Neurology Flashcards
1
Q
Types of parkinsonism + and distinguishing features
A
Progressive supranuclear palsy - early speech and swallowing issues, gaze palsy
Multiple system atrophy - autonomic features including incontinance and postural hypotension
Lewy body dementia - dementia and visual hallucinations
Corticobasal degeneration - spreading from one limb
Vascular parkinsonism - cvd risk factors, ataxia
2
Q
Drugs with high risk of parkinsonism
A
Neuroleptics
Metoclopramide
Prochlorperazine
3
Q
Three cardianal features of parkinsonism and their characteristics
A
Tremor - worse at rest, pill rolling, slow frequency (4/sec), initially asymptomatic
Rigidity - cogwheeling / lead pipe usually worse on one side
Bradykinesia - slow to initiate movement, freezing
4
Q
Parkinson features of gait
A
Stooping, shuffling, decreased arm swing, turns on box, loss of balance
5
Q
Features of parkinsons face and speech
A
Expressionless face
Hypophonic, monotone, slurring speech
6
Q
What is parkinsons type handwriting
A
Micrographia, small shaky handwriting
7
Q
Effects of parkinsons on mental health, other neuro, GI, GU systems
A
Dementia, depression, visual hallucinations, insomnia, anosmia
Constipation
Heartburn
Uriary difficulties, frequency, urgency,
8
Q
Prognosis of idiopathic parkinsons disease. How do drugs alter this?
A
Progressive with no remission (though can ease for seconds to minutes in intense emotion e.g. Fear or excitement)
Life expectancy 10-15 years with death from pneumonia
Medications have very little benefit to natural history but can provide marked relief in symptoms.
9
Q
Risk factors for idiopathic PD
A
None smokers
Genetics
Age
10
Q
What is the use of head imaging in suspected idiopathic parkinsons disease?
A
To look for differentials - alzheimers, stroke (vascular parkinsons), repeated head injury sequale,
11
Q
Classes of drugs used in parkinsons disease
A
Levodopa Dopa decarboxilase inhibitors Dopamine agonists MAOB inhibitors COMT inhibitors Anticholinergics
12
Q
What is levadopa commonly given with in PD? Short and long term side effects?
A
Dopa decarboxylase inhibitor eg carbidopa S/E: short term N+V Confusion Hallucinations S/E: long term Dyskinesia Dystonia
13
Q
Consequences of long term levodopa therapy
A
Resistance leading to:
End of dose deterioration
On/off freezing
14
Q
2 examples of a weak dopamine agonist used in PD? Use? Side effects?
A
Ropinirole, bromocriptine,
Can delay need for levodopa
S/E: nausea, hallucinations, compulsive behaviour
15
Q
What drug is best used in PD for drug induced dyskinesia in late disease? What is it?
A
Amantidine, a glutamate antagonist
16
Q
What can be used to even out end of dose deterioration in late PD or for off episodes? What class is it? How is it administered for each?
A
Apomorphine
Strong dopamine agonist
Administered by sc infusion for end of dose or as a rescue pen for off
17
Q
Example of a anticholinergic used in pd. What is it best for? Problems?
A
Benzhexol
Reduces tremor
Associated with confusion, dry mouth, dizzyness, urinary retention
18
Q
Example and use of a MAOB inhibitor in PD
S/E
A
Selegiline
Alternative to a dopamine agonist in early pd,
Postural hypotension, af
19
Q
Example and use of a comt inhibitor in pd. S/e
A
Entacapone
Lessen end of dose deterioration
Abdo pain, diarrheoa N+V
20
Q
Surgical methods of treating PD
A
Deep brain stimulation
21
Q
Rating scale for PD?
A
Hoehn and Yahr
1) unilateral and functionally normal
2) bilateral, able to balance normally
3) bilateral with impaired reflexes, physically independant
4) severe disease, able to walk and stand unassisted
5) confined to bed or wheelchair unless assisted
22
Q
Advice for pd patients
A
Cloths - avoid fiddly items e.g. use tshirts and velcro shoes
Chairs - use high and upright
Place rails around the house
Remove trip hazards e.g. rugs
23
Q
How to test for bradykinesia in suspected parkinsons
A
Ask to tap foot or touch thumb to index finger repeatedly - look for slowing or decreased amplitude.
24
Q
Distinguish the tremor of benign essential tremor from PD
A
Postural tremor (occurs in a certain position, eg. Grasping something)
No micrographia but shaky writing
Worse when anxious
Occurs at rest and on action
25
Managment of essentail tremor
Usually non but can consider
Propanolol
Mirtazapine
26
DDx of a tremor
Parkinsonism
Benign essential tremor
Functional
Asterixis - hepatic or co2 retention
27
Things to examine in PD and why.
| I would then ...
```
Gait - characteristic
Eye movements - psnp
Tremor and coordination - removed by movement?
Bradykinesia - characteristic
Tone - cogwheeling and lead pipe
```
I would then do:
Postural BP - msa
Handwriting - micrographia
28
Risk factors for MS
Family Hx
Northern or southern lattitudes (ie away from equator)
Female
29
General age of onset of ms
20-45 mean 30
30
The 4 presentation patterns of MS
Relapsing remitting
Primary progressive
Secondary progressive
Fulminating
31
The three areas of the cns effected by MS that lead to classic presentations
Optic nerve
Brainstem
Spinal cord
32
Effects of optic nerve demylination in ms
Optic neuropathy
Symptoms - blurred vision to blindness, mild eye pain, worse when hot
Signs - disc swelling (or not if lesion further back), relative afferent pupillary defect (pupil fixed and no contralateral response)
33
How long does ms optic neuropathy come on over? How long does it last?
Hours to days
| Several months
34
What is a long term sequale of optic neuropathy in ms?
```
Defects in colour vision or scotomata
Optic atrophy (pale optic disc)
```
35
If a demylinating lesion is futher back on the optic nerve in MS what is the effect on symptoms and examination
The patient sees nothing
| The doctor sees nothing
36
S+S of brainstem demyelination in MS
```
Diplopia, vertigo, facial numbness or weakness, dysarthria, dysphagia
Intranuclear opthalmoplegia (adducting eye lags behind abducting eye), nystagmus,
```
37
Differentiate vestibular neuronitis (labrinthitis) from a brainstem demylinating MS lesion
VN can cause deafness or tinnitus whereas MS does not
VN often follows URTI
MS causes gaze paresis such as intranuclear opthalmoplegia whilst VN does not
38
How do spinal cord lesions in ms present?
Spastic paraparesis
Numbness
Electric type pain down limb on flexion of neck
Urinary symptoms
39
How long does spastic paraparesis of spinal cord ms lesions typically come on over?
Days to weeks
40
Diagnostic test in ms? Precondition to diagnosis?
Mri
| Lesions disseminated in space and time with no other cause. Thus needs multiple episodes
41
Treatment of acute ms relapses?
Steroids
| Consider ivig and plasmapheresis
42
Long term treatment of ms (general)
Lifestyle - decrease stress
Beta interferon - expensive not license
Monoclonal antibodies eg alemtuzumab - not licenced
Immunosuppressants - limited evidence
43
Ms symptom management
```
Spasticity - baclofen, diazepam
Tremor - botulinum
Incontinence - anticholinergics
Swallowing - fluid thickeners
Depression - ssri
Pain - gabapentin, tcas
```
44
Who is typically effected by primary progressive ms. What typical symptoms
Middle aged men, bowel and bladder problems and difficulty walking
45
Term for single episode of suspected ms?
CIS - clinically isolated syndrome
46
If ms like lesions are detected on mri but the patient has never had symptoms what is this called?
RIS - radiologically isolated syndrome
47
Some ddx for ms
Lupus
Sarcoidosis
Lymes disease
Brain tumour
48
Causes of parkinsonism
```
Idiopathic parkinsons disease
Parkinsonism +
Drug induced
Post encephalopathy
Post repeated head trauma (e.g. Boxer)
Wilsons disease
HIV
```
52
What is a stroke?
A sudden onset focal neurological deficit attributable to a neurovascular cause
53
Why do some people assume that a stroke on waking occurred at the moment of waking?
Surge in hormones raises risk at waking far more than when asleep
54
What is the typical pattern of stroke paralysis?
Hemiparesis effecting all muscles proximal to distal and the face
55
How does an acute stroke progress in the hours following onset?
Persists or improves. Doesnt tend to worsen
56
risk factors for stroke
Age, male, fhx (young)
Htn, af, antiphospholipid syndrome, diabetes
Smoking, obesity, sedentary style, drugs (esp cocaine)
Hiv, hepititis
57
How will tone and reflexes present acutely in a stroke?
Reduced. Only become increased later. Planters upgoing throughout though.
58
How can a cve with blockage of the basiler artery present?
Cerebellar stroke - ataxia, slurred speech, vertigo, N+V, ipsilateral reduced coordination
Brainstem stroke - usually dead, autonomic instability, crossed neurology (ipsilateral facial weakness with contralateral arm weakness for example), cranial nerve palsy
59
How can a stroke of the pca present?
Occipital - homonymous hemianopia
| Temporal - hearing, language, memory, quadrantanopia
60
How can strokes of the mca present?
Parietal - motor, reading, writing recognition, inattention, quadrantianopias, dressing dyspraxia (non-dominanant hemisphere), sensation
61
What territories of stroke cause weakness in the legs? Why?
ACA - frontal lobe - area for leg motor in primary motor cortex
MCA - parietal - neurones for leg motor pass through
Basilar - brainstem - corticospinal tract
62
What area of vision is spared in a pca infarction? Why?
Macula - area supplied by branch of the mca
63
Symptoms of an ACA stroke
ACA - frontal lobe - hemiparesis, personality, memory problems, continence
64
What would occur with a transient occlusion of the retinal artery? Medical name and description.
Amaurosis fugax
| Sudden transient monocular blindness
65
Sources of ischemic stroke?
Thrombotic - in situ
| Emoblitic - carotid artery, AF, arch of the aorta, PFO
66
Subclassifications of haemorrhagic stroke
Primary - hypertensive, iatrogenic (e.g anticoagulation)
| Secondary - aneurysm, AV malformation, tumour
67
How are types of stroke sub classifed by symptoms (name of scale and description)
Bamford scale
TACS - total anterior - all of unilateral weakness, hemianopia, higher dysfunction.
PACS - partial anterior - 2/3 of above OR higher cerebral dysfunction OR monoparesis (e.g. Isolated clumsy hand)
LACS - lacunar anterior - one of unilateral weakness, ataxic hemiparesis pure sensory
POCS - posterior - one of loss of consciousness, cerebellar or brainstem syndromes, isolated homonymous hemianopia
68
What sort of thrombotic event is most likely to have caused each of the bamford scale?
TACS - emboli from af or aorta - large vessels
PACS - emboli from carotids
LACS - thrombus - small vessel
POCS - thrombus or emboli
69
How is stroke clinically diagnosed in ED?
Rosier scale
+1 each for unilateral arm leg face weakness or visual field defect or speech disturbance
-1 for unconscious or seizure
Stroke unlikely if score =/<0
70
How is severity of stroke assessed?
NIHSS score
71
On the bamford scale which subtype of stroke has the best prognosis? Which has the worst?
Best LACS
| Worst TACS
72
A patient has suffered a TACS and is not independent at 1 month. What proportion will improve to independent by 12 months?
Essentially none.
73
Why does the bamford scale rank more deaths from TACS than POCS?
Most POCS are dead prior to hospital.
74
How can level of independance/dependance be monitored post stroke?
Barthel index
| Rankin score
75
A suspected stroke arrives in ED, what immediate investigations are you going to perform/order?
BM
ECG
Bloods - FBC, U+E, clotting
CT head
76
Justify a fbc taken in acute stroke
Hb prior to aspirin
| Plts prior to thrombolysis
77
What bloods would you want to order in a stroke a little later?
Lipids, lfts, tfts
78
Timing and symptom severity for stroke thrombolysis
<4.5 hrs from onset though can be considered up to 6
| Technically any level of disability
79
Contraindications to stroke thrombolysis
```
Untreated hypoglycaemia
Seizure at onset
Uncertain time of onset or >4.5 hrs
Arterial puncture in 7 days at non compressible site
NOAC or warfarin with INR >1.7
Intercranial haemorrhage
Stroke in past 3 months
Uncontrolled HTN (>185/110)
Known av malformation or neoplasm in brain
Known bleeding disorder
Resolving stroke
Surgery or major trauma in last 14 days
Pregnancy
Recent lumbar puncture
```
80
What medications should a stroke patient be started on if not undergoing thrombolysis? How does this change if they are?
Aspirin 300mg for 2 weeks (delay by 24 hrs if thrombolised)
Switch to clopidogrel 75mg lifelong
Atorvastatin 20-80mg lifelong
81
What medication is used to thrombolyse strokes
Alteplase
82
What gold standard treatment is emerging for stroke
Embolectomy
83
What treatment should be administered to a haemorrhagic stroke?
Anticoagulation reversal
Blood pressure control
Neurosurgical review
Supportive care
84
If thrombolysis is administered at <3 hrs what is the NNT and NNH
NNT 3
| NNH 20
85
Why might you be less agressive with bm management with a stroke than with an mi
They are likley to be nbm so more at risk of hypos
86
Complications of stroke
Disabity, incontinance, pain, aspiration, infections, seizure, depression, spacticity, contractures, siadh, malnutrition, dvt, death
87
If a patient has a seizure post stroke <24 hrs what is the rule for driving? What if it was 48 hrs
<24 hrs follow standard stroke guidance
| If >24 hrs follow epilepsy guidance
88
What tias must go straight to hospital?
On anticoagulants
| Crescendo tias
89
How are tias graded?
Abcd2 score
AGE >60 +1
BLOOD PRESSURE >140/90 +1
CLINICAL unilateral weakness +2 speech +1
DURATION 10-60mins +1 >60 mins +2
DIABETIC +1
0-3 low risk, 4-5 mod risk, 6-7 high risk
90
What management for a tia?
300mg aspirin +/- statin
Refer to tia clinic
Dont drive
91
Typical pretension of myasthenia gravis?
Fatiguable eye signs and bulbar signs
92
Eye signs of myasthenia gravis and how to test for?
Ptosis - worsens with 60s upgaze, eases with eyes closed or with ice pack.
93
Bulbar symptoms of myasthenia gravis?
Dysphonia, dysarthria, dysphagia
94
Other than bulbar and eye signs and symptoms what else can myasthenia cause?
Proximal limb weakness
| Respiratory muscle weakness
95
What sort of muscle signs would you find on examination of myasthenia gravis
Lmns
96
What ages and sex are at risk of myasthenia gravis?
20s-30s mainly female 60s-80s mainly male
97
How can myasthenia gravis be diagnosed?
Autoantibodies
Tensilon test (give ACHase inhibitor and monitor change in symptoms)
EMG with fatigability
98
What workup would be needed in a confirmed myasthenia gravis? Why?
CT chest to look at thymus
| Large number of thymus hyperplasia and risk of thymus tumours
99
What major syndromes complicate myasthenia gravis
```
Myasthenic crisis
Cholinergic crisis (from treatment)
```
100
What can trigger myasthenic crisis?
Stress, medications, pregnancy, menses, illness, trauma, surgery
101
Problems in a myasthenic crisis?
Respiratory compromise
Aspiration pneumonia
DVT
102
How to monitor for respiratory compromise myasthenic crisis?
FVC monitor
If not available ask to count seconds in one breath - should be 20s
NOT peak flow or SpO2
103
Symptoms of cholinergic crisis?
```
Salivation
Sweating
Lacrimation
Urinary incontinance
Deification
Gastric hypermobility
Emesis
```
Bradycardia, myosis
104
Management of myasthenia gravis
```
ACHase inhibitor - neostigmine, pyridostigmine
Steroids
Azothioprine
Ivig
Plasmapheresis
```
105
How should steroids be administered in myasthenia gravis
Start low and build - high dose can trigger crisis
106
Main ddx of myasthenia gravis. Name. Pathology. Big difference.
Other ddx
Lambert eaton
Decreased ach secreation presynapticly
Not fatigable -actually strengthens
Botulism
107
Natural history of guillian barre syndrome?
Infection followed by rapidly ascending polyneuritis several weeks later peaking at 4 weeks then declining again over months.
108
What infection does GBS typically follow
Capylobacter
109
There are different subtypes of GBS. What is the practical significance of one of the rare ones?
Leads to autonomic instibility thus gbs patients should be monitored
110
What is the pathological mechanism of gbs?
Crossed antigenicity of immune system from infection to myelin sheath resulting in peripheral demylination
111
How should gbs patients be motored for impending respiratory failure
Handheld fvc
| Counting seconds in one breath
112
Other than limb paralysis what other symptom is typical in gbs?
Back painf
Paraesthesia and mild sensory impairment
Bulbar involvment - eg blurred vision or dysphagia
113
Typical features of gbs paralysis
Symmetrical lmns with loss of reflexes
Ascending
Proximal to distal
114
What proportion of gbs patients need ventilation? How many are fully recoved by 1 year? How many die?
25%
70%
5%
115
Complications of gbs?
```
Respiratory failure
Dvt
Autonomic instability
Siadh
Hypercalcaemia
Renal dysfunction due to tx
```
116
Treatment of gbs?
Symptomatic
| If severe ivig or plasmapheresis
117
What happens if gbs keeps worsening post 4 weeks?
Not gbs, another similar condition, will probably be progressive and only relapse temporarily with treatment
118
What condition causes a bulbar followed by a symmetrical decending weakness of the limbs and resp muscles accompanied by fever, N+V and parasympathetic dysfunction? Treatment?
Botulism
Antitoxins
Acetylcholine agonist
119
Long term tia treatments
Aspirin and dipyridamole (or clopidogrel if aspirin intolerant)
Consider statin
Control bp
Stop smoking
120
In clinic what are the indications for various investigations
Carotid imaging if patient a candidate for intervention
| MRI if pathology or vascular territory uncertain
121
A total MCA stroke to which side is more likely to cause dysphasia? What is a complication of a stroke on the opposite side to this?
Left
| Unilateral neglect of contralateral space
122
What are the effects of an MCA branch occlusion to the areas supplying brocas and wernicks areas?
Brocas - expressive dysphasia
| Wernicks - receptive dysphasia
123
What is used for blood pressure control in an acute stroke awaiting thrombolysis with bp >185?
Labetolol
124
Post thrombolysis or in a stroke not awaiting thrombolysis what is used to control bp in very severe (diastolic >140) cases?
Sodium nitroprusside
125
Early signs of acute ischemic stroke on ct scan
Insular ribbon sign
Obscuration of lentiform nucleus
Hyperdense artery sign
126
How do you describe a darkening or lightening on a. Ct scan
Hypoattenuation
| Hyperattenuation
127
What colour does blood appear on a ct?
Acute - hyperdense
| Old - hypodense
128
How is a sah diagnosed? Pitfalls?
Ct - can be negative, especially after 6hrs as blood mixes with csf
Lp - can only do after 12 hours as looking for xanthochromia
129
Initial management of sah
Analgesia to decrease stress
Antiemetics
Nimodipine to decrease vasospasm
D/w neurosurgery
130
What is a possible cause of a patient presenting with neck pain and focal neurology post a minor rtc?
Carotid or vertebral artery dissecton
131
What predisposes a patient to central venous thrombosis
Female
| Dehydration (labour!)
132
Presentation of central venous thrombosis
Diffuse headache, drowsy, seizure, low visual acuity
133
How would a patient with trigeminal neuralgia present?
Electric type pain
| Normal neuro exam!
