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EOY3 > Neurology > Flashcards

Neurology Flashcards

1
Q

types of pain

A

cancer vs non-cancer

nociceptive vs neuropathic

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2
Q

WHO pain management ladder

A

step 1 - mild analgesic (NSAIDS, paracetamol)
step 2 - weak opioids (codeine, tramadol)
step 3 - strong opioids (morphine, fentanyl, oxycodone, diamorphine, methadone)
step 4 - nerve block, epidurals, PCA pumps, spinal stimulators, neurolytic block therapy
adjuvants (ketamine, gabapentin, clonidine, amitriptyline)

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3
Q

nociceptive pain

A 
aching and localised if somatic 
diffuse if visceral 
associated with movement 
e.g. injury or post-op pain
Rx: conventional analgesia
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4
Q

neuropathic pain

A

burning, electric, shooting type
independent of movement
e.g. peripheral neuropathy, shingles and cancer pain
Rx: conventional analgesia plus anti-depressants and anticonvulsants

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5
Q

homunculus

A

somatotopy
face and hands have a disproportionately large area
upper extremity and head is supplied by the middle cerebral artery
the hip, lower extremity and genital are supplied by the anterior cerebral artery

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6
Q

DCML tract (ascending)

A

fine touch, proprioception and vibration

1st neurone enters the spinal column dorsally, synapses at the medulla (cuneate nucleus if above waist or gracile nucleus if below waist)
2nd neurone decussates at the medulla and synapses at the thalamus
3rd neurone travels to the sensory cortex

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7
Q

spinothalamic tract (ascending)

A

pain and temperature (lateral), crude touch and pressure (lateral

1st neurone enters the spinal column dorsally, synapses at the spinal cord (1 or 2 levels above synapse)
2nd neurone decussates at the spinal cord at level of 1st synapse and synapses at the thalamus
3rd neurone travels to the sensory cortex

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8
Q

corticospinal tract (descending)

A

lateral (primarily limbs), anterior (primarily axial)

UMN travels from the motor cortex through the lower medulla were it decussates, synapses with LMN in the anterior horn
LMN exits the spinal cord at the anterior horn and travels to the target muscle

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9
Q

brain blood supply

A

ANTERIOR CIRCULATION (from the internal carotids)

  • anterior cerebral artery: to frontal lobe and middle cerebrum
  • anterior communicating artery: connects the anterior cerebral arteries
  • ophthalmic arteries: to eyes
  • middle cerebral artery: lateral brain, parietal and temporal lobes
  • anterior choroidal artery
  • posterior communicating artery: supplies circle of Willis, dual supply with the posterior circulation

POSTERIOR CIRCULATION (from the vertebral arties)

  • posterior communicating artery: supplies circle of Willis, dual supply with the anterior circulation
  • posterior cerebral artery
  • superior cerebellar artery: superior cerebellum
  • basilar artery: brainstem
  • pontine arteries: pons
  • anterior inferior cerebella artery (AICA): anterior cerebellum
  • posterior inferior cerebella artery (PICA): inferior cerebellum
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10
Q

berry aneurysms

A 
predisposing factors "SHAME"
smoking
HTN
adult polycystic kidney disease
Marfans
Ehlers-Danlos

common sites: anterior communicating artery, posterior communicating artery and middle cerebral artery - circle of Willis

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11
Q

brainstem infarction

A

causes “locked in syndrome”
- basilar artery
reduced GCS, quadriplegia, miosis, absent horizontal eye movements
risk - uncontrolled HTN

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12
Q

middle cerebral artery

A

anterior circulation
affects upper body and causes facial paralysis on contralateral side (forehead sparing)
eyes deviate towards lesion, contralateral homonymous hemianopia, if ophthalmic artery affected get amaurosis fugax
verbal deficits - expressive aphasia or receptive aphasia (especially if left sided), verbal agnosia, confusion, apraxia
special defects - hemispacial neglect if parietal lobe affected

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13
Q

anterior cerebral artery

A

anterior circulation
causes contralateral hemiplegia of lower body and affects pelvic floor causing incontinence of urine (no sensory symptoms)
if olfactory bulb affected get anosmia
if frontal lobe affected get personality changes

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14
Q

posterior cerebral artery

A

posterior circulation
(no motor symptoms)
contralateral homonymous hemianopia with macular sparing, visual agnosia
visual hallucinations

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15
Q

Weber’s syndrome

penetrating branch of the PCA at midbrain

A

posterior circulation
contralateral hemiplegia - complete facial paralysis and unilateral parkinsonism
ipsilateral CNIII palsy (down and out), ipsilateral Horner’s syndrome
mild contralateral gait disturbance

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16
Q

Benedik’s syndrome (Weber’s plus right nucleus affected)

A

posterior circulation
contralateral hemiplegia - complete facial paralysis and unilateral parkinsonism
ipsilateral CNIII palsy (down and out), ipsilateral Horner’s syndrome
more severe contralateral gait disturbance

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17
Q

Wallenberg’s (PICA)

A

posterior circulation
ipsilateral facial sensory loss (CN V), contralateral body sensory loss
ipsilateral Horner’s syndrome
vertigo, ataxia, dysarthria and dysphagia

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18
Q

total anterior infarcts

A

MCA and ACA

unilateral hemiparesis +/or hemisensory loss of face, arm and leg, homonymous hemianopia, higher cognitive dysfunction

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19
Q

partial anterior circulation infarct

A

smaller arteries, 2 out of 3 of the signs of the total anterior infarct

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20
Q

posterior circulation infarct

A

vertebrobasilar artery: 1 of cerebellar or brainstem syndrome, loss of consciousness, isolated hemianopia

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21
Q

lacunar infarct

A

perforating artery around the internal capsule, thalamus and basal ganglia
1 of: unilateral weakness of face and arm, arm and leg or all three, pure sensory stroke, ataxic hemiparesis (ipsilateral pyramidal weakness)

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22
Q

ischaemic stroke

A

90% of all strokes
- thrombotic or embolic
- commonly caused by AF, HTN, smoking, hyperlipidaemia, DM
TIA symptoms last less than 1 day (use ABCD2 to assess)
treatment of ischaemic stroke - once a haemorrhagic stroke has been ruled out: aspirin 300mg STAT, thrombolysis with alteplase (if <4.5 hrs)
thrombolysis is CI if pregnant, uncontrolled HTN, history of intercranial haemorrhage
secondary prevention - clopidogrel and aspirin

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23
Q

haemorrhagic stroke

A

10-15% of all strokes
shows as white CT
- intracerebral haemorrhage or subarachnoid haemorrhage
- risk factors include HTN, AV malformations and anticoagulation therapy
more likely to have reduced consciousness, headache, nausea and vomiting and seizures in 25%
if CT/MRI confirms then neurosurgeon consultation to assess suitability for surgery
stop blood thinners or reverse if possible, control blood pressure acutely

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24
Q

epilepsy treatment

A

chronic condition of recurrent seizures, medication is usually started after 2nd epileptic seizure unless very strong family history or if first seizure was status epilepticus
investigations - EEG and MRI (looks for SoL)

  • sodium valproate for generalised seizures, P450 enzyme inhibitor
  • carbamazepine for partial seizures (and best if pregnant), P450 enzyme inducer
  • lamotrigine - high risk of Steven-Johnsons syndrome
  • phenytoin - P450 enzyme inducer
  • ethosuximide - used for absence seizures
  • benzodiazepines (e.g. diazepam) - status epilepticus
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25
Q

focal seizure

A 
aka partial seizure 
start in a specific area on one side of the brain 
often involves an automatism (tic)
simple = aware
complex = altered consciousness
26
Q

generalized seizure

A

affects both sides of the brain, LOS immediately
motor (tonic-clonic) and non-motor (absence)

can get secondary generalised which is a focal seizure which progresses to a bilateral seizure

may bite tongue, experience incontinence
may have a post-ictal phase

27
Q

Multiple Sclerosis

A

chronic cell mediated AI disorder characterised by demyelination in the CNS
MRI is diagnostic
different subtypes with the most common being relapsing remitting (65% will progress to secondary progressive within 15 years of diagnosis)
management:
- acute relapse (high dose methylprednisolone) shortens duration of relapse but not extent of recovery
- disease modifying: beta-interferon (has to met criteria, reduces relapse rate by 30%), glatiramer acetate (immunomodulating drug), natalizumab (recombinant monoclonal antibody)
- gabapentin, diazepam and dantrolene
- smoking cessation

28
Q

UMN vs LMN lesions

A

UMN

  • causes: stroke, spinal cord injury, motor neurone disease
  • signs: clasp-knife reflex/rigidity, no wasting, hypertonia, hyperreflexia, clonus, hemiparetic gait, positive Babinski sign

LMN

  • causes: traumatic injury, peripheral neuropathy, motor neurone disease
  • signs: muscle weakness, muscle weakness, hyporeflexia, hypotonia, fasciculations, negative Babinski sign
29
Q

peripheral neuropathy

A

ABCDE - alcohol, B12, CKD and carcinoma, DM and drugs, every vasculitis
predominantly motor loss (Guillian-Barre, porphyria, lead poisoning, diphtheria, HSMN e.g. Charcot-Marie-Tooth, CIDP)
predominantly sensory loss (DM, uraemia, leprosy alcoholism, vitamin B12 deficiency, amyloidosis
drugs (amiodarone, isoniazid, vincristine, nitrofurantoin, metronidazole)
alcoholic neuropathy (secondary to toxic effects and reduced B vitamin absorption)
vitamin B12 deficiency (subacute combined degeneration of the spinal cord, dorsal column usually affected 1st prior to distal paraesthesia)

30
Q

Wernicke’s area

A

interprets language (left posterior superior temporal gyrus)

Wernicke’s (receptive) aphasia - due to a lesion of the superior temporal gyrus, “forms” the speech, so sentences make no sense, word substitution and neologisms but fluent speech
comprehension is impaired

31
Q

Broca’s area

A

produces speech (left inferior frontal gyrus)

Broca’s (expressive) aphasia - due to a lesion of the inferior frontal gyrus, speech is non-fluent, laboured and halting
comprehension is normal

32
Q

conduction aphasia

A

classically due to a stroke, affects the arcuate fasiculus (the connection between Wernicke’s and Broca’s)
speech is fluent but repetition is poor, they are aware of the errors they are making
comprehension is normal

33
Q

global aphasia

A

large lesion affecting Wernicke’s, Broca’s and the arcuate fasiculus resulting in severe receptive and expressive aphasia

34
Q

cerebellar syndrome

A 
unilateral cerebellar lesions cause ipsilateral signs 
causes: "PASTRIES"
posterior fossa tumour, alcohol, sclerosis (MS), trauma, rare causes, inherited (Friedreich's ataxia), epilepsy medication, stroke 
symptoms: "DANISH" 
dysdiadochokinesia, dysmetria 
ataxia
nystagmus 
intention tremor
slurred speech, scanning dysarthria 
hypotonia
35
Q

epidural haemorrhage

A

between skull and parietal layer of dura mater
LEMON SHAPED
presents with: raised ICP, lucid interval followed by unconsciousness
location: MMA under the pterion (temporal)
causes: acceleration-deceleration or blow
target BP: >100-110

36
Q

subdural haemorrhage

A

between the dura and arachnoid mater
BANANA SHAPED
presents with: gradual increasing headache and confusion, can be acute or chronic (acute is whiter)
location: bridging veins (frontal/parietal)
causes: increased age, alcoholism
target BP: <140-180

37
Q

subarachnoid haemorrhage

A

between the pia and arachnoid mater
presents with: thunderclap headache, N&V, may lead to coma and death (25% die before they get to hospital)
location: berry aneurysm, circle of WIllis
causes : HTN and trauma
target BP: if spontaneous <140-160, if traumatic then >100-110

38
Q

intracerebral haemorrhage

A

bleed within the brain parenchyma
hyperdense on CT +/- clots possible mass effect
location: areas of traumatic contusion which fuse to form a haematoma

39
Q

management of raised intracranial pressure

A

if life-threatening give IV mannitol/ furosemide, whilst waiting for transfer
if diffuse cerebral oedema then decompressive craniotomy

40
Q

syringomyelia

A

the development of a syrinx in the central canal of the spinal cord, affects the cervical and the upper thoracic
slowly progressive, elongates over time - causes compression and pressure ischaemia
- get a “cape-like” distribution of pain and temperature sensation loss (spinothalamic), compresses them as they decussate
- many cases are linked to Arnold-Chian malformation
- may also get wasting and weakness of the arms, loss of reflexes, bilateral upgoing plantars and Horner’s syndrome
diagnosis - MRI
management - neurosurgical evaluation for surgical decompression

41
Q

motor neurone disease

A

presents with UMN and LMN signs
presents before 40 y/o, fatal within 3 years of onset
includes amyotrophic lateral sclerosis, progressive muscular atrophy and bulbar palsy
features: fasciculations, absence of sensory signs and symptoms, mixture of UMN and LMN signs, wasting of the small hand muscles/ tibialis anterior is common, sphincter dysfunction is a late feature
diagnosis is usually clinical but electromyography shows reduced number of action potentials with increased amplitude
management; riluzole (increases survival by six months)

42
Q

Brown-Sequard syndrome

A

ipsilateral loss of fine touch and vibration (DCML)
contralateral loss of pain and temperature (spinothalamic)
ipsilateral loss of motor function (corticospinal)

is the result of a hemisection to the spinal cord - due to trauma, tumour
MRI identifies cause

classic presentation = one sided motor loss/ spastic hemiplegia with same side loss of fine touch and vibration, opposite sided pain and temperature loss

43
Q

myasthenia gravis

A

an autoimmune disorder resulting in insufficient functioning of acetylcholine receptors
features: muscle fatigability (improves with rest), extraocular muscle weakness - diplopia
ix: single fibre electromyography, CT thorax to exclude thymoma, autoantibodies to acetylcholine receptors in 85-90%
Rx: pyridostigmine (long acting anticholinesterase), prednisolone (immunosuppression)

myasthenic crisis when respiratory muscles are affected –> plasmapheresis, IV immunoglobulins
exacerbating factors: exertion, drugs (penicillamine, beta-blockers, quinidine, procainamide, lithium, phenytoin, gentamicin, macrolides, quinolones, tetracyclines
patients are resistant to the GA suxamethonium

44
Q

conductive hearing loss

A

causes: blocjed external auditory meatus, ruptured tympanic membrane, otitis media +/- effusion, otosclerosis
bone > air in Rinnes
localises to affected ear in Webers

45
Q

sensorineural hearing loss

A

hair cell destruction due to noise or hair cell death due to ototoxic drugs (gentamycin or streptomycin)
air > bone in Rinnes
localises to normal ear

46
Q

acoustic neuroma

A

(vestibular schwannoma) is a benign tumour that develops on the balance (vestibular) and hearing, or auditory (cochlear) nerves leading from your inner ear to the brain, as shown in the top image. The pressure on the nerve from the tumour may cause hearing loss and imbalance.

47
Q

tension headache

A

recurrent non-disabling, bilateral, often described as a tight band
not exacerbated by activities of daily living

48
Q

cluster headache

A

pain occurs once or twice a day, every day for 4-12 weeks

intense pain around one eye may be accompanied with redness and swelling of that eye

49
Q

temporal arteritis

A

typically presents >60y/o
usually rapid onset (<1month) of unilateral headache with jaw claudication, tender palpable temporal artery and raised ESR
may get amaurosis fugax

50
Q

medication overuse headache

A

present for 15+ days per month

pts taking opioids and triptans are most at risk

51
Q

migraines

A

recurrent, severe, usually throbbing, associated nausea, aura and photosensitivity, pts describe going to bed, may be associated with menstruation in women
triggers “CHOCOLATE”
chocolate, hangovers/dehydration, orgasms, cheese/caffeine, OCP, lie-ins/lights, alcohol, travel, exercise
management:
acute - (5-HT receptor agonist)
oral triptan plus NSAID/paracetamol
prophylaxis - (5-HT receptor antagonist)
topiramate or propranolol (triptan if related to menstruation)

52
Q

headache red flags

A

immunocompromised patient or history of malignancy
vomiting without an obvious cause
sudden onset, peaking within 5 minutes (SAH)
orthostatic
change in personality
triggered by cough, sneeze, exercise

53
Q

Guillain-Barre syndrome

A

immune mediated demyelination of the peripheral nervous system often trigged by infection (campylobacter jejuni) anti-GMI antibodies in 25%
features: ascending paralysis - progressive weakness of all four limbs starting in the lower extremities, proximal before distal muscles

54
Q

Parkinson’s Disease

A

degeneration of dopaminergic neurones in the substantia nigra
features: bradykinesia, hypokinesia, pill rolling tremor, cogwheel rigidity, micrographia, anosmia, REM sleep behaviour disorder, depression
(if unilateral then likely to be multiple system atrophy)
treatment of parkinsons: levodopa plus carbidopa, selegiline and amantadine
us domperidone as an anti-emetic
do not use haloperidol

55
Q

dementia

A

a syndrome of progressive global decline in cognitive function

  • alzheimers disease
  • vascular dementia
  • lewy body dementia
  • frontotemporal dementia (Pick’s disease)
  • Huntington’s disease
  • (Creutzfeldt-Jakob disease)
56
Q

Alzheimer’s disease

A

risk factors: downs syndrome (due to increased APP gene), family history, hypothyroidism, previous head trauma
signs and symptoms: amnesia, disorientation, personality changes, reduced self care, apraxia, agnosia, aphasia, lexical anomia, paranoid delusions, depression, wandering, aggression, sexual disinhibiton
investigations: mental state exam, blood, ECG, CT, MRI
histologically: “BAT” - beta amyloid plaques, acetylcholine reduced, tangles (neurofibrillary)
treatment:
memantine (inhibits glutamate by blocking NMDA receptors)
donepezil (acetylcholinesterase inhibitors)
rivastigmine (acetylcholinesterase inhibitors)

57
Q

Vascular dementia

A

caused by infarcts in the small and medium vessels CVS risk factors
follows a stepwise deteriorating progression
1) following stroke
2) multi-infarct following multiple strokes
3) binswanger disease following microvascular infarcts
- amnesia, disorientation, personality changes, UMN signs, seizures, reduced self care, depression, issues with planning and concentrating
investigation - vasculitis screen, cholesterol levels, ECG, CT/MRI head
treatment - manage HTN, treat DM, aspirin, smoking cessation, statins

58
Q

Lewy body dementia

A

avoid antipsychotics, is associated with Parkinson’s
features: parkinsonism, visual hallucinations, fluctuating course of disease
investigations: alpha-synuclein cytoplasmic inclusions in substantia nigra, paralimbic and neocortical areas
management: avoid antipsychotics
levodopa (but may worsen symptoms), donepezil and rivastigmine

59
Q

Huntington’s dementia

A

(disease is the progressive degeneration of the indirect basal ganglia pathway - autosomal dominant)
features: uncontrollable choreiform movements, depression, irritability, anxiety, psychosis, OC behaviour
diagnostic genetic testing
treatment - no cure but treat symptoms
chorea (use and atypical antipsychotic)
OC thoughts and irritability (use SSRIs)

60
Q

Creutzfeldt-Jakob disease

A

caused by prions from infected meat
rapidly progressive (4-5 months), no cure, is fatal
EEG - triphasic spikes seen, LP 14-3-3 protein, CT/MRI

EOY3 (20 decks)

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