Neurology Flashcards
Unilateral weakness/sensory deficit
Homonymous hemianopia
Higher cerebral dysfunction e.g. dysphasia, neglect
Anterior cerebral artery stroke
Patient can understand but not reply following stroke
Dominant frontal lobe (Broca’s area) affected
Patient has impaired comprehension but replies fluently with jargon following stroke
Dominant temporoparietal lobe (Wernicke’s area) affected
- Vertigo, vomiting, dysphasia
- Ipsilateral: ataxia, Horner’s syndrome, V, VI palsy
- Contralateral: loss of sensation
Lateral medullary syndrome
Effects of cerebellar syndrome
Effects: DANISH • Dysdiadochokinesis • Dysmetria: past-pointing • Ataxia: limb/truncal • Nystagmus: horizontal = ipsilateral hemisphere • Intenion tremor • Speech: slurred, staccato, scanning dysarthria • Hypotonia
Causes of paraneoplastic syndrome
Causes: PASTRIES • Paraneoplastic • Alcohol: B1 and B12 deficiency • Sclerosis • Tumour • Rare: MSA, Freidrich’s, Ataxia Telangiectasia • Iatrogenic: phenytoin • Endo: hypothyroidism • Stroke: vertebrobasilar
Anterior cerebral artery stroke
- Supplies frontal and medial part of cerebrum
- Contralateral motor/sensory loss in the legs > arms
- Face is spared
- Abulia (pathological laziness)
Middle cerebral artery stroke
- Supplies lateral/ external part of hemisphere
- Contralateral motor/ sensory loss in face and arms > legs
- Contralateral homonymous hemianopia due to involvement of optic radiation
- Cognitive changes: dominant (L) aphasia, non-dominant (R): apraxia, neglect
Posterior cerebral artery stroke
- Supplies occipital lobe
- Contralateral homonymous hemianopia with macula sparing
Vertebrobasilar circulation
- Supplies cerebrum, brainstem and occipital lobes
- Combination of symptoms:
- Visual: hemianopia and cortical blindness
- Cerebellar: DANISH
- CN lesions
- Hemi-/quadriplegia
- Uni-/bilateral sensory symptoms
Lateral Medullary Syndrome/ Wallenberg’s Syndrome
- Occlusion of one vertebral artery or PICA
- Features: DANVAH
- Dysphagia
- Ataxia (ipsilateral)
- Nystagmus (ipsilateral)
- Vertigo
- Anaesthesia: ipsilateral facial numbness + absent corneal reflex, contralateral pain loss
- Horner’s syndrome (ipsilateral)
Pontine lesions (e.g. infarct) 6th and 7th nerve palsy + contralateral hemiplegia
Millard-Gubler Syndrome: crossed hemiplegia
Causes of locked in syndrome
- Ventral pons infarction: basilar artery
- Central pontine myelinosis: rapid correction of hyponatraemia
Causes of cerebellopontine angle syndrome
- Acoustic neuroma
- Meningioma
- Cerebellar astrocytoma
- Metastasis (e.g. breast)
Guess the syndrome:
- Ipisilateral CN 5, 6, 7, 8 palsies + cerebellar signs
- Absent corneal reflex (V1 afferent, VII efferent)
- LMN facial palsy
- LR palsy
- Sensorinerual deafness, vertigo, tinnitus
- DANISH
Cerebellopontine angle syndrome
Guess the syndrome:
- Syncope/ presyncope or focal neurology on using the arm
- BP difference of >20mmHg between arms
Subclavian Steal syndrome
- Subclavian artery stenosis proximal to origin of vertebral artery may lead to blood being stolen from this vertebral artery by retrograde flow
Guess the syndrome:
- Para-/quadriparesis
- Impaired pain and temperature sensation
- Preserved touch and proprioception
Anterior spinal artery/ Beck’s syndrome
- Infarction of spinal cord in distribution of anterior spinal artery: ventral 2/3 of cord
- Caused by aortic aneurysm dissection or repair
Causes of sympathetic under activity/ postural hypotension faint
• Sympathetic underactivity = Postural Hypotension (STAND UP)
o Salt deficiency: hypovolaemia, Addison’s
o Toxins
Cardiac: ACEi, diuretics, nitrates, alpha blockers
Neurology: TCAs, benzos, antipsychotics, L-DOPA
o Autonomic Neuropathy: DM, Parkinson’s, GBS
o Dialysis
o Unwell: chronic bed-rest
o Pooling, venous: varicose veins prolonged standing
Causes of Delirium
Causes: DELIRUMS
• Drugs: opioids, sedatives, L-DOPA, steroids
• Eyes, ears and sensory deficits
• Low oxygen states: MI, stroke, PE
• Infection
• Retention of stool or urine
• Ictal
• Under-hydration or nutrition
• Metabolic: DM, post-op, sodium, uraemia, calcium
• Subdural haemorrhage or other intracranial pathology
Total Anterior Circulation Stroke (TACS)
All 3 of:
- Hemiparesis (contralateral) and/or sensory deficit (>2 of face, arm and leg)
- Homonymous hemianopia (contralateral)
- Higher cortical dysfunction - dysphasia (dominant hemisphere) or hemispatial neglect
Partial = 2/3 of the above (usually 1 and 3)
Posterior Circulation Stroke (PACS)
Any of:
- Cerebellar Syndrome
- Brainstem Syndrome
- Contralateral Homonymous Hemianopia
Lacunar Stroke (LACS)
Small infarcts in white matter tracts (deep penetrating arteries)
Absence of: higher cortical dysfunction, homonymous hemianopia, drowsiness, brainstem signs
5 syndromes:
- Pure sensory
- Pure motor
- Mixed sensorimotor
- Dysarthria/ clumsy hand
- Ataxic hemiparesis: anterior limb of internal capsule
Lateral Medullary Syndrome (Wallenberg’s)
PICA or vertebral artery DANVAH - Dysphagia - Ataxia (ipsilateral) - Nystagmus (ipsilateral) - Vertigo - Anaesthesia (ipsilateral facial numbness and contralateral pain) - Horner's syndrome (ipsilateral)
Side effects of lamotrigine
o Skin rash (SJS)
o Diplopia
Side effects of valproate
• Valproate o Appetite increased o Liver failure o Pancreatitis o Reversible hair loss o Oedema o Ataxia o Teratogen, tremor, thrombocytopaenia o Encephalopathy
Side effects of carbamazepine
o Leukopenia
o Skin reactions
o Diplopia
o SIADH
Side effects of phenytoin
o Gingival hypertrophy o Hirsutism o Cerebellar syndrome: ataxia, nystagmus and dysarthria o Peripheral sensory neuropathy o Diplopia o Tremor
Glasgow Coma Scale
E4 V5 M6
Eyes opening 4 - spontaneous 3 - to speech 2 - to pain 1 - none
Verbal 5 - oriented 4 - confused 3 - inappropriate 2 - incomprehensible 1 - none
Motor 6 - commands 5 - localises 4 - withdraws 3 - flexion 2 - extension 1 - none
Imaging: CT head (+ C-spine) guidelines in TBI
o Open, depressed or basal skull fracture o Retrograde amnesia >30 minutes o Neurological deficit or seizure o GCS <13 at any time or <15 2 hours after injury o Vomit more than once o LOC or any amnesia + any of: Dangerous mechanism Age >65 Coagulopathy including warfarin
Management of benign intracranial hypertension
Obese young woman, raised ICP but no mass lesion
Mx: weight loss, acetazolamide, loop diuretics, prednisolone, LP shunt
Management of raised ICP
- ABC
- Treat seizures and correct hypotension
- Elevated bed to 40 degrees
- Neuroprotective ventilation (PaO2 >13, PCO2 4.5, sedation with NM blockade)
- Mannitol or hypertonic saline
C5 compression
Weakness
Deltoid
Supraspinatus
Loss of supinator jerk
Sensory - numb elbow
C6 compression
Motor - Biceps
Brachioradialis
Lost biceps jerk
Sensory - numb thumb and index finger
C7 compression
Motor - Triceps
Finger extension
Lost triceps jerk
Sensory - numb middle finger
C8 compression
Motor - Finger flexors
Intrinsic hand
Sensory - numb ring and little fingers
L4/5 - L5 Root Compression
• Weak hallux extension +/- foot drop
o In foot drop due to L5 radiculopathy, weak inversion (tibialis posterior) helps distinguish from peroneal nerve palsy
• Decreased sensation of inner dorsum of foot
L5/S1 – S1 Root compression
- Weak foot plantarflexion and eversion
- Loss of ankle jerk
- Calf pain
- Reduced sensation over sole of foot and back of calf
Causes of mononeuritis multiplex
Definition: 2 or more peripheral nerves affected
Usually systemic cause e.g. DM
Others: inflammatory disease, AIDS, Leprosy
Median (C6-T1) nerve lesion
Cause: trauma, carpal tunnel
Motor: LOAF, thenar wasting
Sensory: radial 3.5 fingers and palm, Tinel’s and Phalen’s +ve
Ulnar (C7-T1) nerve lesion
Cause: elbow trauma e.g. supracondylar fracture
Motor: claw hand, hypothenar wasting, Froment’s +ve
Sensory: Ulnar 1.5 fingers
Radial (C5-T1) nerve lesion
Cause: wrist, humerus or axilla
Motor: finger drop +/- wrist drop +/- triceps paralysis
Sensory: snuff box
Erb’s palsy
Cause: trauma, RT e.g. breast leading to high brachial plexus (C5-6) injury
Motor: Waiter’s tip
Sensory: C5-6 dermatome
Klumpke’s palsy
Cause: trauma/ RT causing low brachial plexus (C8-T1) palsy
Motor: claw hand
Sensory: dermatomal
Phrenic nerve (C3-5) lesion
Cause: lung cancer, myeloma, thymoma, cervical spondylosis, zoster, HIV, Lyme, TB
Motor: orhtopnoea + raised diaphragm
Lateral cutaneous nerve of thigh lesion (L2-3)
Cause: entrapment under inguinal ligament
Sensory: anterolateral burning thigh pain
Sciatic (L4-S3) lesion
Cause: pelvic tumour, pelvic or femoral fracture
Motor: hamstrings and all muscles below knee
Sensory: bellow knee laterally and foot
Common perineal (L4-S1) lesion
Cause: fibular head trauma, sitting cross legged
Motor: foot drop, weak ankle dorsiflexion and eversion (inversion intact cf. with L5 radiculopathy)
Tibial (L4-S3) nerve lesion
Motor: can’t plantar flex, invert foot or flex toes
Loss of sensation to sole of foot
Amyotrophic Lateral Sclerosis (ALS) or Lou Gehrig’s disease
UMN or LMN?
Most common form of MND, often used synonymously. Combined degeneration of upper and lower motor neurones, producing a mix of UMN and LMN signs.
Progressive Muscular Atrophy
UMN or LMN?
Only LMN signs, e.g. flail arm or flail foot syndrome. Only affects anterior horn cells. Better prognosis.
Progressive Bulbar Palsy
UMN or LMN?
Dysarthria and dysphagia with wasted fasciculating tongue (LMN) and brisk jaw jerk (UMN). Only affects cranial nerves 9-12.
Neurofibromatosis 1
Features: CAFÉ NOIR
• Café au lait spots o Increase in size and number with age o Adult: >6, >15mm across o DDx: McCune-Albright, Multiple Lentigenes, Urticaria Pigmentosa • Axillary freckling • Fibromas o • Eye o Lisch nodules – brown/ translucent iris hamartomas under slit lamp o Optic nerve glioma • Neoplasia o CNS: meningioma, astrocytoma, ependyoma o Phaeochromocytoma o Chronic or acute myeloid leukaemia • Orthopaedic o Kyphoscoliosis o Sphenoid dysplasia • IQ low + epilepsy • Renal – RAS and HTN
