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Finals!!! > Neurology > Flashcards

Neurology Flashcards

1
Q

Difference between UMN and LMN lesion

A
  • UMN: Spastic, brisk reflexes ++, regional distribution, upgoing plantars
  • LMN: Atrophy ++, fasiculations, flaccid, diminished reflexes, segmental distribution, downgoing plantars
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2
Q

Common meningitis orrganisms by age

A
  • Neonates- GBS, E. coli
  • Infants- HiB
  • Adults + older children- N. Meningitidis, S. pneumoniae
  • Elderly/ immunocompromised- CMV, listeria
  • Viruses eg HSV, HIV
  • Fungi eg Candida (immunocomp)
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3
Q

Presentation of Meningitis/ meningococcal septicaemia

A
  • Headache ++
  • Neck stiffness
  • Photophobia
  • Confusion, low GCS, seizures, coma, +/- focal signs
  • Vomiting
  • Myalgia, arthralgia
  • Fever
  • Shock- Tachycardia, hypotension, cool peripheries
  • Non-blanching rash- septicaemia
  • Brudinski’s
  • Kernig’s
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4
Q

What is Brudinski’s sign and what does it indicate?

A
  • Passive neck flexion when legs flexed
  • Meningitis
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5
Q

What is Kernig’s sign and what does it indicate?

A
  • Hip flexed to 90 degrees –> unable to straighten leg.
  • Meningitis
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6
Q

Ix and Tx of meningitis

A
  • Ix:
    • Bedside- throat/rectal swabs, fundoscopy
    • Bloods- FBC, U+Es, LFTs, CRP, culture, glucose, coags
    • Imaging- CXR (?TB), CT head ?raised ICP
    • Special- LP
  • Tx:
    • GP- IM Benzylpenicillin
    1. ABCDE + IVT
    2. Dexamethasone –> CT/LP
    3. Cefotaxime 2mg slow IV (+ampicillin if >55y). Before LP if delayed.
    4. Shock –> ICU –> ?intubation ?inotropes
    • Ongoing Tx- D/w micro. ?viral –> aciclovir. Contact prophylaxis with ciprofloxacin/ rifapmicin. Contact public health.
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7
Q

Interpretation of LP results

A
  • Bacterial- Yellow/ turbid. +++ WCC/granulocytes, +++ protein, low protein
  • Viral- Clear. ++ lymphocytes
  • TB- Yellow/ viscous. +++ lymphocytes. Low protein.
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8
Q

Causes and presentation of encephalitis

A
  • Causes:
    • Mainly viral (HSV, CMV, EBV, VZV, mumps, Japanese encephalitis).
    • Others- any bacterial meningitiis, TB, malaria, Lymes etc
  • Presentation:
    • Infectious prodrome
    • Odd behaviour
    • Headache
    • Confusion/ Low GCS/ coma
    • Seizures
    • Focal neurology
    • Meningism
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9
Q

Investigations and treatment of encephalitis

A
  • Ix:
    • Bedside- throat + MSU cultures, EEG
    • Bloods- Cultures, serum viral PCR
    • Imaging- contrast enhanced CT, MRI - temporal lobe changes
    • Special- LP (high protein and lymphocytes, low glucose) –> PCR
  • Tx:
    • Aciclovir within 30 mins for 14 days (HSV protection) –> guided by micro
    • HDU/ITU
    • Supportive and Symptomatic eg seizures
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10
Q

Key features and causes of cerebral abscess

A
  • Features- Raised ICP, fever, low GCS/ coma, localising signs.
  • Causes- may follow ear/ sinus/ dental infection. Or congenital heart disease/ endocarditis/ bronchiectasis
  • Ix- bloods, CT, MRI
  • Tx- Neurosurgery
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11
Q

Causes of raised ICP

A
  • Trauma
  • Tumour- primary vs mets
  • Infection- meningitis/ encephalitis/ cerebral abscess
  • Haemorrhage
  • Hydrocephalus
  • Cerebral oedema
  • Status epilepticus
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12
Q

Presentation of raised ICP

A
  • Headache- worse leaning forward/ coughing
  • Vomiting
  • Low GCS/ confusion/ coma
  • Seizures
  • Cushing’s response- hypertension, bradycardia
  • Cheyne-stokes breathing
  • Pupil changes
  • Poor visual acuity/ peripheral visual fields
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13
Q

Investigations and treatment of raised ICP

A
  • Ix:
    • Fundoscopy, HR, BP, neuro obs
    • Bloods- FBC, U+Es, LFTs, glucose, serum osmolality, clotting, culture
    • Imaging- CXR (?source), CT head
    • Special- LP, ?ICP monitor/ bolt
  • Tx: Tx cause
    • ABCDE. MAP kept >90mmHg. Tx seizures
    • Elevate bed head 30-40 degrees
    • If ventilated –> hyperventilate
    • Osmotic agents- mannitol
    • ?tumour –> dexametasone
    • Restrict fluids <1.5L/d
    • NEUROSURGERY! Craniotomy/ burr hole
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14
Q

What is a subarachnoid haemorrhage and how might it present?

A
  • = Bleed between pia and arachnoid mata in subarachnoid space. 80% due to aneurysm.
  • Presentation:
    • Sudden occipital headache ++
    • Vomiting
    • Collapse
    • Seizures
    • Coma/ low GCS/ drowsy
    • Focal neurology
    • Photophobia
    • Neck stiffness
    • Kernig’s
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15
Q

Ix and Tx of subarachnoid haemorrhage

A
  • Ix:
    • Urgent CT head (hung chicken)
    • >12h –> LP (xanthochromia)
  • Tx:
    • ABCDE resus
    • Cons- lie flat, neuro obs
    • Morphine + metoclopramide
    • Nimodipine prevents vasospasm
    • Beta blocker - SBP <130mmHg
    • Surgery- aneurysm coiling, evacuate haematoma, relieve hydrocephalus
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16
Q

What is a subdural heamatoma, what causes it and how might it present?

A
  • = venous bleed between dura and arachnoid mata
  • Causes- trauma, low ICP, dural mets
  • Presentation:
    • Fluctuating consciousness
    • Insidious physical/intellectual slowing
    • Sleepines
    • Headache
    • Raised ICP
    • Low GCS
    • Seizures
    • Chronic- more likely in elderly, alcoholics, patients on anti-coagulation
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17
Q

Ix and Tx of subdural haematoma

A
  • Ix- CT/MRI= crescent shaped collection of blood over 1 hemisphere +/- midline shift
  • Tx- Surgery! Burr hole –> craniotomy
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18
Q

What is an extradural bleed and how might it present? + Ix and Tx

A
  • = Bleed between bone and dura. Usually temporal trauma –> lacerated middle meningeal artery.
  • Presentation:
    • Well in lucid period –> declining GCS over 4-8h
    • –> Headache, vomiting, confusion, fits, UMN signs
    • –> pupil dilation, coma, weakness, irreg breathing, Cushing’s response
  • Ix- CT head = lemon. Head x-ray ?fracture
  • Tx- Neurosurgery ASAP (evacuation)
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19
Q

Signs of basal skull fracture

A
  • CSF/ blood leaking from ears/ nose
  • Battle’s sign- bruising over mastoid process
  • Blood behind ear drum
  • Panda eyes
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20
Q

Indications for CT head

A
  • GCS <13
  • GCS <15 with head injury persisting 2 hours after injury
  • Focal neuro deficit
  • ?depressed skull fracture/ basal skull fracture
  • Post-traumatic seizure
  • Vomiting > once i
  • LOC + 1 of: >65y, coagulopathy, antegrade anesia, high risk injury eg car crash
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21
Q

Tx of head injury

A
  1. ABCDE + check c-spine + o2 + IVT
  2. ?Intubate
  3. Seizures –> lorazepam
  4. Ix- U+Es, glucose, FBC, blood alcohol, toxicology, ABG, clotting.
  5. Evaluate lacerations
  6. Palapate neck tenderness ?c-spine injury –> immobility + CT/ X-ray
  7. Trauma series? CT neck/ chest/ abdo/ pelvis
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22
Q

Define a stroke and TIA

A
  • Sudden onset of Sx lasting >24h, with focal loss of cerebral function of presumed vascular origin.
  • Stroke= >24h
  • TIA= <24h
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23
Q

Causes of ischaemic and haemorrhagic stroke

A
  • Ischaemic:
    • Atherosclerosis
    • Atherothromboembolism from carotid
    • Cardiac embolism- AF, MI, endocarditis
    • Arterial dissection
  • Haemorrhagic:
    • Hypertension
    • Trauma
    • Aneurysm rupture
    • Anticoagulation
    • Thrombolysis
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24
Q

Features of TACS

A
  • All 3 of:
    • Hemiparesis/ hemiparalysis in face/ arm/ leg
    • Homonymous hemianopia
    • Higher cortical function- dysphasia/ inattention
  • Cortical MCA/ ACA
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25
Q

Features of PACS

A
  • 2 of:
    • Hemiparesis/ hemiparalysis in face/ arm/ leg
    • Homonymous hemianopia
    • Higher cortical function- dysphasia/ inattention
  • Cortical MCA/ ACA
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26
Q

Features of POCS

A
  • 1 of:
    • Cerebellar/ brainstem syndrome (Dysdiadokokinesia, ataxia, nystagmus, intention tremor, slurred speech, hypotonia)
    • LOC
    • Isolated homonymous hemianopia
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27
Q

Features of LACS

A
  • Lacunar/ subcortical small vessel disease
  • No evidence of higher cortical dysfunction + 1 of:
    • Hemiparesis/ hemiparalysis face/ arm/ leg
    • Pure sensory stroke
    • Ataxic hemiparesis
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28
Q

NIH stroke score

A
  1. Level of consciousness, LOC questions and commands
  2. Best gaze
  3. Visual fields
  4. Facial paresis
  5. Motor arm (L+R
  6. Mortor leg (L+R)
  7. Limb ataxia
  8. Sensory
  9. Best language
  10. Dysarthria
  11. Extinction and inattention
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29
Q

Stroke RF

A
  • Cardiac RF
  • OCP
  • >55y
  • HTN
  • Hypercholesterolaemia
  • DM
  • Alcohol
  • Drugs
  • Obesity
  • PMH/ FHx
  • Carotid bruit
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30
Q

Features of cerebral, brainstem and lacunar infarcts

A
  • Cerebral- Sensory/ motor loss, dysphasia, homonymous hemianopia, visuospatial defect
  • Brainstem- quadriplegia, disturbance of gaze/ vision, locked in syndrome (basilar artery)
  • Lacunar- Ataxic hemiparesis, pure motor or sensory, dysarthria, clumsy hand. Cognition intact.
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31
Q

Acute management of stroke

A
  • ABCDE –> stroke unit. NB airway.
  • Pulse, BP, ECG - ?AF
  • Blood glucose (aim 4-11)
  • Urgent CT/MRI head. ??Haemorrhagic/ischaemic
  • Thrombolysis- alteplase if ischaemic + <4.5h. CI= Haemorrhage, major infarct, mild Sx, aneurys, BP >220/130, severe liver disease, anticoagulation
  • Aspirin 300mg for 2w –> 75mg
  • NBM until SALT assessed
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32
Q

Long term stroke management

A
  • Rehab= MENDS
    • MDT
    • Eating- screen swallowing and malnutrition
    • Neurorehab (physio + SALT)
    • DVT prophylaxis
    • Sores- AVOID
  • Discharge medication:
    • Atorvastatin
    • ACEi
    • Clopidogrel
  • No driving at least 3 months. Inform DVLA
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33
Q

Stroke DDx

A
  • Head injury
  • High/ low glucose
  • Subdural
  • Tumour
  • Hemiplegic migraine
  • Epilepsy
  • CNS lymphoma
  • Wernicke’s
  • Drug OD
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34
Q

Ix RF for further stroke

A
  • BP
  • Cardiac source- ECG, CXR, ECHO
  • Carotid artery stenosis- USS Doppler
  • Glucose
  • Lipids
  • Vasculitis
  • Prothrombotic states eg antiphospholipid
  • Hyperviscosity eg sickle cell
  • Genetic testing
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35
Q

Complications of stroke

A
  • Aspiration pneumonia
  • Pressure sores
  • Contractures
  • Constipation
  • Depression
  • Family stress/ pressure
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36
Q

Ix and Tx of TIA

A
  • Ix: Find cause and define vascular risk!
    • ABCDE
    • Bedside- ECG
    • Bloods- FBC, ESR, U+Es, glucose, lipids
    • Imaging- Carotid USS dopler, CT, MRI, ECHO
  • Tx:
    • Conservative- improve RF, no driving 1month
    • Medical- ACEi, statin, clopidogrel, aspirin
    • Surgical- ?endarterectomy
  • See specialist within 7 days!
  • See specialist <24h if 4 or more on ABCD2 score (Age >60y, BP >140/90), clinical features (weakness, speech disturbance), duration, diabetes
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37
Q

Features of venous sinus thrombosis

A
  • Sx gradual
  • Sagittal (most)- Headache, vomiting, seizures, reduced vision, papilloedema
  • Transverse- Headache +/- mastoid pain, focal CNS signs, seizures, papilloedema
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38
Q

Features of cortical vein thrombosis

A
  • Stroke like focal Sx that develop over days
  • Sudden headache- thunderclap
  • Signs- seizures (more common than stroke), encephalopathy, slowly evolving focal deficits
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39
Q

Features of acute glaucoma

A
  • Headache- constant, aching pain. Develops rapidly and radiates to forehead.
  • Loss of vision and visual haloes
  • N+V
  • Red congested eye, with cloudy cornea
  • Dilated non-responsive pupil (may be oval)
  • Precipitants- dilating eye drops, emotional upset, sitting in dark.
  • Tx –> specialist. Acetazolamide if delayed
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40
Q

Features and Tx of tension headache

A
  • Headache- bilateral “tight band”. Throbbing (not pulsatile). Can spread to neck/ back/ shoulders/ behind ears
  • Other Sx- irritability, poor concentration, want to sleep. Able to do daily activities.
  • RF- stress, anxiety, poor posture, tiredness, dehydration.
  • Tx- paracetamol, ibuprofen (not >6 times/ month)
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41
Q

Features of medication overuse headache

A
  • Episodic –> daily chronic
  • Use analgesia 6d/month max!
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42
Q

Features of migraine

A
  • RF: Female, obese, patent foramen ovale
  • Triggers= CHOCOLATES: Chocolate, hangovers, OCP, Cheese, Orgasms, Lie ins, Alcohol, Tumult, Exercise, Stress
  • Sx:
    • Unilateral throbbing headache. 3-72h.
    • Temporal/ frontal area
    • Photo/phonophobia
    • N+V
    • Prodrome: yawning, cravings, mood/sleep change, aura (visual, parietal, frontal)
  • Ix: headache diary
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43
Q

Diagnosis of Migraine

A
  • Typical aura + headache
  • OR >4 headaches lasting 4-72h with N+V or photo/phonophobia + 2 or more of:
    • Unilateral
    • Pulsating
    • Interferes with normal life
    • Worsened by routine activity
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44
Q

Treatment of migraine

A
  • Acute attack:
    • Paracetamol + metoclopramid/ domperidone
    • NSAIDs eg ketoprofen + M/D
    • Triptan eg sumatriptan
    • Ergotamine
  • Prophylaxis
    • ?>2 attacks/ month, increasing frequency, ++disability, unable to take acute Tx
    • Propranalol, topiramate
    • Valproate, pizotofen (weight gain), gabapentin
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45
Q

Features and Tx of TMJ dysfunction

A
  • Sx:
    • Pain- ear, jaw temple
    • Temporal headache/ earache
    • Difficulty opening mouth
    • Jaw locking
    • Crepitus
    • Clicking/ popping/ grinding when move jaw
  • Tx:
    • Conservative= mainstay. Eat soft foods, ice packs, massage, avoid gum and biting nails. Refer to dentist/ psychologist
    • Med- Paracetamol/ ibuprofen, analgesia injections
    • Surgergy- last resort
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46
Q

Features and Tx of cluster headache

A
  • RF: FHx, male, smoker
  • Sx:
    • Rapid onset of excruciating headache around 1 eye. UNILATERAL.
    • 15-160 mins
    • Eye- watering, bloodshot, lid swelling, lacrimation, rhinorrhoea, miosis +/- ptosis
    • Facial flushing
    • Clusters 4-12w once-twice a day. Months remission between.
  • Tx:
    • Acute attack- 100% o2 for 15 mins via non-rebreath. Sumatriptan.
    • Prevention- verapamil, lithium, melatonin
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47
Q

Features, Ix and Tx of trigeminal neuralgia

A
  • Sx:
    • Paroxysms of intense stabbing pain in trigeminal n. distribution (esp maxillary and mandibular). Secs. Face scrunches in pain.
    • Triggers- washing, shaving, eating, talking, dental prostheses.
    • Pt: Male >50. More likely in Asian.
  • Secondary cause in 14%- compression of CNV, MS, zoster –> Ix = MRI
  • Tx:
    • Medicine- Carbamazepine, lamotrigine, phenytoin, gabapentin
    • Surgical- microvascular decompensation
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48
Q

Features of GCA

A
  • = Giant Cell Arteritis.
  • Rule of 60: >60y, ESR> 60, pred 60mg
  • Sx:
    • Headache
    • Temporal artery/ scalp tenderness (combing hair)
    • Jaw claudication
    • Amourosis fugax
    • Sudden blindness
    • Extracranial- SOB, morning stiffness, unequal pulses
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49
Q

Ix and Tx of GCA

A
  • Ix:
    • Bedside- Fundoscopy
    • Bloods- ESR >50, CRP (up), FBC (high platelets, normocytic normochromic anaemia), LFTs (high alk phos)
    • Imaging + special- temporal artery USS/ biopsy
  • Tx:
    • Prednisolone 60mg/d PO ASAP!!!!
    • Methyprednisolone IV if eye Sx
    • Wean off steroids. NB PPI + bisphosphonates
    • Low dose aspirin
  • Prognosis- 2y –> complete remission
50
Q

Causes of seizures

A
  • Epilepsy= recurrent seizures (>2)
  • Idiopathic = 2/3
  • Structural- cortical scarring, head injury, developmental, SOL, stroke, vascular malformation
  • Acquired- Sarcoid, SLE
  • Non-epileptic/ provoked: Trauma, stroke, haemorrhage, raised ICP, CVA, alcohol, meningitis/ encephalitis, malaria, HTN/eclapsia, drugs (OD, antidepressants, tramadol, withdrawal- alcohol, opiates, BDZs), pyrexia, metabolic disturbance (hypocalcaemia, sodium, glucose, ureamia)
51
Q

Seizure classification

52
Q

Seizure classification

A
  • Partial (1 hemisphere)
    • Simple - aware
    • Complex - Aura, ANS Sx, not aware, automatisms, amnesia
  • Generalised (2 hemispheres)
    • Tonic clonic- LOC, stiffening –> jerking. Cyanosis, incontinence, tongue biting
    • Absence- <10s pauses.
    • Atonic/ tonic= sudden loss of muscle tone. No LOC
    • Myoclonic- sudden muscle jerks
53
Q

Partial seizure localising features

A
  • Occipital- visual
  • Parietal- sensory
  • Fronal- motor
  • Temporal- automatisms, deja vu, delusions, emotional disturbance, aura
54
Q

What are Stokes- Adams attacks?

A

Transient arrhythmias. Fall to ground, pale, absent pulse. Recovery in seconds –> flushes and pulse increases. +/- clonic jerks

55
Q

Features of PNES

A
  • Psychiatric RF
  • Gradual onset
  • Non-stereotypical movements- pelvic thrusting, back arching, thrashing
56
Q

Epilespy Ix

A
  • Bedside- BM, ECG, urine tox, drug screen
  • Bloods- FBC, U+Es, glucose, ?AED levels, lactate (up), prolactin 10 mins after fit (up).
  • Imaging- MRI if focal onset, refractory to Tx, adult onset. (CT)
  • Special- ?LP, EEG- supports Dx, ?focal/generalised
57
Q

Epilepsy Tx

A
  • Start after 2nd seizure. MDT approach.
  • Conservative:
    • Driving- inform DVLA, no driving 6-12m after 1st seizure. Need to be seizure free 1y.
    • Education- swimming, bathing, 1st aid, avoid triggers, healthy lifestyle, min alcohol.
  • Medical:
    • Tonic-clonic: Sodium valproate –> lamotrigine
    • Absence: Sodium valproate/ ethosuxamide –> lamotrigine
    • Tonic/ atonic/ myoclonic: sodium valproate –> levetiracetem
    • Focal: Lamotrigine –> carbamazepine
    • Preg- lamotrigine, 5mg folic acid
  • Surgical: ?resection if single lesion
58
Q

When and how to stop AED?

A
  • Consider when seizure free 2y
  • Decrease 10% every 2-4w.
  • 50% remain seizure free.
59
Q

AED side effects

A
  • Sodium valproate- teratogenicity, liver failure, tremor, weight gain
  • Lamotrigine- Rash, diplopia, blurred vision
  • Carbamazepine- Cerebellar toxicity, SIADH (–> hyponatraemia)
  • Phenytoin- Ataxia, tremor, hepatoxicity, gum hypertrophy
60
Q

Definition of status epilepticus

A
  • Seizure lasting >30mins
  • OR repeated seizures with no intervening consciousness.
  • (New seizure if 30min between)
61
Q

Status epilepticus management

A
  • 0-5 mins:
    • ABCDE. NB airway. 100% o2. Recovery position. ​
    • Monitor: HR, o2, sats, BP, temp, heart tracing
    • Venous access + bloods: FBC, U+Es, LFTs, Ca2+, glucose, cultures, ABG, ?AED
    • ?CT
    • Glucose <3.5mmol/L –> 100mL 20% glucose
  • 5-20 mins: 5 mins = senior help!
    • BDZ: Lorazepam 4mg IV over 2 mins OR Diazepam 10mg PR OR buccal midazolam. Repeat after 10 mins if needed.
    • Pabrinex if alcoholic/ malnourished
    • Tx acidosis
  • 20-40 mins: NB anaethetist!
    • Phenytoin 20mg/Kg IV at <50mg/min
    • Alt: diazepam infusion, phenebarbital
  • >40 mins: ICU. GA, intubation, EEG monitoring.
62
Q

Causes of Parkinsonism

A
  • Degenerative- PD, Parkinson’s plus
  • Infection- Syphilis, HIV, CJD
  • Vascular- Infarcts to substantia nigra
  • Drugs- Antipsychotics, metoclopramide
  • Genetic- Wilson’s
  • Trauma eg boxing
63
Q

Symptoms of Parkinsonism

A
  • Triad of:
    • Tremor- pill rolling. 4-6Hz.
    • Bradykinesia/ hypokinesia. Slow initiation of movement, slow blink rate, micrographia.
    • Ridigity- cog wheel, lead pipe
  • Gait- less arm swing, shuffling
  • Expressionless face
  • Stooped posture
  • Postural instability
64
Q

Presentation of Parkinson’s Disease

A
  • Parkinsonism- tremor, ridigity, bradykinesia
  • Stooped posture
  • Shuffling gait
  • Postural instability
  • Neuropsychotic- depression, anxiety, depression
  • Sensory- olfactory, pain, paraesthesia
  • Fatigue
  • Diplopia
  • ANS- Bladder, sexual dysfunction, dry eyes, constipation
  • Insomnia
65
Q

Diagnosis of PD

A
  • Bradykinesia
  • At least 1 of: rigidity, 4-6Hz tremor, postural instability
  • Exclude DDx- stroke, head injury, dementia, cerebellar signs
  • DAT scan- retreating comma.
66
Q

Tx of Parkinson’s Disease

A
  • MDT
  • Assess disability with UPDRS
  • Conservative- postural exercises
  • Medical:
    • Young/ fit: MAOi (selegeline/ rasagiline) or dopamine antagonist (rotigotine) –> L-dopa/ COMTi (entacapone)
    • Old/ frail: L-dopa (sinemet/ co-careldopa/ madopar) –> MAOi/ COMTi
    • Dyskinesia- reduce L-Dopa, add amantadine
    • Motor fluctuations- duodopa
  • Severe resistant tremor/ motor fluctuations –> DBS
67
Q

Side effects of PD medications

A
  • L-Dopa: Tolerance, N+V, confusion, hallucination, dyskinesias
  • Rotigotine: Lack of impulse control
  • MAOi: Seratonin syndrome with SSRIs
  • Amantadine: Confusion in elderly
68
Q

Parkinson’s Plus syndromes

A
  • = Basal ganglia degeneration and other systems
  • Lewy Body Dementia- Flutuating cognition, visual hallucinations, apathy, more day time sleep, poor attention
  • Multiple systems atrophy- cerebellar signs
  • Progressive supranuclear palsy- postural instability
  • Corticobasilar degeneration- aphasia, dysarthria, apraxia
69
Q

Definition and classification of MS

A
  • Multiples episodes of CNS dysfunction dissemintated in time and space (2 diff eps in diff places of NS)
  • Patterns:
    • Relapsing-remitting (80%)
    • Secondary progressive
    • Primary progressive (10%)
    • Progressive relapsing
70
Q

Presentation of MS

A
  • TEAM- tingling, eye, ataxia + cerebellar, motor
  • Spastic weakness
  • Sensory- paraesthesia, pain, trigeminal neuralgia
  • Eyes- diplopia, nystagmus, optic neuritis (unilat central vision loss, pain on eye movements).
  • CNS- fatigue, poor cognition, depression
  • Sexual/ GU- ED, anorgasmia, retention, incontinence
  • GI- swallowing probs, constipation
  • Speech- dysarthria, dysphagia
  • Cerebellar- trunk and limb ataxia, falls
71
Q

MS Ix

A
  • Bloods- B12, FBC, Abs- anti-MBP, NMO-IgG
  • Imaging- MRI: Gd enhancing plaques
  • Special:
    • LP- oligoclonal bands of IgG
    • Evoked potentials delayed
72
Q

MS Tx

A
  • Acute- Methylprednisolone 1g IV PO for 24h
  • Disease modifying:
    • Beta-interferons
    • Monoclonal Abs- natalizumab, alemtuzumab
    • ?Stem cells
  • Symptomatic tx:
    • Depression- SSRI
    • Pain- amitriptylline, gabapentin
    • Spasticity- physio, baclofen, botulinum
    • Urgency/ frequency- oxybutinin
    • Tremor- clonazepam
73
Q

MS Complications

A
  • Ambulation
  • Spasticity
  • Pressure sores
  • UTIs
  • Osteoporosis
  • Aspiration pneumonia
  • Epilepsy/ seizures
  • Depression/ stress/ anxiety
74
Q

What is Motor Neurone Disease?

A
  • Progressive selective loss of neurones in motor cortex, cranial nerve nuclei and anterior horn cells. UMN + LMN signs.
  • NO sensory loss, sphincter disturbance or affect on eye movement
  • Types:
    • ALS- UMN + LMN
    • Progressive bulbar palsy
    • Progressive muscular atrophy- LMN only
    • Primary lateral sclerosis- mainly UMN
75
Q

Presentation of MND

A
  • >40y
  • Stumbling spastic gait
  • UMN signs- Spasticicty, hyperreflexia, upgoing plantars
  • LMN signs- Wasting, fasiculations
  • Bulbar- speech/ swallow/ tongue fasiculations
  • Fronto-temporal dementia
  • Aspiration pneumonia
  • Weakness- shoulder abduction, grip
  • Foot drop/ proximal myopathy
76
Q

Ix and Tx of MND

A
  • Ix:
    • EMG- denervation
    • Imaging- brain/ cord MRI exclude structial cause eg SC compression
    • Special- LP - exclude inflammatory
  • Tx: MDT + family!
    • Specific- Rilozole (prolongs life)
    • Dysphagia- NG/PEG
    • Resp failure- NIV
    • Pain- analgesia ladder
    • Spasticity- baclofen, botulinum
77
Q

What is myaesthenia gravis and how does it present?

A
  • AI disease against post-synaptic ACh receptors
  • Presentation:
    • Increasing/ relapsing muscular weakness. Muscle groups affected in order. Worsens with exercise
      1. Ptosis, diplopia
      1. Bulbar
      1. Myaesthenic snarl
      1. Head droop
      1. Limb proximal weakness
    • Normal reflexes
78
Q

Ix and Tx of myaesthenia gravis

A
  • Ix:
    • Bedside- FVC
    • Bloods- Anti-AChr Abs, TFTs
    • Imaging- ?thymus CT
    • Special- EMG (reduced response), tensilon test (improvement 1min)
  • Tx:
    • Sx- anticholinesterase
    • Immunosuppression- Pred in acute, azathiprine, methotrexate
    • Surg- thymectomy
79
Q

Key features, presentation, Ix and Tx of Lambert Eaton syndrome

A
  • Cause= AI or paraneoplastic. Abs against pre-synaptic Ca2+ channels
  • Presentation: Leg weakness early, hyoreplexia and weakness that improves with exercise. Diplopia and resp muscle involvement rare.
  • Ix: Anti-VGCC Abs
  • Tx: IV immunoglobulins.
  • Reg CXR + screening for lung Ca
80
Q

Features and Ix of Brown- Sequard syndrome

A
  • Lesion to 1/2 spinal cord
  • Ipsilateral loss of proprioception + vibration. UMN weakness (spastic, brisk)
  • Contralateral loss of pain and temperature
  • Ix- MRI
81
Q

What is Guillain barre syndrome and how does it present?

A
  • = Acute AI demyelinating polyneuritis
  • Triggers= campylobacter, CMV, VZV, HIV, EBV. FEW WEEKS POST INFECTIVE.
  • Presentation:
    • Symmetrical asceening flaccid paralysis
    • LMN signs- areflexia, fasiculations
    • Proximal > distal. Esp trunk and resp muscles.
    • Back pain
    • Paraesthesia
    • ANS neuropathy- arrhythmias, labile BP, sweating, unrinary retention
82
Q

Ix and Tx of Guillain Barre

A
  • Ix:
    • Bedside- FVC, stool sample
    • Bloods- antiganglioside Abs
    • LP - increased protein
    • Nerve conduction studies - slow
  • Tx:
    • Cons- physio
    • Supportive- Airway (ventilation), Analagesia (NSAIDs, gabapentin), Autonomic (inotropes, catheter), Antithrombotic (TEDS, LMWH)
    • IV immunoglobulins
83
Q

What is muscular dystrophy and how might it present?

A
  • Group of genetic diseases with progressive degeneration and weakness of specific muscle groups.
  • Duchenne MD:
    • Commonest. X-linked recessive. Non-functional dystrophin
    • Presents around 4y. Difficulty standing, calf pseudohypertrophu, resp failure.
    • Ix= CK. Tx: ?home ventilation
  • BMD: Partially functioning dystrophin –> presents later, less severe, better prognosis
84
Q

Causes of spinal cord compression

A
  • Trauma
  • Infection
  • Intrinsic cord tumour
  • 20 to malignancy- breast, thyroid, lung, kidney, prostate
  • Disc prolapse
  • Haematoma
  • Myeloma
85
Q

Presentation of spinal cord compression

A
  • Local radicular back pain at level of lesion, anaesthesia below
  • LMN signs at level of lesion, UMN signs below.
  • Bladder hesitancy/ frequency –> retention
  • Constipation/ faecal incontinence
  • Reduced tone and reflexes in acute
86
Q

Ix and Tx of spinal cord compression

A
  • Ix:
    • URGENT MRI - neuro surgery emergency
    • Screening bloods- FBC, ESR, B12, syphilis, U+Es, LFTs, PSA, electrophoresis
    • CXR- screen for primaries. ?biopsy
  • Tx: Refer oncology + neurosurgery.
    • Cons- catheter
    • Cancer- dexamethasone 16mg OD IV. ?chemo/ radio
    • Abscess- ABx
    • Surgical decompression
87
Q

Signs of conus medullaris and cauda equina lesions

A
  • Conus medullaris:
    • Mixed UMN and LMN weakness
    • Early constipation and retention
    • Back pain, sacral sensory, ED
  • Cauda equina:
    • Saddle anaesthesia
    • Back pain and radicular pain down legs
    • Bilat. flaccid, areflexic lower limb weakness
    • Incontinence, retention of faeces/ urine
    • Poor anal tone
88
Q

What is cervical spondylosis and cervical myelopathy?

A
  • Cervical spondylosis= degeneration of cervical spine due to trauma/ aging (degen. of annulus fibrous) + bony spurs) –> compression of SC and nerve roots –> progressive quadriparesis + sensory loss below neck
  • Degenerative cervical myelopathy= compression of cervical spinal cord from disc herniation or cervical spinal stenosis.
  • DDx carpal tunnel!
89
Q

Presentation of cervical spondylosis

A
  • Most ASx
  • Progressive
  • Neck pain/ stiffness +/- crepitations
  • Stabbing/ dull pain in arm
  • Radiculopathy- pain/ electrical sensations in arms/ fingers at level. DDx carpal tunnel
  • Upper limb motor/ sensory disturbance according to compression level
  • Later- spastic quadriparesis, sphincter dysfunction (bladder/ bowel)
    *
90
Q

Ix, Tx and complications of cervical spondylosis

A
  • Ix= MRI
  • Tx:
    • Conservative- stiff colar, analgesia
    • Medical- steroid injections
    • Surgical- decompression, laminectomy/ laminoplasty
  • Complications= quadriplegia, diaphragm paralysis, spinal artery syndrome
91
Q

What is carpal tunnel and how does it present?

A
  • = Mononeuropathy. Compression of median nerve (C1-T1) - test= pincer grip
  • Presentation:
    • Sensory loss/ paraesthesia in thumb, index and middle fingers
    • Wasting of thenar eminence
    • Aching pain, esp at night
    • Weakness of muscles of precision grip (LOAF)
  • Tinel’s- tap wrist
  • Phalen’s- wrist flexion 1 min
92
Q

Ix and Tx of carpal tunnel

A
  • Ix- neurophysiology
  • Underlying cause? Myoedema, DM, idiopathic, acromegaly, neoplasm, RA, amyloidosis, pregnancy, sarcoid.
  • Tx-
    • Splint
    • Steroid injections
    • Surgical decompression
93
Q

Features and Tx of ulnar nerve neuropathy

A
  • C7-T1
  • Presentation:
    • Weakness/ wasting hypothenal eminence/ medial muscles/ 4th/5th digitis –> test= abduction and adduction of fingers
    • Claw hands
    • Sensory loss medial 1.5 fingers
  • Tx:
    • Rest
    • Elbow/ hand splint
    • Surgical decompression, epicondylectomy, nerve re-routing
94
Q

Radial nerve neuropathy

A
  • C5-T1
  • Motor- muscles that open fist of hand –> test = extension of wrist and fingers
  • Sensory loss in anatomical snuff box
95
Q

Causes and features of brachial plexus neuropathy

A
  • Causes- trauma, radiotherapy, heavy rucksack, cervical rib fracture, thoracic outlet compression
  • Sx- pain, paraesthesia + weakness in arm
  • Erb’s palsy- tip the waiter
96
Q

Phrenic nerve palsy

A
  • C3,4,5 keep the diaphragm alive
  • Sx- orthopnoea
  • CXR- raised hemidiaphragm
  • Causes- Cancer (lung, paraneoplastic), TB, MD
97
Q

Features of sciatic nerve neuropathy

A
  • L4, S1
  • Affects hamstrings, muscle below knee –> foot drop
  • Loss of sensation below the knee
  • Sciatica= lower back pain, shooting pain down leg. Ix- MRI. Tx- physio, physio, decompression
98
Q

What is polyneuropathy and what might cause it?

A
  • Motor and/or sensory disorders of multiple peripheral/ cranial nerves. Usually symmetrical, widespread. Often distal ‘glove and stocking’.
  • Causes:
    • Infective- HIV, leprosy, Lymes’, syphilis
    • Inflammatory- Guillain-Barre, sarcoid
    • Metabolic- DM, CKD, hypothyroid, hypoglycaemia, B12/ folate deficiency
    • Vasculitis- PAN, GPA, RA
    • Malignancy- Paraneoplastic, polycythaemia
    • Inheritied- CMT, porphyria
    • Drugs- Cisplatin, nitrofurantoin, metronidazole
99
Q

What is vertigo?

A
  • An illusion of movement, often rotatory, of patient or their surroundings.
  • Worse on movement.
  • Associated symptoms:
    • Difficulty walking
    • N+V
    • Hearing loss/ tinnitus (labryth or CNVIII involvement)
    • Pallor
    • Sweating
100
Q

Causes of vertigo

A

IMBALANCE

  • Infection/ Injury- Labrynthitis, Ramsay Hunt, trauma
  • Meniere’s
  • Benign positional vertigo
  • Arterial- Migraine, TIA, CVA
  • Lymph - perilymph fistula
  • Aminoglycosides/ cisplatin/ furosemide- ototoxicity
  • Nerve
  • Central- MS, tumour, infarct
  • Epilepsy
101
Q

What is labrythitis?

A
  • Vestibular neuronitis. Cause= viral, vascular
  • Sx- abrupt onset of vertigo, N+V
  • No deafness or tinnitus
  • Tx- rest and reassurance. ?sedation
102
Q

What is Ramsay Hunt syndrome? Treatment?

A
  • Latent VZV
  • –> Painful vesicular rash in auditory canal with ipsilateral facial palsy, loss of taste, vertigo, tinnitus, deafness, dry mouth and eyes.
  • Tx within 72h! Aciclovir, prednisolone
103
Q

Features, Ix and Tx or Meniere’s

A
  • Meniere’s = endolymphatic hydrops –> recurrent attacks of vertigo >20mins (+/- N+V), fluctuating sensorineural hearing loss + tinnitus.
  • Sense of aural fullnes
  • Tx:
    • Acute- rest
    • Prolonged- antihistamine
    • Severe- buccal prochlorperazine
    • Prevention- Betahistine
    • Inform the DVLA! Drive when Sx under control
104
Q

Features of Benign Positional Vertigo

A
  • Canalithosis in semicircular canal
  • Disturbs with head movement –> vertigo for few seconds
  • Dx= nystagmus on hallpike manoever
  • Tx= Epley manoever
105
Q

Features of perilymph fistula

A
  • = Connection between inner and middle ear. Cause= congenital, trauma
  • PC- vertigo, sensorineural hearing loss.
  • O/E- Tullio’s phenomenon- nystagmus evoked by loud sound
106
Q

Features of acoustic neuroma

A
  • = Schwannoma of vestibular nerve.
  • Sx= unilateral hearing loss –> vertigo.
  • Progression –> ipsilater CN and cerebellum
107
Q

Causes of cranial SOL

A
  • Vascular - chronic subdural haematoma, AVM, aneurysm
  • Infection - abscess, cyst
  • Neoplasm:
    • Primary- astrocytoma, glioblastoma, meningioma, haemangioblastoma, CNS lymphoma, ependyoma etc
    • Secondary- Breast, lung, melanoma
  • DDx- CVA, head injury, encephalitis, MS, metabolic disturbance
108
Q

Presentation, Ix and Tx of cranial SOL

A
  • Presentation:
    • Signs of raised ICP- headache, vomiting, papilloedema, low GCS
    • Subtle change in personality
    • Evolving focal neurology
    • Seizure - esp adult onset, localising aura, post-ictal weakness (Todd’s)
  • Ix:
    • CT/ MRI
    • Biopsy
  • Tx:
    • Medical- pred, chemo, stereotactic radio, prophylactic phenytoin, analgesia
    • Neurosurgery- debulking
      *
109
Q

Causes of Facial Palsy

A
  • CNII palsy- Bell’s, Ramsay hunt, lyme’s, meningitis, TB, viruses
  • Brainstem- stroke, tumour, MS
  • Cerebella-pontine- acoustic neuroma, meningioma
  • Systemic- DM, sarcoid, GB
  • ENT- parotid tumour, otitis media
  • Other- Trauma to base of skull, diving, intracranial hypotension
110
Q

What is Bell’s Palsy and how does it present?

A
  • = Entrapment and inflammation of CNVII. Dx of exclusion. 70% facial palsy. Likely viral origin- HSV1
  • Presentation:
    • Suddon onset - overnight
    • Complete unilateral facial palsy. Not forehead sparing (LMN). Can’t close eye, drooling, speech difficulty
    • Numbness/ pain around ear.
    • Ageusia (loss of taste)
    • Hypersensitivity to sound
111
Q

Ix and Tx of facial palsy

A
  • Ix:
    • Bloods- glucose, ESR, VZV (ramsay hunt), borrelia Ab (lyme’s)
    • Imaging- MRI ?stroke/MS/SOL
    • Special- LP- ?infection. Nerve conduction @2w
  • Tx:
    • Cons- protect eye (dark glasses, drops, tape)
    • Med- pred within 72. 60mg PO for 5 days. Vasaciclovir if ?VZV
    • Surgery- lid loading, botulinum toxin
  • 80% full recovery
112
Q

Features of CN3 palsy

A
  • Sx- diplopia
  • Signs- Eye down + out, ptosis, pupil dilation
113
Q

Features of CN4 palsy

A
  • Sx: neck pain
  • Signs: Head tilt away from lesion. Eye in + up
114
Q

Features of CN6 palsy

A
  • Inward eye deviation. Inability to look out.
115
Q

Types/ causes of tremor

A

RAPID

  • Resting- 6-12Hz, pill rolling. Improves with distraction. Cause= Parkinsonism.
  • Action/ Postural- 6-12Hz. Absent at rest. worse with movement. Causes= BEATS
    • Benign essential tremor - arms/neck/voice
    • Endocrine- hyperthyroid, hypo, phaeo
    • Alcohol/ caffeine/ opioid withdrawal
    • Toxins - beta-agonists, valproate
    • Sympathetic - anxiety increases tremor
  • Intention- Large amplitude. Worse at endo of movement –> past pointing. Cause= cerebellar
  • Dystonic
116
Q

What is chorea and what causes it? Tx?

A
  • Chorea= “dance”. Non-rhythmic, purposeless, jerky movements
  • Causes:
    • BG- stroke, Huntington’s
    • Sydenham’s- streptococci (rheumatic fever)
    • SLE
    • Wilson’s
    • Neonatal kernicterus
    • Polycythaemia
    • Hyperthyroid
    • Drugs- L-dopa, OCP, HRT, chlorpromazine, cocaine
  • Tx= Dopamine agonists
117
Q

What is dystonia and what causes it?

A
  • = Prolonged muscle contracture –> unusual joint position/ repetitive movements
  • Idiopathic generalised/ focal dystonia. General= autonomic dominant, onset children. Focal= most common. 1 part of body, worse with stress.
  • Acute dystonia- torticollis, trismus, occulogyric crisis. Typically drug reaction- neuroleptics, metocloramide, L-dopa –> Tx= procyclidine
118
Q

Back pain DDx

A
  • Cord compression
  • Cauda Equina
  • Spinal mets
  • Myeloma
  • Vertebral collapse fracture
  • Aortic aneurysm
  • Infection
  • Renal colic
  • Mechanical- sprain, disc prolapse, spondylosis, lumbar spine stenosis
  • Pregnancy
119
Q

Features, Ix and Tx of mechanical back pain

A
  • Lower back pain. Worse on movement/ coughing
  • Normal sensation and tone on PR
  • Radiculpathic pain/ numbness
  • May radiate to leg
  • Tender around vertebrae
  • Pain on straight leg raise
  • Ix- usually none
  • Tx:
    • Cons- early mobilisation, hot/cold packs, posture, swimming/ walking, physio
    • Med- analgesia, diazepam for muscular spasm, facet join injection
    • Surg- ?decompression
120
Q

Back pain red flags

A
  • Age <20 or >55y
  • Weight loss
  • Fever, night sweats
  • Night pain/ worse on rest
  • Thoracic pain
  • Hx of cancer
  • Recent trauma
  • Recent steroids
  • Serious infection
  • O/E- hyperreflexia/clonus
  • Limb weakness/ paraesthesia
  • Urinary/ bowel retention/ incontinence
  • Constant/ progressive pain
121
Q

Ix of back with red flags

A
  • Bloods- FBC, ESR, CRP, ALP, PSA, serum electrophoresis, Ca2+
  • Imaging- MRI, spinal x-ray, CXR, DEXA
  • REFER TO NEUROSURGERY IF NEUROLOGY PRESENT
122
Q

What nerve is damaged with a Seargent’s Patch and how might this happen?

A
  • Axillary nerve
  • Due to shoulder dislocation

Finals!!! (19 decks)

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