Neurology Flashcards
Upper motor neurone signs
Hypertonia, Spasticity Clonus Weakness- in pyramidal pattern Hyperreflexia Pathological reflexes (eg extensor plantars)
Lower motor neurone signs
Muscle wasting Fasciculations Hypotonia Reduced power not in pyramidal pattern Reduced or absent reflexes
Cerebellar dysfunction
“am i std please”
alcohol
ms (demyel)
inherited - friedrich (young)
stroke
tumour
drugs (isoniazid, henytoin)
paraneopastic
cerebellar signs
DANISH dysdiadocokinesia ataxia nystagmus intention tremor slurred speech hypotonia
peripheral neuropathy
Polyneuropathy I DAVID - can be sensory, motor or mixed S: dm, alcohol M: GB, polio MS: CMT, CIDP
Radiculopathy
- often w spondylosis
- pain, ting, sensory dist, motor dist
Mononeuropathy
- eg carpal (median), common peroneal (foot drop), radial (wrist drop), ulnar (hand)
- can get multiplex in DM, hypothyroid, vasculitis
speech problems
cortical - dysphasia - expressive, receptive or mixed
cerebellar - staccato, loss of normal scanning
parkinsonian - hypophonic
pseudobulbar - spastic, hot potato
bulbar (palatal paralysis) - nasal
leg myotomes
hip flex: L1/2
hip ext: L5 S1
knee flex: S1
knee ext: L3/4 (jerk)
ankle dorsi: L4
ankle plantar: S1/2 (jerk)
arm myotomes
wrist extension (cocked)
shoulder: C5 axillary
bicep: C5/6
(reflex C5/6)
tricep: C7 radial
(reflex C7/8)
(supinator C6/7)
wrist ext: C7 radial nerve
wrist flex: C8 uln and med
fingers: T1 ulnar
thumb: C8 median
stroke
sudden neurolog deficit of vascular origin
1/6 are hem; 5/6 are infarct
Assess w Rosier criteria
abc, source of embolus, assess swallow
do CT asap to rule out hem,
- thrombolysis (alteplase) if w/in 4.5 hrs
- if CI 300mg aspirin stat,
other: bloods (fbc, esr, clot), cxr, ecg, carotid ddoppler
mx: longterm CLOPIDOGREL
mdt rehab,
treat htn/chol/diab
?endarterectomy ?warfarin (if AF)
embolism - AF, valvular disease, recent MI
thrombosis - atheroma
stroke prognosis
25% die in a year
50% dependant
25% independant
mdt rehab - phsyio, ot, salt stop: smoking, cocp, hrt manage bp, chol, diab clopidog (stroke) asp + dipyrid (tia) ?warfarin ?endarterectomy
AC stroke
carotid circultaion
1) cortical deficit - Aphasia, visuospatial, attention
2) homonymous hemianopia
3) hemiparesis including face (+sensation)
all - TACS
or partial - PACS
highest mortality
lacunar strokes
pure motor or sensory
cognitive impairment
PC stroke
vertebrobasilar circulation
1) brainstem - cerebellar (ataxia), CN, bulbar (swallowing), dysphasia, horners,
2) hemiparesis on opposite sides to CN
3) hemianopia
extradural haematoma
aka epidural
tearing of meningeal artery - often middle near pterion
history of trauma -> lucid period -> icp and gcs (coma)
ct: biconvex
not spread past falci
midline shift
TIA
less than 24 hrs
Assess w ABCD
hemiparesis and aphasia - common
amaraurosis fugax, amnesia
Could do ecg, carotid duplex
30% stroke in 5 yrs
- start aspirin + dipyradamole daily
sah
sudden (thunderclap) occipital
meningism - neck stiff, photophob
papilloedma ?focal neurology
ruptured berry aneurysm, avm
ct
lp (xanthochromia, blood on serial tap)
mx:
maintain bp
nimodipine (prev ischaemic damage)
surgical - coiling
subdural haematoma
venous bleed in oldies
can be chronic + acute
gradual accum of neuro defecits - may be non specific (off legs, cogntiive)
ct: concave density (but old bleed are isodense)
can spread around brain
Epilepsy history
Preceding factor
- head injury, infection
- stress, tiredness, alcohol, missed meals
Fh?
Pmh? - febrile seizures as child?
Seizure markers
- tongue biting
- incontinence
- confusion/tiredness afterwards
Epilepsy management
Generalized
1) sodium valproate (avoid in reproductive female)
- se: wg, tremor, (tiredness, nausea at first)
2) lamotrigine
Focal
1) Lamotrigine
2) carbamazepine
treatment for generalized vs focal epilepsy
Generalised (inc absence)
- sodium valproate
- (se: weight gain, temporary hair loss, ntd)
- lamotrigine if pregnancy risk
Partial: carbamezipine (se rash)
general se: drowsy, dizzy, nausea
sv: avoid alcohol
for absence - ethosuximide is second line
Focal seizures
Start w strong aura Affect specific distribution Short duration Stereotyp pattern Altered consciousness
- must image brain (mri)
Juvenile myoclonic epilepsy
Three features
- myoclonus - often in morning
- absense seizures
- gen tonic clonic
Do eeg if suspected
Start SV if man, lamotrigine if woman
Status epilepticus
Pre hosp rescue therapy - buccal medazolam
Hosp
- iv lorazepam
- ?phenytoin
- ?aneasthetize
Identify/treat cause
ie hypoglycaemia?
status epilepticus mx
recovery posit
avoid injury
call amb
buccal medaz or rectal diaz
in hosp
iv loraz
o2
check glucose
cluster headache
severe, quick onset, around eyes
runny noise, red eye
*come in clusters, daily 4-12 weeks
T: acute: O2, nasal triptan
proph: verapamil
tension headache
tightness, bilateral
recurrent/chronic, worse at end of day
precip: stress, noise, depression, analgesia overuse
tension, tenderness, stiff neck
m: simple analgesia
lifestyle - stress, alcoho, exercise, antidep
avoid analgesia overuse
physical massage/icepacks
treat migraine
attack: analgesia, metoclopramide, sleep/darkness, triptans
lifestyle - avoid triggers (sleep, eat well)
prophylaxis if severe, affecting life, frequent
- b block (avoid asthma, raynauds)
- topiramate (avoid if preg risk)
- acupuncture, gabapentin
migraine
unilateral, throbbing
pre: aura - visual, sensory
assoc: photo/phonophobia, nausea, vom
aggrav/triggered by choc, caffeine, alcohol, exercise
acute: analgesia, triptan
prevent: b block, or topiramate, or amitript
giant cell arteritis eg temporal
painful - rapid, unilat, v tender, erythema
jaw claudication
! risk visual loss
clinical diagnosis: give prednisolone
see rasied ESR, do biopsy
trigeminal neuralgia
unilateral face pain in trigem distrib - brief, severe, shock/stab, w/or w/out background ache
triggered by shaving/washing face/wind
treat: carbamezipine
check neuro signs - suggest tumour/lesion
(can be sign of MS)
pt typically > 50 yrs
may be idiopathic
due to compression of sensory root adjacent to brainstem
- eg tumour in cerebello pontine angle (v, vii, viii),
- also multiple sclerosis if younger patient
ms presentation
lethargy
ocular
- unilateral blurry/loss of vision
- pain - dull ache, worse w move
- colour desat
- RAPD, nystag (INO)
- late optic atrophy
worse with temperatrue - uhtoff’s phenom
neck bend->paraesth - lhermitte’s phenom
sensory and motor signs trigem neuralgia cerebellar signs - ataxia, tremor urinary cog/psych
investigations and treatment in ms
mri - visualise plaques
vep - slowed
csf - lymphocytes, protein, oligoclonal bands
steroids for relapses
?disease modifier: beta IFN, azathioprine
mdt support
treat symptoms (see card)
patterns of ms
relapsing remitting
primary progressive
- little or no recovery from episodes
secondary progressive
- starts as relapse/remit but recovery becomes less and less
aetiology: genetic and environmental, not fully understood
- certain parts of the world
specific treatmetns in ms
shooting pains, paraesthesia - gabapentin, carbamazepine
bladder - oxybutinin, self cath
constip - laxaives
muscle spasticity - baclofen
depression - ssri (fluox, cital)#
erectile - viagra
Acute spinal cord compression
- primarily MOTOR dysfunction below certain level - weakness, umn
- sensory level
may not be symmetrical
- tumour (slow appearance)
- prolapsed disc (more acute)
similar pic may be due to
- transverse myelitis
- ant spinal artery thrombosis
(no compression, weakness tends to be flaccid)
–> do urgent MRI
Progressive spastic paraparesis
Bilateral weakness and spasticity of legs
Differentials
- B12 deficiency (SACD)
- also copper deficiency (SACD)
- HEREDITARY spastic paraparesis
B12 deficiency - subacute combined degeneration of spinal cord (SACD)
May precede megaloblastic anaemia
1) Corticospinal tract
- prog spastic paraparesis
2) Dorsal columns
- proprioception, vibration, fine touch
- see high stepping gait, rhombergism, pseudoathetosis
3) Peripheral neuropathy
- sensory and motor
Cervical spondylotic myelopathy
Vertebral degen can cause
1) radiculopathy of local nerve roots
- pain, tingling, sensory dist, lmn signs
2) spinal cord syndrome
- spastic paraparesis
- gait and sphincter dysturb
Transverse myelitis
Localised inflammatory lesion across one level of SC
—> acute flaccid weakness w sensory level below this point
1) viral (recent flu-like) illness
2) MS
Do MRI to rule out SC compression
Transverse myelitis
Inflam on spinal cord across transverse plane
Often self limiting
Often viral - tends to be complete - paraplegia
Also w MS - tends to be partial - patchy motor sensory loss
Spinal shock
Sudden transaction of spinal cord (trauma)
Loss of autonomic control of vasoconstriction
- catastrophic hypotension - need fluid
Neuromuscular disease
1) MND
2) MG
3) Muscular disorders
mnd
upper and lower mn signs
no sensory signs
CLASSICALLY: >40, ataxia develops, weak grip
survival 2-5 yrs
TYPES:
50% amyotrophic lateral sclerosis
- UMN legs, LMN arms
primary lat sclerosis - only UMN
progressive muscular atrophy - only LMN, best prog
progressive bulbar palsy - swallowing/speech prob
- worst prog
myaethenia gravis
autoimmune vs ACh at nmj
fatiguable
particularly ocular (diplopia and ptosis) and facial muscle
- also bulbar, respiratory, limb
assoc w thymoma
80% succesfully managed with iv Ig (remission/improvement)
MG examine and invest
fatiguability
- eg counting and rep movem
impaired upward gaze
nb reflexes normal
Ix:
antibody to ACh
nerve conduction
tensilon test - improves with edrophonium
?thymoma
Muscle disorders
Distinguished by weakness with normal reflexes
Muscular Dystrophy
- inherited x linked - present in childhood - life exp ~ 20’s
- duchennes and beckers
- prog wasting and weakness
Myotonic Dystrophy
- hered autosomal dom
- male pattern baldness
- dm, cataracts, cardiac, sleep
- successive generations more severe
- distal weakness and wasting
- diff relaxing grip **
Also
- inflammatory (myositis)
- metaboilic (steroids, cushings, thyroid)
Ix: creatinine phosphokinase
EMG, biopsy
genetics
Peripheral neuropathy subtypes
Polyneuropathy I DAVID - can be sensory, motor or mixed S: dm, alcohol M: GB, polio MS: CMT, CIDP
Radiculopathy
- often w spondylosis
- pain, ting, sensory dist, motor dist
Mononeuropathy
- eg carpal (median), common peroneal (foot drop), radial (wrist drop), ulnar (hand)
- can get multiplex in DM, hypothyroid, vasculitis
polyneuropathy
- length dependant
I DAVID
inherited - charcot marie tooth diabetes alcohol vitamin B12 inflammatory GB, CIPD, polio drugs - isoniazid, vincristine
neuropathy w nutritional deficit
thiamine - beriberi
- peripheral neurop + WK (confusion, speech probs, nystagmus)
wernicke korsakoff - seen w thiamine def - W enceph: confusion, nystag, ataxia - K psychosis: amnesia, halluc, confabulation
B12- subacute combined degen
- peripheral neurop
- prop and vib (dorsal column)
- umn signs (corticospinal)
Guillain barre
immune mediated demyel of PNS
- often triggered by infec
- classically campyobacter jejuni
prog weakness of 4 limbs (starts in legs)
reduced reflexes
?paraesthesia
?cranial nerve
Ix:
nerve conduction
monitor lung function
CSF: increased protein
T: IV Ig
charcot marie tooth
hered sensory motor polyneuropathy
weakness, wasting distally especially lower limbs
atrophic calf, prominent shin, champagne bottles
variable sensory loss
proprio loss - sensory ataxia, high step gate,
pes cavus and clawing of toes
mononeuropathies
carpal tunnel - median
saturday night - radial - wrist drop
common peroneal - foot drop
wrist drop
Mono or radiculo?
- from c7 nerve root lesion or radial nerve lesion
Test brachioradialis
- innervated by radial but not c7
- affected in radial lesion but not c7 lesion
Also mononeuritis multiplex
Foot drop
Mononeuropathy or radiculopathy?
Often L5 or common popliteal lesion
- get patient to invert foot - this uses median popliteal, L5
- ability retained in comm perin lesion not L5
Also could be
- diabetic mononeuritis multiplex
If bilat: i david
T1 vs ulnar lesion
Mono or radiculo
T1 nerve root lesion
- takes out all the muscles of the hand - wasting and weakness
Ulnar nerve root lesion
- thenar eminence preserved
- causes claw hand (4th and 5th fingers drawn in)
carpal tunnel
Idiopathic or 2dry to ra, trauma, preg, hypothyroid, dm
Numb pain at night and on waking
- relieved by shaking
- thenar wasting if severe
T:
- splinting at nights
- corticosteroid temporary but effective relief
- surgical decompression
Parkinsonism exam
General around bed
- salbut, thyroid, ldopa
Facies - hypomymia Eyes - blink rate, upgaze Nose - anosmia Greasy skin Glabellar tap Speech - hypophonic
Look: Tremor rest, amplify, essential, intention
Feel: Rigidity
Move: Brady (quack), handwriting
Posture (stooped) Righting reflex Gait - shuffle festinant small steps - no arm move - difficult initiating, freezing, turning - stooped
Follow up with
- lying standing bp
- righting reflex
- look at meds
Good Q - turning over in bed
Differentials
- PSP - up gaze
- MSA - cerebellar, post hypot, incontinence
- LBD - dementia
- Drug induced - haloperidol, prochlorpromazine
parkinsons management
Mdt etc
co-beneldopa - L dopa + periph inhibitor
- v effective (not vs tremor) but limited after 5 years
- dyskinesia, painful distonia, on/off
- se: halluc, post hypo
dopamine alternative/adjuncts:
- selegeline (MAOi),
- ropinirole (dop rec ag),
- amantadine (block dop reuptake),
give domperidone if drugs casue nausea
vs tremor - anti-muscarinics (orphenadine, benzhexol)
Parkinsons plus
MSA - autonomic, cerebellar
PSP - upgaze impaired
LBD - dementia
movement disorders
tremor - rhythmic oscillate
dystonic - invol contract
myoclonus - jerks
tic - can transiently suppress, relief post move
athetosis - slow writhing
choreoform - randome flowing dance-like
ballismus - high amplitude limb flail
essential tremor
exag by arms outstretch
dec with alcohol
T: propranolol
huntingtons
hereditary chorea (inviol writhing) dementia/behavioural element - cerbreal atrophy
onset in 30’s, progressive, usually die within 15yrs
autosomal dominant
causes of choreoform
huntingtons
wilsons
ataxic telangectasia
sle
antiphospholipid
drugs - L dopa, antipsych
meningitis
fever, headache, stiff neck, photophobia
bacterial - may be sepetic - tachy, hypot, shock -> purpuric rash, DIC - neisseiria meningitidis (meningococcus), strep pneumonia - risk neuro deficits - deaf, blind, cog Ix: blood cluture, csf T: high dose ceftriaxone
viral - often sefl limiting - less meningism (neck, photo) - often enterovirus T: treat as bacterial until ruled out, rehydrate, analgesia, ?acyclovir
encephalitis
fever, headache, confusion/drosy/changed behaviour, seizures
CSF - lymphocytes
most treatable form in herpes - so give acyclovir
- affects temporal lobes (seen on eeg, mri)
- affects memory and speech
- poor prognosis
cerebral abscess
rare
headache, fever (swingin), focal neurology
signs of raised ICP - papilloed
spread from ears, sinuses, or embolic
do not perform LP - risk coning
T - prolonged abx and surgery
25% mortality
Brain tumours
Can be classified as supratentorial and infratentorial
50% secondary - look for primary
Generally present w Headache - constant, at night, worse w cough/bend Seizures ICP - ha, vom, drowsy, papilloedema Focal neurology
If suspected do contrast enhanced CT
Supratentorial
- more of a mass effect - ICP and focal neuro
- inc astrocytoma, oligodendroglioma, lymphoma, meningioma
Infratentorial
- often specific defects (CN) and early/dramatic ICP rise
- eg acoustic neuroma most common
tumours metastasising to brain
LUNG, breast, genitourinary, bone
acoustic neuroma
benign tumour (schwannoma) in cerebellopontine angle
Schwanoma of sheath of 8th cn
affects nerve 8 first:
unilateral sn hearing loss
then vertgo
then affects 5 and 7:
trigem neuralgia?
unila facial weakness
Neurocutaneous syndromes
assoc w phaeochromocytoma
Neurofibromatosis
- type 1 - skin nf’s, cafe au lait, axillary freckles
- brain/meningeal tumours
- type 2 central tumours common - eg bilateral acoustic neuroma, also cutaneous
Von hippel lindau
- brain, renal, adrenal tumours
Dementia types
Alzheimers
- senile (beta amyloid) plaques and neurofibrillary tangles
- also cerebral atrophy on mri
- gradual progressive decline
- memory, visuospatial, nocturnal wondering, verbal, intellect, personality, self care
Vascular
- stepwise cog decline, vascular risk factors/history
- characteristic gait: march a petit pas
- cerebral atrophy and vascular lesions on mri
Lewy body
- parkinsonism - tremor, rigid, brady, gait - non treatable w dopa
- fluctuating consciousness
- nocturnal visual halluc
normal pressure hydrocephalus
triad
gait disorder
dementia (reversible)
urinary incontinence
- see enlarge of 4th ventricle
hydrocephalus
infantile: arnold chiari malf
- cereb tonsils in f.m.
- assoc spina bifida, syringomyelia
adult: tumour, post SAH (clot blocks ventricles)
Visual field defects
homonymous hemi
- lesion in contralat optic tract
homonymous quadratanopia
-PITS
(parietal inferior, temporals superior)
macula sparing - occip cortex
temporal - optic chiasm eg pit tumour
Cranial nerves 1 and 2
1 - olfactory
2 - optic - FARO(C) - fields - acuity - reflexes: light, accom - opthalmoscopy (- colour - ishihara)
Fields
- 4 quadrants, inattention, blind spot
Acuity
- wearing correction, 1 eye at a time
Reflexes
- light: hand divider. direct, consensual, swing (rapd)
- accom
Cranial nerve 3, 4, 6
3 Oculomotor 4 trochlear (sup oblique) 6 abducens (lat rectus)
Look for ptosis, squint
Ask about diplopia
Do H ?nystag or diplopia
3rd nerve palsy
eye down and out ptosis pupil dilate (in aneurysm)
post comm artery aneurysm
- painful
- pupil dilate
DM
weber’s syndrome - midbrain stroke
- w contralat hemiplegia
6th nerve palsy
failure of lateral rectus
may have strabismus (bad eye pulled in)
diplopia and strabismus maximal on lateral gaze
- eye may visibly fail to abduct
- patient reports double vision
- cover one eye at a time
- false image is fainter and more lateral
causes
- trauma
- diabetes, ms, tumour affecting 6th nerve
Cranial nerve 5, 7
5: trigeminal
- muscles of mastication
- sensation throughout face (opthalmic, maxillary, mandibular)
(corneal reflex)
7
- facial movements
bilateral facial weakness
primary muscle disease - muscular distrophy
nmj disease - myaeshenia gravis (bilat ptosis, opthalmopleia, fatiguable)
bells palsy
idiopathic unilateral lmn facial paralysis
? viral aetiology ?herpes simplex
onset over hours
assoc w pain in/behind ear
if caught early could start prednis and aciclovir
also eye drops to pretect cornea or tape down eyelid
90%self-limiting - few weeks
few have only partial recovery
7th facial nerve palsy
Upper vs lower motor neurone
Forehead will be spared in upper motor neurone lesion
Lower motor neuron (Bell’s) - whole side affected
Cranial nerves 8 - 12
8 - vestibulocochlear
- any hearing changes - rhinnes and webers
- any vertigo
9 glossopharyngeal
10 vagus
11 accessory
12 hypoglossal
causes pes cavus
Charcot Marie tooth disease
Hereditary spastic paraplegia
Cerebral palsy
causes of high stepping gait
sensory ataxia - sacd
peripheral neuropathy - bilat foot drop
Increased physiological blind spot
Pappiloedema
Level that spinal cord stops
L1/L2
post herpetic neuralgia treat
amitriptyline
pregabalin
Spinal cord tracts
Descending: Corticospinal
- decussation at medullar oblongata
- lateral and anterior cs tracts
- carry motor signals
Ascending
Dorsal column
- proprio, vibration, fine touch
Spinothalamic
- lateral and anterior tracts
- pain and temp; curde touch/pressure
neuro systems review
headache
fit faint funny turn
memory
eyes - diplopia
speech and swallow
weakness
tingling or loss of sensation
Approach to exam
Power- test normal side first
Sensory- test abnormal side first
EXPLAN: MS
disease where body attacks nerves in cns (brain and sc)
- causes injury to the insulation/coating of nerves
- impairs function
Can occur at different sites and come and go (r+r, episodic)
- often eyes - blurry vision, pain, colour/loss, movements
- weakness - limbs (spasticity), face, speech
- sensation - tingling, numb
- bladder
- coordination
FATIGUE AND DEPRESSION
All can come and go, but may have left over problems: accumulate disability
- very variable - three main patterns - after ten year some will be disabled, wheelchair, some functioning ok
Ix to monitor (mri, ver, csf)
Tx: prednis for attack
beta IFN prevents relapses
physio and support
EXPLAN: temporal arteritis
body attacks and causes inflammation in artery in side of face
- not fully understood, genetic and environmental factors
pain, claudication, v tender
FATIGUE MALAISE
can be assoc PMR - mornign v stiff in muscles
prednisiolone for about 2 years, slowly reducing
aspirin (prevent thrombo-occlusion)
MUST LOOK OUT FOR VISUAL CHANGES
se steroids: gastric bones infection sleep cushing
Signs of raised ICP
headache (progressive, worse w bending, coughing, on waking)
vomitting
visual disturbance, pupillary changes, papilloedema
reduced consciousness
rarer causes of dementia
Picks disease - Fronto Temporal dementia
- largely personality change - disinhibition, emotional unconcern
Normal pressure hydroceph
- gait, urinary, dementia
Pellagra
- niacin defic
- dementia, diarrrhoea, dermatitis
Prion disease
- dementia, myclonus, ataxia, blindness
- associated w CJD
infantile hydrocephaly features
big head 'sunset' appearance of eyes mental impair convulsions diplegic spasticity optic atrophy
causes of ptosis
congenital
- often w impaired upgaze (sup rectus)
acquired
- CN 3 palsy - eye down and out
- 2dry to PCA aneurysm; DM
- Horner’s - w anhydrosis and miosis
- MG - fatiguable
- myotonic dystrophy - w catarract
Senile myogenic ptosis
- most common*
- degen of muscle w age
