Neurology Flashcards
Pathogenesis of MS
Cells Effected in MS
Multifactorial
- Inflammation
- Demyelination
- Axonal degeneration
Mostly effecting Oligodendracyte
Diagnosis of MS
MacDonald Criteria
- Separation of Time
- >2 clinical neurological events @ different time intervals
- Separated on MRI gadolinium scan - Separation of Space
- >2 different clinical neurological features
- >2 lesions on MRI in deferent areas
Subtypes of MS
- Relapsing and remitting
- 90%
- Return to some residual deficit
- F > M - Secondary progressive
- Primary Progressive
- 10%
- M > F - Progressive Relapse
Treatment of MS
- limited head to head studies
Interferon
- monitor LFTs
- Flu like symptoms
#
Dx of MS
oligoclonal bands in the cerebrospinal fluid
syringomyelia
Cyst in the middle of spinal cord
White T2 Image
GBS
Campylobacter jejuni
Aetiology of epilepsy
- Genetic: direct result of a known or presumed genetic defect that is the core symptom of the disor-der
- Structural or metabolic: structural or metabolic condition or disease that has demonstrated to be associated with a substantially increased risk of developing epilepsy
- Gentic: tuberous sclerosis or malformations of cortical development
- Aquired: stroke, trauma or infection
- Autoimmune
Epilepsy in elderly
Aetiology
- CVA
- Dementia
- Intracranial tumors
- Unknown one-third to half
Dystonia
- Sustained or intermittent muscle contraction causing abnormal movements and/ or postures
- Often repetitive
- Twisting pattern
- Worsened by voluntary action
Chorea
- Involuntary movements limbs, trunk, neck or face; which rapidly flit from region to region Irregular pattern, unpreductable manner ‘no sense of abnormal muscle contraction’
- Not repetitive
- ?caudate nucleus & putamen
Myoclonus
Fast hyperkinetic disorder
Sudden increase in muscle tone
Focal, multifocal, segmental or generalised
Dyskinesia
Overactivity of movement
ie. Over treatment in Parkinsons (motor fluctuation)
Resting tremor
When the limbs are completely at rest
Postural tremor: when the arms are held up by the patient
- Kinetic tremor: during movement, may significantly worsen toward the end of
movement - Intention: coarse terminal tremor when limb approaches a target
- Action tremor: postural + kinetic
Essential tremor
- Bilateral, mildly asymmetrical involving the hands and forearms
- May have concomitant head and jaw tremor
- Can be at rest but posture predominant
- Slow progression
- Begins 60’s
- ETOH improves
Family history - 30-50% familial form
Treatment (May not require treatment) - First line: propranolol & primidone
- Second line: clonazepam, topiramte, gabapentin and nimodipine
- Others: botulinum toxin & DBS
Physiologic tremor
- Bilateral symmetrical
- Onset any age
- Worsened by anxiety & fatigue
- No family history
- Possible identification of enhancing cause
Dystonic tremor
- Irregular and jerky oscillatory
- Other signs of dystonia
Phenytoin
- 90% bound to albumin
- 10% free
- Free is important to levels - active
- only need to change dose if symptomatic
Stroke management
1.
Migraine
# acute: triptan + NSAID or triptan + paracetamol # prophylaxis: topiramate or propranolol - if 2 or more attacks per month
Visual field defects:
- left homonymous hemianopia means visual field defect to the left, i.e. lesion of right optic tract
homonymous quadrantanopias: PITS (Parietal-Inferior, Temporal-Superior) - incongruous defects = optic tract lesion; congruous defects= optic radiation lesion or occipital cortex
Homonymous hemianopia
- incongruous defects: lesion of optic tract
- congruous defects: lesion of optic radiation or occipital cortex
- macula sparing: lesion of occipital cortex
Homonymous quadrantanopias*
- superior: lesion of temporal lobe
- inferior: lesion of parietal lobe
- mnemonic = PITS (Parietal-Inferior, Temporal-Superior)
Bitemporal hemianopia
- lesion of optic chiasm
- upper quadrant defect > lower quadrant defect = inferior - chiasmal compression, commonly a pituitary tumour
- lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma
Cataplexy
sudden and transient loss of muscular tone caused by strong emotion (e.g. laughter, being frightened). Around two-thirds of patients with narcolepsy have cataplexy.
Eclampsia
- condition seen after 20 weeks gestation
- pregnancy-induced hypertension
- proteinuria
Mx - IV Magnesium Sulphate (to prevent and treat seizures
- Fluid restriction - prevent fluid overload
Bells Palsy
- LMN - affects forehead
- Often associated with pain around the ear (Ramsey-Hunt syndrome), altered taste, dry eyes, hyperacusis
Mx - Prednisalone
- Aciclovir adds no benefit
Note UMN (Stroke) - spares forhead
Myasthenia gravis
- The key feature is muscle fatigability
- Antibodies to acetylcholine receptors are seen in 85-90% of cases*
Management - long-acting anticholinesterase e.g. pyridostigmine
- immunosuppression: prednisolone initially
- thymectomy
Management of myasthenic crisis - plasmapheresis
- intravenous immunoglobulins
Guillain-Barre syndrome
- immune mediated demyelination of the peripheral nervous system
- Often triggered by an infection (classically Campylobacter jejuni).
Management - Plasma exchange
- IVIG - as effective as plasma exchange
- No benefit in combining treatments
- steroids and immunosuppressants have not been shown to be beneficial
- FVC regularly to monitor respiratory function
Prognosis
- 20% suffer permanent disability, 5% die
Subdural haemorrhage
Basics
- most commonly secondary to trauma e.g. old person/alcohol falling over
- initial injury may be minor and is often forgotten
- caused by bleeding from damaged bridging veins between cortex and venous sinuses
Features
- headache
- classically fluctuating conscious level
- raised ICP
Treatment
- needs neurosurgical review ? burr hole
Epilepsy medication:
first-line
- generalised seizure: sodium valproate
- partial seizure: carbamazepine
Tuberous sclerosis (TS)
- is a genetic condition of autosomal dominant inheritance.
- Like neurofibromatosis, the majority of features seen in TS are neuro-cutaneous
Dopamine receptor agonists
- e.g. Bromocriptine, ropinirole, cabergoline, apomorphine
Progressive supranuclear palsy
- parkinsonism
- impairment of vertical gaze
Management - poor response to L-dopa
Idiopathic intracranial hypertension
Classically
- Obese
- young female with headaches / blurred vision
cholinesterase inhibitors
- Only role is to improve some cognitive function and improvement in activities of daily living.
- There is no role for cholinesterase inhibitors in advanced Alzheimer’s disease.
Tremor
- Difficulty in initiating movement (bradykinesia), postural instability and unilateral symptoms (initially) are typical of Parkinson’s.
- Essential tremor symptoms are usually eased by alcohol. - Mx by propranalol
acoustic neuroma
Classically
- Loss of corneal reflex
- Hearing loss
Motor neurone disease
amyotrophic lateral sclerosis
- mixture of upper and lower motor neurone signs
- normal sensation
C9ORF72 is associated with an autosomal dominant inheritance of motor neurone disease and frontotemporal dementia
Mx (Riluzole)
- prevents stimulation of glutamate receptors
- prolongs life by about 3 months
FXN is the gene for Friedreich Ataxia
Vertigo
- Viral labyrinthitis typically causes constant symptoms of a shorter duration.
- Meniere disease usually have associated hearing loss and tinnitus. Also, the vertigo associated with Meniere disease typically lasts much longer
Normal pressure hydrocephalus
Classically
- Urinary incontinence + gait abnormality + dementia
Von Hippel-Lindau syndrome
- Retinal and cerebellar haemangiomas are key features
- Retinal haemangiomas are bilateral in 25% of patients and may lead to vitreous haemorrhage
Normal pressure hydrocephalus
Classical triad
- urinary incontinence
- dementia and bradyphrenia
- gait abnormality (may be similar to Parkinson’s disease)
Neglect in Stroke
often contralateral stroke of parietal lobe
Medication to improve severe motor deficits post stroke
FLAME Trial - The Lancet Neurology. 2011. 10(2):123-130
- fluoxetine
- initiated 5 to 10 days after stroke onset
- in addition to conventional physiotherapy
- improves motor recovery in patients with moderate to severe motor deficits due to ischemic stroke.
Meniere disease
Triad
- episodic vertigo
- sensisorineural hearing loss
- tinnitus
