Neurology Flashcards
1
Q
WHAT IS A TRANSIENT ISCHAEMIC ATTACK?
A
Blood flow to part of the brain TEMPORARILY stops
Lasts for less than 24 HOURS
NO lasting damage
Usually caused by emboli
2
Q
What are the risk factors for TIAs?
A
Non-modifiable risk factors
Age
Sex
Family history
Race/ethnicity
Modifiable risk factors
Smoking
Hypertension
Diabetes
Hyperlipidemia
Activity level
3
Q
What are the causes of TIAS?
A
Thromboembolism
From carotid
Cardioembolism
Post-MI or AF
Hyperviscosity
Polycythaemia,
4
Q
What are the signs and symptoms of a TIA?
A
Mimic a stroke in the same vessel
5
Q
What are the tests for TIAs?
A
Carotid Doppler
Angiography
Fundoscopy (amaurosis fugax)
Listen for carotid bruits because of atherosclerosis
Aim to find the cause and define vascular risk
FBC + prothromibin (test for bleeding/hypercoaguable conditions)
ESR
U&Es
Glucose (if low could cause altered mental state)
lipids (risk for atherosclerotic disease)
6
Q
What is the treatment for TIAs?
A
-
Reduce risk factors
Blood pressure/diabetes/cholesterol -
Antiplatelet drugs
Clopidogrel or aspirin - Warfarin/DOAC (if cardiac emboli)
- Carotid endarterectomy (if >70% stenosis)
7
Q
What is the ABCD2 scale?
What are the values?
A
Scale to determine risk of having a future stroke. 2/7 days
Age ≥60 yrs old 1 point
Blood pressure ≥140/90 1 point
Clinical features
Unilateral weakness 2 points
Speech disturbance without weakness 1 point
Duration of symptoms
Symptoms lasting ≥1h 2 points
Symptoms lasting 10–59min 1 point
Diabetes 1 point
8
Q
What does the scores indicate in ABCD2?
A
More than 6 strongly predicts a stroke
More than 4 should be seen by a specialist in 24 hours
9
Q
WHAT IS AMAUROSIS FUGAX?
A
Painless progressive loss of vision in one or two eyes
“like a curtain descending over my field of view”
10
Q
What causes amaurosis fugax?
A
Emboli passing into the retinal artery
11
Q
What are the tests for amaurosis fugax?
A
Ultrasound
MRI and CT
Fundoscopy
12
Q
What is the treatment for amaurosis fugax?
A
- Atherscleoric lesion = ASPIRIN or CLOPIDOGREL
- Cartoid atherscleosis = Carotid endarterectomy
- Cadiac cause = warfarin/correct AF
13
Q
WHICH IS THE MORE COMMON STROKE?
A
ischamemic
14
Q
WHAT IS AN ISCHAEMIC STROKE?
A
Interupption of the blood supply to the brain
15
Q
What causes ischaemic stroke?
A
- Thromobsis
- Embolism
- Systemic hypoperfusion
- Cerebral venous sinus thrombosis
16
Q
What are the signs and symptoms of a stroke?
A
Depends on location of the stroke
Symptoms affected the contralateral side of the brain area
Cerebral (contralateral sensory loss or hemiplegia—initially flaccid)
Brainstem (quadriplegia, dis- turbances of gaze and vision, locked-in syndrome)
Lacunar (ataxic hemiparesis, pure motor, pure sensory, sensorimotor, and dysarthria/clumsy hand)
17
Q
What are the investigations for a stroke?
A
Clinical examination - NIHSS (national institues of health stroke scale)
-
Risk factors
Hypertension -
Cardiac cause
Echo/ECG -
Carotid
Ultrasound/bruits
CT/MRI/Angiography
18
Q
What is the treatment for an ischaemic stroke?
A
1st line: Thrombolysis
IV alteplase
2nd line: Antiplatelets
Aspirin for 2 weeks then Clopidogrel 75mg OD
Stroke therapy long term
S+L
Physio
OT
19
Q
When must thombolysis be given in stoke and what are the contraindications?
A
Less than 4.5 hours
Surgery in last 3months
Pt. on warfarin
Hx of active malignancy
Platelets <100,000/mm3
20
Q
WHAT IS A HEMORRHAGIC STROKE?
A
Rupture of a blood vessel or abnormal vascular structure
21
Q
What are the different types of hemorrhagic strokes?
A
Intracerebral hemorrhage
Subarachnoid hemorrhage
22
Q
What are the causes of haemorrhagic strokes?
A
- Hypertensive haemorrhage
- Ruptured aneurysm
- Ruptured AV fistula
- Drug induced bleeding
23
Q
What are the signs and symptoms of a stroke?
A
Depends on location of the stroke
Symptoms affected the contralateral side of the brain area
Cerebral (contralateral sensory loss or hemiplegia—initially flaccid)
Brainstem (quadriplegia, dis- turbances of gaze and vision, locked-in syndrome)
Lacunar (ataxic hemiparesis, pure motor, pure sensory, sensorimotor, and dysarthria/clumsy hand)
24
Q
What are the investigations for a stroke?
A
Clinical examination - NIHSS (national institues of health stroke scale)
-
Risk factors
Hypertension -
Cardiac cause
Echo/ECG -
Carotid
Ultrasound/bruits
CT/MRI/Angiography
25
What is the treatment for a haemorrhagic stroke?
- _Control BP_
B-blocker
- Beriplex if warfarin-related bleed
- Clot evacuation
26
How do you distinguish between a haemorrhagic and ischaemic stroke?
CT head
27
WHAT ARE THE DIFFERENT INTER-CRANIAL HAEMORRHAGE?
Extradural haemorrhage
Subdural haemorrhage
Subarachnoid haemorrhage
Intracerebral haemorrhage
28
WHAT ARE SOME EXAMPLES OF INTRACEREBRAL HAEMORRHAGE?
Lobar haemorrhage
Thalamic haemorrhage
Pontine haemorrhage
Cerebellar haemorrhage
29
What are the different layers of the meninges?
Dura, usually firmly adherent to the inside of the skull
Arachnoid, more adherent to the brain
Pia, on the surface of the brain and cannot be separated from the brain
30
Where are the meningeal vessels? What veins cross the subdural space?
Meningeal vessels are in the Extradural space
Bridging veins cross the subdural space
31
In which space does the circle of willis lie?
The circle of Willis lies in the subarachnoid space
32
Are there any blood vessels below the pia?
There are no vessels deep to the Pia, the Pia forms part of the blood brain barrier
33
WHAT IS A SUBARACHNOID HAEMORRHAGE?
Rupture of the arteries forming the circle of Willis
Often because of ‘Berry aneurysms’
34
What are the causes of subarachnoid haemorrhages?
Trauma
Berry aneurysm
Arteriovenous malformations
Idiopathic
35
What are the signs and symptoms of a subarchanoid haemorrhage?
What is the headache called which they call a warning sign of a leaky vessel?
Sudden onset severe headache (‘Thunderclap headache’)
Photophobia
Reduced consciousness
Vomiting
Collapse
Seizures
Kernig's sign
Terson syndrome (retinal, subhyaloid and vitreous bleeds)
3rd oculomotor palsy (posterior communicating artery)
Sentinel headache
36
What are the investigations for a subarchanoid haemorrhage?
**_CT_**
Spider sign
**_LP_**
CSF bloody early
Becomes xanthochromic (yellow), breakdown of haem to bilibrubin
**_Angio_**
To determine location
37
What is the treatment for subarchanoid haemorrhage?
Neurosurgery!!!!
Keep blood pressure low
Keep hydrated and nutrition
Nimodipine (recued vasospasm)
If anneurysm deteced either coil or clipping.
38
WHAT IS A SUBDURAL HAEMORRHAGE?
Bleeding between the dura on the skull and the arachnoid layer
39
What is the cause of subdural haemorrhages?
Where is the bleeding from? Who is it most common in?
Trauma
Bleeding from bridging veins
Commonest where the patient has a small brain (alcoholics, dementia)
Occurs in ‘shaken babies’
**_GRADUAL_**
Gradual rise in ICP over many weeks
40
What are the symptoms of a subdural haemorrhage?
**_Fluctuating level of consciousness_**
Slow physical or intellectual slowing
Sleepiness
Headache
Personality change, and unsteadiness.
Neurological symptoms happen later
41
What investigations can you do for a subdural haemorrhage?
CT/MRI shows clot ± midline shift
Look for crescent-shaped collection of blood over 1 hemisphere.
42
What is the treatment for a subdural haemorrhage?
Evacuation 1st-line
Craniotomy is 2nd-line
43
Where does bleeding occur in subdural haemorrhage?
Between arachnoid and dura
44
WHAT IS AN EXTRADURAL HAEMORRHAGE?
Bleed between skull and dura membrane
45
How is an extradural haemorrhage caused? What artery bleeds in extradural?
Traumatic
Fractured skull
Bleeding from Middle meningeal artery and vein
Also dural venous sinus
46
What normally happens to the pressure during an extradural bleed?
What period is seen?
Rapid rise in inter-cranial pressure (ICP)
Conscious level falls or is slow to improve
Lucid period
Coning and death if not treated
47
What symptoms does an extradural haemorrhage show?
Increasingly severe headache
Vomiting
Confusion, and fits follow
Brainstem compression later on
48
What investigations for an extradural haemorrhage can you do?
**_CT_**
Haematoma
Often biconvex/lens-shaped
**_X-ray_**
Fractures
49
How can you treat a extradural haemorrhage?
Clot evacuation ± ligation of the bleeding vessel.
Care of the airway in an unconscious patient
50
What is the difference in CT shape for extradural and subdural haemorrhage?
Biconvex/lens-shaped in extradural
the blood forms a more rounded shape
Compared with the sickle-shaped
Subdural haematoma as the tough dural attachments to the skull keep it more localized
51
WHAT IS EPILEPSY?
https://www.youtube.com/watch?v=L0XqL2I35n8
Seizure diorder
Recurrent and unpredictable seizures
52
What is the definition of an epileptic seizure?
Paroxysmal event
Caused by excessive, hypersynchronous neuronal discharges
Behaviour, sensation or cognitive processes change
53
What is the treatment of focal epilepsy?
How do they work?
Carbamazepine (inhibits Na+ channels)
Lamotrigine (inhibits glutamate release)
54
What is the first line of therapy for generalised epilepsy?
Sodium Valproate
Lamotrigine
55
What is the main excitatory transmittor in the brain? What is the receptor for it?
Glutamate
NMDA
56
What are the patinet only signs of a seizure?
Fear
Certain smells
57
What is the main inhibitory transmittor in the brain? What is the receptor?
GABA
GABA receptors
58
What are the outward signs of a seizure?
Jerking
Moving
Losing consciousness
59
What is it called when a seizure starts focal and becomes generalised?
Focal onset bilateral tonic-clonic
60
What is it called when both hemispheres of the brain are affected?
**_Generalised_**
Can start as focal and become generalised
61
What is a jacksonian march?
Which lobe is this most common in?
When jerky movements affect one area then move to other areas
Most common in frontal lobe
62
What are the focal seizures divided into?
_**Simple partial
Without impaired awareness**_
Small area
Strange sensation - hearing or tasting
Jerky movements
Awake and alert
_**Complex partial
With impaired awareness**_
Loss of awareness
May not remember
63
What is it called when the effect of a seizure is limited to one hemisphere or single lobe
Focal or partial seizure
64
What is the treatment of a staticus epilepticus?
Open + maintain airway
Community - Diazepam
Hospital - Lorazepam
Give phenytoin if seizures continue
65
What is a seizure called if it lasts longer than 5 minutes ongoing or without returning to normal?
What type of seizure is it normally?
Status epilepticus
Usually tonic-clonic
MEDICAL EMERGENCY
66
What are generalised seizures divided into?
**_Tonic_**
Muscles stiff and flexed
Fall backward
**_Atonic_**
Suddenly relaxed muscles
Fall forward
**_Clonic_**
Violent muscle contractions
Convulsions
**_Tonic-Clonic_**
**_Myoclonic_**
Short muscle twitches
**_Absence_**
Spaced out, unresponsive
67
What are the different parts of seizure?
Prodrome
Aura
Ictal symptoms
Post-ictal symptoms
Prodrome= mood/behaviour change
Aura = part of seizure patient is aware of
Ictal symptoms = dependent on part of brain affected
Post-ictal symptoms = headache, confusion, amnesia, etc.
68
Where do complex partial seizures always start?
Temporal lobe
69
WHAT IS PARKINSON'S?
Movement disorder where the dopamine producing neurons in the substantia nigra of the brain die
70
What is the cause of parkinson's?
Usually no known cause
**_Sometimes_**
Genetic with environment
71
What are the direct and indirect pathways?
_Control movement_
Direct = movement
Indirect = no movement
_Direct_
Striatum
Global pallidus interna
Substantia nigra pars reticularis
Thalamus
_Indirect_
Striatum
Global pallidus externa
Subthalamic nucleus
https://www.youtube.com/watch?v=NcIWYCkKwVA
72
What happens in parkinson's to the substantia nigra?
What do the remaining neurons contain?
Blackened areas gradually disappear
**_These form_**
Lewy bodies containing alpha-synuclein protein
Present in the dopamine neurons before they die
73
What are the signs and symptoms of parkinsons?
Resting tremor (Pill roll)
Rigidity (cog-wheel)
Bradykinesia
Postural instability
Also non motor symptoms (dementia)
**_NO WEAKNESS_**
74
What are the investigations for parkinsons?
Medical history and examination
Give levodopa and improvement in symptoms helps with diagnosis
MRI and CT to rule out other causes
75
What is the management for Parkinson's?
**_Increase dopamine_**
_Co-careldopa_
L-DOPA (levodopa) + carbidopa
_Dopamine receptor agonists_
Ropinirole
_**Decrease dopamine breakdown**
MAO-B inhibitor_
Selegiline
_COMT inhibitor_
Entacapone
**_Motor symptom treatment_**
Amantadine and anticholingergics
**_Surgery_**
Deep brain stimulation
76
How does levodopa work?
Levodopa crosses blood brain barrier
Converted to dopamine
By dopa decarboxylase
Within nigrostriatal neurons
77
What does the no weakness of parkinson's tell you?
Not a disease of motor cortex or corticospinal pathway diseases
78
What does the resting tremor of parkinson's tell you?
Not a cerebellar disase
As would be action or intention tremor
79
WHAT IS HUNTINGTON'S DISEASE?
Cell loss within a specific set of neurons in the basal ganglia and cortex
80
What is the cause of HD?
What does it cause the death of and where?
Autosomal dominant
CAG repeated sequece of DNA
Abnormal protein produced
Death of GABA (inhibitory) neurons particularly
Striatum
81
What gene is involved with what is the code?
How many is need for HD?
Huntingtin gene
Contains triplet repeat CAG
Normal person has 10-35
HD has \>36
82
What is anticipation?
What does more repeats mean?
When is anticipation more likely?
CAG repeats increase with generations.
More repeats means an earlier onset.
Anticipation more likely if parent affected is the father.
83
What are the symptoms of HD?
When is the normal onset?
Chorea
Psychiatric/behavioural changes
Cognitive decline and dementia
30-50
84
How can you treat HD?
**_Chorea_**
Sulpiramide
**_Agression_**
Risperidone
85
What are the diffential diagnosis of Huntington's?
Sydenham’s chorea
Benign hereditary chorea
Drug induced (e.g. L-DOPA)
Other dyskinesias
Other causes of dementia
86
What are the investigations for HD?
**_History_**
Confirm chorea
**_Imaging_**
Bicaudate diameter
**_Exclude differentials_**
**_Genetic testing_**
**_Histology_**
Identify huntington
87
WHAT IS A HEADACHE?
88
What are the different types of headache?
And give some examples for each?
**_Primary_**
Tension, cluster, migraine, sins
**_Secondary_**
Meningitis, encephalitis, GCA, medication overuse, venous thrombosis, tumour, SAH
**_Other_**
Trigeminal neuralgia
89
What are secondary headaches?
Red flag headaches
90
WHAT IS A MIGRAINE?
Recurrent headache associated
Visual & GI disturbance
91
What is the location of a migraine?
Unilateral
92
What are the features of a migraine?
How long does it last?
Gradual onset
Crescendo pattern
Moderate-severe intensity
Duration 4-72 hours
93
What are migraine's associated symptoms?
Nausea
Vomiting
Photophobia
Phonophobia
Aura - feeling something about to happen
94
What is the treatment for migraines?
Acute and prophylaxis?
**_Acute_**
Oraltriptan e.g. Sumatriptan
+ NSAID e.g. Ketoprofen
**_Prophylaxis_**
B-blocker e.g. Propanolol
95
What are the triggers of migraines?
Chocolate
Hangobers
Orgasms
Cheese
Oral contraceptives
Lie-ins
Alcohol
Tumult
Exercise
96
WHAT IS A TENSION HEADACHE?
More muscular
Most common reason why over the counter analgesics are bought
97
What is the location of a tension headache?
Bilateral eyebrow region
98
What is the character of tension headaches?
Pressure or tightness which waxes and wanes
Duration is variable
99
What are the associated symptoms which a tension headache?
None
100
WHAT ARE CLUSTER HEADACHES?
Hyperactivity to 5HT
101
Where is the pain in a cluster headache?
Rapid onset severe unilateral, orbital, supraorbital or temporal pain
102
What is the character of cluster headaches?
How long do they last?
Pain begins quickly, deep, continuous pain, excrusiating and explosive in quality
Duration 30 mins to 3 hours
103
What are the associated symptoms of cluster headaches?
Pain
Hornems
Ptosis
Drooping of eyelid
Miosis
Unable to dilate pupils
Lacrimation
Nasal discharge
104
What is the treatment for a cluster headache?
How can you prevent them?
100% oxygen
Sumatriptan
Verapimil
Lithium
105
WHAT IS GIANT CELLS VASCULITS?
Vascultis that affect the carotid artery
When they affect the temporal artery
They cause headaches
106
Who does giant cell arteries affect?
Older than 50 year olds
Women more than men
107
What does giant cell arteritis cause?
What does it lead to high amount in, in the blood?
Lots of inflammation
Leading to high ESR and CRP
108
What does a biopsy look like of an affected giant cell arteritis artery?
Giant cell infiltration of elastic lamina between tunica intima and media
109
What does segmental giant cell mean?
Only sections of the artery are affected
Could take out unaffected part of vessel
110
What are the treatments for giant cell arteritis?
Corticosteroids
111
What condition is GCA associated with?
POLYMYALGIA RHEUMATICA
112
What are the symptoms for GCA?
Headache
Scalp tenderness (egon combing hair)
Jaw claudication
Amaurosis fundax
113
What drugs do you need to prescribed with steroids?
PPI (gastric protection) & bisphosphonate(bone protection)
114
What does the trigeminal nerve do?
Sensation to the face
Three branches
Opthalmic
Maxillary
Mandibular
115
What are sinus headaches?
Associated with sinusitis
116
WHAT IS TRIGEMINAL NEURALGIA?
| (this quesiton inside headaches)
117
What is the epidemology of trigeminal neuralgia?
Man
50-60
118
What is the treatment for trigeminal neuralgia?
1st line Carbamazapine
2nd line Lamotrigine, phenytoin or gabapentin
Surgery
119
What is the diagnosis of trigeminal neuralgia?
1. ≥3 attacks of unilateral facial pain
2. Pain in ≥1 division of trigeminal nerve with no radiation
3.Pain must have 3 of the following:
Paroxysmal attacks lasting from 1-180 seconds
Severe intensity
Electric shock-like/shooting/stabbing/sharp
Precipitated by innocuous stimuli to the affected side of the face (vibration, washing/shaving, brushing teeth, etc.)
4. No neurological deficit
120
What are the symptoms of trigeminal neuralgia?
Sudden severe pain
Sharp, stabbing, piercing
Comes and goes
More when chewing or mouth movemnts
121
What side of the face will be affected?
Only one side
122
WHAT IS CAUDA EQUINA SYNDROME?
Where is the damage?
Compression of nerve roots
Spinal damage distal to L1
123
What vertebrae are involved with cauda equina?
L4 and L5
124
What are the symptoms of cauda equina?
Foot drop
Numbness
Saddle anesthesia
Bladder and Bowel incontinence
125
What is the treatment for cauda equina?
Surgical decompression
126
What is the anatomy of the spine?
What happens in cauda equina?
Nucelus pulposus surrounded by annulus fibrosis
Herniates out and compresses spine
127
What are the tests for cauda equina syndrome?
MRI of spine
128
What is sciatica?
What are the symptoms
What is the treatment?
Sciatica = most common radiculopathy
Unilateral pain w/o neurological signs
Neuromedical (physio + NSAIDs)
129
What is a radiculopathy and what causes it?
What is the treatment?
Radiculopathy= NERVE ROOT gives LMN
Disc prolapse
Osetoarthrits
Conservative
130
What is a myelopathy and what causes it?
What is the treatment?
Myelopathy= CORD gives UMN
Oseophytes
Disc prolapse (slower onset)
Tumour (slow onset)
Surgical decompression
131
WHAT IS MULTIPLE SCLEROSIS?
https://www.youtube.com/watch?v=yzH8ul5PSZ8
Inflammatory, demyelinating disease.
Specific to the central nervous system.
Has relapsing and remitting symtptoms.
132
When does MS begin?
Between the ages of 20-40
133
What is the cause of MS?
**_Vit D deficiency_**
**_Genetics_**
Female
HLA DR2
**_Environment_**
Infections
134
What are the symptoms of MS?
What is the sign seen in MS?
Optic neuritis (impaired vision and eye pain)
Nystagmus, double vision and vertigo
Bladder and sexual dysfunction
Spasticity and other pyramidal signs
Sensory symptoms and signs
Lhermitte's sign (electric shock-like sensation that occurs on flexion of the neck.)
135
What is the diagnostic criteria for MS?
Two or more CNS lesions disseminated in time and space
Exclusion of conditions giving a similar clinical picture
136
What are the investigations for MS?
**_History_**
E.g. brief unexplained visual loss.
**_CSF_**
Oligoclonal bands of IgG
**_MRI_**
Plaques
**_Visual evoked potential_**
Measures nervous system response to visual stimuli
137
What is the treatment for MS?
How would you treat the symptoms?
E.g. tremor and spasticity?
**_Acute_**
Steroids = Methylprednisolone
**_Chronic_**
1st line = **_Beta Interferon_**, Glatirameracetate
2nd line = **_Natalizumab_**
**_Symptom management_**
Tremor = Beta blocker, Spasticity = Baclofen
Other drugs: Azathioprine may be as good as interferons for relapsing-remitting MS.
138
What are the differential diagnosis of MS?
SLE
Lyme disase
AIDS
139
What is the criteria for MS?
McDonald
140
What are the characterisitcs of fatigue specific to MS?
What is this phenomenom called?
Exacerbated by heat
Improved by cool temperatures
Called Uthoff's
141
What does all this destruction leave behind?
Fibrosis
Plaques or sclera
142
What happens in MS?
Pathology (Start with T cell)
What does this lead to?
T cell ligand on BBB wall
It then gets activated by myelin
Causes more expression of surface ligands on BBB
Also releases cytokines, vasodilation and damage to oligodendrocytes
B cells mark myelin, macrophages eat it
Regulatory T cells stop this eventually
Sensory, motor and cognitive problems
143
What type of hypersensitivity reaction is MS?
Type 4 (cell mediated)
144
What are the different types of MS?
Relapsing remmiting MS
Secondary progressive MS
Primary progressive MS
Progressive relapsing MS
145
What happens after an attack?
Myelin grows back
After times this stops
Axons then die
146
What is charcot's neurological triad?
What is it described in?
Dysarthria
Nystagmus
Intention tremor
MS
147
How is MG diagnosed?
**_Bedside test_**
Arm outstretched, count to 50
**_Antibodies_**
Anti-AChR antibodies increase in 90%
MuSK antibodies (muscle specific tyrosine kinase)
**_Neurophysiology_**
Decremental muscle response
**_Imaging_**
CT of thymus
148
What is the treatment for MG?
**_Acetylcholinesterase inhibitors_**
Pyridostigmine
**_Immunosupressive drugs_**
Prednisone
**_Surgical removal of thymus_**
Reduce helper T cells
149
What is a myesthemic crisis?
Life threatening part of the disease
Affect muscles of breathing
150
What is associated with MG in 10% of cases?
Thymic neoplasm
151
What do the B cells release?
| (Two antibodies)
**_Release IgG antibodies_**
Bind to the nicotinic receptors
Unable to bind acetylcholine
No contractions
Antibodies can also affect complement pathway
**_Muscle receptor specific tyrosine kinase antibodies_**
Attack inside cells
CAUSE INFLAMMATION
152
WHAT IS MYASTHENIA GRAVIS?
https://www.youtube.com/watch?v=bYGxGdu9MsQ
Autoimmune disease of acetylcholine receptors
153
What type of sensitivity reaction is MG?
Type 2
Cytotoxic injury
Damage or lysis to host cells
Medaited by autoantibodies
154
What is the epidemology of MG?
BIMODAL!!!!!
Women in 20-30s
Older men 60-70s
155
What are the symptoms of MG?
When do the symptoms get worse?
Muscle weakness
**_Ptosis_**
Drooping eyelid
**_Diplopia_**
Double vision
Towards the end of the day
156
WHAT IS MOTOR NEURON DISEASE?
Cluster of major degenerative diseases
Selective loss of neurons in motor cortex
Cranial nerve nuclei, and anterior horn cells
157
What are the lower motor neuron symptoms?
Hypo-reflexia
Hypo-tonia
Denervation atrophy
Babinski -ve
158
What are the upper motor neuron symptoms?
Hyper-reflexia
Hyper-tonia
Spasticity
Babinski +ve
159
What does ALS result loss of?
Motor neurons in motor cortex and the anterior horn of the cord
160
What is the most common type of MD?
What gene is affected?
ALS/amyotrophic lateral sclerosis
SOD-1 gene
161
How is MD different from myasthenia?
MND never affects eye movements
162
How is motor neuron different to MS and polyneuropathies?
No sensory loss or sphincter disturbance
163
What are the investigations for motor neuron?
**_Neurophysiology nerve conduction studies_**
Electromyography
**_Blood tests_**
Creatine Kinase
**_MRI head/spine_**
**_Lumbar puncture_**
Exclude differentials
164
What is the treatment of motor neuron disease?
**_Antiglutamatergic drugs_**
Riluzole
Slows progression
**_Baclofen, diazepam_**
Spasicity
**_Amitriptyline_**
Drooling
**_Pallative_**
Tracheostomy
165
What are the different onset of symptoms of ALS?
**_Limb onset_**
Dropped foot, awkwardness running
**_Bulbar onset - worse prognosis_**
Dysphagia
Slurred speech
Difficulty speaking
Progress to same symptoms
166
What are characteristic of motor neurons?
Fasciculations
167
What are the different types of motor neuron disease?
Do they do upper or motor neuron damage?
ALS (Amyotropic Lateral sclerosis) (Both)
Progressive bulbar Palsy
Progressive muscular atrophy (Only LMN)
Primary lateral sclerosis (Only UMN)
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WHAT IS GUILLAIN-BARRE SYNDROME?
Acute neuropathy
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What are the symptoms of GB syndrome?
Symmetrical
Rapid ascending paralysis and sensory deficits
Absent reflexes
NO WASTING
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What type of neuropathy is it?
Demyelinating
**_Two types_**
Axonal motor
Axonal sensorimotor
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What is the most likely cause of GB syndrome?
Infection
**_Campylobacter jejuni_**
2-4 weeks following GI or resp infection
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What is the treatment of GB?
**_Plasmaphoresis (plasma exchange)_**
**_IV - Ig_**
Clear debris
IV antibiotics
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What are the tests for guillain-Barre syndrome?
**_LP_**
High protein and low WBC in CSF
**_Nerve conduction studies_**
Slower conduction
**_Electromyography_**
Decreased muscle involvement
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WHAT ARE PERIPHERAL NEUROPATHIES?
Any disorder of the peripheral nervous system
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What are alpha delta and C fibers?
Aδ and C fibers are thin, considered as the small fibers.
Aδare myelinated and C unmyelinated.
Both transmit signals regarding pain and additionally
Aδsignals about cold sensation
C signals about warm sensation
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What type of fibres are A alpha and beta fibers, what do they transmit?
Aα and Aβ are the large myelinated fibers.
Αα are transmitting signals regarding proprioception
Aβ about light touch, pressure and vibration.
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Where can a peripheral neuropathy affect?
The receptors at the skin, to the peripheral nerve, to the spinal nerve or selectively affects the dorsal root ganglia where the cell bodies of the first sensory neuron are.
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What are the demyelinating neuropathies normally?
Genetic or inflammatory
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What can chronic neuropathies be further divided into?
Small fiber
**_Large fiber_**
Axonal or demyelinating
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What are the characteristics of acute neuropathies?
Evolve quickly and require prompt treatment
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What is an example of an acute neuropathy?
Guillain-Barre syndrome
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How can peripheral neuropathies be calssified?
Acute and chronic
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What is the pattern of nerve involvement called for symetical sensorimotor neuropathy? What nerves are involved first?
Length-dependent
Initially sensory, but eventually sensorimotor
| (longer fibers are affected first)
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What are the common causes of polyneuropothies?
**_DAVID_**
Diabetes
Alcohol
Vitamin deficiency (B12)
Infective (GB)
Drugs (isoniazid)
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What are the common mononeuropathies?
Carpal tunnel syndrome (median nerve)
Ulnar neuropathy (entrapment at thecubitaltunnel)
Peronealneuropathy (entrapment at the fibular head)
**_Cranial mononeuropathies(III or VII cranial nerve palsy)_**
idiopathic
immune mediated
ischemic
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How can you distinguish axonal neuropathies, what groups?
Symmetrical Sensorimotor
Asymmetrical Sensory
Asymmetrical Sensorimotor
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What are the two different types of neuropathy in terms of number of nerves?
Mononeuropathy: problem with one nerve
Polyneuropathy : problem with many nerves
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What is affected first in symetrical senori-motor neuropathies?
Initially with sensory symptoms affecting the
**_Toes and fingers_**
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What are the motor symptoms of neuropathies?
Muscle cramps
Weakness
Fasciculations–muscle twitches
Atrophy
**_High arched feet (pes cavus)_**
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What is ataxia?
Poor balance
Sensory (loss of proprioception) or cerebellar
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Asymetrical neuropathy is very uncommon but where is it more common?
Vasculitis
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What is asymetical sensorimotor also called?
Mononeuritis multiplex
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The asymetical sensory neuropathy is uncommon but where is it more commly found?
Paraneoplastic
Sjogren
Gluten sensitivity / CD
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What nerves are affected in asymetical sensory neuropathy?
Dorsal root ganglon exclusively
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What is the most common neuropathy?
Symetrical sensorimotor
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What would each type of neuropathy tell you in nerve conduction studies?
Demyelinating --\> slow conduction velocities
Axonal --\> reduced amplitudes of the potentials
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What are nerve conduction tests useful for?
Telling the type of neuropathy
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What are the first steps in diagnostic approach for peripheral neuropathies?
**_History_**
**_Clinical examination_**
Reduced or absent tendon reflexes
Sensory deficit
Weakness –muscle atrophies
**_Neurophysiological examination (i.e. NCS/QST)_**
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What are the causes of axonal peripheral neuropathies?
Associated with systemic diseases
Inflammatory–immune mediated (mainly acute)
Infectious (i.e. hepatitis, HIV, Lyme)
Ischemic (i.e. vasculitis)
Metabolic (i.e. Fabry’s, porphyria)
Hereditary (CMT, HLPP)
Toxins (pharmaceuticals, environmental toxins, B6)
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WHAT ARE SPINAL ROOT LESIONS?
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WHAT ARE CRANIAL NERVE LESIONS?
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WHAT IS CARPAL TUNNEL SYNDROME?
Compression of the median nerve in the carpal tunnel in wrist
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What is the treatment for carpal tunnel?
Behaviour modification
Physical therapy
Splinting
Corticosteroids
Surgery of ligament
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What are the tests for carpal tunnel?
Electrophysiological testing
Description of symptoms
**_Phalen's moneuver_**
Flex wrist down for 1 min - tingling
**_Tinel's sign_**
Tap nerve
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What are the risk factors for capal tunnel?
Typing
Obesity
Pregnancy
Rheumatoid
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What causes carpal tunnel syndrome?
Inflammation of nearby tendons and tissues
Causing oedema
Causing compression
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What are the symptoms of carpal tunnel syndrome?
Pain, numbness and tingling
Thumb
Index
Middle
RIng finger(thumb side)
Wasing of abductor policisbrevis and thenar eminence
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WHAT ARE THE COMMON PRESENTATIONS OF A BRAIN TUMOUR?
Why do these occur?
Headache, worse in morning
N+V
Seizures, focal neurological deficits
**_Papiloedema_**
Symptoms of a raised ICP
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What is the treatment of a brain tumour?
Oral steroids (dex) can help to relieve symptoms
Surgery
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When are the features of raised ICP worse and better?
Worst on waking from sleep in the morning.
Increased by coughing, straining, and bending forwards
Sometimes relieved by vomiting
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Where are the sites that cancers to the brain metastisise from?
Lung (most common)
Breast
Bowel
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What are the investigations for a brain tumour?
CT with contrast/MRI.
Brain biopsy
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WHAT IS MENINGITIS?
https://www.youtube.com/watch?v=gIHUJs2eTHA
Inflammation of the meninges (membrane covering the brain)
Leptomeninges
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What are most types of primary brain tumours?
The majority are glial cell in origin:
Astrocytoma (85-90%)
Oligodendroglioma’ (~5%)
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What are the grades of brain tumours?
Grade 1 resectable
Grade 2 10 years
Grade 3 and 4 12 months
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What are the red flag symptoms of a brain tumour?
Headache with history of malignancy
New onset focal seizure
Cluster headache
Rapidly progressing focal neurology
Papilloedema
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What are the leptomeninges?
Inner two layers
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What are the clinical signs of meningitis?
What signs are associated with meningitis?
What is the rash from?
Fever
Headache
Neck stiffness
Photophobia
Phonophobia
Kernig’s sign
Brudzinski’s sign
**_Petechial rash (non-blanching)_**
Meningococcal septicaemia
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What are the differential diagnosis of meningitis?
Malaria
Encephalitis
Septicaemia
Subarachnoid
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What are the main investigations for bacterial meningitis?
**_Blood cultures_**
FBC, U&E, CRP, serum Glucose, lactate
**_Lumbar puncture_**
Glucose decrease, protein increase, WBC
**_CT Head_**
**_Throat swabs_**
Pneumococcal and Meningococcal serum PCR
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What is the management of bacterial meningitis?
**_Benzylpenicillin_**
Community
**_Cefotaxime_**
Hospital
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What meningitis prophylaxis do you give to people who were in contanct with a patient with meningitis??
Rifampicin
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What are the viral causes of meningitis?
Herpes
HIV
EBV
Mumps
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What are the bacteria causing meningitis?
Neisseria meningitis
Streptococcus pneumonia
Listeria monocytogene
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WHAT IS ENCEPHALITIS?
Swelling of the brain
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What causes encephalitis?
**_Herpes simplex_**
Virus
Autoimmune
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What is the differential diagnosis of encephalitis?
Hypoglycaemia
Hepatic encephalopathy
Diabetic ketoacidosis
Drugs
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What are the signs and symptoms of encephalitis?
Bizarre encephalopathic behaviour or confusion
Decreased GCS or coma
Fever
Headache
Focal neurological signs
Seizures
History of travel or animal bite.
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What are the investigations for encephalitis?
**_Bloods_**
Cultures
**_Contrast-enhanced CT_**
Focal bilateral temporal lobe involvement is suggestive of HSV encephalitis.
**_LP_**
Increased CSF protein and lymphocytes, and decreased glucose. PCR
**_EEG_**
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What is the management of encephalitis?
What would you give for seizures?
**_Acyclovir_**
**_Phenytoin_**
Seizures
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What happens in encephalitis?
Brain swells causing oedema and may destroy the nerve cells
may cause bleeing and brain damage
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WHAT IS HERPES ZOSTER?
Shingles
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What is the treatment for shingles?
What is the treatment for post-herpetic neuralgia?
**_Acyclovir_**
**_Amitriptyline_**
Post-herpetic neuralgia
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What is the diagnosis of shingles?
The rash
Quality of pain
Location
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What are the symptoms of shingles?
Rash across a dermatome that doesn't cross the midline
Stabbing, piercing pain
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How is herpes zoster caused?
Varicella zoster virus reactivates
It lays dormant in dorsal root ganglion
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WHAT IS DEMENTIA?
A clinical syndrome with many underlying causes
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What is dementia characterised by?
Decline in memory, intellect or personality severe enough to intere with daily life
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What are the clinical features of Alzheimer’s?
Memory Loss
Visuospatial problems
Reasoning and language problems
Psychiatric features
Death
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What are the risk factors for Alzheimer’s?
Increased Age
Female
Poor socioeconomic status
ph of head injury
Down syndrome
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What is the pathophysiology of Alzheimer’s?
Presence of extracellular plaques in the cortex composed of
**_beta amyloid peptide_**
Intracellular
**_neurofibrillary tangles composed of tau._**
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What is the treatment for Alzheimer’s?
Acetylcholinesterase inhibitors
(Donepezil, rivastigmine) can give modest benefit
NMDA-Receptor antagonist
(Memantine) may also help
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What is dementia with lewy bodies?
What are its clinical features?
2nd most common type
Visual hallucinations
Fluctuating cognition
Parkinsonism
Cognitive decline
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How much of dementia does vascular make up?
What its risk factors
10% dementia
RFs: Increased BP, Smoking, PH of stroke/IHD, obesity, diabetes, cholesterol
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What is FTD dementia?
Selective degeneration of the frontal and temporal lobes
Onset typically in middle age
FH present in 40%
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What are the clinical features of FTD dementia
Progressive deterioration in behaviour, personality and language
Disinhibition
Can be characterised by presence of tau positive Pick inclusions (a variant is Pick’s Disease)
Some association with developing MND
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How can you distinguish vascular dementia from alzeihmers?
Mood changes more prominent
Degree of memory loss less obvious
Focal neurological symptomsu
Imaging: patches rather than overall
