Neurology Flashcards
1
Q
What percentage of strokes are embolic?
A
85%
2
Q
What percentage of strokes are haemorrhagic?
A
10%
3
Q
What are the rarer causes of strokes?
A
Vasculitis
4
Q
What is the typical presentation of an intracerebral haemorrhage?
A
Sudden onset headache
Drowsiness
Vomiting
Focal deficit
5
Q
What are the primary causes of ICH?
A
Hypertension - Charcot-Bouchard aneurysms
Amyloid angiopathy
6
Q
What are the secondary causes of ICH?
A
Tumour, AVM, cerebral aneurysm, haemorrhagic transformation infarct, venous infarct, anticoagulants
7
Q
What locations of ICH are typical of hypertensive bleeds?
A
Basal ganglia
Pons
Cerebellum
8
Q
What are the three complications of Charcot-Bouchard aneurysms?
A
Rupture
Thrombosis
Leakage
9
Q
What complication does intraventricular extension cause?
A
Hydrocephalus as the brain cannot resorb CSF
10
Q
What is the management of an anticoagulant-related ICH?
A
Discuss with haematologist
If on warfarin check INR and consider reversal with Beriplex and Vit K
If has low platelets - consider transfusion
11
Q
What imaging can be used post-stroke?
A
CTA, MRA, catheter angiography
12
Q
Why is imaging used post-stroke (ICH)?
A
To look for causes of the ICH e.g. vascular abnormalities, tumours or microbleeds
13
Q
What are the symptoms of an ACA stroke?
A
Leg weakness Sensory disturbance in the legs Gait apraxia - truncal ataxia Incontinence Drowsiness Akinetic Mutism - decrease in spontaneous speech - stuporous state
14
Q
What are the symptoms of an MCA stroke?
A
Contralateral arm and leg weakness Contralateral sensory loss Hemianopia Aphasia Dysphasia Facial droop
15
Q
What are the symptoms of an PCA stroke?
A
Contralateral homonymous hemianopia
Cortical blindness with bilateral involvement of the occipital lobe branches
Visual agnosia
Prosopagnosia - face blindness
Dyslexia, anomic aphasia, colour naming and discrimination problems
Headaches unilateral
16
Q
What is the treatment for an ischaemic stroke?
A
Thrombolysis (up to 4.5 hours post onset of symptoms)
Clot retrieval
Intra-arterial thrombolysis
Decompressive craniectomy
17
Q
What are the contraindications of thrombolysis?
A
Recent surgery in the last 3 months Recent arterial puncture History of active malignancy Evidence of brain aneurysms Patient on anticoagulation Severe liver disease Acute pancreatitis Clotting disorder
18
Q
Name 3 types of primary headache.
A
Migraine
Cluster
Tension type
19
Q
Name 3 types of secondary headaches.
A
Meningitis Subarachnoid haemorrhage Giant cell arteritis Idiopathic intracranial hypertension Medication overuse headache - caused by overuse of OTC medications
20
Q
Under what circumstances would you consider immediate referral to a neurologist regarding a headache?
A
Thunderclap headache - ?SAH Seizure and new headache ?meningitis ?encephalitis Red eye - ?acute glaucoma Headache and new focal neurology including papilloedema
21
Q
What are the red flags with headache?
A
New headache with a history of cancer Cluster headache Seizure Significantly altered consciousness, memory, confusion, coordination Papilloedema Other abnormal neuro exam of symptoms
22
Q
What are the different types of common headache?
A
Migraine (episodic with and without aura; chronic migraine)
Medication overuse
Tension type headache
23
Q
What is the abortive treatment for migraine?
A
An oral triptan and an NSAID or an oral triptan and paracetamol
Consider an anti-emetic, even in the absence of N&V.
24
Q
What is the preventative treatment of migraine?
A
Topiramate or propanolol, amitriptyline. Advise patients to take 400 mg riboflavin OD.
25
What do nerve conduction studies assess?
The peripheral nervous system
26
What can nerve conduction studies show?
Axon loss - small responses
| Myelin loss - slow responses
27
What is electromyography used for?
To determine whether a PNS problem is in the nervous system or muscle. The NCS is normal even though the patient is weak, the problem is with the muscle.
28
What are EEGs used for?
Primarily done for patients with seizures.
29
What do somatosensory evoked potentials examine?
Look at the integrity of the dorsal columns.
30
How do somatosensory evoked potentials work?
You stimulate the peripheral nerve and record a response from the somatosensory cortex using scalp electrodes, like an EEG.
31
What do visual evoked potentials examine?
The visual pathways
32
What are visual evoked potentials used for?
To look for demyelination in the optic nerve in conditions such as MS
33
What are somatosensory evoked potentials used for?
To diagnose MS and intraoperative monitoring e.g. in spinal cord surgery
34
What is transcranial magnetic stimulation?
A brief magnetic pulse induces an electric current that excites cells in the motor cortex.
35
What are the main uses of transcranial magnetic stimulation?
To diagnose motor neuron disease, MS and to treat severe depression.
36
What is meningitis?
Inflammation of the meninges; it can be bacterial, viral or fungal.
37
What is encephalitis?
Inflammation of the brain, it is usually viral
38
What is encephalopathy?
A reduced level of consciousness/diffuse disease of brain substance, usually non-infective but has multiple aetiologies.
39
What is neuropathy?
Damage to the peripheral nerve e.g. diphtheria, Guillain-Barre syndrome, Lyme disease and Hep A
40
What is polyradiculopathy?
Inflammation of the nerve roots e.g. in cauda equina, HIV + CMV/syphilis/HSV
41
What is myelitis?
Inflammation of the spinal cord (whole cord cross section vs. anterior horn cells)
42
What is meningoencephalitis?
It resembles both meningitis and encephalitis.
43
What are the clinical signs of meningeal irritation?
Reduced GCS
Headache
Neck stiffness
Papilloedema
Kernie's sign (extension of the knee is painful when the hip is flexed)
Burdzinski's sign (severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed
44
What are the important steps in the management of meningeal irritation?
```
Blood cultures before antibiotics
Antibiotics
Bloods: FBC, U&E, CRP, serum glucose, lactate
Lumbar puncture
CT head
Throat swabs (bacterial and viral)
Pneumococcal and meningococcal serum PCR
```
45
What are the important adverse effects of a lumbar puncture?
```
Headache
Parasthesia
CSF leak
Damage to the spinal cord
Cerebral herniation and death
```
46
What investigations should be performed on CSF for ?meningitis?
```
CSF protein and glucose
MC&S
Viral PCR (enterovirus, HSV/VZV)
Bacterial PCR
Simultaneous serum glucose
```
47
What are the common bacterial causes of meningitis in children and adults?
Neisseria meningitides
Streptococcus pneumoniae
Listeria monocytogenes
Haemophilus influenzae
48
What are the common bacterial causes of meningitis in neonates?
E. coli (gut flora can spread easily in a neonate)
Group B streptococci (carried by some women in the vagina)
Listeria monocytogenes
49
What is the management for suspected bacterial meningitis?
IV Cefotaxime (or ceftriaxone; chloramphenicol if the patient has severe anaphylaxis with beta-lactams)
Add amoxicillin IV for listeria cover if >55, immunocompromised or the patient has a Hx of alcohol excess
Add steroids
Consider vancomycin in return travellers
50
What forms of meningitis don't require prophylaxis?
Those caused by H. influenzae and pneumococcal bacteria if the patient has been vaccinated.
51
What is meningococcal sepsis?
Meningitis and septicaemia where the bacteria are in the blood; this is a medical emergency.
52
What is the treatment for viral meningitis?
There is no specific treatment, treatment is just supportive.
53
What is the management of encephalitis?
Treat empirically with IV acyclovir.
54
What are the symptoms of encephalitis?
Fever
Headache
Lethargy
Behavioural change
55
What are the symptoms of rabies?
```
Fever
Anxiety
Confusion
Hydrophobia
Hyperactivity/uncontrollable excitement
Hallucinations
Violent movements
```
56
What are the symptoms of tetanus?
```
Paraesthesia of the wound
Lockjaw
Sustained muscle contractions
Involvement of the facial muscles
Paroxysmal generalised spasms
```
57
What are the symptoms of Clostridium botulinum infection?
```
Descending paralysis with cranial neuropathy first then:
Diplopia
Dysarthria
Dysphagia
Peripheral weakness
```
58
What is the aetiology of a TIA?
It is usually embolic but it may be thrombotic. The most common source of emboli is the carotids, usually the bifurcation. It can also originate with AF and valve disease.
59
What is the pathophysiology involved in a TIA?
There is temporary inadequacy of the circulation in part of the brain leading to a cerebral or retinal deficit. It doesn't last >24 hours and most last <30 minutes.
60
What are the risk factors associated with TIA?
```
HTN
Smoking
DM
Heart disease
Peripheral arterial disease
Polycythaemia vera
Combined OCP
Hyperlipidaemia
Excess alcohol
Clotting disorders
```
61
Which gender experiences more TIAs?
Males
62
What are the symptoms of a TIA?
Unilateral weakness, unilateral sensory loss, drooping face, confusion, difficulty with speech, amaurosis fugax (painless, fleeting loss of vision)
63
What are the signs of a TIA?
Dysarthria (difficulty with speech), dysphagia, loss of memory, abnormal behaviour, homonymous hemianopia, diplopia, ataxia
64
What tests are used to diagnose a TIA?
A TIA is a retrospective diagnosis as it is only once it's over that it's diagnosed as a TIA
Bloods: FBC, ESR, U&Es, fasting lipids and glucose, LFTs, TSH
ECG - may show AF, MI or evidence of myocardial ischaemia
Imaging - carotid doppler
ABCD2 score - predicts risk of a stroke
65
What is the treatment for a stroke?
Control cardiovascular risk factors e.g. HTN, hypercholesterolaemia, smoking cessation
Clopidogrel
Carotid endarterectomy if stenosis is >70%
66
What is the aetiology of a stroke?
Young patient: vasculitis, thrombophilia, SAH, venous sinus thrombosis, carotid artery dissection
Older patient: thrombosis, thromboembolism, CNS bleed, vasculitis
67
What is the pathophysiology of a stroke?
A stroke is due to disruption of the blood supply caused by ischaemic infarction of part of the brain or from intracranial haemorrhage
68
What are the risk factors for a stroke?
```
HTN
Smoking
DM
Heart disease
Peripheral arterial disease
Polycythaemia vera
Combined OCP
Hyperlipidaemia
Excess alcohol
Clotting disorders
Post-TIA
```
69
What is the epidemiology of a stroke?
Most occur in patients >65
70
What are the symptoms of a stroke?
Facial drooping, weakness in a limb or side of the body, hemisensory loss, dysphagia, diplopia, ataxia, imbalance, unsteadiness, dysarthria
71
What are the signs of a stroke?
Nystagmus, Horner's syndrome, hemianopia, flaccid paralysis (becomes spastic later), locked in syndrome - complete infarction affecting the pons
72
What tests are used to diagnose a stroke?
Bloods: FBC, ESR, glucose and lipids
Imaging - head CT, MRI head, carotid doppler, cerebral angiography
Echo if suspected cardiac emboli
ECF - AF
73
What is the treatment for a stroke?
Ischaemic - thrombolysis (IV alteplase, must be given <4.5 hours from onset), aspirin for 2 weeks then clopidogrel
Haemorrhagic - BP control, beta blockers, Beriplex if it's warfarin related, clot evacuation
Risk factor management e.g. antihypertensives, statins
74
What are the risk factors for a SAH?
HTN, smoking, cocaine use, excess alcohol, Ehlers-Danlos syndrome (type 4), ADPKD and neurofibromatosis (type 1) - all genetic conditions associated with aneurysms
75
What is the pathophysiology involved in a SAH?
It is usually a result of bleeding from a Berry aneurysm, there is spontaneous arterial bleeding into the subarachnoid space
76
What is the epidemiology of SAH?
Women > men
77
What are the symptoms of a SAH?
Sudden onset severe headache, loss of consciousness, photophobia, seizures, nausea and vomiting, diplopia
78
What are the signs of a SAH?
Positive signs of meningism e.g. Kernig's sign (painful knee extension when the thigh is flexed), neck stiffness, papilloedema.
79
What tests are used to diagnose a SAH?
Head CT without contrast - white star shape
Angiography
LP - xanthochromia (yellow discolouration of the CSF)
ECG
80
What is the treatment for a SAH?
Refer to neurosurgery - clip or coil the aneurysm
Supportive treatment e.g. intubation and ventilation if necessary (+/- NG feeding)
Analgesia and antiemetics for conscious patients
81
What are the complications of a SAH?
Cerebral ischaemia and hydrocephalus
82
What is the aetiology of a subdural haemorrhage?
Blunt head trauma e.g. banging the head on the floor after falling is the usual mechanism of injury; can be acute, subacute (3-7 days post injury) or chronic (2-3 weeks post injury)
83
What is the pathophysiology involved in a subdural haemorrhage?
There is tearing of the bridging veins from the cortex to one of the draining venous sinuses. Days/weeks later the haematoma starts to autolyse causing an increase in oncotic pressure and osmotic pressure, water enters the heamatoma and causes a gradual increase in ICP
84
What is the epidemiology involved in a subdural haemorrhage?
Incidence increases with age
85
What are the symptoms of a subdural haemorrhage?
Headache, seizures, vomiting, nausea, anorexia, increasing drowsiness/confusion, speech difficulties
86
What are the signs of a subdural haemorrhage?
Papilloedema, bradycardia, hypertension, bruising or purpura
87
What tests are used to diagnose a subdural haemorrhage?
Bloods: FBC, U&Es, LFTs, clotting screen - could show coagulopathy
CT head - crescent shaped mass and midline shift
88
What is the treatment for a subdural haemorrhage?
Refer to neurosurgery - clot evacuation and craniotomy
Hypertonic saline or mannitol can be used to treat increased ICP
Treat any coagulopathy
89
What is the aetiology of an extradural haemorrhage?
It is most often due to a fractured temporal or parietal bone damaging the middle meningeal artery or vein; they can also occur in the spinal column
90
What is the pathophysiology involved in an extradural haemorrhage?
There is a collection of blood between the dura and bone, usually the skull but can be the spine
91
What is the epidemiology of an extradural haemorrhage?
Males > females
92
What are the symptoms of an extradural haemorrhage?
Loss of consciousness, severe headache, vomiting, seizures, confusion, nausea, coma
Weakness, numbness, urinary and/or faecal incontinence - spinal EDH
93
What are the signs of an extradural haemorrhage?
Bradycardia +/- hypertension, CSF otorrhoea or rhinorrhoea, unequal pupils.
Patients are often knocked unconscious at the time of injury, have a lucid interval and then deteriorate
94
What tests are used to diagnose an extradural haemorrhage?
XR of the skull - might show a fracture
CT head - lentiform shaped mass
Bloods
Avoid an LP
95
What is the treatment for an extradural haemorrhage?
ABCDE
Protect the neck until injury has been excluded
Refer to neurosurgery - evacuate the haematoma
Raised ICP can be treated with hypertonic saline and mannitol
96
What is the cause of epilepsy?
Most cases are idiopathic but epilepsy can also be caused by CVA, head injury, CNS infections, autoimmune disease, brain neoplasm, genetic diseases and drugs
97
What is the pathophysiology involved in epilepsy?
There is a sudden, synchronous discharge of cerebral neurons causing symptoms/signs of abnormal electrical activity.
98
What are the symptoms of epilepsy?
Seizure-related symptoms include sudden falls, involuntary jerky movements of limbs whilst awake, blank spells, unexplained incontinence of urine, deja vu, fear, premonition, olfactory, gustatory, visual or auditory hallucinations, post-ictal symptoms
99
What are the signs of epilepsy?
There are no obvious physical signs
100
What tests are used to diagnose epilepsy?
Bloods: FBC, U&Es, glucose, serum calcium, LFTs, renal function
EEG, sleep recordings or 24 hour ambulatory EEG, inpatient EEG videotelemetry
MRI of the head
101
What is the treatment for epilepsy?
Focal - carbamazepine (inhibits Na channels) or lamotrigine (inhibits glutamate release)
Generalised - sodium valproate (inhibits Na channels) or lamotrigine
102
What is status epilepticus?
It is a medical emergency which occurs when someone has had a seizure longer than 30 minutes or 2 or more seizures without recovery of consciousness between them over a similar period. There is risk of permanent cerebral damage.
103
What is the aetiology of Parkinson's disease?
It is mostly idiopathic, there is a small increased risk with rural living and drinking well water; pesticide exposure increases risk
104
What is the pathophysiology involved in Parkinson's disease?
Pathological hallmarks are the presence of neuronal inclusions - Lewy bodies and loss of the dopaminergic neurones in the substantia nigra
105
What are the symptoms of Parkinson's disease?
Tremor at rest, rigidity, bradykinesia, impairment of dexterity, fixed facial expression and infrequent blinking, cognitive impairment - PD dementia
106
What are the signs of Parkinson's disease?
Progressive fatiguing and reduction in amplitude of repetitive movements, pill-rolling tremor, stooped posture, reduced arm swing on 1 side, shuffling
107
What tests are used to diagnose Parkinson's disease?
Parkinson's disease is a clinical diagnosis and is made by a neurologist upon a thorough neurological examination. MRI is normal but not necessary in typical cases.
108
What is the treatment for Parkinson's disease?
Medication - Levodopa, dopamine agonists e.g. rotigotine, monoamine oxidase inhibitors e.g. selegiline
Deep brain stimulation
109
What is the aetiology of Huntington's chorea?
Huntington's disease is an autosomal dominant disease due to CAG trinucleotide repeat expansion in huntingtin, the protein gene product.
110
What is the pathophysiology involved in Huntington's chorea?
There is cell loss within the basal ganglia and cortex, loss of GABAergic and cholinergic neurones
111
What are the symptoms of Huntington's chorea?
Personality change, self-neglect, apathy and clumsiness, depression, fidgeting with fleeting facial grimaces and then chorea (abnormal, involuntary movements) and dementia
112
What are the signs of Huntington's chorea?
Progressive chorea, rigidity and dementia, seizures, dystonia, Parkinsonian features, cardiomyopathy, skeletal muscle wasting, pyramidal tract signs
113
What tests are used to diagnose Huntington's chorea?
```
Imaging - MRI or CT in moderate-severe disease shows a loss of striatal volume and increased size in the frontal horns of the lateral ventricles
Genetic testing (and extensive genetic counselling)
```
114
What is the treatment for Huntington's chorea?
There is NO cure or disease-modifying treatments, just symptom control
Chorea: sulpiride - atypical antipsychotic
Depression: SSRIs e.g. citalopram, paroxetine
Aggression: Risperidone - antipsychotic
115
What are some triggers for migraine?
```
CHOCOLATE
Chocolate, cheese
Hangovers
OCP
Caffeine
Orgasms
Lie ins
Alcohol
Travel
Exercise
```
116
What is the pathophysiology involved in migraines?
They are thought to be primarily neurogenic rather than vascular.
117
What are the three main types of migraine?
Migraine with aura
Migraine without aura
Migraine aura without headache
118
What are the symptoms of a migraine?
Unilateral headache, pulsing pain, moderate-severe headache, aggravation by routine physical activity
119
What are the signs of a migraine?
Aura - visual, auditory or motor (rare), nausea and/or vomiting, photophobia.
Lasts 4-72 hours
120
What tests are used to diagnose a migraine?
A full history and examination is all that is usually required. Investigations are only required to exclude alternative diagnosis.
121
What is the treatment for a migraine?
Acute: oral triptan e.g. sumatriptan and NSAIDs e.g. ketoprofen
Prophylaxis - beta blocker e.g. propanolol
122
What are the symptoms of a cluster headache?
Recurrent bouts of excruciating unilateral retro-orbital pain, redness or tearing of the eye, nasal congestion, lasts 45-90 minutes and bouts last 6-12 weeks
123
What are the signs of a cluster headache?
Eyelid swelling, transient Horner's syndrome with miosis and ptosis
124
What is the aetiology of trigeminal neuralgia?
It is thought to be caused by compression of the trigeminal nerve by a loop of artery or vein; hypertension is a risk factor
125
What is the pathophysiology of trigeminal neuralgia?
There is intense and extreme episodes of pain in the face, most commonly the maxillary (V2) and/or mandibular (V3) branch are involved
126
What are the symptoms of trigeminal neuralgia?
Preceding symptoms e.g. tingling or numbness, sharp, severe shock like pain on one side of the cheek/face. Pain is episodic and may go into remission.
127
What are some triggers of trigeminal neuralgia?
Light touch to the face, eating, cold winds and vibration can all be triggers.
128
What are the signs of trigeminal neuralgia?
There are no signs of Vth nerve dysfunction on examination
129
What tests are used to diagnose trigeminal neuralgia?
DIagnosis is clinical but can be difficult to make. MRI of the head is indicated to rule out other diagnoses if the diagnosis is uncertain or red flags e.g. deafness, sensory changes are present
130
What is the treatment of trigeminal neuralgia?
Medical: carbamazepine, oxcarbazepine
Surgical: microvascular decompression of the trigeminal nerve or rhizotomy - damage the trigeminal nerve to prevent pain transmission
131
What is the aetiology of giant cell/temporal arteritis?
It is unknown but there are clinical connections with polymyalgia rheumatica, a large vessel vasculitis
132
What is the pathophysiology involved in giant cell/temporal arteritis?
There is a chronic inflammatory process, predominantly of large arteries. There is systemic immune-mediated vasculitis leading to inflammation of the vessel wall.
133
What are the symptoms of giant cell/temporal arteritis?
Severe headaches, tenderness of the scalp, jaw claudication and tenderness, diplopia, malaise, tiredness, weight loss, sweats, proximal stiffness (a feature of PMR)
134
What are the signs of giant cell/temporal arteritis?
Fever, muscle and joints may be tender, bruits (murmur) may be heard over the carotid, axillary or brachial arteries, swelling and tenderness of the temporal or occipital arteries
135
What tests are used to diagnose giant cell/temporal arteritis?
FBC - normochromic, normocytic anaemia
ESR - high
CRP - high
LFTs - abnormal, high alk phos and low albumin
Biopsy of the temporal artery - granulomatous inflammation of the intima and media, giant cells, lymphocytes and plasma cells in the internal elastic lamina
136
What is the treatment for giant cell/temporal arteritis?
High dose corticosteroids e.g. IV methylprednisolone
Calcium and vitamin D supplements (+/- bisphosphonates) to prevent osteoporosis
Tocilizumab - anti-interleukin 6 receptor monoclonal antibody
137
What is the aetiology of cauda equina syndrome?
Herniation of a lumbar disc (L4/L5 or L5/S1), tumours, trauma, infection, congenital e.g. spina bifida, spondylolisthesis, IVC thrombosis, sarcoidosis, late stage ankylosing spondylitis
138
What is the pathophysiology involved in cauda equina syndrome?
There is compression of the nerves forming the cauda equina (L2-S5); it is a MEDICAL EMERGENCY and requires immediate referral
139
What are the symptoms of cauda equina syndrome?
Lower back pain, pain in the legs (unilateral or bilateral), lower limb motor weakness and sensory deficits, urinary and/or faecal incontinence, urine retention
140
What are the signs of cauda equina syndrome?
Asymmetrical lower limb weakness with loss of reflexes, saddle and perineal anaesthesia, loss of anal tone and sensation, decreased bladder and urethral sensation
141
What tests are used to diagnose cauda equina syndrome?
Full history and examination
Emergency MRI of the spine - determine the level of compression
Myelography and CT can be used
Urodynamic studies - monitor the recovery of bladder function
142
What is the treatment for cauda equina syndrome?
URGENT NEUROSURGICAL REFERRAL
Immobilise the spine if trauma is the cause
Surgery to remove blood, bone fragments, tumour, herniated disc or abnormal bone growth
Lesion debulking - tumours, abscess
Radiotherapy for malignant causes
Treat the underlying cause e.g. infection or inflammatory disease
143
What is the aetiology of spinal cord compression?
Trauma, tumours - benign and malignant, prolapsed disc, epidural and subdural haematoma, inflammatory disease e.g. RA, infection, cervical spondylitic myelopathy
144
What is the pathophysiology involved in spinal cord compression?
The pathophysiology is different for each cause but all result in the spinal cord becoming compressed which can lead to irreversible injury
145
What are the symptoms of spinal cord compression?
Principal features of chronic and subacute: spastic paraparesis or tetraparesis, radicular pain at the level of compression and sensory loss below the compression
146
What are the signs of spinal cord compression?
Tendon reflexes: increase below the level of the injury, absent at the level of the injury and are normal above the injury
Sphincter disturbances, loss of autonomic regulation e.g. lack of sweating
147
What tests are used to diagnose spinal cord compression?
Bloods: FBC, U&Es - monitor blood loss and any potential dehydration
MRI of the whole spine
Further investigations depending on the underlying cause
148
What is the treatment of spinal cord compression?
URGENT NEUROSURGICAL REFERRAL
Immobilise the spine if trauma is the cause
Surgery to decompress the spine
Lesion debulking
Radiotherapy for malignant causes
Treat the underlying causes e.g. infection
149
What is the aetiology of MS?
It is not fully understood, it has a complex polygenic inheritance pattern. EBV and HHV6 may be linked to MS, low vitamin D levels are also linked
150
What is the pathophysiology of MS?
It is a T cell mediated autoimmune disease that causes an inflammatory process mainly within the white matter of the brain and spinal cord
151
What are the symptoms of MS?
Optic neuritis (impaired vision and eye pain), sensory symptoms, clumsy/useless limb or hand, ataxia, pain, fatigue, bladder and sexual dysfunction
152
What are the signs of MS?
Symptoms are worse after heat - Urthoffs
Neck flexion gives an electric shock - Lhermittes
Nystagmus, spasticity
153
What tests are used to diagnose MS?
Two or more lesions and one clinical attack disseminated in time and space
MRI head
LP - oligoclonal bands on electrophoresis (not in the seru,)
Visual evoked potentials - delayed p100
154
What is the treatment for MS?
Baclofen for spasticity, beta blockers e.g. propranolol for tremor, oxybutynin for urinary incontinence, pain management
Physiotherapy
Acute relapses - steroids
Disease modifying drugs: interferon-beta, glatiramer acetate, natalizumab, alemtuzumab, fingolimod, dimethyl fumarate, terifluromide, mitoxantrone
155
What is the aetiology of myasthenia gravis?
It is associated with thymic atrophy or a thymic tumour.
| RA, SLE, pernicious anaemia and thyroid disease
156
What is the pathophysiology involved in myasthenia gravis?
It is an autoimmune disorder of the NMJ mediated by antibodies to nAChR resulting in depletion of working postsynaptic AChR sites
157
What are the symptoms of myasthenia gravis?
Muscle that fatigues more readily after exercise, drooping of the eyelids, slurred speech, nasal sound to the voice
158
What are the signs of myasthenia gravis?
Ptosis, diplopia, myasthenic snarl on smiling, peek sign - eyes can't stay shut for long when forced, tone is normal, sensation is normal, tendon reflexes are normal
159
What tests are used to diagnose myasthenia gravis?
Serum anti-AChR and anti-MuSK antibodies, repetitive nerve stimulation and EMG
CT of the thymus - thymoma
160
What is the treatment for myasthenia gravis?
Symptom control - anticholinesterase e.g. pyridostigmine
Immunosuppression - prednisolone (give osteoporosis prophylaxis), can also use methotrexate, azathioprine and ciclosporin
161
What is myasthenic crisis?
Weakness of the respiratory muscles leading to respiratory failure that can result in intubation and mechanical ventilation.
Treat with plasmapheresis and IV IG
162
What are the types of MND?
ALS
Progressive bulbar palsy
Progressive muscular atrophy
Primary lateral sclerosis
163
What is the pathophysiology involved in MND?
There is selective loss of neurones in the motor cortex, cranial nerve nuclei and anterior horn cells. It affects both upper and lower motor neurons.
164
What are the symptoms of MND?
Limb weakness, wrist drop, foot drop, tendency to trip, slurring of speech, dyspnoea and orthopnoea, sensation of heaviness in one/both legs
165
What are the signs of MND?
Muscle wasting, muscle fasciculations, hyporeflexia - LMD
| Hypertonia, hyper-reflexia, upgoing plantar responses - UMD
166
What tests are used to diagnose MND?
EMG and nerve conduction studies
CT and/or MRI brain and spinal cord - rule out other pathology
Bloods e.g. vitamin B12 levels, folate levels, HIV and Lyme disease serology; creatinine kinase will be increased due to muscle breakdown
167
What is the treatment for MND?
Riluzole - sodium channel blocker inhibits glutamate release
Baclofen for spasticity
Amytriptyline for drooling
Analgesia for pain
Palliative care - PEG, non-invasive ventilation, physio
168
What is the aetiology of Guillain-Barre syndrome?
Preceding infection, usually of the GI or respiratory tract e.g. EBV, HIV, Campylobacter Jejuni, cytomegalovirus and mycoplasma
169
What is the pathophysiology involved in Guillain-Barre syndrome?
The antibodies raised against the preceding infection also attack antigens in the peripheral nerve tissue. It is an ascending and progressive neuropathy
170
What are the symptoms of Guillain-Barre syndrome?
Ascending pattern of progressive symmetrical weakness, facial weakness, pain (neuropathic) in the legs and back, sensory loss, reduced sweating
171
What are the signs of Guillain-Barre syndrome?
Reduced or absent reflexes, hypotonia, fasciculations, fluctuations of heart rate and arrhythmias, labile blood pressure, variable temperature
172
What tests are used to diagnose Guillain-Barre syndrome?
Diagnosis is generally clinical.
U&Es,
LP - increased protein, normal WCC
ECG
Nerve conduction studies
Antibody screen for antibodies against the nerves
Spirometry - assess whether the patient needs an ITU admission
173
What is the treatment for Guillain-Barre syndrome?
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Plasmapheresis/plasma exchange
IV IG
VTE prophylaxis e.g. low molecular weight heparin
Analgesia for pain
DO NOT GIVE STEROIDS
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174
What are some risk factors for carpal tunnel syndrome?
Family history, post-Colles' fracture, DM, thyroid disorders, menopause, acromegaly, renal disease, amyloidosis, pregnancy, obesity
175
What is the pathophysiology involved in carpal tunnel syndrome?
There is compression of the median nerve due to increased pressure in the carpal tunnel.
IT IS NOT AN RSI
176
What are the symptoms of carpal tunnel syndrome?
Tingling, numbness or pain in the distribution of the median nerve, pain may radiate to the forearm, elbow, arm and shoulder
177
What are the signs of carpal tunnel syndrome?
Weakness in hand grip and opposition of the thumb, wasting of the thenar eminence
178
What tests are used to diagnose carpal tunnel syndrome?
Phalen's test - flex the wrist for 60s
Tinel's test - tapping over the median nerve
Carpal tunnel compression test - apply pressure over the proximal edge of the carpal tunnel
EMG, USS, MRI, electroneurography (ENG)
179
What is the treatment for carpal tunnel syndrome?
Conservative: pain relief and a splint at night
Hydrocortisone infection
Surgery: decompression of the nerve
180
What is the aetiology of brain tumours?
Primary: astrocytoma (pilocytic astrocytoma to premalignant to anaplastic astrocytoma to GBM) or an oligodendroma (medulloblastoma, lymphoma)
Secondary: lungs > breast > melanoma, renal, GI
Benign: meningioma, neurofibroma
181
What are the symptoms of brain tumours?
Headache, nausea and vomiting, diplopia, cognitive or behavioural symptoms
182
What are the signs of brain tumours?
Seizures, papilloedema, visual field defects, aphasia, numbness/weakness, cerebellar ataxia
183
What tests are used to diagnose brain tumours?
Imaging: CT, MRI, PET scan (to locate primary tumour), CXR
Bloods: FBC, U&Es, CRP, ESR (to rule out other diagnoses e.g. GCA)
Biopsy if possible
184
What is the treatment for brain tumours?
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Surgery: resection or debulking
Radiotherapy
Chemotherapy e.g. temozolomide
Corticosteroids for cerebral oedema
Palliative care
```
185
What are some causes of meningitis?
Bacterial: Neisseria meningitidis, Streptococcus pneumoniae, Listeria (elderly), E. coli (neonates)
Viral: Mumps, HSV, poliovirus, echo virus, Coxsackie virus
186
What is the pathophysiology involved in meningitis?
There is inflammation of the arachnoid and pia mater, microorganisms infect the CSF. There is pus formation in bacterial infection.
187
What are the symptoms of meningitis?
Headache, neck stiffness, leg pains, cold hands and feet, abnormal skin colour, altered mental state
188
What are the signs of meningitis?
Fever, photophobia, seizures, non-blanching rash - septicaemia, signs of sepsis
Kernig's sign - pain and resistance on passive knee extension with the hip fully flexed
Brudzinski's sign - hips flex when head bends forward
189
What tests are used to diagnose meningitis?
Bloods: FBC, U&Es, LFTs, glucose, coagulation, cultures, serology
Swab - throat and rectal
LP - send CSF for MC&S, Gram stain, protein, glucose, virology and lactate
190
What are the common causes of encephalitis?
HIV, mumps virus, measles virus, parvoviruses, herpes simplex virus (worst), varicella zoster virus
191
What is the pathophysiology of encephalitis?
There is inflammation of the cerebral cortex, white matter, brainstem and basal ganglia
192
What are the symptoms of encephalitis?
Headache, altered mental status, seizures, nausea, vertigo, confusion, drowsiness,
193
What are the signs of encephalitis?
Fever, photophobia, sensory changes, neck stiffness, focal neurologic signs
194
What tests are used to diagnose encephalitis?
Bloods: FBC & film, U&Es, LFTs, glucose, ESR, CRP, cultures
Contrast CT of the head
LP - send CSF for MC&S, viral PCR (increased protein and lymphocytes
EEG
195
What is the treatment for encephalitis?
IV aciclovir for 14 days (21 if immunosuppressed)
Supportive therapy
Symptomatic treatment e.g. phenytoin for seizures
196
What is the treatment for meningitis?
IV antibiotics cefotaxime +/- ampicillin for Listeria (aciclovir if viral)
ABCDE if necessary
Contact tracing: rifampicin and meningitis C vaccine
