Neurology Flashcards
Why is Guillain Barre syndrome not very good a exams?
It looses its nerves
How do you get to the pacinian corpuscle from the brain?
Take the spinal cord and dendrite
What Q are in ROS?
(think from head to toe)
Headache
Fits, faints and funny turns
Memory problems
Altered vision or hearing
Weakness and numbness
Incontinence and erectile dysfunction
Balance and cordination (Gait)
DD for headache
Raised ICP
Migraine
Acute glaucoma
Subarachnoid haemorrhage
Trigeminal neuralgia
Cluster headache
Temporal artritis
Tension headache
Sinusitis
What red flags are there for headaches?
First and worst
Fever
Cognitive or neurological deficit
Personality change
Trauma within 3/12
Made worst by coughing, sneezing, exercise or posture
Halo around light or worst in dark
>65y and jaw claudication
DD Transient loss of conscioussness?
Abscence siezure
Generalised tonic clonic
Psychogenic non-epileptic siezure
Early morning myoclonus
Cardiogenic
Vasovagal
What features of a sieure would indicate a psychogenic cause?
Eyes closed
Arching of back
Shaking side to side
What would indicate a cardiogenic syncopy with TLC?
Palipatations
FH of sudden death
Triggered by exercise or turning neck
No post ictal
sweating and pallor
Head ache with stapping pain when brishing or chewing.
MLD (most likely diagnosis) ?
Trigeminal neuralgia
Headache with facial tenderness and rhinorrhoea
MLD (most likely diagnosis) ?
Sinusitis
What MRC grade is movement greater than gravity?
Grade 3+
What MRC grade is twitching with no movement?
MRC Grade 3
What are the LMN signs?
Decreased reflexes
Decreased tone
Fasiculations
What are the UMN signs?
Increased reflexes
Increased tone
What sensory tract are there in the spine?
Spinothalamic
Dorsal Columns
What sensory tracts carry temperature, pain and crude touch?
Spinothalalmic
What sensory tracts carries fine touch and proprioception?
Dorsal columns
At what level does the spinalthalamic tracts decussate?
Level of the rootlet, straight away
At what level does the dorsal coumumns decussate?
Medial lemniscal (medulla)
What part of the dorsal columns carries sensation to the lower limbs?
Gracille fasciculus - Ground for feet
What is Brown-Sequard syndrome?
Hemi-section of the cord is cut leading to…
Ipsilateral UMN signs and fine touch and propioception (dorsal clumumns)
Contralateral loss of paina and temperature (spinothalamic)
What motor tracts are there in the spinal cord?
Pyramidal
Extra-pyramidal
Where do pyramidal tract decussate?
At the level of the medulla
Where is the lesion with a Bitemporal hemianopia?
Optic chiasm
Where is the lesion with a Homonymous hemianopia?
Occipital cortex or optic radiation
Where is the probable lesino for monocular blindness on the optic tract?
Optic nerve
What is the DD for peripheral neuropathy?
VITMIN CDEF
Alchol
Vit B12
hypothyroid
CKD
Vasculitis
Malignancy -Lymphoma, MM
CMT disease
GB syndrome
Amyloidosis
Autoimmune
What investigation can be done for peripheral neuropathy?
CT head
MRI
CXR
X ray head
EEG
EMG
What questions are inculded in neuro review of systems?
(think head to toe)
Headaches
“Fits, faints and funny turns”
Memory problems
Altered vision or hearing
Numbness and Weakness
Incontinence and erectile dysfunction
Balance and co-ordination difficulties (gait)
What is the typical presentation of gruillian barre syndrome?
Areflexia with progressive weakness
Usually progressive over 4w. Can have cranial nerve and autonomic involvement.
Accompanied by features on LP and EMG
Guillain-Barre syndrome is described as a Poly-radiculo-neuropathy, what does this mean?
Involvemnt of the nerve roots and peripheral nerves
What Ix can be done for a presentation of Guillain barre syndrome?
Bedside - Spirometry
Bloods - FBC, UE, LFT, Bone, Ca, Mg, CRP, ESR
Imaging - CXR
Special tests - LP, EMG, ?MRI
What differentials are for Guilian Barre syndrome which may need to be considered?
Acute cervicle myelopathy
Infectinos - botulism, diptheria, lyme disease
What is the management of Guillain Barre syndrome?
IVIG or plasma exchange
VTE prophylaxis
Breathing - Exclude PE, spirometry, ABG for pCO2 ?ICU
Serology - campylobacter
Wgat night be found on LP with GB syndrome?
albuminocytological dissociation - raised protein
What may EMG show with GB syndrome?
Recuced velocity and amplitude of sensory and motor neurone. Incused delayed F waves.
In keeping with an aquired demylinating neuropathy
What is nerve conductino studies (EMG) a good investigation for?
Peripheral neruopathy
Localising pathology in PNS
What is an F wave when concerned with EMG?
Antidromic responce - Impulse created is relfected of the spine leading to a later and lesser muscle depolarisation after the compound motor actino potential (CMAP)
What is CMAP and SNAP in EMG?
CMAP - compound motor action potential
SNAP - sensory actino potential
What should be should be considered in a history history if fever, malaise and weightloss and therefore what maybe seen on LP
May be TB menigitis:
Lymphocytosis
High opening pressures
Very high protien
Very low glucose
Generalised weakness and areflexia with increased protein on LP?
Guilain barre syndrome
Chronic headaches worst when bending and associated visual changes. High opening pressure otherwise normal LP. MLD?
idiopathic intercranial hypertension
There is sensory and motor loss in the thumb, 2nd and 3rd digits as well as thenar eminesce. What nerve distibution is and MLD?
Median nerve
Carpal tunnel syndrome
Patient presents with eye changes: ptosis, diplopia bilaterallly and has proximal fratigue. MLD?
Myethenia gravis
What can oligoclonal bands on LP indicate?
Inflammatory disorder of the CNS which may include transverse myelitis or MS
What is xanthochromia and what does it indicate on LP?
Metabolites (oxyhaemoglobin and biirubin) from heamolysed RBC in CSF. This is surgestive of a bleed like subarachnoid haemorrhage.
A patient has progressive weekness on the right side of the face over 48 hours with difficulty closing the right eye lid. MLD?
Bells palsy
What is the treatment for bells palsy?
Steroids within 72hours +/- acyclovir
Tape eye shut
Resolves normally however may recurr
What differentials are ther for facial weakness?
UMN - tumour, stroke
LMN - truama, bells palsy, otitis media, MS or GB syndrome, Ramsey hunt syndrome
A 65 year old has severe pain on the left side of the face which developes into facial weakness and “ringing in the ears”. On inspection there are vesicles surrounding the external meatus. MLD?
Ramsey hunt syndrome - shingles of the geniculate nucleus of the facial nerve. This is a reactivation of Varicella Zoster
How could a Bells palsy be differentiated from a stroke?
Strokes are acute onset and forehead sparing with peripheral neurological signs. The Bells palsy take hours to days to onset and is a LMN and therefore not forehead sparing.
What is rigidity?
Velocity independent - common in parkinsons
What is spasticity?
Velocity dependent - chronic UMN lesion
Where is the lesion localised?
1) Inferior homonymous quadrantanopias
2) superior homonymous quadrantanopias
1) Parietal lobe
2) Temporal lobe
Function of frontal lobe
Motor control Insight Emotions And output of speech (dominant side)
Functions of temporal lobe
MemoryEmotionsComprehension of speech (dominant side -usually left hemisphere)
Functions of parietal lobe
Sensations Special awareness
Functions of occipital lobe
Eyesight
What is the basal ganglia ?
Deep interconnected nuclei Including putamen, caudate, globus palladium and substantia NigraInvolved in integration of sensation and motor input
Function of cerebellum
Coordination Balance and posture Controls same side of body (ipsilateral)
contents of brain stem
Contains reticular formation and 10 cranial nerve nuclei Contains white matter tracts
What are the levels of the nervous system (proximal to peripheral )
Cerebral cortex Basal ganglia CerebellumBrain stemSpinal cord Nerve rootNerve plexus Nerve Neuromuscular junction
Shoulder abduction
Axillary nerveC5
Elbow flexion
Brachiordialis = radial nerve, C5Biceps = musculocuteneous, C5,C6
Elbow extension
Triceps = radial nerve C6,7,8
Wrist extension
Entensor Capri ulnaris and radialis Radial nerve C7
Finger extension
Extensor digitorumPosterior interosseuous nervec7,C8
Thumb abduction
Abductor pollocks breves T1 Median nerve
Extensor abduction
Ulnar nerve T1
Hip flexion
L1, L2Lumbosacral plexus
Hip extension
Inferior gluteal nerve L5 S1
Knee extension
Femoral nerve L3 L4
Knee flexion
Sciatic nerve L5 S1
Dorsi flexion
Deep peroneal nerve L5
Plantar flexion
Posterior tibial nerve S1
Foot inversion
Posterior tibial nerve S1
Foot eversion
Superficial peroneal nerve L5S1
Toe extension
Deep peroneal nerve L5
Biceps reflex
C5
Supinator reflex
C6
Triceps reflex
C7
Knee reflex
L3/4
Ankle reflex
S1
Tests to do if query myasthenia gravis
Short acting anticholinesterase agent in MG would transiently improve symptoms. Do chest imaging to rule out thymoma Do CT brain Blood as,pale for anti acetylcholinesterase antibodies
Problems with MG
Progressive fatiguable weaknessThey also have problems with mastication, talking, drinking, swallowing. Aspiration pneumonia and resp failure can result as unable to clear secretions
Neuro systems review
Headaches Altered visionFits, faints, funny turnsHearing difficulties Memory problemsSpeech and swallowing difficulties WeaknessNumbness or tinglingIncontince or retentionErectile dysfunctionBalance or coordination difficulties How is it affecting ADLsFH
Progressive weakness without sensory loss. Arm twitching. Legs giving way. Change in speech. Father died when in 30s.
Amyotrophic lateral sclerosis- UMN AND LMN lesions. Some genetic component but sporadic mutations more common
Severe painful unilateral headaches. No warning. Eye watering, nasal stuffiness. No symptoms between headaches. Usually at night.
Cluster headache
Tight band like headache precipitated by stress
Tension headache
Brief stabbing pain when chewing or brushing teeth
Trigeminal neuralgia
Photophobia, neck stiffness, fever, headache
Meningitis
Sudden onset excruciating headache. Reaches climax within minutes
Subarachnoid haemorrhage
Unilateral landing headshcem multiple triggers, lasts for hours, aversion to bright lights, can be preceded by aura
Migraine
20 minute unilateral debilitating headache p. Retro orbital pain with red eye and watering
Cluster headache
Headache triggered by changes in position or exertion. Changes in vision or headache with leaning forward, coughing, sneezing
Raised Icp- SOL- tumour, abscess. Hydrocephalus
Pain around eyes with blurred vision and halos around lights
Acute angle closure glaucoma
Scalp tenderness, unilateral. Jaw claudication .
Temporal arteritis
Red flags for headaches
Sudden onset High severityFeverNew onset neurological deficit New onset cognitive dysfunction Change in personalityImpaired GCSrecent head traumaHeadache triggered by cough, sneeze, exercise or change in postureHeadache with halls around lights Headache with jaw claudication
LOC triggered you vigorous exercise in a young person
Hypertrophic cardiomyopathy or cardiogenic syncope
Triggered by pain, fear, prolonged standing. Preceded by pallor, nausea, sweating, no confusion afterwards
Vaso vagal
Triggered when standing up
Postural hypotension
Collapse on shaving or turning head
Carotid sinus sensitivity
Crying out, falling to floor, period of stiffness followed by rhythmic jerking that gradually decreases in amplitude and frequency, period of confusion after
Generalised tonic clinic seizure
LOC, pale and sweaty beforehand, jerking of limbs, eye rolled back short duration, no confusion
Vaso vagal
Violent shaking, head moving side to side , arching back, episodes of stillness before starting again, forced eye closure
Psychogenic non epileptic struck
Facial weakness on right side, motor weakness on left
Right side brainstem lesion
Left weakness and sensory changes
Right hemisphere lesion
Lower motor neurone weakness in all four limbs and loss of sensation
Peripheral neuropathy
UMN signs in all four limbs and loss of sensation
Spinal cord lesion
Loss of vision and pain in eye. Incontinence. Leg weakness
Think MS Do MRI brain and spine
Elderly patient, head trauma, worsening lethargy, confusion
Subdural haematoma Do CT
Progressive weakness, cannot walk unaided, started off at numbness and tingling in hands and feet. Now SOB. Had food poisoning three weeks ago Absent reflexes , glove and sticking sensory loss
GBSDifferential of transverse myelitis Do LP and MRI
Treatment of GBS
Iv immunoglobulin Or plasma exchange DVT prophylaxis, lots of obs
LP with high protein but normal white cells
GBS
Key features of GBS
Peak disability in four weeks Antecedent trigger AreflexiaCSF- high protein, normal cell count Generally spontaneous recovery occurs
Differentials of GBS
Acute myelopathiesBotulismDiphtheria Lyme disease Vasculitis neuropathy
Oligoclonal bands in CSF and not in blood
Think MS
Four limb symptoms and urinary disturbance
Cervical spine
Right sided facial weakness. Whole face, no sparing. Sensation normal
Right LMN lesion. Bell’s palsy
Treatment of Bell’s palsy
Steroids aciclovir Tape eye closed at night Can initially worsen before getting better
Painful vesicles affecting external ear, palate. Facial weakness. Ear and face pain
Ramsay hunt syndrome Treat with aciclovir within 3 days of onset and steroids
Young female with foot slapping when walking after a weekend kneeling
Common peroneal nerve palsy. Get nerve conduction studiesAsk about back pain as the palsy could be due to prolapsed disc.
Wrist drop
Radial nerve palsy. Often due to compression on mid shaft of humerus. Get neurophysiology assessment. Give splint to help with function
Young man, blurring in right eye, discomfort and pain in movement of eye. Reduction in vision in right eye. Left eye normal
Optic nerve problem. Eg optic neuritis
Blood tests following RAPD
Serum b12 as deficiency can mimic optic neuropathy Look for evidence of multi system inflammationNo pun specific inflammatory markers eg CRP, ESRSpecific immunological markers- ANA, ANCA, serum ACE, Infectious triggers eg HIV, syphillis, hep B and CRarer antibodies eg DevicsMRI scan would show high signal in optic nerve
Causes of an unsteady gait
Cerebellum problems leading to cerebellar ataxiaDorsal column problem leading to sensory ataxiaPeripheral nerve problems leading to sensory ataxia Vestibular problems
Features of cerebellar disease
Vertigo and nauseaVoice changes- staccatoPoor coordination in arms and legsOne side of body affected- ipsilateral lesion
Vestibular problems
Nausea Vertigo Room spinning Can lead to hearing loss and tinnitus
Unsteady gait and sensory loss. Pins and needles. Balance worse in dark. Fall over when eyes closed
Sensory ataxia
Unsteady gait and bladder disturbance
Spinal cord lesion
How to treat MS relapse
High dose steroids, give PPI alongside thisTry to treat symptoms of the relapse
Medications used in MS
Steroids to treat relapseDisease modifying agents eg beta interferonsBaclofen- reduce muscle spasticity. Can be very sedative throughGabapentin- reduce neuropathic pain Sertraline- depression often common with chronic diseaseOxybutinin- if urge incontinence a problem but can lead to bladder retention
How to treat neuropathic pain
PregablinGabapentinTricyclic antidepressant eg amitriptyllineCarbamazepine (useful in trigeminal neuralgia)
Side effects of beta interferons
Injection site reaction or rash Flu like symptoms for a few daysReduced immune system
Conditions that can mimic MS
Devics syndrome- neuromyelitis optics, affects spinal cord and optic nerve. Test for NMO antibodiesAnticsediolipin antibody syndromeNeurosarcoidosisSjogrens
Side effects of steroids
Acne Blurred vision Cataracts Glaucoma Easy bruising Difficulty sleeping High blood pressure Increased appetite and weight gain Increased Body hair Ulcers Diabetes Osteoporosis Impaired wound healing
