Neurology Flashcards
Cerebellar signs (DANISH)
Effects: DANISH x Dysdiadochokinesia x Dysmetria: past-pointing x Ataxia: limb / trunkal x Nystagmus: horizontal = ipsilateral hemisphere x Intention tremor x Speech: slurred, staccato, scanning dysarthria x Hypotonia
Cerebellar dysfunction causes (PASTRIES)
Common Causes: PASTRIES x Paraneoplastic: e.g. from bronchial Ca x Alcohol: thiamine and B12 deficiency x Sclerosis x Tumor: e.g. CPA lesion x Rare: MSA, Friedrich’s, Ataxia Telangiectasia x Iatrogenic: phenytoin x Endo: hypothyroidism x Stroke: vertebrobasilar
ACA infarct signs
Anterior Cerebral Artery
x Supplies frontal and medial part of cerebrum
x Contralateral motor / sensory loss in the legs > arms
x Face is spared
x Abulia (pathological laziness)
MCA infarct signs
Middle Cerebral Artery
x Supplies lateral / external part of hemisphere
x Contralateral motor / sensory loss in face and arms >
legs.
x Contralateral homonymous hemianopia due to
involvement of optic radiation
x Cognitive changes
Dominant (L): aphasia
Non-dominant (R): neglect, apraxia
PCA infarct signs
Posterior Cerebral Artery
x Supplies occipital lobe
x Contralateral homonymous hemianopia c¯ macula
sparing.
Vertebrobasilar system infarct signs
Vertebrobasilar Circulation x Supplies cerebellum, brainstem and occipital lobes x Combination of symptoms Visual: hemianopia, cortical blindness Cerebellar: DANISH CN lesions Hemi- / quadriplegia Uni- / bi-lateral sensory symptoms
Causes of Blackouts (CRASH)
Cardiac - Brady/Tachy/LVF/AS/HOCM/PE/Stoke-Adams attack
Reflexes -Vagal overactivity/ postural HypoTN
Arterial - Stroke/TIA, Subclavian Steal, shock,HTN
Systemic - hypoglyc, hypoxia, hypercapnia, anaemia
Head - epilepsy, drop attacks
Ix in blackouts
x ECG ± 24hr ECG x U+E, FBC, Glucose x Tilt table x EEG, sleep EEG x Echo, CT, MRI brain
Definition postural hypotension
Postural hypotension: difference of >20/10 after
standing for 3min vs. lying down
Resting tremor
Features
4-6Hz, pill-rolling
Abolished on voluntary movement
↑ c¯ distraction (e.g. counting backwards)
x Causes: Parkinsonism
x Rx: Da agonists, antimuscarinic (e.g. procyclidine)
Action/postural tremor
Features
6-12Hz
Absent at rest
Worse c¯ outstretched hands or movement
Equally bad at all stages of movement
x Causes: BEATS
Benign essential tremor
Endocrine: thyroxicosis, ↓glucose, phaeo
Alcohol withdrawal (or caffeine, opioids…)
Toxins: β-agonists, theophylline, valproate, PHE
Sympathetic: physiological tremor may be
enhanced: e.g. in anxiety
Intention Tremor
x Features >6Hz, irregular, large amplitude Worse at end of movement E.g. past-pointing x Causes: cerebellar damage
Benign essential tremor
Autosomal dominant x Occur c¯ action and worse c¯ anxiety, emotion, caffeine x Arms, neck, voice x Doesn’t occur during sleep x Better c¯ EtOH
Acute Dystonia
Torticollis, trismus and/or occulogyric crisis x Typically a drug reaction: Neuroleptics Metoclopramide L-DOPA x Rx: procyclidine (antimuscarinic)
Chorea
Non-rhythmic, purposeless, jerky, flitting movements
x E.g. facial grimacing, flexing / extending the fingers
x Causes
Huntington’s
Sydenham’s
Wilson’s
L-DOPA
Athetosis
Slow, sinuous, writhing movements
x Causes
Cerebral palsy
Kernitcterus
Hemiballismus
Large amplitude, flinging hemichorea
x Contralateral to a vascular lesion in the subthalamic
nucleus: often elderly diabetics
x Recovers spontaneously over months
Reversible causes of Dementia
Infection x Viral: HIV, HSV, PML x Helminth: cysticercosis, toxo Vascular x Chronic subdural haematoma Inflammation x SLE x Sarcoid Neoplasia Nutritional x Thiamine deficiency x B12 and folate deficiency x Pellagra (B3 / niacin deficiency) Hypothyroid Hypoadrenalism Hypercalcaemia Hydrocephalus (normal pressure)
Biceps reflex
C5-6
Knee reflex
L3-4
Triceps reflex
C7-8
Ankle reflex
S1-2
Anti emetic in parkinsons
Domperidone - doesn’t cross the BBB
Lacunar infarct
involves perforating arteries around the internal capsule, thalamus and basal ganglia
presents with 1 of the following:
1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
2. pure sensory stroke.
3. ataxic hemiparesis
Lateral medullary syndrome
(posterior inferior cerebellar artery)
aka Wallenberg’s syndrome
ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner’s
contralateral: limb sensory loss
Weber’s syndrome
ipsilateral III palsy
contralateral weakness
Erbs palsy
Brachial trunks C5-6.
Pronated and medially rotated arm - waiters tip
Klumpke’s palsy
Brachial trunks C8-T1. Classically there is weakness of the hand intrinsic muscles. Involvement of T1 may cause a Horner’s syndrome. It occurs as a result of traction injuries or during delivery.
Pseudoseizures
Phenomenon that can mimic true seizures but generally have findings which are not entirely consistent with a seizure. They are often psychiatric in origin, but it is important to note that while not involuntary, they are usually not deliberate; the movement is compulsive and unwanted. The ability to control the location of symptoms is very typical of a pseudoseizure and does not fit with any of the other options presented
Widespread convulsions without conscious impairment is likely to represent a pseudoseizure
Optic neuritis
Blurred vision and painful movements of one eye
Essential tremor Rx
Improved with propanolol and alcohol
Reasons to start anti-epileptics after first seizure
- the patient has a neurological deficit
- brain imaging shows a structural abnormality
- the EEG shows unequivocal epileptic activity
- the patient or their family or carers consider the risk of having a further seizure unacceptable
stopping AEDS
can be considered if seizure free for >2y, with AEDS being withdrawn over 2-3y
cataplexy
sudden and transient loss of muscular tone caused by strong emotion (e.g. laughter, being frightened)
Medical Rx Trigeminal Neuralgia
carbamazepine
Cardinal features of Parkinsons
Bradykinesia and 2 of the following
- postural instability
- rigidity
- resting tremor
