Neurology Flashcards
What is Multiple Sclerosis?
An inflammatory demyelinating disorder of the CNS characterised by plaques disseminated in time and space
What mediates the demyelination in MS?
T cells
How does pyramidal dysfunction in MS present?
Increased tone, spasticity, weakness
Where is the weakness in MS?
Extensors of upper limbs, flexors of lower limbs
What sensory symptoms may be present in MS?
Pins & needles/numbness
Pain
Trigeminal neuralgia
What is Lhermitte’s syndrome?
Paraesthesia of the limbs on neck flexion
What cerebellar symptoms may be present in MS?
Ataxia, intention tremor, nystagmus, past pointing, pendular reflexes, dysdiadochokinesia, dysarthria
What visual symptoms may be present in MS?
Optic neuritis, optic atrophy, internuclear ophthalmoplegia, Uhtoffs phenomenon
What is Uhtoff’s phenomenon?
Worsening of vision due to increased body temperature
What other symptoms may be present in MS?
Fatigue, urinary incontinence, sexual dysfunction, intellectual deterioration
What are the types of MS?
Relapsing remitting
Relapsing progressive
Primary progressive
Secondary Progressive
What is the commonest type of MS?
Relapsing remitting
What investigations should be done if you suspect MS?
Bloods (FBC, PV, CRP, autoantibodies, B12, folate - all negative)
MRI
CSF
What does an MRI in MS show?
T2 weighted MRI shows plaques disseminated in time and space
What does electrophoresis of CSF show in MS?
Oligoclonal bands of IgG
What does neurophysiology show in MS?
Delayed evoked potentials
What criteria is used to diagnose MS?
McDonald Criteria
How should an acute exacerbation of MS be treated?
Methylprednisolone (oral or IV)
What are some first line disease modifying therapies for MS?
Beta-interferon
Copaxone
Tecfidera
How is fatigue managed in MS?
Amantadine
How is spasticity managed in MS?
Baclofen/gabapentin
How is oscillopsia managed in MS?
Gabapentin/memantine
How is emotional lability managed in MS?
Amitriptyline
What is motor neurone disease?
An untreatable and rapidly progressive neurodegenerative condition characterised by selective loss of motor neurones
What symptoms do you get in MND?
UMN and LMN signs
No sensory loss, no sphincter disturbance, no eye movements affected
What is the commonest type of MND?
Amyotrophic lateral scleorsis
What nerves do pseudobulbar palsy/bulbar palsy affect?
CN IX-XII
What investigations should be done for MND?
MRI (normal)
Nerve conduction studies (normal)
EMG
What does EMG show in MND?
Fasciculations and fibrillations
What drug prolongs life in MND and for how long?
Riluzole - anitglutaminergic drug prolongs life by 3 months
What drugs can be used for symptomatic relief in MND?
Quinine/baclofen for cramps
Baclofen/gabapentin for spasticity
Propantheline/botox for drooling
Supplements/gastronomy for nutrition
What does curare poisoning cause?
Blockage of acetylcholine receptors at NMJ leading to no muscle contraction (can mean no respiration)
What is botulism?
Caused by botilinum toxin, which blocks release of acetylcholine, causing flaccid paralysis
What is Lambert-Eaton Myaesthenic syndrome?
Antibodies against pre-synaptic calcium channels
What is LEMS associated with?
Small cell lung cancer
What are the symptoms of LEMS?
Weakness of limbs (improves with exercise), autonomic involvement, hyporeflexia
What investigations would you do for LEMS?
Bloods (increased autoantibodies)
EMG (shows improvement of potentials after use)
How is LEMS treated?
TREAT UNDERLYING CANCER. Steroids, azaithioprine, pyridostigmine, immunoglobulins
What is Myaesthenia Gravis?
Autoimmune condition against post-synaptic acetylcholine receptors
Who commonly gets Myaesthenia Gravis?
Commonly females in 3rd decade of life or Males in 6th/7th decade
What are symptoms of Myaesthenia Gravis?
Muscular fatigue, eye signs (e.g. ptosis, diplopia), gets worse throughout day. Voice deterioration as they speak.
What can exacerbate symptoms of Myaesthenia Gravis?
Pregnancy, change of climate, emotion, exercise, certain medications
What investigations can be done for Myaesthenia Gravis?
Bloods (autoantibodies)
Tensilon test
Neurophysiology (decreased response to nerve stimulation over time)
How is Myaesthenia Gravis treated?
Pyridostigmine for symptom control
Steroids/azaithioprine/methotrexate for immunosuppression
Thymectomy may be needed if disease not well controlled by anticholinesterases
What is Myaesthenic crisis?
Weakness of respiratory muscles during a relapse which can be life threatening
How is a myaesthenic crisis treated?
Plasmapheresis or IV Immunoglobulins
What makes up the triad of meningism?
Fever, headache and neck stiffness
What are the key symptoms of meningitis?
Meningism, photophobia, confusion, agitation, seizure, non-blanching purpuric rash
What is Kernig’s sign?
Pain and resistance on passive extension of the knee with flexed hip
What are some viral causes of meningitis?
ECHO virus, coxsackie virus, herpes simplex
What are the common bacterial causes of meningitis in neonates?
Listeria, Group B strep, E coli
What is the commonest bacterial cause of meningitis in children?
Haemophilus influenzae
What is the commonest bacterial cause of meningitis in those aged 10-21?
Neisseria Meningitidis
What are the common bacterial causes of meningitis in those over 21?
Strep pneumoniae and neisseria meningitidis
What are the common bacterial causes of meningitis in the elderly?
Strep pneumoniae, Listeria
What is aseptic meningitis?
Inflammation of the meninges with no pus
What are some causes of an aseptic meningitis?
TB, HIV, syphilis, vasculitis, drug induced
What investigations should you consider in someone with suspected meningitis?
Bloods (FBC, U&Es, coag screen, glucose, cultures), throat swab, CXR if suspect TB, LP is diagnostic
When is a lumbar puncture contraindicated?
Immunocompromised
Papilloedema
Focal neurological signs
On LP, which organisms show neutrophilia?
Bacterial
On LP, which organisms show lymphocytes?
Viral and TB
What are protein and glucose like in viral meningitis?
Normal
What are protein and glucose like in bacterial meningitis?
High protein, low glucose
What is the empirical antibiotic treatment for bacterial meningitis?
IV ceftriaxone 2g BD + Dexamethasone 10mg IV QDS
What antibiotic should be added if you suspect listeria as a cause of bacterial meningitis?
Amoxicillin IV 2g 4hrly (Chloramphenicol if allergic)
Who should be contacted if there is a case of bacterial meningitis?
Public Health
What is the contact prophylaxis for bacterial meningitis?
500mg ciprofloxacin orally
What is encephalitis?
Inflammation of the brain parenchyma
What are the common causes of encephalitis?
Herpes simplex, varicella zoster, CMV/HIV
How does encephalitis present?
Similar to meningitis but may also be odd behaviours or aphasia (if temporal lobe affected)
What investigations should be done for encephalitis?
LP - CSF shows lymphocytosis. Do PCR for HSV
MRI - may show ‘temporal lobe enhancement’
What is temporal lobe enhancement on MRI a sign of?
Herpes Simplex Encephalitis
How is Herpes Simplex Encephalitis treated?
IV Aciclovir
How does a brain abscess present?
Raised ICP, focal neurological signs, fever
How is a brain abscess diagnosed?
CT head
How is a brain abscess treated?
Surgically - crainiotomy and debridement
What is progressive multifocal leukoencephalopathy caused by?
JC virus which causes widespread demyelination
What are some risk factors for PML?
Immunosuppression, autoimmune disease, MS drugs
How is PML investigated?
LP shows JC virus DNA
MRI shows focal white matter lesions
What is Parkinsons disease?
Progressive neurodegenerative condition caused by degeneration of dopaminergic neurons in the substantia nigra
What is the biggest risk factor for Parkinson’s Disease?
Age
What are the 3 main motor symptoms of Parkinson’s Disease (Parkinsonism)?
Bradykinesia
Tremor
Rigidity
How does bradykinesia present in Parkinsons?
Slowness of movement with progressive loss of amplitude, decreased facial expression (mask like expression), soft speech, micrographia, shuffling gait, decreased arm swing
What is the tremor like in Parkinsons?
4-7hZ pill rolling resting tremor, worse when stressed/tired. Usually disappears when doing something
How does the rigidity present in Parkinsons?
Increased tone
What is cogwheel rigidity?
Felt at the wrist, the result of the tremor imposed on hypertonia
What are some non-motor symptoms of Parkinsons?
Anosmia, visual hallucinations, REM sleep disorder, depression, drooling, constipation
What is the first line treatment for Parkinsons if QOL is severely affected by motor symptoms?
Levodopa
What is the first line treatment for Parkinsons if QOL not severely affected by motor symptoms?
Dopamine agonist, levodopa or MAO-B inhibitor