Neurology Flashcards
1
Q
Causes of bilateral facial nerve palsy
A
- Infection
- meningitis
- Lyme’s disease - Granulomatous disease
- Sarcoid - Inflammatory disease
- guillan barre disease - Trauma
- base of skull fracture - Malignancy
- leukaemia
2
Q
Differential diagnosis of chorea
A
- Genetic
- Huntington’s disease - anticipation of CAG trinucleotide
- Wilson’s disease - autosomal recessive –> more of a PD picture
- Ataxic telangiectasia –> more of a cerebellar picture - Drug induced chorea
- anti-convulsants
- levodopa
- anti-psychotics - Biochemical
- hyperglycaemia
- polycythaemia - Vascular
- usually unilateral –> hemi-ballismus: ischaemia in subthalamic nucleas - Systemic conditions
- SLE
- Anti-phospholipid
- Thyrotoxicosis - Pregnancy
- chorea gravidarum - Post infectious
- Syndenam’s chorea - post streptococcal infection/rheumatic fever - rare due to use of Abx
3
Q
Management of Huntingdon’s chorea
A
MDT
- Neurologist - to manage symptoms
- Neuropsychiatrist - to manage mood + cognitive manifestations
- Neuropsychologist - as above and to help deal with devastating diagnosis
- Dietician - chorea increases basal metabolic rate and so malnutrition can occur
- PT/OT - manage mobility and adapt home + work environment
- Clinical geneticist - make diagnosis via blood test to look for trinucleotide repeat of CAG and offer support for diagnosis of family members
4
Q
Clinical features of polyneuropathy
A
Inspection - distal symmetrical wasting - champagne legs in CMT - arched foot in CMT - Pes Cavus Tone - flaccid Power - reduced distal >proximal Reflexes - reduced/absent Sensation - reduced in all modalities including proprioception Coordination - not affected Gait - high step - bilateral foot drop
5
Q
Differential diagnosis of peripheral polyneuropathy
A
- Inherited
- Charcot Marie Tooth
- CMT1 - most common, autosomal dominant inheritance, demyelinating pathology
- CMT 2 - autosomal dominant inheritance, axonal (non-demyelinating) pathology
- CMT 3 - autosomal dominant or recessive inheritance, demyelinating pathology - Nutritional deficiencies
- B1/thiamine = Beri Beri - seen in alcohol misues
- B6/pyridoxine - precipitated by isoniazid. Mainly sensory
- B12 = seen in vegan/vegetarian, pernicious anaemia, ileal disease (Crohn’s). Causes triad of Subacute Combined Degeneration of the Cord + optic neuropathy + dementia
- Vitamin E deficiency - Systemic diseases
- Diabetes
- CKD
- Paraneoplastic polyneuropathy - small cell lung cancer, myeloma with paraprotein
- CTD: SLE, rheumatoid arthritis, Sjogren’s
- Porphyria
- Sarcoid - Drugs
- Sensory: isoniazid (B6) + phenytoin
- Motor: amphotericin + gold + dapsone
- Sensorimotor: disulfiran + nitrofurantoin + vincristine - Toxins
- EtOH
- Lead
- Arsenic
- Glue sniffing
6
Q
Investigations for polyneuropathy
A
- Nerve conduction tests
- differentiate between demyelinating + axonal disease in CMT - Sureal nerve biopsy
- Bloods
- HbA1c
- Renal function
- Vitamin levels
- ANCA, dsDNA, RF, anti-Ro + La, anti-CCP, anti-phospholipid screen, anti-cardiolipin
7
Q
Differential diagnosis of spinal cord myelopathy
A
- Trauma
- Compression
- vertebral disc prolapse
- spinal abscess - staph aureas, Pott’s disease (TB) - Malignancy - primary or secondary cord compression, intra or extra medullary
- Vascular -
- anterior spinal artery thrombosis - may have preserved dorsal columns (proprioception, fine touch, vibriation)
- arterio-venous malformation haemorrhage
- vasculitis - polyarteritis nodosum, syphilis
- dissecting aortic aneurysm - Inflammatory - transverse myelitis
- multiple sclerosis
- SLE
- post viral demyelination
- sarcoid
- Sjogren’s disease - Metabolic
- subacute combined degeneration of the cord (B12 deficiency) –> loss of dorsal columns first, progresses to corticospinal tracts (UMN signs), preserved spinothalamic tract (anterior columns = pain, temperature)
- copper deficiency - Intrinsic lesions
- syringomyelia - Genetic
- Hereditary spastic paraplegia
8
Q
Clinical features of MS
A
- Optic neuritis
- loss of central vision
- painful ophthalmoplegia
- pale disc
- relative afferent pupillary defect - Brainstem
- Internuclear ophthalmoplegia due to demyelination of the medial longitudinal fasciculus (MLF)
- -> loss of signal from VI to III via MLF - ABducting eye on side of lesion is slow compared to ADducting eye on contralateral side. Results in horizontal nystagmus on contralateral (to lesion) ADducting
- CN IX + X = dysphagia - Myelopathy
- UMN lesions –> spastic paraparesis/tetraparesis
- sensory deficit
- bladder dysfunction
- Lhermitte’s symptoms - Cerebellar - ataxia
9
Q
MS - investigation
A
- MRI brain + spine: T2 weighted + Gad - hyperintense + gad enhancing lesions
- LP
- high protein
- mild lymphocytosis
- oligoclonal bands (not seen in serum) - Electrophysiology
- visual evoked potentials + auditory evoked potentials
10
Q
Cerebellar syndrome - clinical findings
A
Inspection
- truncal ataxia
- staccato speech - dysarthria
- saccadic eye movements
- head tremor
Tone
- hypotonia
- rebound phenomenon: arms outstretched and arms pushed down - exaggerated upshoot of arms
Power
- normal
Sensation
- normal
- however Ix for sensory cause of ataxia: proprioception may be affected, Romberg’s positive
Reflexes
- normal
Co-ordination
- intention tremor
- past pointing
- dysdiadochokinesis +ve
- heel to shin
Eyes
- nystagmus
11
Q
Cerebellar syndrome - causes
A
- Alcohol misuse
- Vascular
- ischaemic or haemorrhage - Malignancy - SOL
- Metabolic/nutritional
- B12 deficiency
- copper deposition in Wilson’s disease
- hypothyroidism - Drugs
- AED
- Lithium
- Barbituates
- Ketamine - Genetic
- Friedrich’s ataxia
- Spinocerebellar ataxia
- Ataxic telangiectasia
- Von Hippel-Lindau - Degenerative
- Multi-system atrophy (PD plus syndrome) - Paraneoplastic
- small cell lung cancer
- Gynae
- testicular
- breast
- Hodgkin’s
12
Q
Differences between cerebellar and sensory ataxia
A
Cerebellar
- dysarthria
- nystagmus
Sensory
- proprioception deficit
- Romberg’s positive
- able to do coordination with eyes open but difficulty with eyes closed
- pseudoathetosis (writhing motion of arms/fingers with arms outstretched and eyes closed)
13
Q
Ulnar palsy - clinical examination
A
Examination:
- Claw hand: paralysis of interosseous muscles resulting in extension of metacarpophalangeal joints and flexion of interphalangeal joints - most prominent in 4th and 5th fingers
- scar over ulnar aspect of risk: surgery or trauma
- check for scar behind elbow - ulnar nerve runs within olecranon groove behind medial epichondyle
- wasting in small muscles of the hand
Power:
- small muscles of the hand EXCLUDING LOAF (lumbricals, opponens pollicis brevis, abductor policis brevis, flexor policis brevis
- spread fingers apart and push in - weakness
- unable to hold piece of paper between fingers
- ABLE to keep thumb and forefinger in a ring despite examiner trying to break the ring - power of abductor policis brevis + flexor policis brevis
Sensory:
- loss of sensation/reduction in sensation/hyperalgesia in region of ulnar aspect 1.5 fingers anterior + posterior hand.
14
Q
Difference between ulnar palsy + C8/T1 radiculopathy
A
Motor:
Abductor pollicis brevis is inervated by C8/T1 but NOT ulnar
- causes ABduction of thumb
Sensory:
C8/T1 innervates ULNAR side of hand/forearm
Ulnar innervates ULNAR side of hand only (not forearm) (1.5 fingers)
15
Q
Management of neuropathic pain in nerve injury
A
- Start with TCA - Amitriptyline
2. Move on to gabapentin/pregabalin
