Neurology Flashcards
Extraoccular muscles
SR: move eye up - CN3 IR: move eye down - CN3 LR: abduct eye - CN6 MR: adduct eye - CN3 IO: up and out - CN3 SO: down and out - CN 4
Brown sequard
Hemisection of spinal cord
contralateral spintholamic loss - pain, temp, fine touch
ipsilateral loss of motor, vibration, deep touch, proprioception
M.G.
Px - known
Typicially nictonic acetylcholine receptor antibodies
M.S. symptoms
Diagnosis based on clinical signs, evidence of relapsing and evidence of a lesion (MRI dissemination in space and new lesion)
Visual sx:
- optic neuritis
- optic atrophy
- uhtoffs phenomenon: worsening vision following rise in body temp
Sensory sx
- puns and needles
- numbness
- trugeninal neuralfia
- Llhermittes syndrome: parsthesia of limbs on neck flexion
Motor:
- spastic weakness - legs
Atxia
Urinary incontinence
Visual field defects
Homonyous hemianopia:
- incongruous defects: optic tract
- congruous defects: optic radiation or occipital cortex
Homonymous quadrantanopias:
- superior- temporal lobe
- inferior - parietal lobe
Bitemoral hemianopia:
- optic chiasm
- upper quad - inf chiasmal compression - pituitary
- lower quad - superior chiasmal compression - craniopharyngioma
Phenytoin
Bunds to sodium channel and increases refractory period.
Adverse effects: PHENYTOIN
P-450 interaction Hirsuitism/Heamorrhagic dx of the new born Enlarged gums Nystagmus Yellow skin Teratogenic Osteomalacia Inteference with vitamin b12metabolism Neuropathies - vertigo, ataxia
Myasthenia crisis exacerbating factors
Penicillamine Procainimide, quinidine Lithium Phenytoin Abx - macrolides, quinolone, gentamicin, tetracyclines
Gingival
Hyperplasia causes
Phenytoin
CCB - nifedipine
Ciclosporin
Non-drug -AML
Acute disseminated encephalomyelitis
Autoimmune
Occurs typically a few weeks after viral illness or vaccination
Px: Encephalopathy Motor weakness Seizure Coma
INX:
MRI with T2 weighted —> poorly defined hyper intensities in the subcortical
White matter
Mx:
IV glucocorticoid —> fx —> IVIg
Essential tremor management
Propranolol
Second line or CI (Asthma) —> primidone
Aphasia
Wernickes:
- superior temporal gurus lesion
- fluent speech without meaning
- word substitution and neoglism
- impaired comprehension
Brocas;
- inferior frontal gyrus lesion.
- non fluent, effortful soeech
- comprehension normal
Conducting aphasia:
- Arcuate fasiculus
- fluent speech but poor repetition- they are aware
- comprehension normal
Global Aphasia:
- large lesion affectinf all 3 of above
Anterior spinal
Artery syndrome
Bilateral spastic paresis with loss of spinothalamic.
Lateral spinothalamic
And lateral corticopspinal
Subacute combined degeneration of spinal cord
Vitamin B12 and vitamin E deficiency
Lateral corticospinal, dorsal column and spinocerbellar - affected
B/L PERIPH NEUROPATHY & MIX OF UMN/LMN SIGNS
Bilateral spastic paresis
Bilateral loss of prioooception and vibration sensation
Bilateral limb ataxia
Friederichs ataxia
Px same as SCDC
- A.R. trinucleotide repeat
Px:
- Absent knee and ankle reflex
- Extensor plantar response
- Cerebellar symptoms
- Optic nerve atrophy
Syringiomyelia
Spinothalamic tract bellow + LMN at level
Flaccid paresis
Peripheral nueropathies causes
DAM IT BICH
Drugs and chemicals - Pb, phenytoin, metronidazole, vicristine, isoniazid
Alcohol and amyloid
Metabolic - DB, uraemia, hypoglycaemia
Infection - GBS, HIV, leprosy, lime dx, syohillis
Tumor - paraneoplastic syndrome (lung, lymphoma,
Melons)
B12 and other deficiencies
Idiopathic
CTD/ vasculitis
Hereditary/hypothyroidism
Ramsay hunt syndrome
Reactivation of VZV —> geniculare ganglion of CNVII
Ft:
- auricular pain (1st ft)
- cN7 palsy
- vesicular Tash around ear (as well as ant 2/3 of tongue)
- other ft - vertigo and tinnitus
Mx
- PO aciclovir and corticosteroids
Restless legs syndrome
TEST FOR FERRITIN
Akathisia
Paratheasia
Periodic movement in sleeps
Assoc
- FHx
- IDA
- Uraemi
- DB
- Pregnancy
Mx:
- simple measures such as stretching and massage
- tx IDA
- DA agonist = 1st LINE - R-opinirole, pramipexole
- BZD
- Gabapentin
Alzheimer’s disease
Frontal lobe sparing
Pathological findings:
- extracellukar B- amyloid
- hyperphisphorylated tau proteins
- neurofibrillary tangles
- loss of cholinergic fn
Temporal and parietal loves
APOE —> e2,e3,e4 alleles on chromosome 19
Early onset —> presenellin 1& 2 and amyloid precursor protein
Tx:
1) donepezile - cholinesterase inhib
2) memantime NMDA - for moderate to sev Alzheimer’s
Lea body dementia
> 65yrs
Accumulation of LBs in brain stem
And cortex
NT dysfunction
Loss of visuospatial awareness + hallucinations.
Fluctuating
Tx:
Donepezil
Tx PD
EXTREME SENSITICITY TO NEUROLEPTICS- deterioration of PD
FT DEMENTIA
2nd most common in <65 (behind early onset AD)
Cognition intact
Change in behaviour and personality —> DISINHIBITED
Decreased language production
Primary progressive Aphasia
Non fluent - left inf temporal
Semantic - left anterior temprorak
Logopenic - posterior temporal
And parietal
Prion disease - cJD
Transmissible spongiform encephalopathy.
Prions - misfplded proteins- transmitted —> propagation
Prions - resistant to standard sterilisation
Sporadic CJD:
- 45–>75yr
- PRNP GENE
- myoclonus, ataxia And rapidly progressive dementia
Variant CJD:
- 20s age of onset
- psychiatric prodrome —> painful sensory sx
Inx MRI.
Normal P hydrocephalus
Wobbly + whacky + wet
Inx —> MRI
Mx:
- large volume CSF removal by LP
- VP shunt
M.S.diagnosis
Clinical picture
MRI - lesion disseminated in Time and space
Impaired oligoclonal bands on CSF
MS subtypes
Relapsing - remitting
Secondary progressive (secondary to R-R)
Primary progressive - deterioration from outset
Progressive relapsing - primary progressive with superimposed R-R
MS - relapse treatment
Relapse - period lasting 24-48 hrs, when previously stable for 30 day, and other cause especially infection is excluded
Tx: high dose steroids with an oral taper:
1g methylpred—> 500mg PO methyl pred
DMARD therapy in MS
Indicated iff
RRMS:
- =>2 in last two years —> IFN-B
- IFN-beta Or galtiramer resistant —> fingolimod
- => 2 disabling relapses —> natalizumab
Secondary progressive
- tx with IFN-B
Adverse effects:
Natalizumab: PML
Fingolimod: transient AV slowing, macula oedema and Herpes reactivation
Alemtuzumab: autoimmune disease. - ITP and Goodpasteures
Autoimmune encephalitis - non paraneoplastic
Most common
Extracellukar targets
Steroid responsive
AI encephalitis - paraneoplastic
Lung and breast ca
Intracellular targets
Not steroid responsive
Limbic encephalitis is an example:
- seizure
- amnesia
- confusion
Wernicke’s Encephalitis
Low thiamine vitamin B1
Confusion
Ataxia
Abnormal eye movements
Cortical blindness
Severe/complete blindness
Pupil reflexes present
Macular soaring
Bilateral occipital infarct
Marcus Gunn Pupil
Seen on RAPD
Lesion anterior to optic chiasm = optic nerve or retina
Causes:
- Renital detachment
- optic berve - neuritis (MS)
Causes of small pupil (mitosis)
Senile miosis
Pontine haemorrhage
Horner syndrome
Argyll Robertson: bilateralx assymetrical. Small irregular pupils - NORMAL ACCOMODATION NOT REACTIVE TO LIGHT.
Drugs- opiates/pilocarpine
Myotonic dystrophy
Horner syndrome
Miosis
Ptosis
Anhidrosis
Vasodilation and enopthalmos
Horner syndrome investigation
Hydroxyamphetamine - distinguishes between 1st and second order VS 3rd
- 1 and 2 order pupil dilation
- 3rd order - no dilation
Intranuclear opthalmoplegia presentation
Impaired ipsilateral addiction
Abducting nystagmus contralat
Convergence normal
No Diplopia
Causes of INO
BILATERAL INO = MS
Demyelinative disease - young
Vascular - >60
Trauma
Basilar artery occlusion
Miller fisher syndrome
Vascukitis
Overdose - barbiturates, phenytoin, amtryptilline
Supranuclear opthalmoplegia
Disorder in cerebral hemispheres, cerebellar and brainstem
DOLLS HEAD MOVEMENT - increased movement on reflex than voluntary
Examples:
PSP
Gaze palsy
Midbrain syndrome
Coma
interruption of ARAS
Persistent vegetative state
CNS intact
Roving eye movements.
Sleep wake cycle intact
Still have stable BP/Resp drive
Decorticate vs decerebrate
decorticate:
- Flexor response
- Upper brainstem
Decerebrate
- Extensor
- B/L midbrain or pontine.
Brain stem lesions and pupils
Normal - lesion is bellow pons or above thalamus
(P)inpoint - Opiate or (P)ontine lesion
Fixe (m)idpoint - (m)idbrain
Dilated pupil - Midbrain, sympathomimetic, CN3
Eye movements
Spont eye movement - Bihemispheric dysfunction
Horizontal deviation:
- Non status epileptic
- Ipsi hemispheric stroke
- Contralat pontine stroke
Roving eye movements:
- Toxic/metabolic
- Brainstem ifarct
- B/L hemispher.
Skew Deviation - Post fossa lesion
BRainstem death
Brainstem reflexes + Motor responses + Respiratory drive are absent in commatosed pt with irreversible known cause.
Must have satisfactory O2/Temp and no hypercapnia or pharmacological influence and no metobolic disturbance or reversible cause.
Encephalitis causes
Viral - HSV1 - most common VZV Enterovirus Adenovirus
Bacteria mTB Streptococcus - menngitis meningococcus - meningitis Syphillis
Other:
Cryptococcus
toxoplasmosis
nnon-infective
Encephalitis - indications for urgent CT before LP
low GCS Focal neuro uncontrolled seizures Cushing triad (raised ICP) - high BP, Low pulse, High RR Clotting abnormality sepsis immunocomp
Encephalitis Mx:
MRI/LP (CT if indicated)
Start Aciclovir straight away.
Meningitis - causes
Bacterial:
Meningococcus
Pnemococcus
mTB
Viral: - Enterovirus HSV HIV VZV Mump CMV
Other:
Cryptococcus
Toxoplasmosis
MEningitis - CSF findings
Bacteria: - High opening P - Neutrophils Low PRotein Low Gluc
Viral: - Normal opening P - Lymphocytes - Normal/high prtein Normal Gluc
Tb:
- High/V.High opening P
- Lymphocytes
- V.high protein
- VV. Low Glucose
Fungal:
- VVVHigh opening P
- Lymphocytes
- VVVhigh protein
- V. Low gluc
MEningitis management;
<3mnth or >50 - Cefotaxime + amoxicillin
3 mnth - 50 yrs - Cefotaxime
Meningococcus - IV Benpen + Cefotax
Strep - Cefotaxime
- H.influenza - Cefotaxime
Listeria - IV Amox + gent
Contacts:
- streptococc - no prophylaxis
- meningococc - Rifamp
Infectious myelitis
Px: PAIN + FEVER + MENINGIM + MIXED UMN/LMN signs.
Viral
- Entero
- HIV
- HTLV-1
- VZV/ HSV/ CMV
BActerial:
- Syphillis
parasitic causes.
- Schistosomiasis –> Acute transverse myelitis + Raised Eosinophills.
Migraine w/o Aura criteria
A - => 5 attacks
B - Headache lasts 4-->72 hr
C- Headache with 2/4 of:
- Unilat
- pulsating
- worsened by activiy
- Mod sev
D => one of:
- N/V
- photo/phonophobia
E - not explained by other diagnosisMigraine w/ Aura
A - =>2 attacks
B- =>1 of:
- Visual
- Sensory
- brainstem
- Motor
- Retinal
C - =>2 of:
- =>1 aura sx spreading over 5 mins or >1 in succession
- Each sx asts 5-60mins
- => 1 is unilat
- Aura = accompanied by or followed within 60 mins be headacheMigraine Mx
Acute:
1st line - Po Triptan + NSAID or Paracetamol
Fx –> Non-po prochlorperazine + metoclop + Nasal triptan
Prophylaxis:
- 1st line = Propanolol or Topiramate
- Fx –> accupuncture or Gabapentin
Advise suplement with Riboflavin
Menstrual migraine –> Frovatriptan or Zolmitriptan
Migraine Mx in Preg
Acute:
1st line = paracetamol
2nd line = ASA or NSAID (not 3rd trimester)
Prophylaxus - Propanolol
Cluster headache diagnostic criteria
A - =5 attacks
B - Sev/v.sev unilat orbital/supraorbital/temporal pain
- lasts 15 –> 180mins
C - Either or Both of:
1) => 1 of the following:
- conjunctival injection/lacrimation
- nasal congestion
- Eyelid oedema
- Forehead/facial swelling
- " " " " flushing
- Fulness in ear
- miosis/ptosis
2) Sensation of restlesness/agitation
D - Attacks have freq of every other day to 8/day for >1/2 time of cluster period
Cluster headache - Mx
Acute Mx:
- O2 + S/C Triptan
Prophylaxis
1st lie - Verapamil
MS vs NMO
NMO-IgG + in NMO
Caroticocavernous fistula
High flow is between intracavernous artery and cavernous sinus
Secondary to trauma
Pulsation proptosis and CN3/4/6
Raised IOP
Foster Kennedy syndrome
Ipsilateral optic atrophy
Contralat papilloedema
Direct damage if SOL - FRONTAL LOBE
Friederichs ataxia
A.R.
Trinueotide repeatbdisorder - GAA
CARDIACCC
Absent ankle jerks/extensor plantars
Cerebellar ataxia
Optic atrophy
Mixed LMN/UMN
Pea cavus
Valproate side effects
VALPROATE
Vomiting Alopexia Liver toxicity Pancreatitis/pancytopenia Retention of fat - weight gain Oedema Ataxia Teratogenic/ tremor Enzyme inhibition
GBS vs CIDP
CIDP > 8/52 History
Congenital nystagmus causes
Idiopathic X-linked or AD Secondary to visual impairment: -albinism Optic nerve hypoplasia -retinal dystrophy
Acquired Nystagmus causes
Downbeat - foramen magnum lesion
- Arnold chiari malformation
- spinocerebellar degen
- demyelinative
- platybasia
Upbeat
- intrinsic brainstem dx
- cerebellar vermis lesion
- organiphosphates
- wernickes enceph
Pendular:
-demyelinative disease
Neuroleptic malignancy syndrome
Atypical antipsychotics Or dopaminergic drugs
Seen in first 10
Days of tx
Young male
Pyrexia
Rigidity
Tachycardia
Mx:
IV FLUIDS AND DANTROLENE
Migraine affects on GI
Delays gastric emptying during attack
Therefore combine with a pro kinetic such as metoclopramkde
Trigeninal neuralgia
Brief lancet pain
Women >50
Unilateral and trigger points
Can be presenting symptom of MS
Tx
Carbamazepine/phenytoin Clonazepam Backpfen Thermocoagulation of trigeminal ganglion Surgical micro vascular decompression
Vertigo causes
Peripheral - labyrinthine
- BPPV
- Trauma
- Ménière’s disease
- acute viral infection
- chronic bacterial OM
- occlusion if internal auditory artery
Central:
- vascular disease
- ms
- SOL
- alcohol or drugs
- hypoglycaemia
Ménière’s disease
Vertigo
Tinnitus
Sensorineural HL
Drug induced Parkinson’s
Rigidity and tremor are uncommon !!
Vestibular schwannoma
Vertigo + SNHL + Absent corneal reflex
Tumour of CN8
Corneal reflex absent
Facial sensation abnormal
Inx MRI or high res CT
Mx- surgical removal
Lateral medullary syndrome
PIKACHU and mark whallberg with a horn on a hot sunny day
PICA - can’t - CHew
Posterior inferior cerebellar artery
CHew - dysphasia
Mark - Wallenberg syndrome
Big horn - Horners syndrome
Sun - tempersrion problems
- ipsilateral OM face
- contralat in body
Facial nerve paralysis
Supplies face, ears Tate and tear
Can present with
Forehead sign
Hyperacusis - due to paralysis of stapedius muscle
Facial expression
Loss of Tate
MMSE
Normal 30-27
Mild 26-22
Mod 21-10
Sev 9-0
Variant CJD
HOCKEY STICK SIGN
progressive dementia
Mycoclonus
Polyneuropathies
Acute - inflamm, toxic, vasculitic
Chronic - genetic or metabolic
Symmetrical distal weakness and sensory lows - lower>upper limb
IIH
YOung obese female
Headache + Paoilloedema w/o focal neuro or lesion
No neuro signs.
Normal neuro imaging
normal CSF appearance
INCREASED LP OPENING P (>25cmH2O)
Iatrogenic causes:
OCP, steroids, tetracyclin, vit A, Nitrofurantoin, Nalidic acid
Mx: - WL - Acetozolamid or topiramat - Can use rpt LP VP SHUNT or optic Nerve fenestration
Gersstmann syndrome
Acalculia, Right to left disorientation, finger agnosia and agrapgia.
Dominant parietal lobe is affected
syringomyelia
collection of CSF in spinal cannal.
Causes:
- Chairi malformation
- trauma
- tumour
- idiopathic
Patter of Px:
spinothalmic tracts cross i th anteriro commisure of spinal cord –> therefore symptoms first.
CAPE LIKE loss of spinothalamic
preserved lght touch, vibrationa nd propriooception
Inx - MRI with contrast - xcl tumour and MRI bran to excl. chiari.
Untreated –> scoliosis
Mx:
- Tx cause
- symptomatic –> shunt
5-HT3
Acts on CTZ of medulla oblongata
Ondansetron
Side effects - constipation
CN3 palsy
Pupil down and out
Ptosis
Pupil maybe dilated
Causes:
PAINFUL PALSY R/O POST COMMUNICATY ARTERY ANEURYSM
- DB
- vasculitis
- invaluable hernition/raised ICP
- cavernous sinus thrombosis
- Weber’s syndrome (midbrain strikes) - ipsilateral CN3 palsy and contralat hemiplegi
Amyloid and MS
Stopping AED
Stop it seizure free for >2 years and stop over 2-3 months
Craniopharyngioma
Most clmmons upratentorial lesion in children
Originates from
Rathke pouch in ventromedisl area of hypothalamus
Px:
- bitemporal hemianopia inferior quadrant
- hypopituitary
- motor oil like fluid in tumour
Inx —> CT - calcification
Tx - surgical resssction
Narcolepsy
Associate hla DR2
Low level of ore in (hypocretin) control sleep / appetite
Early onset REM
FT: - inset in teens - hypersolmonence Cataplexy Sleep paralysis Vivid hallucinations on SLEEPING AND WAKING
Inx
Sleep latency eeg
Heniballism
Damage to subthalmic nucleus
Contralat proximal sudden jerking movements - basilic movement (choreoform is distal)
Sx - whilst patient ASLEEP
Mx - antidopaminergic - haloperidol
Complex regional
Pain syndrome
CR 1 - no demonstrable nerve lesion
CR2- demonstratable nerve lesion
Ft:
Progressive disproportionate symptoms
Temp and skin changes
Oedema and sweaty d
Mx:
Early PT
Neuropathic analgesia
Pain team
Epilepsy management
Generalised –> Na Valproate
Focal –> Carbamazepine
Generalised T-C:
- Na Valproate
- Carbmazepine/Lamotrigine
Abscence:
- Na Valproate
- Ethosux
Myoclonic:
- Na Valproate
- 2nd clonazepam and lamotrigine
Epilepsy Childhood syndromes
West’s syndrome - Infantile spasms:
- 1st few months
- Progressive mental handicap \
- EEG _ Hypsoarrythmia
- Vibagatran
Absence:
- EEG - 3Hz spike
- Na Valproate/Ethosux
Lennox-Gustaut: - Hx of absence SEV MENTAL HANDICAP - EEG - Slow spike - Ketogenic diet
Benign Rolandic Epilepsy:
- Parasthesia
- M>F
Juvenile myoclonic Ep:
- Seizures in the a.m.
- Daytime somnolence
- Na Valproate
Localising Epilepsy
Temporal lobe - H.E.A.D:
- Hallucionations
- Epigastric rising
- Automatism - lip smacking/hand rubbing
- Deja Vu/Dysphagia
Frontal lobe:
- Motor
- Head-leg
- Jacksonian march
Parietal:
- Parasthesia
Occipital:
- Flashes and floaters
Epilepsy when to start treatment
after 2nd seizure
or
1st seizure if:
- Structural abnormsality
- EEG unequivocal
- Neuro deficit
- PT/family thyink a second is unnaceptable.
Epilepsy in pregnancy
All can be used - Na Valproate is only cobtraidicated
Folic Acid 5mg
- Carbezapine = least teratogenic
Breatsfeeding is safe
Epilepsy and DVLA
1sts eizure - 6/12 off if no structural and no EEG findings (if present 12/12 off)
Epilepsy/multiple seizures –> 12/12 seizure free. IF >5yr seizure free –> drive until 70
Cant drive whilst stopping AED + 6/12 after last dose.
TIA
<24 hours
now no longer time based but tissue based = A transient epilepsy of neuro dysfunction caused by Brain, S.cord, retina ischaemia - w/o infarction - w/o infection
ABCD2 no longer used
Mx:
- ASA 300mg – after exclusion of haemorrhgagic
LT Mx:
- Clopidogrel
- 2nd line - Dipyradimole + ASA
TIA - referral
Crescendo TIA or Cardioembolic –> urgent referral
TIA in last 1/52 –> urgent referral
Prev TIA >1/52 –> referral in 1/52
Carotid endarterectomy
Recommended if Stenosis >70%
Stroke Features and anartomical location
Anterior Cerebral A –> Typical Ft
Middle Cerebral A –> Typical ft + Homonious hemianopia
Post cerebral A –> Homonyous hemianopia w/ macula sparing
Basillar A –> Locked in syndrome
Opthalmic A –> Amurosis Fugax
Stroke assesmment in hospital - ROSIER
ROSIER - exclude BGL then:
LOC (-1)
Seixure (-1)
unilat facial weakness (+1) unilat arm weakness (+1) unilat leg weakness (+1) Speech disturbance (+1) Visual field defect (+1)
> 0 –> stroke likely
MX - Thrombolysis
<4.5 hours
absolute - CI:
- Prev haemorrhage
- Seizure @ onset
- Neoplasm
- suspected SAH
- Stroke or TBI in last 3/12
- Prev GI haewmorrgage in last 3/52
- LP prev 7/7
- Active bleed
- PREG
- varices
- malignnast HTN
Stroke - secondar precention
Clopidogrel life long
2nd line or cantr tolerate : Dipyradimole and ASA
AF post stroke:
- Warfarin or FXa inhib - start 2/52 after stroke
Degenerative cervical myelopathy
Rf:
- Smoking]
- Genetics
- Occupation
- Asians have different aetiology as increased occification of posterior longitudinal ligament
Px sx unknown
Px:
- Pain - neck or limbs
- Hoffmans sign
- loss of motor f/dexterity
- loss of sensory
- loss of autonomic fn
Inx –> MRI C spine
Mx:
- urgewnr eferral for spinal decompression - early tx within 6 months
Trigeminal neuralgia management
1st line - Carbamezapine
S.A.H - Risk factors
PCKD
Ehlers-danlos
Fibromuscular dysplasia
medium vessel vasculitis
Aortic coarctation
SAH inx
CT immed.
LP at 12 hours - Xanthochroia - Bili
SAH poor prognostic factor + Mx
- low GCS
- > 65
- Bleed on CT
Mx: - Nimodipine 60mg 4hrly -Urgent for clipping/coiling \ Prevention if => 2 relatives w/ SAH or PCKD --> Refer
SAH complications
Neurological
- Rebleed
- Hydrocephalus
- Ischaemia - secondary to vasopasm
Systemic
- Fever
- Tachy - secondary to catcholamine releasse
- SIADH
- Neurogenic pulm edema.
Primary CNS vasculitis
can occur as systemic or primary neuro
primary CNS presents as 3 types:
- MS with atypical ft - seizure, stroke like
- Acute/subacute encephalopathy like - Acute confusional state
- mimik an intracranial lesion
inx - R/O other cause
Mx:
- High dose steround –> Taper with PO
- once ion remission –> Azathioprine
Central venous thrombosis
Young fat female.
Suspect if:
- pregnancy in 3rd trimester
- Hx VTE
- PRogressive new neuto decloine
- Ischaemic stroke that crosses arterial territories
Inx:
- CT / CT Venogram
Mx:
- Anticoag w. LMWH
- Antiepileptics.
Reversibel vasoconstrinction syndrome
recurrent sev thiunderclap headache
Post partum
Angiography –> String of bead appearence –> rpt imaging shows resolution
Mx acutely with nimodopine
Neuromyelitis optica (NMO)
MS like - mopre severe
Px:
- Optic neuritis + Transverse myelitis (sev - “sawn off”)
Can be triggered by MS DMARDS
IgG AQP4
Mx:
- Steroids +/ plasmophoresis +/- IV Ig
Neurosarcoidosis
Non spec px
inx - ACE levels
CT
CXR - BHL
CSF - high ACE/Lympogocytes, low gluc, oligoclonal bands
Mx –> immunosupression
CNS tumours
Adults:
- Glioma & MEt dx - 60% - brai between tumour and skull
- MEningioma - no brain between tumour and skull
- Pit lesion 10%
Child:
- Astrocytoma
- medulloblastima
Inx: MRI
Mx
Surgery
- curati e in meningioma
- Glioma - lots of invasion - sx tx
MND
Px Assymetrical progressive motor degen and mix of UMN/LMN
2 types:
1) ALS - UMN lower limbs and LMN upper limbs
2) Bulbar palsy - worst prognosis - FEV1
3) Progressive muscular atrophy - LMN in one limb - BEst prognosis
Inx:
- R/O other cause - imaging
- EMG - chronic dennervation/ N sensory/ Preserved velocity
Mx: - Riluzole - monitor LFT and BM supression - MDT - SALT - PT Nutionin - PEG - Resp NIPPV
Parkinson’s dx
lew body depsoitis in substansia nigra pars compacra –> decrease DA inpout into basal ganglia.
Triad:
- Bradykinesia
- Resting tremor (3-5Hz)
- Rigidity
other - Mask face/micrographia/ flexed ppsture/ depression/ sleep disorder. bowel dysfn.
PD management
Levodopa:
- Good for motor symptojs
- On + Off perdios.
- dyskinesias
- less effective with time
DA Agonist:
- Ropinerole/ Rigotine patch/ Apomorphin/ PRamipexole
- More hallucinations + IMPULSE control
- Apomorphin e good if motor fluctuation
- Ergot derivatives: Carbegoline/bromocriptine –> Retroperitoneal fibrosis –> prior to start Echo/ESR/CXR
MAO-B:
- Selegeline
- more On-time
- less hallucination
- fewer S.E
COMT-I
- Entacapone
- increase on time
- less hallucnations
NMDA- R - antage:
- Amantadine
- improved dyskinesia
Causes of parkinsonism
PD Drugs - antipsychotic/metoclop wilsons psp msa post encephalitis dementia pugilistica toxins - CO/MPTP
PArkinsons plus
LBD
MSA - autonomic
PSP - Vertical upgaze - down>up - cant walk dow stairs - poor response to lefvodopa
CBD - disorder of movement and cognition - alien hand syndrome
Huntingtons diseaser
AD trinucleotide rpt disorder –> complete penetransce and anticipation
Loss of D2 in cortex + Striatum
Px:
- Chorea
- YOUNG PT WITH PD
- slow saccadic ieye movements
inx - MRI
Mx
- Symptomastic
- SSRIs
- Chorea –> Tetrabenazine
Wilson’s disease
A.R. - chromosome 13 - decreased biliary copper exceretion
Child –> hepatic manifestion
late teen –> psychiatric –> exec dysfn/impulsivity./emotinally labile
other ft: kayser-flaischer rings wing beating trremor chorea dyskinesia
inx - MRI
Mx - Cu chelating wih Penicillamine
tabes dorsalis
post column –> loss of dorsal column
anterior horn cell syndrome
LMN signs
seen in poliomyelitis
combined anterior horn + pyramidal
UMN lesions bellow and LMN @ lesion - ALS
anterior spinal artery syndrome
supply anterior 2/3 of SC
Flaccid paralysis + loss of spinothalamic + preserved dorsal.
Cauda equina vs connus medullaris syndrome
see notes essentiall
C.E - assymetrical LMN
CMS - symmetical UMN signs - motor preserved. - Early bladdder/biwel
Mononeuropathies
Median nerve (C6 - T1):
- Carpal tunnel
- L.O.A(d).F
- sensory thenar eminence
Ulnar (C7-T1):
- Claw hand
- Sensation - ulnar border of hand
- distal compression –> Preserved palmar sensation
Radial N (C5-T1) - wrist + finger drop Sensation loss dorsum of hand and 1st web.
Common peroneal
- Foot drop+ weak eversion
- Lateral shin + dorsum of foot sensation.
Mononeuritis multiplex
WARDS PLC
Wegners amyloidosis RA DB Sarcoidposis PAN Leprosy/lyme Carcionmatosis/churg straus
GBS
Flaccid paralysis + polyneuropathy
Follows URTI/GI infection - campylobacter
NADIR 14 dayts
can cause areflexia + Respiratory comprise (FVC)
EMG - Demyelinating dx therefore SLOW CONDUCTION
CSF - high protein otherwise normal
Mx - self terminates
if non-ambulant –> IVIg/Plasma exhange
MG
ACH-R and MUSK (bulbar) . - POST SYNAPTIC
Assoc:
- THYMOMA - CT Chest
- AI disorder - pernicious anaemia/AI Thyroid. Rhwum/SLE
- Thymic hyperplasia
Inx: - EMG - CT Chest - thymoma CK - Tensilon test - IV edrophonium
Mx:
- Pyridiostigmine - long acting acetylcholinesterase inhib
- PRed
MG exac factors
- Penicillamine
- Procainamide/quinidine
- Betablocker
- Li
- phenytoin
- Abx - gent/macrolide/quinolonews/tetracyclines
Myasthenia crisis
increased commen in MUSK Ab + –> May req ventilation
Triggers: - Stressors/sterpods.withdrawl of pyridostigmine/ low K+ or PO4-/ anaemia
Mx:
- Monitor FVC –> <1 –> ITU
- IVIg + plasmophoresis
LEMS
PRESYNAPTIC VOLTAGE GATED Ca channels
Assoc. SCC
rpt contractions –> STRENGTHEN
inx - EMG - shows strength with rpt
Tx
- underlying cause
- =3,4-DAP +/- pyridostigmine
- I.S - pred + Aza
Myopathies
Symmetrical PROXIMAL weakness - difficulty rising from chair or getting uo
Sensation/refleces all normal
Causes:
- imflamm = polymoyositis
- inherited - DMD/BMD.myotonic dystrophy
- Endo - cushings/thyrotoxicosis
- EtOH
inx - MUSCLE BIOPSY
Myotonic dystrophy
20-30 yrs
Think of the Ds for DM1
- Distal weakness
- A.D.
- DB –> glycosuria
- Dysarthria
two types : DM1 and DM2
- DM1 - distal >prox
- DM2 - prox >distal
Ft:
- myotonic facies - haggered
- frontal balding
- B/L ptosis
- catracts –> LOSS OF RED REFLECX
- dysarthric
DMD and BMD
A.R.
Mutuation –> DYSTROPHIN GENE
DMD>BMD severity
DMD:
- 1st 5yrs
- calf pseudohypertophy
- gowers sign
- IQ DOWN
BMD:
- 10yrs
- IQ NORMAL
fascioscapulohumeral dystrophy
A.D.
Affects what it says - facial/scapula/ upper arm
Px at 20yrs
Dermatomyositis
Prox muscle symmetrical weaskness Gottrens papuoles heliotrope rash - purple rash on face + eyelids Photosensitive macula rash on back + shoulder
Inx: - CK!!!!!! ANA Others Jo-1 SRP MI-2 Ab
EMG
CK
MUSCLE BIOPSY
Mx - PRednisolone
Polymyositis
symmetrical proximal weakness
Raynauds
Resp muscle weakness/ILD
Inx: - CK!!!!!!
JO-1 - esp assoc with raynauds !!!!
- EMG
Muscle biopsy
Mx - pred
inclusion body myositis
insidious weakness @ 60yrs
PROX L.L AND DISTAL U.L.
Dysphage
Inx:
- Muscle biops
- Ck can be N
Mitochondrial dx
exclusively maternally inherited
poor phenotype:genotype
Histology - RED RAGGED FIBRES
Examples:
- Leber’s optic atrophy -= B/l painless LOV
- MELAS - Stroke like episodes in <40
- MERRF - Myoclonus/seizures/myopathy
- KEarnes Sayres - ext opthalmoplegis + Retinitis pigmentosa + Ptosis
Neurofibramotosis
NF1 - chromosome 17
- Cafe au lait spots
- axillary groin freckles
- peripheral neurofibromas
- lisch nodules
- phaechromacytomas
NF 2 - Chromosome 22
- Bilateral vestibular schwannomas
- multiple intracranial schwannommas, ependyomas, meningiomas
Tuberous sclerosis
Epilepsy + developmental problems
Shagreen patch ashleaf spot subungal fibromata adenoma sebaceoum Retinal harmartomas
Absence seizure - CI AEDs
CARBAMEZAPINE
Phenytoin, vabigitran, gabapentin
paraneoplastic syndromes affecting nervous system
LEMS
Anti-Hu
- Painful sensory neuropathy
anti-yo:
- Cerebellar syndrome
- assoc with Ovarian Ca and Breast Ca - Y looks like a vagina and (Y) looks like cleavage
Anti - Ri
- Ri Ri - woman - breast cancer
- Rhianna has great eyes
- occular opsiclonus-myoclonus
Anti-GAD
- stiff man syndrome
- Oh My GAD im so stiff
Triptan (5HT-1) Contraindication
Cerberovascualr disease
Ischaemic heart dx
Miller fisher syndrome
typeof GBS
opthalmoplegia + Ataxia + Areflexia
Descending paralysis (Ascending in GBS)
Risks of epilepsy on fetus
Birth defects
new botn epilepsy - 10% if one first degree 25% =>2
Neonatal coagulopathy - Phenytoin.phenobarbital/primidone - Give Vitamin K
Anti-NMDA RECEPTOR encephalitis
Paraneoplastic syndrome - Ovarian tumour
Px - encephalitis and psychiatric features
Tx - immunosupress
Ménière’s disease
Sensorineural deafness + tinnitus + vertigo
Mx:
ENT
DVLA - cease until sx control
Acute - prochloroerazine
Prevention -betahistine
Neuropathic pain
Amitryptilline gabapentine pregabalin duloxetine
Fx —> tramadol
Ataxia telangectasia
AR
Cerebellar ataxia
Telangectasia
IgA deficiency —> recurrent chest infections
- malignancy lymphoma leukaemia
Friederichs atxia vs ataxia telangectasia
Both:
AR
CEREBELLAR ATAXIA
ONSET IN CHILDHOOD
friederichs - DONT get infections
Guillian barre syndrome
Flacid weaknes
Hyporeflexia
Tachycardia
VHL
Retinal and cerebral hemangiomas –> px/fhx of ICH or suddent blindness
Renal cysts –> renal ca
Phaeochromacytoma
stroke secondary prevention
Clopidogrel + statin
LEMS
Small cell lung ca
presynataptic voltage gated Ca channels
PROXIMAL weakness –> can repsond to STEROIDS
Absence seizure - what % seizure freee >16 yrs
90-95%
Pergolide - used in Parkinsons - complication
Can cause pulmonary fibrosis
Pituitary apoplexy
Hypopituitarism (hypotension, low hormones and can mimic SAH
Raised protein in CSF
GBS
TB/Fungal/Bacterial meningitis
Froin’s syndrome - Raised protein bellow blockage “tumour, disc infection”
Viral encephalitids
Otitis media mx
Topical abx + stewroid
Facial nerve palsy
Hyper acusis due to paralysis of stapedius
Facial nerve paralys
loss of supply to ant 2/3 tongue
loss of tears
most common complication following meningitis
Sensorineural Hearing loss
DVLA + NEuro
Stroke/ TIA - 1/12
Multiple stroke/TIA in short period - 3/12
Craniotomy for meningioma - 1 year
Craniotomy for pituitary - 6/12
Transphenoidal - drive once no no impairment
Simple faint - no
1 ep syncope explained + trated - 4/52
1 ep unexplained - 6/12
>1 Ep - 12/12
Narcolepsy/cataplexy - cease on diagnosis
MND - MX
Riluzole:
- prevents stim of glutamate receptors
- used in ALS
- 3/12 prolonged survival
NIV:
- bets for survival - 7/12
Transient global amnesia
Retrograd and antegrade amnes + Repetitive questions - w/o other neuro or cognitive sign
lasta <24 hrs
Menieres dx
tinnitus
SNL HL
VErtigo
nystagmus
mx:
- Acute = prochlorperazine - IM or buccal
- prevention = betahistine
Hemiballism
Damage to Subthalmic nucleus.
contralat Involuntary jerking movements - Prox>dista
Sx better when sleep
Tx:
- Antia DA - Haloperidol
Neuroleptic malignant syndrome
Occurs hrs or days after starting antipsychotic or in PD agter suddenlt stopping Dopaminergic drugs
Ft:
- High Temp
- High BP/HR/RR
- Muscle Rigidity
- Confudion/delirium
Tx:
- Stop Antipsychotic
- IVI
- Dantrolene
VEstibular neuronitis vs viral labyrinthitis
VN:
- No HL or tinnitus
- Vertigo
Horizontal nystagmus
VL:
- Vertigo + HL
Horners syndrome - distinguishing between causes
Heterochromia = congenital hroners
1st order - Central lesion - think of S’s :
- Syringiomyelia
- stroke
- Multiple Sclerosis
- tumour
- enceph
- Anhydrosis to fce + arm + trunk
2nd order - Preganglionic - think Ts:
- Anhydrosis to face
- Pancoast Tumour
- Thyroidectomy
- Trauma
3rd order - Pos-gananglionic - think of Cs:
- Carotid aneurysm
- Carotid dissection
- Cavernous sinus thrombosis
- Cluster headache
Stroke - ant cerebral artery vs middle cerebral artery
Ant:
- Lower extremity > upper extremity
MCA:
- Upper extremity > Lower
- Contralat homonymous hemianopia
- Aphasia
CLuster headache RF / Triggers
RF:
- men
- smoekrs
Trigger = EtOH
What parkins medication can lead to pulmonary fibrosis
Pergolide
Medication overuse headache mx
Simple analgesics - stop abruptly
Opiods - withdraw gradually
Ataxia telangectasia
Cerebellar Ataxia - falling over
Ig-A- leads to recurrent chest infections
Telangectasia
Damage to what structure causes chorea
Damage to the caudate nucleus of the basal ganglia
Myotonic dystrophy - Think of the Ds
DM1
- Dyarthria
- Distal weakness
- A.D
- DB
MS good prognostics
Female young age R-R sensory sx only long interval between episodes full recovery between episodes.
Botulinism
Clostridia = G+ anaerobic bacillus
Seen in IIVDU / contaminated food
Block og ACh release
FLACCID PARALYSIS
Mx - anti-toxin only effective if given earluy
Meningitis bacterial causes
0-3 months:.
- grpup B strep
- e. Coli
- listeria
3months - 6years
- meningococcus
Pneumococcus
H. Influenzae
6-60 yrs:
- meningococcus
- Pneumococcus
> 60:
Meningococcus
Pneumococcus
Listeria
Immunodeficiency - listeria
Bells oalsy vs ramsey hunt
Both cause LMN facial nerve palsy
Ramsey hunt - HZV - RASH around ear
Bells - NO RASH - often vira
Ramsey hunt - give aciclovir
Bells palsy - pred only
Palatale myoclonus SOL - what ate affected?
Olivary nucleus
Types of nstagmus and site of lesion
See-saw = occipital
Alternating + jerky - Cerebelum
Convergence-retraction - Midbrain
Downbeat = medulla
Up-beat = pons
Nerve conduction results
Conduction block - ddue to segmenyal demyelination - seen in GBS
Axonal demyelination - normal conduction Velocity with low AP
Global demyelination - no conduction block
Wallerian degeneration - axonal + myelin degeneration distal to axonal damage - MY INJURY
How to control Droolng in Parkinsons pt
consider gylocpyronium bromide
Pyramidal tract lesion pattern of weakness
Upper limb extensor lower limb flexor
Medication overuse headache
NSAIDs/paracetamol - stop ABRUPTLY
Opiates - withdraw SLOW
Factors that affect rate of LP induced headache
Size of needle
Direction of bevel
not replacing stylet
Inc number of ttempts.
Miller Fisher vs GBS
Miler - Fisher syndrome is a variant of GBD which STARTS with CNS
therefore often start with eye signs
anti-G1qb
Strokke - Alexia but able to write - What area of the brain?
Corpus callosum
GBS poor prognostics
>40yrs Preceeding diarhoeal illness Upper limbs affected High anti-GM1 titre Need for ventilatory support
Subcortical vs cortical dementia
Cortical:
- Memory + language
Subcortical:
- Frontal lobe - planning, verbal fluency, personality
- psychomotor slowing, reduced verbal output, reduced response.
Which AED is contraindicated in absence seizures?
Carbamezapine - can worsen seizures
Myasthenia crisis
FvC measuring
Plasmaphoresiss and IV Ig
