Neurology Flashcards
Name 5 features of neuroleptic malignant syndrome?
Occurs just after start of treatment (first 10 days) Pyrexia Rigidity Elevated CK Renal failure Tachycardia
Tx with Bromocriptine or dantrolene
What is neuroleptic malignant syndrome
Rare SE of antipsychotics, mortality of around 10%
How is neuroleptic malignant syndrome managed?
Stop antipsychotic
IV fluids (prevent renal failure)
Dantrolene or bromocriptine
Neurofibromatosis and tuberous sclerosis are inherited via what pattern?
Autosomal dominant
Name 3 common features of neurofibromatosis T1?
Cafe au lait spots (>6 and around 1.5cm diameter) Axillary/ groin freckles Peripheral neurofibroma's Iris haematomas Scoliosis Pheochromocytomas
Name 2 features of neurofibromatosis T2?
Bilateral acoustic neuromas
Multiple intercranial schwannomas, meningiomas and ependymomas
What is the incidence of neurofibromatosis T1 and T2?
T1 = 1 in 4000 T2 = 1 in 100,000
So T1 is much more common!
What is the main differential when considering alternatives to carpal tunnel syndrome? How could you distinguish?
Degenerative cervical myelopathy (DCM)
- 50% are incorrectly initially diagnosed as CTS
Hoffman’s sign (flick middle finger, watch for flexion of index/ thumb = UMN lesion) can distinguish as CTS is LMN
Which gender is most affected by cluster headaches, name a risk factor and a common trigger?
M3:1F
Smoking is a big RF
Alcohol commonly triggers attacks
What drug is used as prophylaxis for cluster headaches?
Verapamil
What is the management of acute cluster headache?
100% oxygen
Subcut triptan
A 67-year-old man presents to his GP with numbness in his feet and recurrent falls over the past month. He describes difficulty walking. His GP recently started him on folate for a macrocytic anaemia. He takes no other regular medications. He does not drink alcohol. On examination, he has an ataxic gait and Romberg’s test is positive. Examination of his lower limbs demonstrates an increase in tone and bilateral weakness. He has absent ankle and knee jerks with upgoing plantars. Light touch and vibration sense is reduced bilaterally. MLD and cause?
Subacute combined degeneration of spinal cord
- Always replace vitamin B12 before folate - giving folate to a patient deficient in B12 can precipitate subacute combined degeneration of the cord
(Note this is not ALS or other MND as sensory involvement)
What is charcot-marie-tooth disease and how does it present?
A hereditary sensory and motor peripheral neuropathy
UMN signs are not present
Patients can present with lower motor neurone signs in all limbs and reduced sensation (more pronounced distally)
What is Lambert-Eaton myasthenic syndrome?
A rare autoimmune disorder involving the neuromuscular junction, associated with small-cell lung cancer.
- Similar to myasthenia gravis but movements IMPROVE with exercise, in MG they get WORSE with exercise
What is Cervical Spondylotic Myelopathy?
Cervical spondylosis is the term used for osteoarthritis of the spine and can result in compression of the spinal cord. This is more likely to result in LMN signs at the level of the compression (ie. upper limb if the lesion is below C5) with UMN signs below (in the lower limb). Patients usually complain of neck pain and stiffness.
What is first line treatment of trigeminal neuraligia?
Carbamazepine
When should a patient with trigeminal neuralgia be referred? (2)
Failure to respond to treatment or atypical features (e.g. < 50 years old) should prompt referral to neurology
Antipsychotics worsen the symptoms of which common neurological disease?
Parkinsons
What visual defect is seen with pituitary tumours?
Bitemporal hemianopia
Following head trauma, what is the quickest and easiest way to test fluid to determine if it is CSF?
Check glucose of the fluid
How long must a seizure last to be diagnosed as status epilepticus?
> 5mins
What visual defect would be caused by a parietal lobe lesion?
Contralateral inferior quadranopia
What visual defect would be caused by a temporal lobe lesion?
Contralateral superior quadranopia
What visual defect is caused by a pituitary tumour?
Lower bitemporal hemianopia
What medication is used to treat sleep paralysis?
Clonazepam
Which anti-emetic acts on D2 receptors and so can cause parkinsonian side effects?
Metoclopramide
What is the most common type of MND?
ALS
How does MND present?
Male >50 with FHx is typical presentation
Presents with progressive weakness of limb/ thoracic/ abdo muscles
- UL tends to be first = dropping objects, wrist drop, fasiculations etc
Name some common signs seen in MND?
Often asymetrical
UMN (brisk reflexes) with LMN (wasting) signs
No sensory or pain symptoms
What is the only drug proven to have disease modifying abilities in MND?
Riluzole (a neuroprotective glutamate-release inhibitor) is the only drug of proven disease-modifying efficacy
A patient with MND is struggling with drooling, name a drug tx which could improve this?
Hyoscine
A patient with MND is suffering with muscle cramps, name 4 medications which could be trialled to relieve these symptoms?
Diazepam Baclofen Tinzanidine Phenytoin Quinine
What is the pathophysicological cause of Myasthenia Gravis?
IgG1 Antibodies to acetylcholine receptors
How does myasthenia gravis commonly present?
Muscles fatigued after exercise
- Eyes often first (some can remain just eyes for years)
- Proximal muscles tend to be most affected
What is a myasthenic crisis?
Affects 25% MG px, often in first year. Can be first presentation.
Complication where muscle weakness results in respiratory failure and a need for mechanical ventilation
(Tx = intravenous immunoglobulin, plasma electrophoresis)
What signs would be seen on neurological exam in myasthenia gravis?
Weakness (especially after fatigue)
- Normal tone
- Normal sensation
- Normal reflexes
- No muscle wasting or fasiculation
What is the first investigation that should be performed for myasthenia gravis if a patient has ptosis?
Crushed ice in a latex glove is applied to the eye for three minutes. In MG this leads to improvement of ptosis and it has a sensitivity and specificity of over 90%
What is the first investigation that should be performed for myasthenia gravis?
Serum anti-acetylcholine receptor (ACh-R) antibody testing is the first-line investigation for non-urgent patients.
What is the mainstay of treatment for MG?
Pyridostigmine
(Acetylchlinesterase inhibitor)
Immunosuppresion: Steroids, azathioprine
What is the most common form of MS?
Relapsing-remitting (80%)
Also can have primary progressive (10%) or secondary progressive (follows R-R about 50% within first 10yrs)
What are the RF’s for MS?
About 2% of those who have a first degree relative will develop
More common in caucasian, northern latitude
What criteria are needed to diagnose MS?
Dissemination in time AND space (doesn’t NEED MRI for diagnosis)
Name 5 common presenting symptoms of MS?
Optic neuritis/ blindness etc Disorder of eye movement (jerking nystagmus) Facial weakness (Bell's palsy) Deafness Transverse myelitis
What investigations should be done for MS before neurology referral?
Before referring to a neurologist, exclude differential diagnoses by checking FBC, Inflammatory markers, U&E, LFT, TFT, glucose, HIV serology, calcium and B12 levels.
What should be the first line investigation for MS?
Visual evoked potentials
Later followed by MRI
How should an MS relapse be treated?
Oral/ IV methylprednisolone (with gastric protection) - 5 days
What DMARDS are used in MS?
Interferon beta (can give flu like symptoms for 24hours after injection - used ibuprofen) (Needs 2 relapses in last 2 years + able to walk 100m unaided)
Glatrimer (needs at least 2 relapses in last 2 years)
Dimethyl fumarate/ teriflumomide/ alemtuzumab
On neuro exam, what would be found in an MS patient for the 5 neuro domains?
Inspection
(Walking aids, although MS is UMN may have wasting in late disease)
Tone - Increased (UMN)
Power - Weakness
Reflexes- Brisk (UMN)
Co-ordination- Possibly impaired
Gait- Spastic gait suggests UMN, ataxic gait suggests cerebellar
What is guillian barre syndrome?
A disorder which causes demyelination and degeneration causing progressive neuropathy -= weakness, paraesthesia and hyporeflexia
Many subypes but 95% are AIDP
What are the RF’s of Guillan Barre syndrome?
Hx of GI/ resp infection in preceeding weeks
Recent vaccination
Associated with lymphoma and post-partum
What is a common presentation of guillian barre syndrome?
Ascending, progressive, symetrical weakness starting in LL, 3 weeks after viral infection
Max severity after 2 weeks, stops progressing after 5
Possible neuropathic pain, paraesthia and sensory loss
What signs would be seen on a neuro exam for GBS?
I: T: Low (LMN) P: Weakness in affected areas (LMN) R: Reduced or absent (LMN) C: Variable S: Altered sensation
What would be shown on an GBS lumbar puncture?
Very high level of protein with no elevation in CSF cell counts
May not be seen until 1-2 weeks after weakeness onset
How is GBS managed?
IV IG
or Plasma exchange
+/- Steroids
+ DVT prophylactic stockings
What is the prognosis for a patient with GBS?
80% recover in 6 months
10% neuro deficit
10% severely disabled
How does TN commonly present?
Sudden, unilateral, brief, stabbing, episodic, recurrent pain in one or more branches of 5th nerve
Pain in paroxysms from secs-2mins
Possible preceding syx, tingling/ numbness
Name 5 common triggers for TN attacks
Vibration Contact (washing/ shaving) Brushing teeth Oral intake Exposure to wind
What red flags must you look out for with TN?
Sensory changes
FHx of MS
Age <40yrs
Opthalmic divison only (suggestive of MS)
Name 3 differentials for TN?
Dental problems TMJ dysfunction Migraine Temporal arteritis (TN rarely affects foreheard alone) MS
How should TN be investigated?
Referral and MRI only for uncertain diagnosis or red flags
What is the mainstay of tx for TN?
Lifestyle advice
Carbamazepine (until remission for one month)
Refer to pain clinic
Surgical options increasinly promising
How do you distingush between Bells Palsy and possible stroke?
Bells Palsy is 7th nerve so LMN = Forehead is affected
Stroke is UMN as bilaterally inervated = Forehead NOT affected
Name the two biggest RF’s for Bell’s palsy:
Pregnancy
Diabetes
Most are idopathic, now thought to be viral (herpes/ varicella)
(Commonly 15-60yrs)
What is the optimum treatment of Bell’s palsy?
Steroids (Pred for 10days then reducing)
Eye care etc
Refer if doubt, recurrent or bilateral (ENT or neuro)
A 72 year old female presents with progressive immobility, poor balance and a resting tremor of the L hand. She has non-velocity dependant hypertonia of all 4 limbs, dysarthria and difficulties moving her eyes in the superior plane. MLD?
Progressive surapnuclear palsy
PD features (rest tremour, rigidity, bradykinesia, instability) etc. but other features (eye movements and dysarthria) make the PD plus disorder PSP most likely
Name 6 features of cerebellar disease?
D- Dysdiadochokinesia A- Ataxia N - Nystagmus I- Intention tremor S- Slurred stacato speech H- Hypotonia
A left sided cerebellar lesion will give DANISH signs on which side?
Left
Cerebellar is ipsilateral signs
Cerebrum is contralateral signs
What is Charcot Marie Tooth disease, how is it passed from individuals?
A herediatary sensorimotor neuropathy
AD so 50% of children will be affected
What are the criteria for thrombolysis in an acute stroke?
Administered within 4.5hrs Haemorrhage has been excluded No: - Previous intercranial haemorrhage - Seizure with stroke - Intercranial neoplasm - Trauma in last 3 months/ LP in last 7 days - Active bleeding - Pregnancy
What are the rules around driving if a bus driver and had a seizure?
Inform DVLA
- After first seizure - Seizure free for 5years
- Epilepsy: Can return to driving if seizure free for 10 years and off medication
What are the rules around driving and had a seizure?
Inform DVLA
- First seizure = 6 months seizure free
- Epilepsy= May qualify for driving licence if seizure free for 12 months
Before doing an LP in suspected meningitis where there is headache worse on leaning forward or coughing, what additional test should be performed?
CT head (to rule out raised ICP)
What are the main features of neurofibromatosis T1? (3)
Cafe au lait spots (over 6, >15mm) Peipheral neurofibromas Scoliosis Iris haematomas Axillary/ groin freckles
A 42-year-old teacher is admitted with a fall. An x-ray confirms a fracture of the surgical neck of the humerus. Which nerve is at risk?
Axillary nerve runs around the bone at the neck of the humurus
Which nerve is at risk in shoulder dislocation?
Axillary nerve (does Deltoid and teres minor)
How should anti-epileptic drugs be stopped?
Considered if seizure free for > 2 years
Should be stopped over 2-3 months
Which anti-emetic should be used in parkinsons?
Domperidone
(Doesn’t cross BBB)
Don’t use cyclizine or prochlorperazine as antihistamines can make PD worse (or metoclopromide)
What are the features of a third nerve palsy?
Eye deviated down and out
Ptosis
Dilated pupil
What is the first-line anti-epileptic in a 17-year-old girl with tonic-clonic seizures. She is not sexually active but uses the combined oral contraceptive pill to control her periods.
Lamotrigine
(Sodium valproate is first line for tonic-clonic seizures, however it shouldn’t be given to women of child bearing age unless other treatments are ineffective - regardless of whether the patient is sexually active/ using protection)
What drug should be used for a patient with absence seizures if they are intolerant of sodium valproate?
Ethosuximide
A 24 year old man has complex partial seizures, what is the first line anti-epileptic?
Carbamazepine
A 60yoF has lost the ability to pick up small objects with her R hand. She can't fasten buttons and has no other weakness. She is unable to copy the doctor when he asks her to form an 'OK' sign with her fingers. Which nerve is most likely affected? A- Anterior interosseous B- Median C- Musculocutaneous D- Radial E - Ulnar
A
Problems with the anterior interosseous nerve prevent the ability to bring the thumb and forefinger together.
You intended to start a young male with a PMHx of asthma on prophylaxis for migraines, what drug should be used?
Topimerate
propanalol CI in asthma
A portly 46-year-old man and his wife present to the GP. His wife is concerned that he has been acting strangely over the past 3 months. In particular, he has been irritable and criticizes her and the kids more than often. The changes were subtle at first but now arguments arise every other day. The husband does not feel there is an issue and you note he has difficulty initiating conversation and even pauses halfway through sentences. There is no family history of note and the husband is not taking any recurrent medications.
What is the most likely underlying diagnosis?
Frontotemporal dementia (also known as Pick’s disease) is a type of dementia more common in patients younger than 65. There are different forms of this dementia and patients can experience changes in personality and behaviour.
What is the first/ second line treatment for generalised tonic clonic seizures?
Valproate
2nd: Lamotrigine/ carbamazepine
What is the first/ second line treatment for focal seizures?
1st: Carbamazepine or lamotrigine
2nd: Valproate
What is the first line treatment for absence seizures?
1st: Valproate or ethosuximide
When would you tend to begin starting anti-epileptic drugs?
Following second seizure, or after first seizure if:
- Neurological deficit
- Structural brain abnormality on imaging
- Patient/ carers consider further seizure risk unacceptable
Name 4 RF’s for MS?
Smoking
Previous infectious mononucleosis
Genetics
Low vitD
Name 3 common side effects of sodium valproate?
Feeling sick, stomach pain Feeling shaky Weight gain Fatigue Dyskinesias Liver damage
A 55-year-old woman complains of neck and right arm pain for the past two months. The pain is often triggered by flexing her neck. Her past medical history includes osteoarthritis of her knee, obesity and depression. On examination there is no obvious muscle atrophy or weakness of the right arm. There is however some sensory loss over the middle finger and palm of the hand. Which nerve root is most likely to be affected by the impingement?
C7 (middle finger and palm of hand)
C6 just does thumb and index finger
Name 5 features of Parkinsons disease?
Bradykinesia Resting tremor (fine + pill rolling) Rigidity (cogwheel if tremor superimposed) Gait changes (later sign, shuffling) Micrographia Hypophonia (quiet voice) Camptocormia (stooping)
How is a fine essential tremor different to a PD tremour?
Essential tremor - coarse, rare at rest, unilateral, often familial (70%), improved by alcohol
PD- Tends to be asymetrical or unilateral, at rest, fine and not improved by alcohol
How is benign essential tremor treated?
Propanolol 80mg BD
Name two PD plus syndromes and how they are recognised?
Multi-system atrophy (will show poor or temporary response to levodopa)
Progressive supranuclear palsy
- Characterised by paresis of conjugate gaze (eyes in same direction), so struggle to look up or down on request
Name two diseases commonly associated with PD?
Dementia (2-6x more likely)
Depression (in 45% of PD patients)
What is average age of onset of PD?
60
How should a patient suspected to have PD when seen in GP be managed?
Refer for review in 6 weeks (2 weeks if late disease). Although diagnosis is clinical, refer untreated
What is the first line management of PD?
If symptoms affect QoL = Levodopa (with decarboxylase inhibitor - i.e. Co-benaldopa (Madopar) or Co-careldopa (Sinemet)
If syx don’t affect QoL = MAO-B inhibitor (Rasagiline, Selegiline)
As an alternative offer dopamine agonists (Ropinirole, pramipexole)
What is the role of drugs such as entacapone or tolcapone?
To prolong the effects of levodopa in PD
Name three common side effects of levodopa?
Nausea (use domperidone)
Vomiting
Postural hypotension
Name three other presentations which may present similarly to idiopathic parkinsons disease, how do you differentiate?
Vascular parkinsonism - Mainly lower body signs
Dementia with Lewy Bodies - Triad: Parkinsonism with dementia and visual symptoms
Drug induced parkinsons - Antipsychotics or metoclopramide
What are the three main categories of tremor?
Worse at rest (PD)
Worse on movement (Essential tremor, drug induced, hyperthyroid)
Intention tremor (Cerebellar disorders)
Name 3 tremors which are worse on movement and how would you distinguish?
Essential tremor (coarse) - FHx, relived by alcohol
Hyperthyroid- Fine, always present, bilateral, thyroid syx (Too hot, tachycardia, exopthalmos)
Drug induced- (Salbutamol, alcohol, lithium, dopamine agonists, benzodiazepines)
What is the definition of a stroke or TIA?
Stroke (CVA) - Acute focal disturbance of cerebral function lasting > 24hrs
TIA as above lasting < 24hrs
Both clinical diagnosis, not from imaging
What symptoms would be seen in a R sided Total Anterior Infarct (TACI)?
1) Left sided hemiparesis or hemisensory loss
2) Homonymous hemianopia (bilateral loss of left visual field)
3) Cognitive dysfunction (i.e. dysphasia)
Which arteries are involved in a TACI stroke?
Middle and anterior cerebral arteries
Leg weakness worse = anterior cerebral, arm weakness work = middle cerebral
How does a partial anterior infarct (PACI) stroke present?
Two of the Oxford Stroke Classification (Bamford), so two of:
1) Unilateral hemiparesis/ hemisensory loss in face/arm/leg
2) Homonymous hemianopia
3) Higher function - Cognitive dysfunction (i.e. dysphasia)
How does a posterior infarct tend to present, what artery is affected?
Vertebrobasillar arteries
Presents with cerebellar dysfunction, LOC or isolated homonymous hemianopia
A patient presents with just unilateral weakness or sensory deficit and no other symptoms, what type of stroke are they likely to have had?
Lacunar stroke (Perforating arteries around internal capsule, thalamus and basal ganglia)
How should a stroke be managed when presenting to A+E? (3 different scenarios)
Maintain physiology (O2, glucose, BP etc). Urgent imaging - If ischemic and <4.5hrs and no CI = thrombolyse with alteplase - If ischemic and > 4.5hrs = Aspirin and supportive care - If hemorrhagic = Neurosurgical referral
A patient presents with a TIA, how do you manage?
Perform ABCD2 score (Age, Blood Pressure, Clinical features, Duration of Symptoms, Diabetes)
All get 300mg aspirin started, score >4 r/w in 24hrs, if score is 3 or below review in 1 week
What long term secondary prevention is used for stroke or TIA not due to AF? (4 points)
Aspirin 300mg/day for 14 days
Clopidogrel 75mg OD after D14
- If clopi is not tolerate then use Aspirin 75mg plus dipyridamole OD)
PLUS FOR ALL:
- Atorvastatin (20-80mg)
- Review of RF’s
What are the DVLA driving rules regarding stroke? (3 points)
Can’t drive for 1 month after stroke or TIA, do not need to inform DVLA
For lorry or bus the above is one year
If multiple TIA’s then notify DVLA
Which side of the brain is speech normally found?
99% of R handed and 70% L handed it’s on the LEFT hand side
Name 5 CI’s to stroke thrombolysis?
No clear onset time or after 4.5hrs Bleed not excluded Previous bleed Head injury Recent surgery Seizure at onset INR > 1.7 Pregnancy
P presents in A+E following a traumatic head injury. They were unconscious at the time however woke up and were fairly lucid for a few hours however they are now unconscious again. Imaging reveals rupture of the meningeal artery and a biconvex bleeding pattern. What do you diagnose?
Extradural haematoma
noted from biconvex shape of blood
A patient is found having a seizure which has lasted 35 mins. What do you diagnose and how do you treat?
Status epilepticus (Seizure >30min) = Emergency Treat Lorazepam/O2 before 30mins then add phenytoin 30-90min
A patient who has been standing for a while looks pale, feels dizzy and light headed then collapses to the floor, there are some twitching movements, after a few seconds the patient regains conciousness although feels fatigued. ???
Syncope (fainting)
Often precipitated by standing or fear etc
Caused by reflex bradycardia and vasodilation
Fatigue suggests syncope (not status epilepticus- where P drowsy and confused)
What is the difference in shape seen on extradural and subdural bleeds? How do you distinguish between the two clinically?
Subdural = Concave (sub = sunken) - Fluctuating consciousness Extradural = Convex (extra = eggy) - Lucid phase, usually following major head injury, fixed dilated pupil
What initial ‘blind’ therapy should be started in ?meningitis?
Fluids Antipyretics Antiemtics AB's - <3mths = IV cefotaxime plus amoxicillin - >3mths = IV ceftriaxone
Name 3 differentials for an acute, first episode, severe headache with neck stiffness?
Mengitis < Photophobia, rash, fever etc
Encephalitis < Possible odd behaviour + fever
Subarchnoid haemorrhage < Head hit with spade
What are the characteristic features of a tension headache? (3)
Bilateral
+/- Scalp tenderness
NO vomiting, no relation to movement
Tx: Paracetamol, stress relief
Name 4 symptoms of raised ICP?
Worse on waking
Worse lying down
Worse bending forward/ coughing
Vomitting
Papilloedema
Fits
Name 5 features of a classic migraine?
Unilateral Throbbing Photophobia/ phonophobia Nausea Vomitting Aura (Visual, paraethesia, dysphasia or other motor issues) - 15mins, headache then comes within 1hr
How common are migraines, which gender is more affected?
8% prevalence
2F:1M
What are the common triggers of migraine?
CHOCOLATE CHeese Oral contraceptives Caffeine OL - Alcohol Anxiety Travel Exercise
(50% no trigger is found)
What is the pathophysiology (for patients) of migraine?
Thought to be problems which control blood vessels in the brain
What is the diagnostic criteria for migraine if no aura?
> 5 headaches lasting 4-72 hours with either
- Nausea/ vomitting OR photo/phonophobia
AND (2 of)
- Unilateral
- Pulsating
- Interferes with normal life
- Worsened by routine activity
What is the optimum treatment for migraine attacks?
Mild/ mod = Aspirin (not children) or ibuprofen
- Prochlorperazine (buccal) if N+V (not children)
Severe = Add triptans
What advice should be given to patients regarding taking triptans? (2)
Don’t take too early (wait for headache phase)
if one doesn’t work for you, others brands may
Relapse is very common (upto 50% within 48 hours)
Name 3 CI to taking triptan medication?
Uncontrolled HTN
CHD or CVS
RF’s for CHD or CVS
When should migraine prophylaxis be offered and what is given?
When having 2 or more attacks per month
1) Beta blocker (propanolol)
- Can also consider amitriptyline
2) Topiramate (not preg/ or child-bearing age)
Name three features of temporal arteritis (aka GCA)
Common in elderly, rare <55 Headache Scalp tenderness Jaw claudication Visual changes
Associated with PMR
What should be done if GCA/ temporal arteritis is suspected?
Do ESR but start 40-60mg pred before waiting for results!
Do temporal artery biposy within 3 days (but skip lesions can = false neg)
What is the long term treatment of temporal arteritis?
Steroids (start at 40-60mg)
Gradually reduce after 5-7 days, guided by Syx and ESR
Treatment on lower dose for 2 years (protect stomach with PPI and bones with alendronate)
Name three complications of an LP?
Post-LP headache
Infection
Bleeding (2%)
Name three common CI to doing an LP?
Raised ICP signs (reduced GCS, papilloedema etc)
Shock
Coagulopathies
What LP abnormailites characterise bacterial/ viral?
Bacterial - Most likely to have high opening pressure and VERY HIGH WCC (>1000)
Viral - Normal OP and WCC (lymphocytes <1000)
How do you distinguish between focal and generalised seizures?
Onset is key
If starts locally then it’s local, even if it very quickly generalises
What are the three types of partial seizures?
Simple partial - Awareness unimpaired
Complex partial - awareness IS impaired
Partial seizure with secondary generalisation
Name 5 differentials for a blackout?
Vasovagal - Preciptated emotion, fear, pain etc. Rapid recovery, lasts <2mins, jerking is possible
Carotid sinus syncope - Headturning/ shaving precipitate
Seizure - Post ictal! Tongue biting, incontinence, tonic-clonic movements etc
Stokes-Adams attack - Recovery in seconds, preceeding palpitations
Hypoglycemia
Drop attack - Elderly woman, weak legs, no LOC, no post-ictal etc.
Situational syncope - COugh, effort, micturation etc
What is the pathophysiology of a vasocagal episode?
Reflex bradycardia and peripheral vasodilation
How does CTS present?
Aching pain in hand/ arm
Paraesthesia in thumb, index + middle finger (relieved by dangling hand over edge of bed and shaking it)
Possible sensory loss
Possible thenar wasting
What two tests can be done to elicit symptoms CTS?
Phalens (Flexion for 1 min)
Tinnels (Tapping for 1min)
What is the management of CTS?
Wrist splinting
Steroid injections
(Can take 6 months to resolve)
+/- surgical decompression
Name three mostly motor causes of a polyneuropathy?
Guillian Barre
Charcot Marie Tooth
Lead poisioning
Name two mainly sensory causes of a polyneuropathy?
Diabetes
Renal failure
Name 3 investigations which should be performed when a patient has a polyneuropathy?
FBC, ESR, glucose, U+E, LFT
TSH, B12, folate
How is DMD inherited?
X-linked
So almost exclusively affects males
What is the difference between rigidity and spacticity?
Spacticity = Velocity dependant hypertonia Rigidity = Non-velocity dependant hypertonia
What is a serious adverse effect of lamotrigine, carbamazepine, phenytoin?
Stephen-Johnson syndrome
Rash
How is PD treated?
If symptomatic = start levodopa with decarboxylase inhibitor (co-benaldopa)
Asymptomatic = Start with dopamine agonist (ropinerole) or MAO-B inhibitor (selegiline), COMT (entacapone or tolcapone)
Name 4 parkinson plus syndromes?
Progressive supra nuclear palsy = + vertical gaze problems
Multi system atrophy = + cerebellar signs and autonomic signs
Corticobasal degeneration = + cognitive impairement
Dementia with Lewy bodies = Progressive cognitive impairement and hallucinations
What are the causes of peripheral neuropathy?
A- Alcohol (sensory starts first) B- B12 (lose vibration + proprioception first) C- CKD and cancer D- Diabetes E- Every vasculitis
What is first and second line disease for Alzeihmers dementia?
Donzepazil
2nd: Memantidine
3 weeks after a stroke not due to AF what should all patients be taking as a minimum?
Clopidogrel 75mg OD
Atorvastatin 80mg ON
(Aspirin is only for first 2 weeks)
How do you tell between ischemia and haemorrhage on a CT head?
Haemorrhage = Hyper-intense lesion Ischemia = Hypodense lesion
How does an extradural haematoma present?
Lucid phase followed by deterioration
- Fixed dilated pupil due to mass effect on brain
(Lentiform i.e. eggy i.e. convex shape of lesion)
Name three indications for an immediate CT head following trauma?
GCS <13 on initial assessment GCS <15 at 2 hours post injury <1 episode of vomiting Any signs of base of skull # (panda eyes, CSF leak) Seizure post trauma Focal neurological deficit
What are the causes of cerebellar problems?
MAVIS MS Alcohol use Vascular Inherited Space occupying lesions
Name 5 common causes of a seizure?
Hypoglycemia Alcohol misuse/ withdrawal Electolyte abnormalities Space occupying lesions Stroke
IDIOPATHIC
What antibodies are present with Lambert-Eaton Myasthenic Syndrome
Voltage-gated channel autoantibodies
What arteries are commonly affected in extradural, subdural and subarchnoid haemorrhages?
Extradural - middle meningeal artery
Subdural -Tearing of bridging veins
Subarachnoid - Circle of willis berry aneyrysm rupture
What is the classic triad of normal pressure hydrocephalus?
Ataxia
Incontience of urine
Dementia
All patient’s with subarchnoid haemorrhage should be prescribed what prophylactic drug?
CCB (Nimodipine)
- As 30% of those with SAH get vasospasm so this is to reduce that risk
