Neurology Flashcards
Describe neurofibromatosis, it’s types, and features
There are two types NF1 and NF2 both are automsomal dominant.
NF1 - chr17; CAFE SPOT Cafe au lair spots (>5) Axilary freckling Fibromas Eye: lisch nodules Sphenoid dysplasia/short stature/scoliosis Positive FHx Optic Tumour (glioma)
NF2 - chr 22
Cafe au lait spots
bilateral acoustic neuromas + 1 of following
Juvenile cataracts, neurofibromas, glioma,schwannoma
What are the features of a UMN lesion?
Affects muscle groups Upgoing plantar reflex (+ve babinski)/clonus Hyperreflexia No fasciculations Spasticity/hypertonia
What are the featured of a LMN lesion?
Caused by damage from anterior horn cells, nerve roots, plexi, or peripheral nerves
Wasting and fasciculations
Hyporeflexia
Downward going plantars (-ve babinski)
Hypotonia (flaccidity)
What does the anterior cerebral artery supply and what symptoms arise from its occlusion?
Supplies the frontal and medial part of the cerebrum.
Occlusion may cause a weak,numb contralateral leg +/- similar but often milder picture in the arms. The face is spared.
What does the middle cerebral artery supply and what symptoms arise from its occlusion?
Supplies the lateral part of each hemisphere
Occlusion may cause a weak contralateral hemiparesis, Hemisensory loss (esp arm + face), contralateral homonymous hemianopia.
What does the posterior cerebral artery supply and what symptoms arise from its occlusion?
Supplies occipital lobe
Occlusion gives contralateral homonymous hemianopia (often with macular sparing)
Describe subclavian steal syndrome
Subclavian artery stenosis proximal to the origin of the vertebral artery may cause blood to be stolen by retrograde flow down this vertebral artery down into the arm, causing brain stem ischaemia typically after use of the arm.
Suspect if the BP in each arm differs by >20mmHg
What are some causes of an acute single episode headache?
- With meningism: meningitis, encephalitis, subarachnoid haemorrhage
- Head injury
- Venous sinus thrombosis
- Sinusitis
- Tropical illness
- Low pressure headache
- Acute glaucoma
What are some causes of recurrent acute attacks of headache?
- migraine
- cluster headache
- trigeminal neuralgia
- recurrent (mollaret’s) meningitis
What are some causes of subacute onset headaches?
Giant cell arteritis should be excluded in all >50yrs old with a headache that has lasted a few weeks.
What are some causes of chronic headache?
- Tension Headache
- raised ICP
- Medication overuse (analgesic rebound) headache
Describe tension headache, its symptoms, and management
Symptoms:
Usual cause of bilateral, non pulsating headache +/- scalp tenderness, but without vomiting or sensitivity to head movement.
Management:
- Stress relief, massage, or antidepressant (low dose amitryptilline) may help.
- Consider seeing optician
Describe raised intracranial pressure, its symptoms and tests.
Symptoms:
Typically worse on waking, lying, bending forward, or coughing. Also vomiting, papilloedema, seizure, false-localising signs, or odd behaviour
Tests: Do imaging to exclude a space-occupying lesion, and consider idiopathic intracranial hypertension. LP is contraindicated until after imaging!
Describe Acute Glaucoma, it’s presentation, symptoms, and management.
Presentation: Typically elderly, long-sighted people. Constant, aching pain develops rapidly around one eye, radiating to the forehead. Attacks may be precipitated by dilating eye-drops, emotional upset or sitting in the dark.
Symptoms: markedly reduced vision, visual haloes, nausea/vomiting.
Signs: red congested eye, cloudy cornea, fixed dilated non-responsive pupil (may be oval), decreased acuity.
Management:
seek expert help, if delay of treatment of >1h start acetazolamide 500mg IV over several minutes.
Describe Cluster Headaches, its symptoms, and treatment
Unilateral severe headache that occurs once or twice a day for 15-60mins and is often nocturnal. Clusters may be episodic or chronic. 5 times more common in men, can occur at any age and more common in smokers.
Symptoms: Rapid-onset of excruciating pain around one eye that may become watery and bloodshot with lid swelling, lacrimation, facial flushing, rhinorrhoea, miosis+/- ptosis.
Treatment: acute attack - 100% O2 + Sumatriptan SC 6mg
Describe epilepsy and its suggestive features.
Epilepsy is a recurrent tendency to spontaneous, intermittent, abnormal electrical activity in part of the brain, manifesting as seizures.
Features suggestive of epilepsy: attacks when asleep or lying down, aura, identifiable triggers (e.g. tv) altered breathing, cyanosis, typical tonic-clonic movements, incontinence, tongue-biting, prolonged post-ictal drowsiness (slow recovery), confusion, amnesia, and transient focal paralysis (Todd’s palsy)
What are some causes of seizures?
- Idiopathic ~ 2/3
- Structural: (cortical scaring, developlmental, space-occupying lesion, stroke, hippocampal sclerosis, vascular malformations)
- Others: tuberous sclerosis, sarcoidosis, SLE, PAN
- Non-epileptic causes: trauma, stroke, haemorrhage, increased ICP, alcohol or benzodiazepine withdrawal, metabolic disturbance (e.g. hypoxia, hypo/hypernatraemia, hypocalcaemia, hypo/hyperglycaemia, uraemia) liver disease, infection, hyperthermia, drugs (tricyclics, cocaine, tramadol, theophylline), pseudoseizures.
What are the classifications of seizure
seizures are classified into partial of primary generalised seizures.
partial seizures have focal onset, with features referable to a part of one hemisphere. often seen with underlying structural disease. They can be either simple or complex with or without secondary generalisation.
primary generalised seizures have simultaneous onset of electrical discharge throughout the cortex, with no localising features. Examples are absence, myoclonic, tonic-clonic, atonic (akinetic) and infantile spasms
Define a simple partial seizure
Awareness is unimpaired. with focal motor, sensory, autonomic or psychic symptoms. no post-ictal symptoms.
Define a complex partial seizure
awareness is impaired. may have a simple partial onset or impaired awareness at onset. most commonly arise from the temporal lobe. Post-ictal confusion is common with seizure arising from the temporal lobe, whereas recovery is rapid after seizures in the frontal lobe.
Define a partial seizure with secondary generalisation
occurs in ~ 2/3 of patients with partial seziures, electrical disturbances begin focally as either complex or simple seizures but then spread widely, causing a secondary generalised seizure which is typically convulsive.
Define absence seizures
brief (less than 10s) pauses, e,g, suddenly stops talking mid-sentence then continues where they left off. Presents in childhood
Define tonic-clonic seizures
loss of consciousness. limbs stiffen (tonic), the jerk (clonic) may have one without the other. post-ictal confusions and drowsiness occur.
Define myoclonic seizures
sudden jerk of a limb, face of trunk. the patient may be thrown suddenly to the ground or have a violently disobedient limb.
Describe atonic (akinetic) seizures
sudden loss of muscle tone causing a fall, no loss of consciousness
What are some localising features of partial focal temporal lobe seizures?
- Automatisms (brief complex motor phenoma with impaired awareness/ no recollection e.g. may be oral or manual.
- abdominal rising sensation +/- pain
- dysphasia
- memory phenonema e.g. dejavu or the opposite jamais vu
- hippocampal involvement may cause emotional disturbance e.g. terror, anger
- Uncal involvement may cause hallucinations fo smell or taste
- Auditory hallucinations
- delusional behaviour
What are some localising features of partial focal frontal lobe seizures?
- Motor features
- motor arrest
- subtle behavioural distubances
- dysphasia or speech arrest
- post-ictal todd’s palsy
What are some localising features of partial focal parietal lobe seizures?
- sensory disturbances
- motor symptoms
What are some localising features of partial focal occipital lobe seizures?
visual phenomena such as spots lines or flashes
Define pseudo- or psychogenic seizures
these are not infrequent suspect if there are uncontrollable symptoms, no learning disabilities, and CNS, CT, MRI and EEG are all normal. May be part of Munchausen’s syndrome
What are the drug used in treatment of epilepsy?
Generalised tonic-clonic seizures - sodium valproate or lamotrigine are 1st line, then carbamazepine or topiramate.
Absence seizures - sodium valproate, lamotrigine or ethosuximide
Tonic, atonic, and myoclonic seizures same as tonic-clonic but no carbamazepine as it may worsen seizures.
Partial seizures - carbamazepine is first line then valproate and lamotrigine.
What are the side effects of sodium valproate
V alproate side effects A ppetite increased leading to weight gain L iver failure (LFT monitoring) P ancreatitis R eversible hair loss (grows back curly) O edema A taxia T eratogenicity, tremor, thrombocytopenia (Monitor bloods) E ncephalopathy
How do you assess risk of stroke in patients presenting with TIA?
ABCD2 score - >6 strongly predicts stoke, >4 should be assed within 24 hours all suspected TIA should be seen within 7 days.
A ge>60 = 1 point
B lood pressure >140/90 = 1 point
C linical features
unilateral weakness = 2 points
speech disturbance without weakness = 1 point
D uration of symptoms
lasting > 1h = 2 points
lasting 10-59 mins = 1 point
D iabetes = 1 point
Describe Cauda equina syndrome and its symptoms.
A neurosurgical emergency!
Symptoms: Features include back pain and radicular pain down the legs, assymetrical (alternating or bilateral), atrophic, areflexic paralysis of the legs. Sensory loss in a root distribution (saddle anaesthesia) and decreased sphincter tone causing bladder and bowel incontinence (Do PR)
What would you expect to see on CSF analysis from LP of suspected bacterial meningitis?
Appearance: cloudy
Glucose: low less than half plasma glucose
Protein: high >1g/L
White cells: 10-5000 polymorphs/mm
What would you expect to see on CSF analysis from LP of suspected tuberculous meningitis?
Appearance: slightly cloudy, fibrin web
Glucose: low less than half plasma glucose
Protein: high >1g/L
White cells: 10-1000 lymphocytes/mm
