Neurology Flashcards
In MS, what is the name given to symptoms that worsen with heat / exercise?
Uhthoff’s phenomenon
List some brainstem / cerebellar symptoms of MS
ataxia
dysphagia
diplopia
vertigo
Tx MS relapse
Oral methylprednisolone 500mg OD for 5 days (or IV if severe)
Avoid steroid treatment more than 3x per year
What would 2 features be of LP and CSF studies in MS?
oligoclonal bands of increased immunoglobulin concentration
increased protein levels
Diagnostic criteria MS
2 or more CNS lesions disseminated in time and place
Subtypes MS
relapsing-remitting MS
secondary progressive MS
primary progressive MS
Prognosis MS
5-10 years below average
Pts often die from aspiration pneumonia
Pathophysiology Myasthenia Gravis
An AI disease mediated by antibodies against nicotinic anti-cholinergic receptors
AChR IgG
Mx of a myasthenic CRISIS
IV immunoglobulin
Plasma electrophoresis
Tx for MG (not crisis)
Pyridostigmine
What is the only drug licensed for Tx of MND?
Riluzole
RILUZOLE
What Tx for spasticity in MS and spasms in MND?
BACLOFEN
Baclofen
What type of dementia is ALS associated with?
frontotemporal dementia
What type of MND has the worst prognosis?
Progressive bulbar palsy
If ALS is familial, what chromosome does the gene responsible lie on?
Chromosome 21
Differentials for tension headaches
migraine, cluster, GCA, polymyalgia rheumatica, drug-induced, exertional
Chronic tension headache
> 15 days per month for at least 3 months
CFs tension headache
Bilateral, non-pulsative, chronic daily headache. ‘Tight-band like sensation’. Pressure behind eyes. Mild-moderate pain +/- scalp tenderness
Important -ves in tension headache
no vomiting, no aura, no sensitivity to head movement
What is the only prophylactic Tx recommended by NICE for tension headaches?
Acupuncture
Acute treatment of migraine
Combo of an oral triptan (e.g. sumatriptan) and NSAID / Paracetamol +/- an antiemetic if needed
Prophylactic treatment of migraine
If 2+ attacks a month, or acute Tx needed more than twice a week
- Propanol or topiramate is 1st line
What class of drug is topiramate and what must you be cautious of?
An anti-convulsant Its teratogenicity (cleft palate)
Features of cluster headache
Rapid onset of excruciating pain around one eye
Rises to crescendo over minutes and lasts 15-160 mins once/twice a day
- nocturnal / early mornings, often wakes from sleep
- watery blood shot eye with swelling
+/- vomiting
Abortive Tx cluster headache
Subcut Sumatriptan + 100% O2
Preventative Tx cluster headache
Verapamil (a CCB)
Triggers cluster headache
alcohol
~ nocturnal sleep
1st Line Tx for trigeminal neuralgia?
Carbamazepine
Pathophysiology TN?
compression of the trigeminal nerve, causing demyelination and excitation of the trigeminal nerve –> erratic pain singaling
e.g. aneurysm, meningeal inflammation, tmours
RFs for TN and peak age
**Hypertension
F
Peak age = 50yrs
CF TN
Sudden unilateral paroxysms of knife-life, electric-shock like pain
Triggers TN
shaving, eating, talking
Red flag CFs in TN that suggest an underlying cause + prompt referral to neurologist
Sensory changes Deafness or other hearing problem ONSET <40yrs Pain only in ophthalmic division, or bilaterally Optic neuritis FHx of MS
who must have GCA excluded?
All >50year olds with a new headache that has lasted a few weeks
Pathophysiology GCA, aka Temporal Artery
inflammatory granulomatous vasculitis of large cerebral arteries
CFs GCA
scalp tenderness
jaw claudication
sudden blindness
Ix GCA
ESR and CRP raised
Temporal artery biopsy
Normochromic normocytic anaemia
Mx GCA
prednisolone
Why do you need to start treatment asap for GCA?
due to risk of permanent visual loss from anterior ischaemic optic neuropathy from vasculitis of ciliary arteries
What is GCA associated with?
Polymyalgia Rheumatica
RFs SAH?
Hypertension, known aneurysm, polycystic kidney disease
CFs SAH
Sudden onset severe occipital headache - ‘thunderclap’
Vomiting
Neck stiffness
How is SAH graded?
According to the GCS at presentation
What Investigations for SAH?
CT scan
LP (if CT head -ve but high clinical suspicion)
What would CT scan SAH show?
Star shaped lesion - due to blood filling the gyral patterns around the brain adn the ventricles
What would LP show and when should it be performed?
Xanthochromia (yellow) due to bilirubin from Hb breakdown
12hr after the onset of symptoms
Cause of SAH?
Spontaneous not trauma
Most often due to rupture of a berry aneurysm
Mx SAH
- Maintain good cerebral perfusion: hydration + give dexamethasone to reduce cerebral oedema
- Refer to neurosurgery: clipping or coiling of aneurysm
- NIMODIPINE (a CCB) to reduce risk of VASOSPASM
Complications SAH?
Hyponatraemia (SIADH)
rebleeding
hydrocephalus
cerebral ischaemia due to vasospasm
Peak age of onset PD
55-65 years
Pathophysiology PD
Progressive degeneration of dopaminergic neurones in the substantia nigra of the basal ganglia
Triad of Parkinsonism CFs
Rigidity
Bradykinesia
Resting tremour
DDx Parkinsonism
LBD
Drug induced (typical antipsychotics e.g. haloperidol)
Wilson’s disease
Trauma
Gold standard treatment for PD
Levodopa + decarboxylase inhibitor (e.g. carbidopa)
limitations of levodopa, and what does it mean for starting the drug?
reduced efficacy over time, even with increased dose
L-dopa should not be started until absolutely necessary, only when motor symptoms are affecting their quality of life and other treatments are ineffective
What can be used 1st line to delay starting L-dopa? and their side effects?
- Dopamine agonists e.g. ropinirole
SEs: drowsiness, nausea, hallucinations, compulsive behaviour*
What can be used if parkinsons pt is NBM so can’t take levodopa?
Dopamine agonsit patch - to prevent actue dystonia
What can be used 2nd line to delay starting L-dopa, and to reduce the wearing off of L-dopa? and their SEs?
Monoamine Oxidase B inhibitors e.g. selegiline
SEs: postural hypotension, AF
Differentiating between LBD and PD?
If dementia occurs prior to or at the same time as the motor symptoms –> LBD
If dementia occurs >1yr after motor symptoms, it is a feature of the PD
What is Guillain-Barre Syndrome?
An acute inflammatory, ascending polyneuropathy of the peripheral nervous system following an URTI or a GI infection
Cause of Guillain-Barre Syndrome?
Campylobacter Jejuni
CMV
Infection –> production of antibodies that attack myelin –> demyelination and an acute polyneuropathy
What might require ITU admission in Guillain-Barre Syndrome?
Respiratory involvement
Do FVC!!
Dx Guillain-Barre Syndrome?
Nerve conduction studies: slow nerve conduction and prolonged distal motor latency
LP: increased proteins, WCC normal
Mx Guillain Barre Syndrome?
IV Immunoglobulin for 5 days : decreases severity and duration of paralysis
What is a meningioma
A typically benign tumor that develops from the dura mater of the meninges
(benign still have serious consequences due to the closed vault of cranium and risk of compression)
What is coning and what does it result in?
herniation of the cerebella tonsils through foramen magnum –> resp depression, bradycardia and death
CFs brain tumours
Increased intracranial pressure headache (worse in mornings / lying down / coughing / sneezing)
Vomiting
Personality change
Neurological focal symptoms
How are brain tumours graded?
Histology of cell type
Grade I and II beningn, III and IV are malignant
Mx brain tumours
Refer to neurosurgery,
Surgical resection, RT and supportive Tx, - very dependent on tumour type
Define TIA
A transient and reversible episode of sudden onset neurological dysfunction caused by ischaemia, with acute infarction
Symptoms have generally fully resolved within 24hrs
Driving and TIA
Can’t drive for at least 4 weeks after a TIA
What score for risk of stroke for someone with AF? - and why they at increased risk?
CHA2DS2VASC score
Stagnation of blood in the poorly contracting atria –> thrombus formation
What must be done for suspected stroke pt before thrombolysis is give?
CT head to exlude haemorrhagic stroke (30%)
Immediate Tx ischaemic stroke
- Thrombolysis: ALTEPLASE (IV tissue plasminogen activator) within 4.5hrs of onset
- Antiplatalet therapy (75mg clopidogrel) started 24hrs after thrombolysis
Tx If miss the immediate Tx window for ischaemic stroke?
300mg aspirin for 2 weeksn, THEN lifelong clopidogrel 75mg (+statin)
What sign to differentiate between organic and non-organic lower leg weakness?
Hoover’s sign
What is site of lesion in stroke if: contralateral hemiparesis and sensory loss, lower extremity > upper?
Anterior cerebral artery
What is the site of lesion in stroke if: contralateral hemiparesis and sensory loss, upper extremity > lower?
Middle cerebral artery
What CFs would lateral medullary syndrome manifest in?
Ipsilateral: facial pain and temp loss
Contra: limb / torso pain and temp loss
Ataxia, nystagmus
What infarct cause aphasia?
Dominant hemisphere middle cerebral infart
RFs Subdural haematoma
Traumatic head injury
Anticoagulation medication
PMHx of coagulopathy
Alcoholism
What is key about the CFs for Subdural haematoma?
The interval between injury and symptoms can be days –> months
CFs acute subdural haematoma
Signs of raised ICP: headache, vom, nausea, raised BP
Alternating level of consciousness
CFs chronic subdural haematoma
Personality change, cognitive decline, headache - may have no memory of initial trauma
Ix subdural haematoma
Crescent shaped- mass
What might the Dx be in an elderly patient with progressive peronality change and declining GCS?
Chronic Subdural haematoma
due to decreased brain weight, and increased subdural space, may evolve slowly
What is the lucid interval in an extradural haematoma?
The time between Traumatic Brain Injury and decrease in consciousness
Cause of extradural haematoma?
Trauma to the temporal / parietal bone –> laceration of middle meningeal artery
What would CT show in extradural haematoma?
Hyperdense biconvex / ‘ lemon’ shape next to the skull
Most common cause of encepahlitis in UK?
Herpes simplex virus 1 + 2
What is the predominant symptom in encepahlitis?
decreased LoC and confusion
Cause of meningitis
Neisseria Meningitidis transmitted
What is meningococcal septicaemia caused by?
When Neisseria Meningitidis invades into flood, presence of endotoxin leads to inflammatory cascade
CFs meningitis
fever, headache, meningism, seizures,
NON-BLANCHING petechial rash
CSF findings for bacterial meningitis?
Raised protein, low glucose
Polymorphs (neutrophils)
Turbid color
Difference on CSF findings between TB and bacterial meningitis?
TB- cells are lymphocytes
Bacteria - cells are polymorphs (neutrophils)
Viral meningitis CSF findings
cells are lymphocytes
protein and glucose normal
Define epilepsy
A recurrent tendency to spontaneous, intermitted abnormal electrical activity in part of the brain, manifesting as seizures
What are generalised seizures characterised by?
Loss of consiousness from the start
which type of seizure might have awareness impaired and automatisms such as lip smacking and chewing?
Complex partial seizure
What does the clinical diagnosis of epilepsy require?
2 or more unprovoked seizures occuring >24hrs apart
Mx Primary generalised epilepsy?
Sodium valporate or lamotrigine
Mx absence seizure?
Sodium valporate or ethosuxamide
Mx Partial / focal seizure?
Carbemazepine or lamotrigine
DVLA and epilepsy
cant drive until free of daytime seizures for at least 1yr
When and how can you stop anti-epileptic drugs?
If seizure free for >2yrs, with AEDs being stopped over 2-3 months
Cause of huntingtons?
AD inheritance
Mutation on Chromosome 4, repeated expression of CAG sequence
Decreased ACh synthesis and GABA in struatum
CFs huntingtons?
Often a prodromal phase of mild psychotic and behavioural symptoms before the development of chorea
progresses to rigidity, writhing and abnormal posture
behavioural change
dementia
What is brown-sequard syndrome?
Loss of pain temp and light touch on opposite side to lesion
Loss of motor function and vibration, position, and deep touch sensation on same side as the cord damange
