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Neurology Flashcards

1
Q

Virchow’s Triad

A

Factors which increase risk of thrombosis: Hypercoagulable state, vascular injury, circulatory status

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2
Q

Most common site of Cavernous Venous Sinus Thrombosis

A

Transverse > Sagittal > sigmoid

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3
Q

Cavernous Venous Sinus Thrombosis is most commonly a complication of:

A

Acute sinusitis

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4
Q

Risk Factors for Cavernous Venous Sinus Thrombosis

A 
Female > male (3:1)
Under 50 years
Antiphospholipid antibodies (history of miscarriage)
Cirrhosis 
Pregnancy
IBD
Otitis media
Combined OCP
Dehydration 
SLE (PMH or FH)
Factor V Leiden
Sarcoidosis 
History of tobacco and ecstasy use 
History of sinusitis, facial infection or periorbital infection
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5
Q

Most common symptom of Cavernous Venous Sinus Thrombosis

A

Headache (90%) - progressive, constant, diffuse, worse on lying down

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6
Q

Signs of Cavernous Venous Sinus Thrombosis

A

Signs of raised ICP

Eye Changes: Proptosis, Chemosis - distension of orbital veins

Motor: Ophthalmoplegia, Hyperreflexia, Aphasia, Hemianopia, Hemiparesis

Sensory: Ophthalmic/Maxillary paraesthesia

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7
Q

Proptosis

A

Anteriorly displaced orbit

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8
Q

Cushing Reflex

A

HTN and slow pulse indicating severe raised ICP and risk of herniation

May also have wide pulse pressure and irregular respiration.

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9
Q

Differentials for Cavernous Venous Sinus Thrombosis

A

Space occupying lesion:
Tumor abscess
Intracranial haemorrhage
Arterial stroke
Idiopathic intracranial hypertension (IIH) - once CVST has been excluded
Meningitis (fever, headache, vomiting, nuchal rigidity)
HIV-associated opportunistic infections e.g. CMV encephalitis
Migraine
Encephalitis esp. Herpes Simplex

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10
Q

Empty delta sign

A

Dense white triangle of impaired filling seen in Cavernous Venous Sinus Thrombosis on contrast-enhanced CT

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11
Q

Management of Cavernous Venous Sinus Thrombosis

A

Initially, vancomycin and 3rd generation cephalosporin (Ceftriaxone)
Anticoagulation

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12
Q

Anticoagulation in Cavernous Venous Sinus Thrombosis

A

Start Hep/LMWH at Day 1. Start Warfarin at Day 5. Stop Hep/LMWH when INR > 2.

3 months if secondary to transient risk factor e.g. Pregnancy
6-12 months if idiopathic or secondary to mild thrombophilia
Indefinitely if recurrent CVST or severe thrombophilia

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13
Q

Epidural Abscesses arise from

A

osteomyelitis or TB of vertebral column
Infection of a traumatic epidural haematoma
Infection of air sinuses

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14
Q

Subdural Abscesses arise from

A

Air sinuses

Middle ear

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15
Q

Presentation of Epidural Abscess

A

Fever
Spinal pain or tenderness - increased with weight-bearing, not relieved by rest

Often IVDU, immunocompromised, Hx of spinal surgery/trauma

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16
Q

Presentation of Subdural Abscesses

A

Neurological deficit or raised ICP

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17
Q

Management of Epidural Vs Subdural Abscesses

A

Epidural: Triple Antibiotic regimen, Vancomycin + Metronidazole, Ceftaxime

Subdural - evacuation + IV antibiotics

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18
Q

Intracerebral Abscess arise from what types of infection?

  • Sites
  • Trauma/Surgical
A 
Commonly spread from:
Adjacent Air sinuses
Middle Ear
Bloodstream from Bronchiectasis or lung abscess 
Bacterial endocarditis 
Neurosurgical procedures 
Open head injuries
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19
Q

Risk Factors for Brain Abscess

A 
Sinusitis
Otitis media
Recent dental procedure or infection
Recent neurosurgery
Congenital Heart Disease
Endocarditis
DM
Immunocompromised
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20
Q

Presentation for Brain Abscess

A

Headache
Symptoms of Infection
Focal neurological deficits due to destruction of brain tissue
Seizures
Raised ICP - bulging fontanelles, papilloedema
CN III or VI palsy
Positive Kernig or Brudzinski sign

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21
Q

MRI findings of Brain Abscess

A

Ring enhancing pattern with cerebral oedema (vascular leakage)

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22
Q

Management of Brain Abscess

A

All patients:
Antibiotics: vancomycin + metronidazole/clindamycin + cephalosporin
Anticonvulsant prophylaxis: phenytoin, carbamazepine, valproate, levetiracetam
Corticosteroids = rapid reduction in vasogenic oedema (avoid if stable due to suppressed immune response)

Drainage or surgical excision

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23
Q

Presentation of Bacterial Meningitis

A

Initial symptoms :
Severe headache
Fever
Stiff neck (signs right)

Other features:
Leg pains 
Cold hands and feet 
Abnormal skin colour 
Photophobia 
N&V
Late signs:
Low GCS or coma 
Seizures and focal neurological signs 
Petechial rash - non blanching 
Shock (disseminated intravascular coagulation, prolonged capillary refill, hypotension)
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24
Q

Bacterial CSF

A

Cloudy
Low glucose
High protein
WCC - polymorphs

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25
Viral CSF
Clear or cloudy Low or normal glucose Normal or raised protein WCC - lymphocytes
26
TB CSF
Cloudy Very low glucose High protein WCC - lymphocytes
27
Empirical antibiotics in bacterial meningitis (< 3 months)
IV amoxicillin + cefotaxime
28
Empirical antibiotics in bacterial meningitis (> 3 months)
IV ceftriaxone
29
Steroid treatment in bacterial meningitis: - Indications - Regimen - Effect
Dexamethasone Indicated if > 1 month and H.influenzae Before or within 4 hours of first dose Abx Reduces rate of hearing loss and neurological sequelae.
30
Empirical antibiotics in adults with bacterial meningitis
< 50 years = IV cefotaxime | > 50 years = IV amoxicillin + cefotaxime
31
Complications of Bacterial Meningitis
``` Disseminated Intravascular Coagulation Vasculitis Cerebral Oedema Hydrocephalus Epilepsy Sensorineural hearing loss ```
32
Causative Organisms of Bacterial Meningitis in 0-3 months
Group B streptococcus E Coli Listeria monocytogenes
33
Causative Organisms of Bacterial Meningitis in 3 months - 6 years
Neisseria meningitidis Streptococcus pneumonia Haemophilus influenzae
34
Causative Organisms of Bacterial Meningitis in 6-60 years
Neisseria meningitidis | Streptococcus pneumoniae
35
Causative Organisms of Bacterial Meningitis in > 60 years
Streptococcus pneumoniae Neisseria meningitidis Listerior monocytogenes
36
Causative Organisms of Bacterial Meningitis in immunosuppressed
Listeria monocytogenes
37
Group B streptococcus meningitis
Most common cause in neonates Acquired during passage through birth canal Common if low birth weight and prolonged rupture of membranes
38
Listeria monocytogenes meningitis
Found in pate, raw veg/salad, unpasteurised milk/cheese (foods avoided during pregnancy) Resistant to cephalosporins
39
Neisseria meningitidis
Upper RT commensal found in nasopharynx and tonsils. | Cause of meningitis in 3 months and older.
40
Presentation of TB meningitis
Fulminant - similar to bacterial meningitis | Insidious - headache, confusion and CN deficits over weeks to months
41
Fundoscopy in TB meningitis
Choroidal tuberculosis
42
Management of TB meningitis
Rifampicin, Isoniazid, Pyrazinamide and Ethambutol for 2 months Rifampicin and Isoniazid for following 2 months Steroids if severe e.g. tuberculoma, progression to next stage Surgical decompression if hydrocephalus occurs
43
Types of neurosyphilis
``` Endarteritis obliterans Tabes dorsalis Dementia paralytica Gummas Acute meningitis ```
44
Endarteritis obliterans
lymphoplasmacytic meningitis
45
Tabes dorsalis
Inflammation and degeneration of posterior columns of spinal cord
46
Dementia paralytics
encephalitis due to invasion of brain by spirochetes
47
Gummas
Rubbery necrotic and inflammatory mass containing spirocetes. Acts like a space occupying lesion
48
Presentation of neurosyphilis
General meningitis symptoms - headache, confusion, N&V, stiff neck (Endarteritis obliterans/ Lymphoplasmacytic meningitis) Argyll-Robertson Pupil - Accommodation Reflex Present, Pupillary Reflex Present. Irregular pupils Forgetfulness & personality change - General paresis of the insane Loss of proprioception and vibration sense - Tabes dorsalis
49
Argyll-Robertson Pupil
Accommodation Reflex Present, Pupillary Reflex Present. Irregular pupils Seen in Tabes dorsalis (neurosyphilis) and DM
50
Management of neurosyphilis
IV acqueous benxylpenicillin & oral probenicid Probenicid causes uric acid secretion. Used to treat gout.
51
General Features of Lyme Disease
``` Erythema migrans within 1-2 weeks Fever Headache Myalgia Fatigue Arthralgia ```
52
Erythema migrans
Target lesion on the skin seen in Lyme disease
53
Borrelia Burgdorferi
Tick-borne spirochete causing Lyme disease
54
Neurological complications of Lyme disease
Meningitis CN palsies (esp. CN VII) Radiculopathy - Banwarth Syndrome causes pain from spinal column Peripheral Neuropathy - glove and stocking Mononeuritis multiplex Cerebellar ataxia (RARE) Encephalomyelitis (RARE)
55
Neuropathy screen
HIV, syphilis, HbA1c, TFTs, B12, autoantibodies, CMV, HBV and HCV, sarcoidosis (ACE and CXR)
56
Management of lyme disease
Early Disease: Doxycycline OR Amoxicillin OR Cefuroxime | Neurological disease: Doxycycline OR Ceftriaxone if more serious
57
Most common fungal infections of CNS
Candidiasis > Aspergillus > Cryptococcus
58
Fungal CSF
``` Normal or high opening pressure Low glucose High protein Mononuclear pleocytosis Turbid appearance ```
59
Risk Factors for candida infection in the CNS
``` Catheters Broad-spectrum Antibiotics Parenteral nutrition Immunosuppression ```
60
Toxoplasmosis
Protozoa. Ingested by other animals. Forms tissue cysts which invade brain, heart and skeletal muscle. Reproduces in intestinal tract of cats. Usually associated with poorly cooked meat.
61
Risk factors for toxoplasmosis
Immunosuppression Ingestion of raw or undercooked meat Exposure to cat faeces
62
Presentation of toxoplasmosis
``` Headache Confusion Fever Focal neurological deficit Mental status change Seizures Coma ```
63
Toxoplasmosis in pregnancy
Can cross the placenta and cause necrotising encephalitis and chorioretinitis in foetus. Leads to severe brain damage, microcephaly, cerebral calcifications and blindness
64
Diagnosis of Toxoplasmosis
Compatible clinical syndrome Positive T.gondii antibody Multiple ring enhancing lesions on MRI
65
Management of toxoplasmosis
Sulfadiazine and pyrimethamine Leucovorin - to prevent pyrimethamine-induced haematological toxicity Adjuncts: Dexamethasone if related focal brain lesions or oedema Anticonvulsants
66
Psychiatric complications of toxoplasmosis
Schizophrenia and suicide
67
Viral meningitis is most commonly associated with...
Enteroviruses
68
Presentation of viral meningitis
RF: Exposure to insect vectors Young or old ``` Headache Neck stiffness (rarely kernig’s and Brudzinski’s signs) N&V Photophobia Fever +/- rash ```
69
Management of viral meningitis
If patient is very ill, it is reasonable to assume bacterial meningitis and treat accordingly. Wait for CSF results if more stable. Confirmed viral meningitis = supportive care Analgesia and antipyretics Antiemetics if vomiting IV fluids if dehydrated Antivirals for: HSV, VZV or CMV (Aciclovir)
70
Encephalitis
Encephalitis is defined as inflammation of brain parenchyma, associated with neurological dysfunction e.g. altered consciousness, seizures, personality change, CN palsy, speech, motor and sensory deficits.
71
Presentation of encephalitis
``` Fever Rash Altered mental state Focal neurological deficit - CN palsy, aphasia, ataxia, hemiparesis Meningismus ``` Encephalitis can present with altered mental status, motor and sensory deficits, altered behaviour and personality changes. These features are absent in meningitis.
72
CSF analysis in encephalitis
``` Pleocytosis (early neutrophils, late lymphocytes) Elevated erythrocytes Elevated protein Glucose normal PCR is diagnostic (gold standard) ```
73
Presentation of HSV encephalitis
Affects temporal and inferior frontal lobes. Causes bizarre behaviour, personality change, anosmia, gustatory hallucination.
74
Pathology of poliomyelitis
Affects grey matter. Spinal cord - paralysis and subsequent denervation atrophy of muscle Brainstem - cranial neuropathies, neurogenic pulmonary oedema
75
Presentation of poliomyelitis
90% asymptomatic Minor illness = GI Major illness = acute flaccid paralysis of a single affected limb with muscle atrophy, decreased tendon reflexes and tone
76
Management of poliomyelitis
No cure - supportive treatment only | Physiotherapy and mobilisation
77
Post-poliomyelitis syndrome
Fatigue, weakness and wasting of affected muscles. Requires mobilisation and physiotherapy
78
Presentation of West Nile Virus
Fever THEN change in mental status THEN coma May have severe asymmetric areflexic weakness or complete flaccid paralysis. More frequently elderly patients.
79
Zika virus
Most asymptomatic but 20% have non specific symptoms resembling dengue fever. Causes microcephaly in babies born to infected mothers. Placenta is small → IUGR
80
Neurological manifestations of HIV
Direct: HIV encephalitis (AIDS-dementia complex) Indirect: CNS Toxoplasmosis Cryptococcosis CMV encephalitis
81
Presentation of HIV encephalitis
Memory loss Intellectual deterioration Behavioural changes Motor deficits
82
Receptor associated with autoimmune encephalitis
Anti NMDA receptor
83
Presentation of Autoimmune Encephalitis
Young females with ovarian, mediastinal and other teratomas. Males with testicular teratomas Prominent Psychiatric features (Anxiety, Bizarre behaviour, Hallucinations, Delusions, Disorganised thinking, Memory disturbance) ``` Speech disorder Seizures Dyskinesias - orofacial, dystonia, rigidity, opisthotonic postures Decreased consciousness Autonomic instability Hypoventilation ```
84
Management of Autoimmune Encephalitis
IV methylprednisolone +/- IV Ig OR Plasma exchange
85
Creutzfeldt-Jakob Disease
Dementia - Behaviour and personality changes Visual disturbance Movement problems - Myoclonus, Ataxia
86
Risk Factors for Creutzfeldt-Jakob Disease
Genetic predisposition Prion-contaminated instruments Transfusion or blood or blood products Consumption of UK beef from 1980-1996
87
Management of Creutzfeldt-Jakob Disease
Symptom management - Benzodiazepines for anxiety/restlessness and myoclonus - SSRIs for depression - Antipsychotics for psychosis
88
Presentation of Tetanus
``` Lock jaw (trismus) Back pain Muscle stiffness (hypertonia) Dysphagia Spasms ```
89
Management of potential tetanus exposure
Wound debridement | Tetanus vaccine +/- tetanus immunoglobulin
90
Management of clinical tetanus (Hypertonia)
Supportive care Benzodiazepines for painful muscle spasms Metronidazole Tetanus Ig if severe Magnesium Sulphate (presynaptic neuromuscular blockade)
91
Presentation of Botulism
``` Blurred/Double vision Ptosis Dysarthria Dysphagia Symmetrical, descending flaccid paralysis ```
92
Risk Factors for Botulism
Ingestion of contaminated foods (home-canned vegetables) Infants Biological terrorism
93
Management of Botulism
Botulism antitoxin Debridement of any wound infection Mechanical ventilation if upper airway compromise
94
Lyssavirus
Rabies
95
Transmission of rabies
Animal bites
96
Presentation of rabies
``` Encephalitis Hypersalivation Choking sensation when offered a drink - severe laryngeal and diaphragmatic spasm Perspiration Priapism - persistent, painful erection Agitation & hallucination Weakness Reduced sensation ```
97
Prognosis for rabies
Fatal once symptomatic
98
Management of rabies
Aymptomatic: Rabies Ig and wound cleansing Symptomatic: Palliative care
99
Cystericosis
Most common parasitic disease of CNS (Taenia Solium) - TAPEWORM Most common cause of epilepsy worldwide
100
Presentation of cystericosis
New onset seizures Hepatomegaly Cough and haemoptysis Worm segments in stool
101
Risk Factors for Cystericosis
``` Living on farms Poor hygiene Eating or handling undercooked meat or fish Ingestion of contaminated water Dog owners Children ```
102
Management of Cystericosis
Antihelminthic - praziquantel or albendazole If CNS disease - corticosteroid and antiepileptic
103
Features of subfalcial herniation
Drowsiness Progressive LOC One-sided weakness +/- Late visual disturbance
104
Features of uncal herniation
Visual disturbance then LOC
105
Features of Central Herniation
Drowsiness and impaired consciousness then visual disturbance
106
Features of Rostrocaudal herniation
Abrupt LOC Visual, hearing and taste disturbance +/- differences in facial expression or movement
107
Features of Tonsillar Herniation
Difficulty breathing then coma
108
GCS scoring: Opens eyes when you speak to them
E3
109
GCS Scoring: Opens eyes on sternal rub
E2
110
GCS Scoring: Localises pain on sternal rub
M5
111
GCS Scoring: Withdraws by flexion in response to sternal rub
M4
112
GCS Scoring: Decorticate posture/Abnormal flexion (Flexed elbows and wrists, feet turned in)
M3
113
GCS Scoring: Decerebrate posture/Abnormal extension (Extended elbows, wrists flexed outwards, toes pointed)
M2
114
GCS Scoring: Confusion
V4
115
GCS Scoring: Inappropriate words
V3
116
GCS Scoring: Incomprehensible sounds
V2
117
Dysfunction associated with Decorticate posture
Problems with cervical spinal tract or cerebral hemisphere
118
Dysfunction associated with Decerebrate posutre
Problems with midbrain or pons
119
Normal response to Caloric Testing in coma
When irrigating ear with cold water, eyes should deviate to side of irrigation and there will be a nystagmus
120
FOUR Score
More detailed assessment of the unconscious patient (better than GCS)
121
Pinpoint pupils are associated with dysfunction of which structure
Pons
122
Dilate, fixed pupil is associated with...
CN III palsy
123
Function and components of Reticular Activating System
Inducing and maintaining alertness Thalamus, Hypothalamus, pituitary gland, Midbrain, Rostral Pons, Cerebral Hemispheres
124
Indication for immediate CT head
GCS < 13 immediately after injury GCS < 15 2 hours after injury Suspected open or depression skull fracture Signs of base of skull fracture (haemotympanum, panda eyes, CSF leak from ear or nose, Battle’s sign) Post traumatic seizure Focal neurological deficit > 1 episode of vomiting
125
Pathology of Wernicke's Encephalopathy
Exhausted B-vitamin reserves, particularly Thiamine/B1
126
Presentation of Wernicke's Encephalopathy
``` Ataxia Ophthalmoplegia Encephalopathy Hypothermia Coma Preserved pupillary reflexes Ocular movement palsies of absent vestibular-ocular reflexes ```
127
Risk Factors for Wernicke's Encephalopathy
Nutritionally deprived patients Alcoholics Those with gastric stapling Patients on haemodialysis not taking B vitamin supplements
128
Management of Wernicke's Encephalopathy
ABCD approach IV thiamine 50-100mg Correction of Mg2+ deficiency Multivitamin supplementation
129
General seizures affect one or both sides of the brain?
Both sides
130
Focal/Partial seizures affect one or both sides of the brain
One side. May start in a specific area
131
During what type of seizures might patients have awareness
Focal/Partial
132
During what type of seizures to patients lose consciousness
Generalised
133
Features of Temporal Lobe Focal Seizures
Hallucinations Epigastric rising/Emotional Automatisms (lip smacking, grabbing) Déjà vu
134
Features of Frontal Lobe Seizures
Head/Leg movements Posturing Postictal weakness
135
Todd's Paralysis
Affected limb becomes temporarily weak after a Frontal Lobe Focal seizure
136
Features of Parietal Lobe Seizures
Paraesthesiae Sensory disturbance - tingling, numbness, pain Motor symptoms - spread to precentral gyrus
137
Features of Occipital Lobe Seizures
Flashes or floaters
138
Features of Tonic Clonic Seizures
Hypertonia - usually fall backwards, may cry out or bit their tongue Clonus - rhythmic relaxing and contracting of muscles, noisy breathing, wet themself Breathing and colour return to normal. Feeling tired and confused
139
Features of Clonic seizures
Repeated rhythmic jerking movements
140
Features of Tonic seizures
Sudden hypertonia. Usually fall over backwards if standing. Brief.
141
Features of Atonic seizures
‘Drop attack’. Usually fall forwards and may injure head or front of face.
142
Features of Myoclonic Seizures
‘Muscle jerk’. Brief, can occur in clusters, usually after waking. Conscious but classified as generalised as they are normally accompanied by other types of seizures.
143
Features of Absence seizures
Children > adults Looking blank, staring or fluttering of eyelids. Can carry on walking if they are already walking.
144
Differentials for Absence seizures
Daydreaming ADHD Complex focal epilepsy (Frontal or temporal)
145
Indication for drug treatment in epilepsy
2+ attacks in 2 years
146
First line management of focal seizures
Carbamazepine or Lamotrigine
147
Second line management of focal seizures
Levetiracetam, oxcarbazepine, sodium valproate
148
First line management of Generalised Tonic Clonic Seizures
Sodium Valproate | Lamotrigine for females of childbearing age
149
Second line management of Generalised Tonic Clonic Seizures
Carbamazepine, Clobazam, levetiracetam, topiramate
150
First line management of absence seizures
Sodium valproate or ethosuximide
151
Second line management of absence seizures
Lamotrigine
152
First line management of myoclonic seizures
Sodium valproate
153
Second line management of myoclonic seizures
Levetiracetam, topiramate (ADRs) Avoid carbamazepine and oxcarbazepine as they may worsen seizures
154
First line management of Tonic/Atonic seizures
Sodium valproate or Lamotrigine
155
MOA of Sodium valproate
GABA transaminase inhibitor i.e. increased inhibitory effect of GABA
156
ADRs of Sodium Valproate
``` P450 inhibitor Teratogenic GI: Nausea Alopecia - regrowth curly Ataxia Tremor Hepatitis Pancreatitis Thrombocytopenia Hyponatraemia ```
157
Effect of Sodium Valproate on drug metabolism
P450 inhibitor i.e. inhibits breakdown of other drugs, increasing their effect
158
Contraindications of Sodium Valproate
Females of reproductive age Pregnant women Breastfeeding Hepatic dysfunction
159
MOA of Lamotrigine
Na+ channel inhibitor Stabilises neuronal membranes and modulates glutamate release
160
ADRs of Lamotrigine
Exacerbation of myoclonic seizures Aggression or agitation Drowsiness or fatigue Stevens-Johnson Syndrome (flu-like + rash w/ blisters)
161
Lamotrigine should be used with caution if...
Myoclonic Seizures | Parkinson's disease
162
MOA of Carbamazepine
Na+ channel blockade - inhibits synaptic transmission in spinal cord. Effects in trigeminal nuclei cause analgesia.
163
ADRs of Carbamazepine
``` P450 inducer (reduces effect of other drugs) Dizziness Ataxia Headache Visual disturbance - DIPLOPIA Steven-Johnson Syndrome SIADH ```
164
Effect of carbamazepine on drug metabolism
P450 inducer - increases metabolism of drugs therefore reducing their effects
165
Contraindications for Carbamazepine
Acute porphyrias AV conduction abnormalities History of bone marrow suppression
166
MOA of Ethosuximide
Ca2+ channel blockade
167
Indication for Ethosuximide
Absence seizures
168
ADRs of Ethosuximide
MANY Agranulocytosis Impaired concentration GI disorders Stevens-Johnson Syndrome
169
Contraindications for Ethosuximide
Acute Porphyrias
170
DVLA rules for seizures
Patient must inform DVLA and be 1 year seizure free before driving 6 months seizure free if single seizure only
171
Definition of Status Epilepticus
State of continued seizures for more than 5 minutes without regaining consciousness
172
Risk Factors for Status Epilepticus
``` Non adherence to medication Chronic alcoholism Refractory epilepsy Toxic or metabolic causes Direct cortical structural damage Drug use Tramadol lowers seizure threshold ```
173
Management of Status Epilepticus
ABCDE approach Add thiamine and glucose if hypoglycaemic IV Lorazepam 0.1mg/kg (Or IV diazepam or Buccal midazolam if no IV access) - administer 2 doses before 2nd line therapy below. 20mg/kg IV phenytoin if no effect + ECG monitoring General Anaesthesia: Rapid sequence induction (propofol)
174
Features of Tension Headache
Bilateral, tight band sensation Associated with stress Tension and tenderness in neck and scalp muscles. Mild to moderate Not aggravated by physical activity +/- photosensitivity or phonosensitivity
175
Management of Tension Headache
Simple analgesia | Avoid triggers
176
Features of Cluster Headache
``` Short attacks around the eye Rapid onset Last 30 mins to 3 hours 1-2x/day for 1-3 months Associated with lacrimation, flushing, conjunctivitis, eyelid swelling, Horner’s syndrome during attack (ipsilateral) Males, 20s, smokers ```
177
Management of Cluster Headache
Acute: 100% O2 & Triptan Prophylaxis: Verapamil
178
Criteria for migraine diagnosis
A - At least 5 attacks. Meeting B, C, D and E. B - Last 4-72 hours C - 2 or more of the following: Pulsing, Severe, Unilateral, Aggravated by or causing avoidance of routine daily activities D - 1 of the following: Nausea +/- vomiting, Photophobia and phonophobia E - cannot be attributed to another cause
179
Management of Migraine
Abortive; Paracetamol or Triptan Preventative: Propranolol, Pizotifen, Amitriptyline Pregnancy: Paracetamol is first line, Aspirin/Ibuprofen can be 1st or 2nd line in 1st and 2nd trimester
180
Features of medication overuse headache
Present for 15 days or more per month. Developed or worsened whilst taking regular medication. Patients using opioids and triptans are most at risk May be psychiatric comorbidity
181
Features of Trigeminal Neuralgia
Stabbing pain in unilateral trigeminal nerve region Face screws up with pain Triggered by washing, shaving, talking or underlying cause e.g. tumour, MS, aneurysm
182
Risk Factors for Trigeminal Neuralgia
MS HTN Age Female
183
Management of Trigeminal Neuralgia
MRI to find cause Antiepileptics e.g. 1st line carbamazepine. 2nd line Baclofen Ablative surgery/Neurostimulation
184
Most common cause of SAH
Trauma
185
Most common pathology of SAH
Berry aneurysms
186
Risk Factors for SAH
``` HTN Smoking FHx AD Polycystic Kidney Disease Coarctation of aorta Ehlos Danlos Syndrome ```
187
Features of SAH
``` ‘Thunderclap’ headache Occipital in nature N&V Meningism (photophobia and neck stiffness) Coma Seizures Sudden death ```
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Diagnosis of SAH
CT - acute, hyperdense/bright blood in basal cisterns, sulci +/- ventricular system LP - 12 hours after onset of symptoms, xanthochromia
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Management of SAH
Coiling of intracranial aneurysm by interventional radiologist OR craniotomy & clipping by neurosurgeon (rare) Strict bed rest + Well controlled blood pressure + Avoid straining to prevent rebleed
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Features of Subdural Haematoma
Elderly Those on anticoagulants ``` Usually following head injury There may be a long interval between injury and presentation (days/weeks/month) Headache Drowsiness & Confusion Hemiparesis and sensory loss Epilepsy (occasionally) Stupor, coma and coning (later) ```
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Features of Extradural Haemorrhage
Usually young (Dura is less adherent to the skull in the young) Following a linear skull vault fracture Brief duration of unconsciousness followed by improvement (lucid interval) Stupor Ipsilateral dilated pupil Contralateral hemiparesis Uncal Herniation → bilateral fixed pupils, tetraplegia and respiratory arrest
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Management of Subdural Haematoma
Less immediate treatment than extradural. Imaging and monitoring - bleeds can usually drain spontaneously
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Management of Extradural Haematoma
Urgent neurosurgery for drainage
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Complications of SAH
Vasospasm | Obstructive Hydrocephalus
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Management of Vasospasm in SAH
Prophylaxis: Nimodipine (CCB targeting brain vasculature) - 21-day course Treatment: hypervolaemia, induced-hypertension and haemodilution
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Management of Obstructive Hydrocephalus in SAH
External ventricular drain (CSF diverted into a bag at the bedside)
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Features of Amyotrophic Lateral Sclerosis
``` Muscle weakness and wasting Fasciculations Cramps Brisk reflexes Extensor plantar responses Spasticity ``` Single limb initially, progresses to other limbs and trunk Progression takes place over months
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Presentation of Progressive Bulbar Palsy
Dysarthria THEN Dysphagia Nasal regurgitation of fluids Choking Fasciculating tongue with slow, stiff tongue movements Emotional incontinence i.e. pathological laughter and crying
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Diagnosis of MND
Upper and lower motor neuron signs EMG shows active and chronic partial denervation Relentless progression of signs and symptoms
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Complications of MND
Respiratory failure - inadequate ventilation, hypoxaemia, ineffective cough, risk of aspiration Feeding difficulty VTE
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Indications for ventilatory support in MND
Acute - cardiorespiratory arrest, respiratory distress, blood gas abnormality, severe bulbar dysfunction, impaired consciousness Chronic - VC < 60% predicted, FVC < 50% predicted
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Problems with NIV
Mask causes skin breakdown - cannot be used long term Unsuccessful if severe bulbar dysfunction, upper airway obstruction or retention of respiratory secretions
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Indications for Tracheostomy in MND
Difficulty clearing secretions Progressive chronic respiratory failure requiring intermittent long-term mechanical ventilation but NIV contraindicated or insufficient e.g. severe bulbar dysfunction Patients who fail to wean off invasive mechanical ventilation
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Management of VTE risk in MND
Educate patient and family on signs and symptoms Antiembolism stockings + devices e.g. intermittent pneumatic compression Pharmacological - Fondaparinux, LMWH or Heparin
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Stages of a Swallowing Assessment
Inspect patient, especially lips and tongue Examine CN V, VII and IX including gag reflex Assess swallow using a cracker, thickened fluid and water. Feel their neck when swallowing. Ask them to say 'ah' when finished and listen for rattling.
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Pathology of Parkinson's Disease
Dopaminergic Neurons in Substantia Nigra are replaced with Lewy Bodies.
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Key Features of Parkinsonism
Akinesia Bradykinesia Cogwheel Rigidity (occurs throughout the range of movement) Resting tremor Shuffling gate + freezing e.g. when walking through a doorway
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Earliest sign of Parkinson's
Anosmia
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Complications in Parkinson's
Increased risk of falls Increased risk of fractures (osteoporosis) Dementia Psychiatric illness
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Sleep problems seen in Parkinson's
Restless legs REM sleep behaviour - hitting out Excessive daytime somnolence Sudden onset sleep
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First line treatment of Parkinson's symptoms which are affecting daily life
Co-careldopa (levodopa with carbidopa) or Co-beneldopa (Levodopa with Benserazide) i.e. L-dopa containing drugs and dopa-decarboxylase inhibitor to prevent peripheral conversion to dopamine
212
ADRs of Levodopa
ADRs: Dyskinesia, Painful dystonia | Psychosis, visual hallucinations and N&V → non motor ADRs treated with Domperidone
213
Symptoms of levodopa withdrawal
Acute Akinesia in response to sudden withdrawal Often misdiagnosed as Neuroleptic Malignant Syndrome
214
First line treatment of Parkinson's disease without affect on daily life
Dopamine agonists e.g. Ropinirole, Pramipexole MAO-B Inhibitors e.g. Rasagiline, Selegiline
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ADRs of Dopamine agonists e.g. Ropinirole
Drowsiness, Nausea, Hallucinations, Compulsive behaviour (gambling, hypersexuality - both are reversible).
216
ADRs of MAO-B inhibitors e.g. Rasagiline
Postural hypotension, AF
217
Management of sleep disorders in Parkinson's
Modafinil for daytime somnolence Clonazepam or melatonin for REM sleep disorder
218
Management of orthostatic hypotension in Parkinson's
Midodrine (alpha agonist - vasopressor) | Fludrocortisone (mineralocorticoid effects)
219
Management of hallucinations and delusions in Parkinson's
Do not treat if well tolerated Quetiapine (2nd generation antipsychotic) Clozapine (5-HT antagonist) Avoid olanzapine and other dopaminergic drugs.
220
Management of drooling in Parkinson's
Glycopyrronium bromide Specialist referral for Botulinum toxin A Anticholinergics if cognitive impairment is minimal
221
Management of dementia in Parkinson's
``` Acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) Memantine ```
222
Features of Progressive Supranuclear Palsy
Similar to Parkinson's Abnormal eye movements (unable to look upwards)
223
Features of Multisystem Atrophy
``` Similar to Parkinson's Rigidity > tremor Autonomic dysfunction e.g. incontinence, postural hypotension Cerebellar signs No dementia ```
224
Features of Corticobasal Degeneration
``` Similar to Parkinson's Akinetic rigidity of one limb Sensory loss (astereognosis) Apraxia Early cognitive impairment ```
225
Chorea
Brief, abrupt, irregular, unpredictable, stereotypes movements. i.e. very fidgety
226
Pathology of Huntington's disease
AD Trinucleotide repeat disorder (CAG repeat) Causes degeneration of cholinergic and BAGAergic neurons in striatum of basal ganglia.
227
Features of Huntington's disease
> 35 yrs Chorea Personality change - irritable, depressed Intellectual impairment Dystonia Saccadic eye movement Low BMI - difficulty swallowing and high calorific demand Often have a family history
228
Management of Huntington's disease
Counselling for patient and family | Symptomatic, MDT approach
229
Presentation of Benign Hereditary Chorea
Mild chorea and hypotonia from infancy. | Frequently improves with age and does not progress
230
Definition of a 'tic'
Brief, sudden, repetitive movements or sounds (stereotyped). Preceded by an inner urge or local premonitory sensation which is relieved by performing the tic. Increased with stress, anxiety and excitement, decreased by distraction. They CAN be suppressed temporarily UNLIKE focal seizures (DDx).
231
Criteria for Tourette's Syndrome
Multiple motor tics & at least 1 phonic tic (Echolalia - repeating something someone else has said, Coprolalia - swearing) Starts under the age of 18 yrs
232
Risk Factors for Tic Disorders
``` < 18 years Male Family history of tics or OCD ADHD Depression Behavioural disorder e.g. ADHD or OCD ```
233
Secondary causes of Tic disorders
``` Infections Substance abuse usually stimulants Medicine e.g. Lamotrigine Toxins e.g. carbon monoxide Head trauma Stroke Metabolic and endocrine (chorea gravidarum, thyrotoxicosis) Neurodegenerative (HD, Wilson’s) ```
234
Conservative management of Tic Disorders
Comprehensive behavioural intervention for tics Habit-reversal training CBT
235
Pharmacological management of Tic Disorders
First line: Alpha-2-adrenergic agonists e.g. Clonidine Second line: Topiramate (vg Na+ and Ca2+ channel blockade, excitatory glutamate inhibitor) Third line: atypical neuroleptics e.g. Aripiprazole or risperidone (for severe disease)
236
Presentation of Dystonia
Sustained, involuntary contractions of agonist and antagonist muscles - loss of coordination of muscle relaxation with contraction. Often leads to repetitive twisting movements and abnormal postures of trunk, neck, face or extremities. Dystonia appears or gets worse with action Children - leg movement Adults - blepharospasm (tight eyelid closure), Cervical torticollis (neck turning)
237
An example of physiological dystonia
Writer's cramp
238
Management of generalised dystonias
First line: Levodopa PLUS Physiotherapy Antispasmodic e.g. baclofen (GABA-B stimulator), clonazepam Treatment of underlying disease Second line: Trihexyphenidyl (centrally-acting muscarinic antagonist) PLUS above Third line: Deep Brain Stimulation
239
Management of focal dystonia
Botulinum toxin is first line +/- TENS
240
Definition of tremor
Involuntary rhythmic oscillation of 1+ body parts. Mediated by alternating contractions of reciprocally acting muscles.
241
Deep brain stimulation: - Indication - Site of action - Criteria
Used for PD, tremor, dystonia. Stimulates globus pallidus and thalamus Not eligible if > 70, cognitive decline or falls.
242
Multiple Sclerosis tends to affect:
Periventricular white matter Optic nerves Spinal Cord
243
L'hermitte's phenomenon
Neck flexion causes paraesthesiae down the spine. Caused by a plaque in the spinal cord. Commonly associated with MS. Differentials include spinal cord compression, B12 deficiency, idiopathic cause.
244
Uhthoff's phenomenon
Worsening of MS symptoms when temperature is raised e.g. during exercise, in the batj
245
Internuclear ophthalmoplegia
Classical symptom of MS. E.g. If the left eye is affected, when looking to the right, left eye adducts minimally and right eye abducts with nystagmus
246
Signs and symptoms of Transverse myelitis
Sensory loss - begins distally and ascends, with a level Weakness e.g. foot dragging or slapping Urinary symptoms e.g. incontinence, retention, urgency Bowel symptoms, usually constipation UMN signs e.g. spasticity, hyperreflexia
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Signs and symptoms of Optic Neuritis
Painful eye movements (dull ache) Relative Afferent Pupillary Defect (RAPD) Impaired colour vision - low saturation of red Visual fields - central scotoma Reduced visual acuity Fundoscopy: Optic atrophy, swollen, hyperaemic disc
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Presentation of MS
Transverse myelitis Optic neuritis Wide-based gate or limb ataxia if brainstem/cerebellum affected Cognitive dysfunction if cerebral hemispheres affected
249
Definition of a relapse in MS
New neurological symptoms or exacerbation of old symptoms lasting > 24 hours, in the absence of fever or infection. Remission needs to last for at least 30 days between relapses. Remyelination, reduction of oedema and insertion of Na+ channels into demyelinated nerve membrane are responsible for periods of remission.
250
Most common form of MS
Relapsing-remitting (85%)
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Immune cells responsible for MS
T helper cells and macrophages
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Criteria for MS diagnosis
McDonald Criteria Dissemination in time and space demonstrated by MRI or clinical symptoms
253
Imaging essential for diagnosis of MS
MRI brain - hyperintensity in periventricular white matter. Gadolinium used to distinguish active from inactive plaques. MRI spine
254
CSF evaluation in MS
Oligoclonal bands (IgG) Moderately elevated protein Mild mononuclear pleocytosis
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Management of Acute Relapse in MS
Methylprednisolone (IV 1g OD for 3 days or PO 500 mg OD for 5 days, give in the morning to reduce insomnia) +/- Plasma exchange Steroids will only accelerate recovery, not improve outcomes. Patients can be offered nursing/home support during these episodes.
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Disease-modifying treatment of MS
``` Interferon beta 1a/b (SC or IM) - only drug which is licensed in 2o progressive disease Peginterferon beta 1a Glatiramer acetate (SC) Teriflunomide Dimethyl fumarate ```
257
Indications for disease modifying treatment in MS
2 relapses in the last 2 years 1 disabling relapse in the last year No substantial progression Ability to walk
258
Efficacy of Disease Modifying Drugs in MS
Reduce relapse rate by ⅓ for 2 years of treatment AND reduce relapse severity.
259
Lifestyle modifications recommended in MS
Regular exercise including resistance training to combat fatigue Good sleep hygiene Mind-body therapy e.g. yoga
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Hypersensitivity reaction seen in Myasthenia Gravis
Type II
261
Immune cells associated with Myasthenia Gravis
B cells and T cells
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Receptors affected in Myasthenia Gravis
Nicotinic ACh receptors
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Presentation of Myasthenia Gravis
Fluctuating muscle weakness, affecting muscle groups in the following order: Extraocular, bulbar, face, neck, limb girdle, trunk. Muscle fatiguability Ptosis Diplopia Myasthenic snarl on smiling
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How do male and female patients with Myasthenia Gravis differ?
Females are 20-30 yrs with thymic dysplasia. | Males are 60-70 years with thymic atrophy or tumour.
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EMG findings in Myasthenia Gravis
Decremental response to repetitive nerve stimulation
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Antibodies seen in Myasthenia Gravis
Anti-AChR (90%) Anti-MUSK (Muscle-specific tyrosine kinase)
267
Management of Myasthenia Gravis
Symptom control - Neostigmine/Pyridostigmine (Acetylcholinesterase inhibitors) Immunosuppression: Prednisolone or Azathioprine Osteoporosis prophylaxis if steroid management. Surgical: Thymectomy (if poor response to drug treatment)
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ADRs of Neostigmine/Pyridostigmine
``` Increased salivation Lacrimation Sweats Vomiting Miosis (constriction of pupil of one eye) ```
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Myasthenic Crisis
Life threatening weakness of respiratory muscles during relapse
270
Management of Myasthenic Crisis
Ventilatory support Plasmapheresis - removes AChR antibodies from circulation OR IV Ig Identify and treat trigger
271
Pathology of Lambert Eaton Myasthenic Syndrome
Anti-voltage-gated Ca2+ channels at neuromuscular junction Usually associated with small cell lung cancer
272
Risk Factors for Lambert Eaton Myasthenic Syndrome
Underlying malignancy (esp. SC lung CA) Coexisting AI disease Cigarette smoking FH of AI disease
273
Features of Lambert Eaton Myasthenic Syndrome
Proximal leg weakness and waddling gait - improves with movement Dry mouth Areflexia Impotence
274
EMG findings in Lambert Eaton Myasthenic Syndrome
Positive decrement on repetitive nerve stimulation
275
Management of Lambert Eaton Myasthenic Syndrome
Treat underlying cause - usually lung CA Pyridostigmine (AChesterase inhibitor) Steroids/Azathioprine
276
Features of Myopathy
Proximal Weakness Elevated CK Myopathic EMG (small motor units) Irregular, necrotic muscle fibres on biopsy
277
How does denervation atrophy differ from myopathy?
Distal weakness Normal CK Fibrillations +/- fasciculations on EMG Normal muscle biopsy
278
Examples of Myopathy
Duchenne Muscular Dystrophy Myotonic Dystrophy Polymyositis/Dermatomyositis Inclusion body myositis
279
Myotonic dystrophy affects which age group?
Adolescents and young adults
280
Duchenne muscular dystrophy affects which age group?
Children
281
Prevalence of Duchenne Muscular dystrophy
1 in 4000
282
Inheritance pattern of Myotonic Dystrophy
Autosomal dominant
283
Inheritance pattern of Duchenne Muscular Dystrophy
X-linked recessive
284
Typical Features of Myotonic Dystrophy
'Slapped' face - atrophy of face muscles, ptosis, frontal baldness Myotonia - cannot let go of handshake Percussion myotonia - muscles become activated by tapping then cannot relax
285
Extramuscular features of Myotonic Dystrophy
``` Cataracts Cardiac arrhythmia Testicular atrophy Gynaecomastia Diabetes ```
286
Children with Duchenne Muscular Dystrophy are normally confined to a wheelchair by the age of:
10-12 years
287
Signs and symptoms of Duchenne Muscular Dystrophy
Calf pseudohypertrophy Toe-walking Gower's manoeuvre - unable to use proximal muscles to get up off the floor May have cognitive and behavioural impairment (dystrophin is found in cortical neurons)
288
Complications of Duchenne Muscular Dystrophy
``` Respiratory insufficiency - causes death by 2nd decade Dilated cardiomyopathy (also seen in female carriers) ```
289
Becker Vs Duchenne Muscular Dystrophy
Becker is less severe. Diminished quantity/quality of dystrophin.
290
Management of Myotonic Dystrophy
Symptomatic e.g. fitted collar for head-drop, eyelid crutches for ptosis, modafinil for daytime sleepiness Genetic counselling Monitoring of extramuscular features Swallowing assessment
291
Management of Duchenne Muscular Dystrophy
Corticosteroids Physiotherapy + exercise + psychological support Surgery for contractures Cardioprotective drugs Positive pressure ventilation if contractures of lungs & chest wall Surgery for scoliosis
292
Presentation of Polymyositis
Adults with proximal weakness
293
Lymphocytes associated with Polymyositis
CD-8
294
Presentation of Dermatomyositis
All ages Proximal weakness + Rash Purple discolouration of upper eyelids Oedema around eyes and mouth Facial erythema Red scaly papules over extensors
295
Autoantibody associated with Dermatomyositis
Anti-Jo-1 autoantibodies
296
Lymphocytes associated with Dermatomyositis
CD-4
297
Muscle biopsy findings in Polymyositis
Myonecrosis of myomysium
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Muscle biopsy findings in Dermatomyositis
Atrophy of perimysium
299
Features of Inclusion Body Myositis
Men, > 50 yrs Distal muscle weakness - wasting of forearms causing watch to be loose Elevated CK
300
Causes of Rhabdomyolysis
``` Trauma Excessive exertion inc. seizures Muscle ischaemia e.g. compartment syndrome Infection Hyperthermia Toxins Drugs e.g. Statins ```
301
Presentation of Rhabdomyolysis
``` Weakness Myalgia Muscle swelling Elevated CK Red-brown urine (myoglobinuria) AKI ```
302
Management of Rhabdomyolysis
Fluids Haemodialysis if anuric or unresponsive to hydration
303
Signs and symptoms of Steroid Myopathy
Proximal muscle weakness Lower extremities then upper Cushingoid features
304
Non pharmacological treatment of neuropathic pain
Hot/Cold pads Relaxation and Breathing exercises Staying active Treatment of mood
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First line drug management of neuropathic pain
Amitriptyline, Duloxetine, Gabapentin, Pregabalin. If any of these treatments are ineffective, one of the other 3 should be offered.
306
First line drug management of neuropathic pain associated with diabetic neuropathy
Duloxetine
307
ADRs of amitriptyline
Anticholinergic syndrome - drowsiness, dry mouth, constipation, blurred vision QT prolongation
308
Contraindications for Amitriptyline
Arrhythmias Mania Heart block post-MI recovery
309
Duloxetine should be used with caution in patients with...
History of seizures Raised intraocular pressure Susceptibility to angle-closure glaucoma
310
Duloxetine MOA
SNRI
311
Duloxetine: ADRs
``` Constipation Drowsiness Dry mouth Headache Weight change ```
312
Gabapentin: MOA
Vg Ca2+ channel blocker. Enhances GABA responses and reduces release of neurotransmitters
313
Gabapentin: ADRs
``` Anticholinergic syndrome Arthralgia GI upset Increased infection risk Gynaecomastia Hyponatraemia ```
314
Pregabalin: MOA
Vg Ca2+ channel blocker. Inhibiting release of excitatory neurotransmitters
315
Pregabalin: ADRs
``` Anticholinergic syndrome Increased infection risk GI upset Prolonged QT Gynaecomastia ```
316
First line management of trigeminal neuralgia
Carbamazepine
317
Autoantibodies associated with Neuromyelitis Optica
Anti-Aquaporin-4 (AQP4)
318
How does NMO differ from MS?
Long segments of spinal cord demyelination | Optic neuritis is more severe with worse recovery
319
Presentation of NMO
Transverse Myelitis +/- Optic neuritis Attacks occur over days, with varying degrees of recovery over weeks to months
320
CSF findings in NMO
Elevated protein No oligoclonal bands Neutrophilic pleocytosis during acute attacks
321
Diagnosis of NMO
CSF - no oligoclonal bands MRI spine - longitudinally extensive spinal cord lesion.
322
Management of NMO
IV Methylprednisolone. Plasma exchange if unresponsive to steroids. Long term immunosuppression (steroid sparing)
323
Pathology of Central Pontine Myelinolysis
Degeneration of midline patch of pons through loss of myelin. Triggered by osmotic stress e.g. rapid correction of hyponatraemia
324
Presentation of Central Pontine Myelinolysis
Usually asymptomatic UMN signs: Babinski, hyperreflexia, spastic paralysis (can be of bulbar muscles causing dysarthria and dysphagia) Behavioural disturbance Locked-in syndrome or Coma
325
Management of Central Pontine Myelinolysis
Relower sodium | ET intubation and ventilation
326
Prevention of Central pontine myelinolysis
Na+ should be raised by no more than 6-8 in any 24 hour period
327
Pathology of communicating hydrocephalus
Overproduction or reduced absorption of CSF
328
Differentials for communicating hydrocephalus
Choroid plexus papilloma (rare) Subarachnoid haemorrhage - arachnoid granulations cannot absorb CSF normally. Meningitis
329
Treatment of Hydrocephalus
Ventriculoperitoneal shunt Dexamethasone to reduce inflammation Decompressive craniectomy if refractory to other management
330
Pathology of non communicating hydrocephalus
Obstruction to flow of CSF May be due to aqueduct stenosis (gradual), tumour, abscess, cysts.
331
Presentation of communicating hydrocephalus
``` Signs of raised ICP: Headaches Worse with stooping or straining N&V Papilloedema ```
332
Presentation of non communicating hydrocephalus
``` Signs of raised ICP: Headaches Worse with stooping or straining N&V Papilloedema ``` If acute - may cause rapid LOC and death If incomplete or gradual - may be asymptomatic
333
CT head findings in hydrocephalus
Ventriculomegaly Enlarged temporal horns of lateral ventricles if acute
334
Management of non communicating hydrocephalus
Shunting if long term, Extraventricular drain if short term (E.g. SAH) Treat underlying cause Dexamethasone to reduce inflammation Decompressive craniectomy if refractory to other management
335
Pathology of Normal Pressure Hydrocephalus
Gradual increase in pulse pressure in major arteries with age, due to atheroma and calcification. Brain becomes ischaemic due to high CSF outflow resistance impeding cerebral perfusion.
336
Presentation of Normal pressure hydrocephalus
Adam's triad 1. Gait disturbance (unresponsive to LDOPA) 2. Dementia 3. Urinary incontinence
337
Risk Factors for Normal Pressure Hydrocephalus
Age > 65 yrs Vascular disease DM
338
Management of Normal Pressure Hydrocephalus
Control cardiovascular risk factors Repeated large volume CSF taps VP shunt or 3rd ventriculostomy if suitable for surgery.
339
Nerve conduction studies: Demyelination vs Axonal Neuropathy
Demyelination - slowing of conduction | Axonal - Low action potential amplitudes
340
Pathology of Peripheral Neuropathy
May be due to axonal degeneration, demyelination or vascular damage
341
Peripheral neuropathy affecting large sensory fibres causes...
Pins and needles
342
Peripheral neuropathy affecting small sensory fibres causes...
Pain
343
Presentation of Common Peroneal Nerve Injury
Foot drop Weak dorsiflexion Weak toe extension Weak foot eversion
344
The common peroneal nerve is vulnerable as it runs along the...
Fibular head
345
Meralgia Paraesthetica
Burning/Electric shock/numbness in anterolateral thigh region. Caused by entrapment or compression of lateral cutaneous nerve of thigh
346
Carpal tunnel syndromes is caused by compression of the...
Median nerve
347
Examples of mononeuropathies
Meralgia Paraesthetica Carpal tunnel syndrome Foot drop due to common peroneal nerve injury
348
Symptoms of Carpal Tunnel Syndrome
Aching pain in hand and arm, may be worse at night | Tingling/numbness in thumb, index and middle finger - may be relieved by dangling off the bed
349
Signs of Carpal Tunnel Syndrome
Sensory loss in median nerve distribution Wasting of thenar eminence Weakness of abductor pollicis brevis
350
Management of Carpal Tunnel Syndrome
Splinting Vit B6 supplementation (controversial) Local steroid injection Decompressive surgery
351
Presentation of ulnar nerve compression at the level of the elbow
Flexion of wrist can only occur with abduction Loss of abduction and adduction of fingers (interossei paralysed) Froment's Sign - unable to hold a piece of paper between thumb and index finger (adductor pollicis paralysis) Loss of sensation in entire ulnar nerve distribution (medial 1.5 fingers, anterior and posterior)
352
Presentation of ulnar nerve compression at the level of the wrist
Paralysis of intrinsic muscles of hand - loss of finger abduction and adduction Froment's Sign - unable to hold a piece of paper between thumb and index finger (adductor pollicis paralysis) Sensory loss over palmar side of medial 1.5 fingers
353
Presentation of radial nerve injury due to dislocated shoulder or fracture of proximal humerus
Wrist drop | Loss of sensation over full radial nerve distribution
354
Presentation of radial nerve injury due to humeral shaft fracture
Weak elbow extension Wrist drop Loss of sensation on dorsal surface of lateral 3 digits and associated palm
355
Presentation of injury to superficial branch of radial nerve in the forearm due to a laceration
No motor deficit | Loss of sensation in lateral 3 digits and associated palm
356
Presentation of injury to deep branch of radial nerve in the forearm due to a radial head fracture/dislocation
Weak wrist extension No wrist drop - extensor carpi radialis longus unaffected No sensory deficit
357
Differentials for Peripheral Polyneuropathy
Diabetes - glove and stocking, slowly progressive, painful Amyloid Nutritional (B12) Guillain Barre - rapidly progressive - days to weeks, follows respiratory or GI infection (esp. campylobacter) Toxic - amiodarone, lead Hereditary - Charcot-marie tooth, Friedreich's ataxia Endocrine Recurring/Renal Alcohol Pb (lead)/Porphyria Infection - leprosy, HIV, Lyme’s Systemic - sarcoid, SLE, hypothyroid, syphilis Tumours - paraneoplastic
358
Most common hereditary Peripheral neuropathy
Charcot-Marie Tooth
359
Presentation of Charcot-Marie Tooth
``` Pes cavus (High arched feet) Altered gait with loss of heel-toe pattern Distal muscle weakness and atrophy Hyporeflexia Frequently sprained ankles ```
360
Management of Charcot-Marie Tooth
Symptomatic - physiotherapy and orthotics. Orthopaedic surgery if severe.
361
Most common form of Guillain-Barré
Acute inflammatory demyelinating neuropathy
362
Typical presentation of Guillain-Barré
Paraesthesias in toes and fingers, preceding weakness Rapidly progressive flaccid weakness (upper limb then lower) Areflexia Slurred speech Back and leg pain Weakness may affect respiratory muscles, requiring ventilation
363
Miller Fisher Syndrome
Guillain-Barré syndrome affecting cranial nerves | Causes ophthalmoplegia, ataxia and areflexia
364
Management of Guillain-Barré Syndrome
Supportive treatment Plasma exchange IV Ig
365
Erb's palsy is usually caused by...
Falling onto shoulder or traction on neck and shoulder at birth
366
Erb's palsy is due to a lesion of..
Upper brachial plexus (C5/6)
367
Erb's palsy: Presentation
'Waiter's tip' arm internally rotated, extended and slightly adducted Loss of shoulder abduction and elbow flexion. Sensory loss in C5/6
368
Klumpke's palsy is usually caused by...
Forceful abduction of arm at birth or following trauma
369
Klumpke's palsy is due to a lesion of..
Lower brachial plexus (C8/T1)
370
Klumpke's palsy: Presentation
'Claw hand' Loss of function of intrinsic muscles of hand, long flexors & extensors of fingers Loss of sensation in C8/T1 +/- Horner's syndrome
371
Pathology of Radiculopathy
Conduction block of spinal nerve and its roots due to nerve compression. May be due to disc prolapse, neurodegenerative disease of spine, fracture, neoplasm, infection.
372
Signs and Symptoms of Radiculopathy
Radicular pain - sharp, stabbing, electric shock radiating down the limb Asymmetric weakness, atrophy and fasciculations Sensory loss Exact symptoms depend on site of injury
373
Red flags of Radiculopathy
``` Faecal Incontinence Urinary retention Saddle anaesthesia Immunosuppression IVDU Chronic steroid use Osteoporosis New onset in over 50 yrs History of malignancy ```
374
Gold standard imaging for radiculopathy
MRI spine > CT spine > X-ray spine
375
Features of radiculopathy of L2-4
Back pain radiating to anterior leg and knee | Weak hip flexion, knee extension and leg adduction
376
Features of radiculopathy of L5
Back pain radiating down lateral aspect of leg to foot. Weak foot dorsiflexion, toe extension and foot inversion/eversion Sensory loss in lateral shin and dorsum of foot.
377
Features of radiculopathy of S1
Back pain radiates down posterior leg and into foot. Weak plantarflexion and toe flexion Sensory loss on posterior leg and lateral foot. Loss of ankle reflex
378
Features of Cauda Equina Syndrome
Lower back pain Urinary incontinence or retention Reduced sensation in perianal area (saddle anaesthesia) Decreased anal tone
379
Management of radiculopathies
Analgesia using WHO pain ladder Neuropathic pain management (Amitriptyline, Gabapentin, Pregabalin, Duloxetine) Surgery if pain continues, progressive weakness or spinal cord becomes affected.
380
Features of radiculopathy of C5
Neck, shoulder and scapular pain Lateral arm numbness (axillary nerve area) Weak shoulder abduction, elbow flexion & forearm supination Loss of biceps and brachioradialis reflexes
381
Features of radiculopathy of C6
Neck, shoulder, scapula, lateral arm, forearm and hand pain Numbness of lateral forearm, thumb and index finger Weakness of shoulder abduction & external rotation, elbow flexion & forearm rotation Loss of biceps and brachioradialis reflexes
382
Features of C7 radiculopathy
Neck, shoulder, middle finger and hand pain Numbness of index and middle finger Weak elbow and wrist extension, forearm pronation and wrist flexion Loss of triceps reflex
383
Features of C8 radiculopathy
Neck, shoulder, medial forearm, medial hand and finger pain Numbness in medial forearm, medial 2 digits and hand Weak wrist extension, finger movements and thumb flexion
384
Features of T1 radiculopathy
Pain in neck, medial arm and medial forearm. Numbness in anterior arm and medial forearm Weak thumb abduction and flexion Weak finger ab/adduction
385
Corticospinal tracts decussate in the...
Medulla of the brainstem
386
Dorsal column tracts decussate in the...
Medulla of the brainstem
387
Spinothalamic tracts decussate in the...
Spinal cord
388
Spinal tracts affected by Amyotrophic Lateral Sclerosis
Corticospinal tracts - Upper and lower motor neurons
389
Spinal tracts affected by Poliomyelitis
Anterior horns of corticospinal tracts - lower motor neurons only
390
Spinal tracts affected by Brown-Sequard Syndrome
Lateral corticospinal tract Dorsal columns Lateral spinothalamic tract
391
Signs of Brown-Sequard Syndrome
Contralateral loss of pain and temperature sensation. Ipsilateral loss of proprioception and vibration sense. Ipsilateral spastic paralysis below the level of the lesion
392
Subacute combined degeneration of the spinal cord is caused by
Vitamin B12 and E deficiency
393
Tracts affected in subacute combined degeneration of the spinal cord
Lateral corticospinal tract Dorsal columns Spinocerebellar tracts
394
Features of subacute combined degeneration of the spinal cord
Bilateral symptoms. Spastic paresis, loss of proprioception and vibration sense and limb ataxia
395
Tracts affected in Freidrich's ataxia
Lateral corticospinal tract Dorsal columns Spinocerebellar tracts
396
Features of Freidrich's ataxia
Bilateral symptoms. Spastic paresis, loss of proprioception and vibration sense and limb ataxia Plus dysarthria, nystagmus and dysdiadochokinesia
397
Anterior spinal cord syndrome is caused by...
Anterior spinal artery occlusion
398
Tracts affected in anterior spinal cord syndrome
Lateral corticospinal tract | Lateral spinothalamic tract
399
Features of anterior spinal cord syndrome
Bilateral spastic paresis (UMN) Bilateral loss of pain and temperature sensation Preserved vibration sense and proprioception.
400
Syrinx
Cyst full of CSF causing central cord syndrome
401
Syringomyelia
Syrinx (cyst full of CSF) within the spinal cord
402
Syringobulbia
Syrinx (cyst full of CSF) within the brainstem
403
Tracts affected in central cord syndrome
``` Ventral horns (containing motor neurons) Lateral spinothalamic tracts ```
404
Features of central cord syndrome
Often occurs in cervical spinal cord. Flaccid paralysis - typically intrinsic hand muscles Loss of pain and temperature sensation - 'cape-like' distribution if in cervical cord
405
Differential diagnosis for posterior cord syndrome
Neurosyphilis (Tabes dorsalis) Combined Subacute Degeneration of Spinal Cord (B12 deficiency) Trauma MS
406
Features of posterior cord syndrome
Bilateral loss of proprioception and vibration sense
407
Cervical spine injury typically occurs at which vertebral levels?
C2 (1/3) | C6-7 (1/2)
408
Definition of spasticity (complication of UMN lesions)
Velocity dependent resistance to stretch
409
Treatment of spasticity which is interfering with sleep in UMN lesions
First line: Baclofen - GABA derivative Other options include diazepam, dantrolene, tizanidine and botox
410
Pathology of autonomic dysreflexia in a patient with a spinal cord lesion
Excessive sympathetic output in patient with an injury at T6 or above. Precipitated by noxious stimulus below level of injury - most commonly due to bladder distension. Other causes include UTI, constipation, gallstones, pressure sores and ingrowing toenails.
411
Management of Autonomic Dysreflexia
Sit patient upright Remove tight clothing Regularly monitor blood pressure Check for precipitants e.g. catheter obstruction, constipation requiring manual evacuation. Pharmacological management: Nitrates or nifedipine
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Presentation of Autonomic Dysreflexia
``` Bilateral pounding headache Elevated BP Sweating above level of injury Nasal congestion Nausea Blurred vision ``` In a patient with spinal cord injury at T6 or above. Precipitated by noxious stimulus below level of injury
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Prevention of pressure sores in patients with spinal cord injury
Position changes every 4-6 hours
414
Most common cause of acute cord compression in patients 16-30 years
Trauma
415
Most common cause of acute cord compression in patients 30-50 years
Disc disease
416
Most common cause of acute cord compression in patients 40-75 years
Malignancy
417
Risk factors for acute cord compression
``` Trauma Cancer Osteoporosis High risk occupation/recreation IVDU Immunosuppression ```
418
Presentation of acute cord compression
Depends on level of injury. ``` Back pain Numbness or paraesthesias Weakness or paralysis (wasting if chronic) Bladder or bowel dysfunction Hyperreflexia (UMN lesion) Saddle anaesthesia (Cauda Equina) ```
419
General management of Acute Cord Compression
ABCD approach VTE prophylaxis Prevention of gastric stress ulcers - omeprazole Pressure ulcer prophylaxis
420
Management of traumatic spinal cord compression
Spinal immobilisation | Decompression/Stabilisation surgery within 72 hours
421
Management of Cauda Equina Syndrome
Emergency decompression within 48 hours of onset of symptoms
422
Management of malignant spinal cord compression
Palliative. Corticosteroids - analgesia, reduce oedema and oncolysis Laminectomy or vertebrectomy Radiotherapy
423
Causes of transverse myelitis
Most commonly MS and Neuromyelitis optica. Parainfectious e.g. HSV, HZV, CMV, TB, Syphilis, Lyme Post vaccination Autoimmune e.g. SLE, Sjogren's Sarcoidosis Paraneoplastic
424
Broca's area is involved in...
Production of coherent speech
425
Wernicke's area is involved in...
Speech processing and understanding language
426
Signs and Symptoms associated with Posterior Cerebral Artery Stroke
Homonymous hemianopia (may be the only symptom) Prosopagnosia - can’t recognise faces Alexia - inability to read Receptive Aphasia (can’t comprehend spoken words) +/- cerebellar or brainstem signs
427
Signs and Symptoms associated with middle cerebral artery stroke
Contralateral face and arm weakness and sensory loss Mild or no leg weakness Head and eyes deviate towards lesion. Broca's aphasia if left sided.
428
Signs and Symptoms of Anterior Cerebral Artery Stroke
Contralateral leg weakness and sensory loss Mild or no upper extremity involvement. Broca's aphasia may occur if left sided.
429
Signs and symptoms of Lacunar stroke
Pure motor or pure sensory +/- Ataxia +/- Clumsy hand syndrome Higher cortical function such as language, vision, facial recognition not affected.
430
Most common causes of ischaemic stroke
Atherosclerosis or embolism (e.g. from AF)
431
Haemorrhagic strokes are usually caused by...
``` HTN AV malformations Vasculitis Vascular tumours e.g. haemangioma Amyloidosis ```
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Signs and symptoms which are essential for diagnosis of stroke
``` Sudden onset Maximal symptoms at onset Negative symptoms ONLY Focal Unilateral ```
433
ROSIER
Recognition of Stroke in Emergency Room
434
Signs and symptoms which reduce likelihood of stroke
``` LOC Acute confusion Seizure Gradual progression Multiple recurrent symptoms Severe headache Isolated memory loss, dizziness, lightheadedness or vertigo ```
435
Management of Ischaemic stroke
Thrombolysis (Alteplase) within 4.5 hours of onset of symptoms. Dual antiplatelet therapy (Aspirin 300mg and Clopidogrel 75mg) within 24 hours of thrombolysis or within 48 hours of symptom onset if no thrombolysis. Dual antiplatelet therapy for 3 months then continue Clopidogrel long term.
436
Contraindications for Thrombolysis
``` Previous intracranial haemorrhage Seizure at onset of stroke Brain tumour Stroke or traumatic brain injury in preceding 3 months Lumbar puncture in preceding 7 days GI haemorrhagic in last 3 wks Active bleeding Pregnancy Oesophageal varices Uncontrolled HTN >200/120mmHg ```
437
Management of haemorrhagic stroke
Omit drugs which exacerbate bleed. FFP/PCC and vitamin K on warfarin. Admission to critical care. Usually require intubation and invasive monitoring of blood pressure. Surgical interventions if unstable.
438
Transient Ischaemic Attack
'Mini-stoke' Symptoms of stroke which resolve within 24 hours. 15% of ischaemic strokes are preceided by TIA.
439
ABCD2 score
Determines risk of stroke after a TIA Age > 60 - 1 pt Clinical features unilateral weakness (2 pt) or speech impairment (1 pt) Duration > 60 minutes (2 pt), < 60 minutes (1 pt) Diabetes 1 pt Hospital observation necessary if score > 4
440
Management of TIA
Immediate Aspirin 300 mg Urgent (24 hours) stroke assessment within 24 hours if within 7 days. Routine stroke assessment (1 week) if more than 7 days ago. Advise not to drive. Management of risk factors Clopidogrel 75mg Carotid doppler scan
441
Indications for Carotid Artery Endarterectomy
Anterior circulation only (only offer doppler if symptoms of anterior circulation) Must be symptomatic Stenosis >50% in men and >70% in women
442
Mild Traumatic Brain Injury
GCS 13-15
443
Moderate Traumatic Brain Injury
GCS 9-12
444
Severe Traumatic Brain Injury
3-8
445
Definition of coma
GCS 3-8 lasting more than 6 hours
446
Persistent vegetative state
State of wakeful unconsciousness at least 1 month after coma. Patient appears awake and has sleep-wake cycles with no evidence of awareness or responsiveness to any stimuli. Recovery from this state is rare.
447
Brainstem Death
GCS = 3 No spontaneous respiratory effort and absent brainstem reflexes. Recovery considered impossible. Must be tested for by 2 practitioners, both registered for over 5 years, one a consultant + neither a member of the transplant team.
448
Extradural haematomas usually occur in which region? Which vessels are responsible for the bleeding?
Temporal and parietal areas. Middle meningeal vessels.
449
Pathology of diffuse axonal injury
Stretching of axons due to movement of the brain around a fixed brainstem. Results in axonal swelling due to influx of calcium.
450
Which structures are damaged in diffuse axonal injury?
Midline structures e.g. corpus callosum and brainstem | Junctions between white and grey matter
451
Presentation of diffuse axonal injury
Immediate loss of consciousness, remain comatose or enter persistent vegetative state
452
Features of chronic traumatic encephalopathy
``` Inattention Low mood behaviour change Confusion Memory loss ``` Eventually, dementia and Parkinsonism
453
Features of Shaken Baby Syndrome (Non accidental head injury)
Triad: Encephalopathy Subdural haematomas Retinal haemorrhages Non specific presentation: hypotonia, listlessness, vomiting, irritability, lethargy.
454
Signs of raised ICP in infants
``` Irritability Failure to thrive Sleepiness Prominent head veins Sunset sign (Parinaud’s Syndrome) - white sclera visible above iris Apnoea if brainstem compression ```
455
Definition of subfalcial herniation
Cingulate gyrus moves from one hemisphere to the other, under the falx cerebri
456
Definition of uncal herniation
Transtentorial - medial temporal lobe moves from the middle, into the tenotorial opening
457
Signs of uncal herniation
Ipsilateral, fixed, dilated pupil (CN III compression) Ipsilateral cortical blindness (infarct of posterior cerebral artery) False localising sign i.e. CN VI palsy (paralysis ipsilateral to lesion due to compression of cerebral peduncle)
458
Definition of cerebellar tonsillar herniation
Cerebellar tonsils displaced into foramen magnum
459
Presentation of cerebellar tonsillar herniation
Stiff neck and head tilt. | Cardiorespiratory arrest due to compression of pons and medulla
460
Traumatic brain injury can result in cerebral oedema. What is the difference between vasogenic and cytotoxic oedema?
Vasogenic - accumulation of water in interstitial CNS spaces due to increased vascular permeability. More likely to involve white matter, and extends along optic nerves → papilloedema. Cytotoxic - accumulation of water in injured cells.
461
Cervical immobilisation is indicated if:
``` GCS < 15 Neck pain or tenderness Focal neurological deficit Paraesthesia in extremities Clinical suspicion of cervical spine injury ```
462
Battle's sign
Post auricular bruising seen in basal skull fracture
463
Indications for CT scan within 8 hours
Loss of consciousness or amnesia PLUS: > 65 yrs OR History of bleeding or clotting disorders OR Dangerous mechanism OR > 30 mins retrograde amnesia
464
General features of neuro rehabilitation
Dimming of lights Minimal sensory stimulation Maximum of 2 people per visit
465
Most common primary brain tumours in adults
Meningioma Glioblastoma Astrocytoma
466
Most common primary brain tumours in children
Pilocytic astrocytoma | Medulloblastoma
467
Most common tumours of the spinal cord
Schwannoma Meningioma Ependymoma
468
Pilocytic astocytoma
Most frequent brain tumourin children. | Usually arise from cerebellum, hypothalamus and optic chiasm.
469
Astrocytomas can progress to...
Glioblastoma
470
Why is cerebral oedema common in brain tumours?
Tumours have a high metabolism, therefore new vessels must form to supply it. New vessels have no blood-brain barrier, therefore fluid can leak into surrounding tissue.
471
Glioblastoma
Most malignant form of glioma, seen in middle aged adults. Usually affects frontal ad temporal lobes. Masses are irregular with cavitation and surrounded by large area of oedema.
472
Ependymoma
Brain tumour usually intraventricular (4th ventricle) Can cause hydrocephalus. Children > adults
473
Choroid plexus tumours
Children and young adults Arise in both lateral and 4th ventricles Cause hydrocephalus and raised ICP due to blocking CSF pathways and overproduction of CSF.
474
Medulloblastoma
Embryonal tumours of the cerebellum (usually posterior vermis) Can block 4th ventricle and aqueduct causing hydrocephalus. Usually seen in children < 10 yrs Rapid growth - present over weeks to months with signs of raised ICP and cerebellar dysfunction
475
Meningioma
``` CNS tumour arising from arachnoidal cells. Adults > children Women > men (ostrogen receptors) Usually benign Can be completely resected ```
476
Risk factors for meningiomas
``` Neurofibromatosis Type II Cranial Irradiation Environmental irradiation Post HI Breast CA Females of repro age Exogenous hormones - HRT or COCP ```
477
Schwannomas
CNS tumour arising from cranial and spinal nerve roots, and peripheral nerves. 90% arise from CN VIII nerve root - Acoustic Schwannoma Displace brain tissue without invading, cause symptoms due to compression.
478
Anatomic Landmark associated with Acoustic Scwannoma
Cerebellopontine angle
479
Bilateral acoustic schwannomas are associated with...
Neurofibromatosis type II
480
Investigation of choice for suspected acoustic neuroma
MRI of cerebellopontine angle
481
Cranial nerves which can be affected in Vestibular/Acoustic Schwannoma inc. symptoms
CN VIII - sensorineural hearing loss, vertigo, tinnitus CN V - absent corneal reflex CN VII - facial palsy
482
Features of craniopharyngioma
``` Endocrine abnormality e.g. prolactinoma Bitemporal hemianopia (compression of optic chiasm) Hydrocephalus (compression of 3rd ventricle) ```
483
Management of craniopharyngioma
Compressive, non functioning lesions are surgically removed. Smaller, functioning lesions are managed surgically (hormone treatment)
484
Type of lymphoma which may affect the CNS
Large B cell lymphoma
485
Most common site of metastasis in the CNS
Frontal lobe
486
Central Vs Otological vertigo
Central - sense of spinning. Associated with MS, posterior stroke, migraine Otological - sense of floating or tilting. Associated with BPPV, Meniere's disease
487
Central causes of vertigo
``` MS Posterior stroke Posterior fossa tumours Migraine Intracranial SOL ```
488
Otological causes of vertigo
BPPV Meniere’s disease Vestibular Neuronitis Labrynthitis
489
Hoffman's Sign
Hoffmans sign is elicited by flicking the distal phalaynx of the middle finger to cause momentary flexion. A positive result is exaggerated flexion of the terminal phalanyx of the thumb.

Clinical Medicine (9 decks)

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