagmus is suggestive of a central cause?

A

Bidirectional nystagmus

- beats to both sides

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18
Q

RTC and patient presents with Horner’s syndrome, what has occurred?

A

Carotid dissection

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19
Q

How is a carotid dissection treated?

A

Anti-coagulation

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20
Q

In terms of onset of weakness - if a patient describe s a progressive weakness over 24-72 hours what is the likely underlying pathology?

A

Inflammatory

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21
Q

If you have a lesion in the internal capsule what kind of symptoms can you expect?

A

Dense hemiparesis of the face and body on contralateral side
- all the motor fibres pass through there

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22
Q

If you have a lesion in the thalamus what symptoms can you expect?

A

Hemisensory loss

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23
Q

If you have a lesion within the medulla what symptoms can you expect?

A 
Dysphagia
Dysarthria 
Dysphonia 
Wasting of tongue 
Lack of soft palate risen when saying "ahh"

*this is because cranial nerves 9,10,11 exit from the medulla.

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24
Q

What is a prognostic indicator on how well someone will do following a spinal transection?

A

Their ability to use truncal muscles.

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25
Q

What is a positive Romberg’s sign indicative of?

A

Sensory neuro-ataxia

  • they’ve lost proprioception input
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26
Q

Give some differentials for length dependent polyneuropathy:

A

Diabetes
Alcohol
Multiple myeloma

B12 deficiency

Autoimmune:

  • RA
  • Lupus

Drugs:

  • Isoniazid
  • Amiodarone

Kidney disease

Hypothyroidism

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27
Q

What are some of the risk factors for a SAH?

A 
Female 
Smoking 
HTN 
Polycystic kidney disease 
Ehlor Danlos 
Family history 
Coarctation of aorta
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28
Q

What is a sign seen in the eyes which is very characteristic of a SAH?

A

Subhyaloid haemorrhage causing vitreous detachment

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29
Q

Once a SAH has been established what tests should then be conducted to establish the cause?

A

CT angiogram
- assess for aneurysms

  • digital subtraction to view the vessels can also be done.
  • assess eGFR
  • a digital subtraction graph can be done if CT not appropriate
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30
Q

What investigations other than a CT Scan do you want to order in a SAH?

A

Bloods:

  • U&Es - hyponatraemia
  • Troponin levels

X-rays:

  • Echocardiogram (Takusubo)
  • pulmonary oedema

ECG
- non-specific ST elevation

31
Q

What are the complications of a SAH and some treatments used:

A

Re-haemorrohage

  • 10% within the first 72 hours
  • immediate repair can help

Delayed Ischemia

  • peaks around day 7
  • nimodipine is used to reduce
  • Inotropic may be needed
  • microvascular dilation

Hydrocephalus

  • due to arachnoid granulation irritation
  • needs shunted

SIADH

  • can become fluid depleted by passing lots of water
  • hypertonic saline

Takotsubo cardiomyopathy
- large catecholamine release

Troponin rise
- due to catecholamine release

DVTs

  • Mechanical compression
  • use of LMWH is controversial and should be with held 24 hours between surgeries
32
Q

What is the mortality rate in SAH?

A

50%

1/3rd who survive will require dependent care

33
Q

What are the pathological processes behind cervical myelopathy?

A

Disc prolapse

Facet joint degeneration

Osteophyte formation

Cervical stenosis

Malignancy

34
Q

What kind of symptoms occur in radiculopathy?

A

Lower motor sign

Pain is the biggest sign first.

35
Q

How does an UMN lesion affect the bladder and sphincter complex?

A

Spastic bladder

  • urgency
  • strangury
  • incontinence

Bowel:

  • constipation
  • unable to open
36
Q

What condition will inhibit an approach from the front to treat cervical myelopathy? and what is the surgery called that is conducted from the front?

A

Posterior longitudinal calcification

Anterior cervical discectomy with fusion

37
Q

Name three operation which can be conducted to fix a cervical myelopathy and what would help you decide to take an anterior or posterior view?

A

Anterior cervical discectomy with fusion

Posterior laminectomy

Cervical foraminotomy

Decision:

  • Where the most amount of compression is
    i. e. if anterior then anterior approach
38
Q

What are the red flags of lumbosacral radiculopathy?

A

Foot drop

Bilateral leg pain

Bladder/ bowel dysfunction

Saddle anaesthesia

Known cancer

39
Q

What are the treatment options for lumbosacral radiculopathy?

A

Physiotherapy

Analgesia

  • Duloxetine
  • Gabapentin
  • TCAs

Nerve root blocks

Surgical:
- Lumbar microdiscectomy ** definitive management

40
Q

Contrast a LMN bladder and an UMN bladder and list one condition it is seen with:

A

UMN:

  • hyperactive
  • inability to fill and relax
  • Strangulation
  • Urgency
  • cervical myelopathy
LMN: 
- Atonic 
- Drippling
Progresses to retention and incontinence 
*cauda equina syndrome
41
Q

What test can you do to establish if there is bladder dysfunction in cauda equina syndrome?

A

Post- void ultrasound scan

Residual of >100mls is suggestive of dysfunction

42
Q

What is the definitive management for cauda equina?

A

Lumbar microdiscectomy
+/-
Laminectomy (done if unsure its decompressed)

*should be conducted with 24 hours - as soon as possible

43
Q

What criteria can be used to help establish which patients are likely to benefit from surgical surgery who have a spinal tumour?

A

Patchel criteria

44
Q

What are the two types of haemorrhagic transformation?

A

Petechial

  • not of much clinical significance
  • usually antiplatelet therapy is withheld for one day following this

Intraparenchymal
- carries worse prognosis

**this is why a repeat CT is done following thrombolysis therapy 19-24 hours later

45
Q

What are the two main types of primary intracerebral bleeds?

A

Hypertension
- this is centrally located bleeds

Cerebral amyloid angiopathy

  • seen with susceptibility weighted MRI
  • there are peripherally located
46
Q

Where is the most common place for a SAH to occur?

A

Anterior communicating Artery

47
Q

What imaging modality should be utilised for follow up of a coil in SAH?

A

MRI

in CT there is too much artefact

48
Q

On imaging how do you differentiate between atrophy and hydrocephalus?

A

In hydrocephalus the sulci are squished as well
Low density is found around the ventricles
- this is CSF leaking out into the parenchymal

In atrophy the sulci are equally enlarged

49
Q

What are the layers of the scalp and what is the vein that passes through from the scalp to the superior sagital sinus?

A

SCALP

  • Skin
  • Connective tissue
  • Aponeurosis
  • Loose aorola tissue
  • Peritoneum

Emissary vein
- source of infection

**above the aponeurosis it will not be influenced by the pull of the frontalis muscle thus can be fixed with glue

50
Q

List some signs of myasthenia gravis:

A 
Diplopia 
Proximal  muscle weakness (neck, limb girdle) 
Dysphonia 
Dysphagia 
Ptosis
  • pernicious anaemia
  • Thyroid disease
51
Q

What are the core symptoms of Parkinson’s disease?

A

Tremor at rest
Rigidity
Bradykinesia
Postural instability - due to poor postural reflexes

52
Q

What tests do you want to order to help diagnose Myasthenia Gravis?

A

Bloods:

  • ACh receptor antibodies
  • Anti- Muscle specific Kinase receptor (MuSK)
  • Low Density lipoprotein receptor - 4

X-rays:
- CXR (thyoma)

Special tests:

  • Pulmonary function - Spirometry looking at FVC
  • single fibre EMG
53
Q

What are some triggers to a myasthenia crisis and how is it treated?

A

Drug

  • gentamicin
  • beta blockers
  • over dose of Acetylcholinesterase inhibitors
  • pregnancy
Treatment: 
- Ventilator support or BiPAP
- plasmapheresis 
or 
- IV immunoglobulin
54
Q

What drug is given in an overdose of an Acetylcholinesterase inhibitor?

A

Glycopyrronium

55
Q

What symptoms would point away from Parkinson’s disease and to one of the Parkinson plus syndromes?

A

Early onset dementia

  • fluctuation in consciousness
  • Hallucinations

Early postural instability and postural hypotension
- Multisystem atrophy

Multiple early falls

Symmetrical presentation

`Levodopa non-responsiveness

56
Q

What drug can be given as a rescue medicine for sudden “off” freezing in Parkinson’s? and how is it delivered?

A

Apomorphine

- Sub cut

57
Q

What are the two common dopamine agonists used in Parkinson’s disease? why are these preferred over other dopamine agonists and what are some side effects to them?

A

Ropinirole
Pramipexol

Typically used initially in young persons with Parkinson’s due to reduced efficacy of L-DOPA as time goes on.
Preferred over other domapine agonists as they can cause fibrotic reaction of the heart

Side effects:

  • N&V
  • Postural hypotension
  • Increased compulsivity
  • Hypersexuality
  • Psychotic features
58
Q

When a patient is admitted with Parkinson’s disease - what important question should you ask them? and list some consequences of not:

A

Establish when they take their medication
- it is important this is given at the same time of day each day.

Missing dosages or changing dosages can result in:
- neuroleptic malignancy syndrome

59
Q

What are COMT inhibitors used for and name two:

A

Help reduce the on-off effects of levadopa
*typically used in late disease

  • Entacapone
  • Tolcapone
60
Q

What are some side effects of levadopa?

A

Dyskinesia

On-off affect

Psychosis

Hallucinations

61
Q

What anti-emetic can be given for Parkinson’s?

A

Domperidone (even though it is a dopamine antagonist - it doesn’t cross the BBB)

62
Q

What features would suggest a Psychogenic non-epileptic seizure?

A

Gradual onset
Hip thrusting
Crying after seizure
Rarely occurs alone

63
Q

How do posterior circulating strokes present?

A 
Brainstem signs 
or 
Cerebellar signs 
or 
Unconsciousness 
or 
Isolated homologous hemianopia
64
Q

Outline the pathological mechanisms of traumatic brain injury:

A

Diffuse neural exonal injury
- can be opposite side of injury (contrecoup)

Neuronal and axonal damage directly from blow

Brain hypoxia

Oedema build up afterwards

65
Q

What are some long term consequences of trauma to the brain?

A

Incomplete recovery
- cognitive impairment

Post-traumatic epilepsy

Post-traumatic syndrome

  • recurring headaches
  • dizziness

Hydrocephalus

BPPV

66
Q

What is the treatment for idiopathic intracranial hypertension?

A

Acetazolamide

67
Q

Which class of antibiotics can lower the seizure threshold in epileptics?

A

Quinolones

68
Q

What is the management for an extra-dural haemorrhage and give some differentials:

A

Differentials:

  • epilepsy
  • Carbon monoxide poisoning
  • Carotid artery dissection

Management:

  • ABCDE (early intubation is needed)
  • Clot evacuation
  • Ligation of bleeding vessel
  • control if ICP
  • Ventilation
  • Mannitol
69
Q

What is conduction aphasia?

A

Where speach is fluent but they have difficulty repeating what is said to them
- comphrension is present

70
Q

What investigations would you consider in someone presenting with a seizure?

A 
Blood glucose 
ECG - rule out cardiac 
FBC - infection? 
U&Es/ Toxicology 
Head CT

Later on:

  • EEG
  • EEG doesn’t diagnose unless it is occurring but can help with prognosis i.e. to look at normal activity
71
Q

Following one seizure how likely is a person to have another?

A

40%

*if there is abnormal EEG this rises to 60%

72
Q

What are some risk factors for a epilepsy?

A

Family history

Birthing injury/ preterm

Meningitis

Febrile convulsions
- especially if out-with normal ages

Head injuries

73
Q

When asking about seizures at night - what kind of things do you want to think about?

A

If they wake up with muscle aches

Tongue biting through the night

74
Q

When treating cauda equina - what initial things are done?

A

Dexamethasone

Urinary catheter ***

Whole spinal MRI

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