Neurology Flashcards
1
Q
Define myasthenia gravis
A
A disorder of neuromuscular transmission characterised by: weakness and fatiguing of some or all muscle groups, weakness worsening on sustained or repeated exertion, or towards the end of the day, relieved by rest
2
Q
Myasthenia Gravis pathophysiology
A
Autoimmune destruction of the nicotinic postsynaptic receptors for acetylcholine (AChR)
3
Q
Clinical features of myasthenia gravis
A
Ptosis, muscle paresis, weakness of jaw muscles leaves mouth hanging open,, characteristic smile - myasthenic snarl, muscle wasting, hyperactive limb reflexes
4
Q
Investigations for myasthenia gravis
A
Acetylcholine receptor antibodies (anti-AchR)
Anti-MUSK also
Anticholinesterase drugs used to confirm diagnosis - Tensilon test
CT of the thymus - thymic hyperplasia found in 70% of sufferers
5
Q
Treatment for myasthenia gravis
A
Anticholinesterase durgs - Pyridostigmine
Muscarinic inhibitor - atropine to counter side effects
Prednisolone
Thymectomy
6
Q
Define meningitis
A
Inflammation of the leptomeninges and underlying subarachnoid CSF
7
Q
Risk factors for meningitis
A
Alcoholism, overcrowding, spinal procedures, diabetes mellitus, IV drug abuse, malignancy, cystic fibrosis
8
Q
Causes of meningitis
A
Neonates= Gram -ve bacilli: E.coli, Klebsiella, H.influenzae Children= H.influenzae, Strep. pneumoniae, N.Meningitidis Adults= Strep. pneumoniae, H.influenzae,
9
Q
Symptoms of meningitis
A
Fever, headache, stiff neck, photophobia, non-blanching petechial skin rash, Kernig’s sign, Brudzinski’s sign, seizures
10
Q
Differential diagnoses of meningitis
A
Encephalitis, subarachnoid haemorrhage, malaria, septicaemia
11
Q
Investigations for meningitis
A
LP - Ziehl-Neelsen stain, glucose, protein, rapid antigen screen,
U&Es, FBC, LFT
X-ray
CT scan
12
Q
Treatment for meningitis
A
Dexamethasone + Ceftriaxone (E.Coli)/Benzylpenicillin (Pneumococcus + Meningococcus)
13
Q
Define Guillain Barre syndrome
A
A disorder causing demyelination and axonal degeneration resulting in acute, ascending and progressive neuropathy, characterised by weakness, paraesthesiae and hyporeflexia
14
Q
Causative organisms of Guillain Barre syndrome
A
CMV EBV Camplyobacter jejuni HIV Haemophilus influenzae
15
Q
Risk factors for Guillain Barre syndrome
A
History of GI or respiratory infection, association with Zika virus, vaccinations, malignancies, pregnancy
16
Q
Symptoms of Guillain Barre syndrome
A
Weakness - facial, dysphasia, dysarthria, back pain, reduced reflexes, paraesthesiae, hypotonia
Autonomic symptoms - reduced sweating, reduced heat tolerance, urinary hesitancy, tachycardia
17
Q
Differential diagnosis for Guillain Barre
A
Stroke Encephalitis Spinal cord compression Vasculitis Myasthenia Gravis
18
Q
Investigations for Guillain Barre
A
Confirmed with Nerve conduction studies
Electrolytes - inappropriate ADH secretion
LP - Elevated CSF: elevated protein, low WBC
ECG - T-wave abnormalities, ST depression, QRS widening
Spirometry
19
Q
Management of Guillain Barre
A
IV immunoglobulin
Plasma exchange
Low molecular weight heparin
20
Q
Define Parkinson’s disease
A
A progressive neurodegenerative condition caused by degeneration of dopaminergic neurons in the pars compacta of the substantia nigra - low levels of dopamine
21
Q
Causes of Parkinson’s
A
Idiopathic Drugs - Neuroleptics, Metocloparide, Prochloperazine, sodium valproate Truma HIV Manganese/copper toxicity
22
Q
Triad of symptoms of Parkinson’s
A
Bradykinesia - slowness of movement
Pill-rolling tremor
Cogwheel rigidity
23
Q
Other symptoms of Parkinson’s
A
Constipation Frequency, urgency and incontinence Hallucinations Sweating Dribbling of saliva Weight loss Sleep problems Depression Anxiety
24
Q
Main treatment for Parkinson’s
A
Levodopa (converted to dopamine)
Complications: Postural hypotension
On-off effect
25
What is levodopa given with?
Decarboxylase inhibitor - Carbidopa
26
Other treatments for Parkinson's
Dopamine agonists - Ropinirole
MAO-B inhibitors - Rasagiline
COMT inhibitors - Tolcapone
27
How is meningitis spread?
By respiratory droplet
28
Define meningococcal septicaemia
Petechial rash + signs of sepsis
29
CSF findings in bacterial meningitis
Raised protein
| Low glucose
30
CSF findings in viral meningitis
Normal protein
| Normal glucose
31
Prophylaxis for meningitis
Rifampicin
32
Define TIA
Transient ischaemic attack
| Sudden onset of neurological dysfunction which lasts less than 24 hours
33
TIA pathophysiology
Cerebral ischaemia due to arterial embolism or thrombosis in an atheromatous carotid, vertebral or cerebral artery
34
Risk factors for TIA
```
Smoking
Hypertension
Diabetes mellitus
Increasing age
Alcohol
Previous TIA
Hypercholesterolemia
Vasculitis
AF
```
35
Signs and symptoms of TIA
Hemiparesis, hemi sensory disturbance, dysphasa, amaurosis fugax
36
Define amaurosis fugax
Painless transient monocular visual loss - 'a curtain coming down vertically into field of vision'
Leads to retinal hypoxia
37
Differential diagnosis for a TIA
Stroke
Hypoglycaemia
Migraine aura
Focal epilepsy
38
Diagnosis for TIA
ECG - check for AF or myocardial ischaemia
FBC, U&Es, glucose, ESR, LFTs, TSH
Echocardiogram or cardiac monitoring
Doppler ultrasound of the carotid arteries
39
How is risk of a stroke following a TIA assessed?
Use ABCD2 score
A - age >60
B - BP 140/90 or greater
C - Clinical features: unilateral weakness/speech disturbance without weakness
D - duration of symptoms: 60 minutes 2 points, 10-59 = 1 point
D - diabetes
High risk = 4+
Refer for specialist assessment within 24 hours. Low risk need assessment within 1 week
40
How is a TIA managed?
```
Control cardiovascular risk factors: stop smoking, improve diet, regular exercise, cut down on alcohol, lose weight
Manage AF, diabetes, hypertension
Aspirin
Antiplatelet therapy - clopidogrel
Statin - simvastatin
```
41
Define stroke
Disruption of blood to the brain lasting for more than 24 hours
42
Pathophysiology of a stroke
May be due to a blockage in a cerebral blood vessel leading to ischaemic infarction (70%) or due to a intracerebral haemorrhage (30%)
43
Causes of a stroke
```
Small vessel occlusion/thrombosis
Cardiac emboli (AF, MI, IE)
Atherothromboembolism
CNS bleeds (trauma, SAH)
Coronary artery dissecton
Vasculitis
Hyperviscosity (polycythaemia, sickle cell anaemia, myeloma)
```
44
Risk factors for a stroke
```
Diabetes mellitus
Hypertension
AF
Smoker
Alcohol
Increasing age
Previous TIA
Hypercholesterolemia
```
45
Signs and symptoms of a stroke
```
Total anterior circulation stroke = Unilateral weakness of face, arm and leg, homonymous hemianopia, higher cerebral dysfunction (dysphagia, visuospatial disorder)
Partial anterior circulation stroke: 2 of the 3 above
Posterior circulation syndrome = cerebellar or brainstem syndromes, loss of consciousness, isolated homonymous hemianopia
Lacunar syndrome (LACS) = unilateral weakness, pure sensory loss, ataxic hemiparesis
```
46
Diagnosis of a stroke
Urgent CT head
MRI
BP/ECG, blood glucose
47
Management of a stroke
ABCDE approach
Ensure hydration, keep O2 saturation >95%
Thrombolysis for ischaemic stroke = Alteplase
Antiplatelet therapy - Clopidogrel
MDT team
48
Define primary prevention
Risk factor control before any stroke
49
Define secondary prevention
Risk factor control to prevent recurrence of a stroke including lifelong antiplatelet
50
Define Subarachnoid haemorrhage
Bleeding into the subarachnoid space - between the arachnoid layer of the meninges and the brain parenchyma
51
Risk factors for a subarachnoid haemorrhage
Hypertension
Family history
Diseases which predispose to aneurysms - Polycystic kidney disease, Ehlers Danlos syndrome, coarcation of the aorta
52
Pathophysiology of a subarachnoid haemorrhage
Rupture of a berry aneurysm (70%), 10% are due to an ateriovenous malformation
53
Signs and symptoms of a subarachnoid haemorrhage
Thunder clap headache, vomiting, Kernig's sign, neck stiffness, altered level of consciousness - drowsiness, collapse, seizures, coma, papilloedema
54
Diagnosis of a subarachnoid haemorrhage
CT scan
| Lumbar puncture - blood xanthochromic (yellow) due to billirubin from Hb breakdown
55
Management of a subarachnoid haemorrhage
Dexamethasone to decrease cerebral oedema
Neurosurgery - surgical clipping or coiling of anuerysm
Nimodipine to reduce risk of vasospasm
56
Complications of subarachnoid haemorrhage
Rebleeding
Hydrocephalus
Hyponatraemia (SIADH)
Cerebral ischaemia due to vasospasm
57
Define subdural haematoma
A collection of clotting blood in the subdural space (space between the dura mater and the arachnoid mater)
58
Pathophysiology of subdural haematoma
Due to a rupture of a vein between the venous sinuses and the cortex, the accumulating haematoma causes raised ICP, shifting the midline structures
59
Risk factors for subdural haematoma
Traumatic head injury
Increasing age
Alcoholism
Anticoagulation medications
60
Signs and symptoms for subdural haematoma
```
Raised ICP - headache, nausea, vomiting, raised BP
Confusion
Seizure
Focal neurology
Alternating level of consciousness
```
61
Complications of a subdural haematoma
Death due to herniation
Raised ICP
Cerebral oedema
Coma
62
Differential diagnosis for subdural haematoma
EDH, SAH, meningitis, encephalitis, stroke, dementia, DKA
63
Investigations for a subdural haematoma
CT - gold standard = crescent shaped mass
FBCs, U&E's, LFT's
MRI
64
Management for subdural haematoma
Prioritise CT head
Surgery - evacuate the haematoma e.g. Craniotomy
Mannitol if raised ICP
65
Define extradural haematoma
Collection of blood between the dura mater and the bone, usually caused by head injury
66
Pathophysiology of an extradural haematoma
Due to fracture of the temporal or parietal bone causing laceration of the middle meningeal artery, typically after trauma to the temple
67
Risk factors for extradural haematoma
Young adults
68
Signs and symptoms for extradural haematoma
Loss of consciousness
Lucid interval
Headache, nausea and vomiting, confusion and seizures
Increased ICP
69
Differential diagnosis for extradural haematoma
Subdural haematoma
SAH
Meningitis
Encephalitis
70
Diagnosis for extradural haematoma
CT scan - gold standard = lemon shape
71
Management for extradural haematoma
ABCDE
Mannitol if increased ICP
Surgery - Craniotomy and clot evaculation
72
Define tension headache
Commonest primary headache. Can be episodic (<15 days/month) or chronic (>15 days for at least 3 months)
73
Risk factors for tension headaches
Stress
Anxiety
Noise
Fumes
74
Signs and symptoms of tension headaches
Bilateral, non-pulsatile, chronic daily headache - 'tight band-like sensation', pressure behind eyes, mild-moderate pain
Scalp muscle tenderness
No vomiting, no aura
75
Differential diagnosis for tension headache
Migraine, cluster, GCA, PMR
76
Diagnosis for tension headache
Clinical diagnosis
77
Management for tension headache
Lifestyle advice - regular exercise, avoid triggers, massage
| Aspirin, paracetamol, NSAIDs
78
Define migraine
Recurrent throbbing headache often preceded by an aura and associated with nausea, vomiting and visual changes
79
Triggers for a migraine
Cheese, caffeine, alcohol, menstruation, oral contraceptives, anxiety, travel, exercise
80
Symptoms and signs
Aura - lasting 5-60 minutes, visual = flashing, jagged lines, hemianopia, sensory = paraesthesia, numbness, motor
Classic features - moderate to severe headache, unilateral pulsatile throbbing aggravated by movement, nausea + vomiting, photophobia
81
Differential diagnosis for migraine
Tension headache, cluster headache
82
Investigations for migraine
Clinical diagnosis
CRP, ESR,
LP
83
Management for migraine
Reduce triggers - e.g. dietary factors
| Oral triptan - sumatriptan + NSAIDs/paracetamol
84
Prophylaxis for a migraine
Propanolol/topiramate
| Consider amitriptyline
85
Define cluster headache
'Migraineous neuralgia' - rapid onset, excruciating unilateral pain around one eye, typically wakes the patient from sleep
Occurs in clusters of 1-2x a day, lasting 5-12 weeks, followed by pain free periods of months-years
86
Risk factors for cluster headache
Male: Female = 5:1
| Smoking
87
Signs and symptoms for cluster headache
Pain around one eye
Lasts 15-60 minutes
Wakes patient from sleep
Watery and bloodshot eye, lid swelling, lacrimation, facial flushing, rhinorrhoea, miosis + ptosis
88
Investigations for cluster headache
Clinical diagnosis
89
Management for cluster headache
100% 15 O2
| Sumatriptan or Zolmitriptan
90
Prophylaxis for cluster headache
Verapamil
Avoid alcohol
Prednisoline may help
91
Define trigeminal neuralgia
Paroxysms of instense, debilitating pain in the distribution of the trigeminal nerve
92
Pathophysiology of trigeminal neuralgia
Compression of trigeminal nerve causing demyelination and excitation of the trigeminal nerve
93
Risk factors for trigeminal neuralgia
Hypertension
94
Signs and symptoms of trigeminal neuralgia
Sudden, unilateral, paroxysms of knife-like/electric shock like pain
Starts in mandibular divison, spreading upwards to maxillary and ophthalmic divisions, lasts seconds to minutes
95
Triggers for trigeminal neuralgia
Shaving, eating, talking, vibration, exposure to cold wind
96
Differential diagnosis for trigeminal neuralgia
Temporal arteritis
| Multipel sclerosis
97
Investigations for trigeminal neuralgia
MRI
98
Management for trigeminal neuralgia
Carbamazepine
Others: Gabapentin, lamotrigine, phenytoin
Percutaneous procedures: Rhizotomy
Surgical: Neurovascular decompression
99
Pathophysiology of Giant Cell Arteritis
Inflammatory granulomatous vasculitis of large cerebral arteries
100
Risk factors for giant cell arteritis
Male
| >50 years
101
Signs and symptoms for giant cell arteritis
Temporal pulsating headache
Scalp tenderness (when combing/washing hair)
Jaw claudication (jaw pain on eating)
Amaurosis fugax (sudden blindness)
Tender, thickened, pulseless or nodular temporal artery
Fever, fatigue, breathlessness, myalgia, morning stiffness
102
Investigations for giant cell arteritis
ESR raised
| Temporal artery biopsy
103
Management for giant cell arteritis
Prednisolone
104
Complications of giant cell arteritis
Polymyalgia rheumatica
105
Define encephalitis
Infection and inflammation of the brain parenchyma
106
Pathophysiology of encephalitis
Disease which mostly affected the frontal and temporal lobes, so causes decreased consciousness, confusion and focal signs
107
Causes of encephalitis
Viral infection
Herpes simplex virus
Varicella zoster virus, EBV, CMV, HIV, mumps, measles
Non viral: TB, toxoplasma, malaria, listeria
108
Risk factors for encephalitis
Extremes of age
| Immunocompromised patients
109
Signs and symptoms for encephalitis
Fever, headache, myalgia, fatigue, nausea
| Decreased consciousness, confusion, seizures, coma
110
Differential diagnosis for encephalitis
Meningitis, stroke, brain tumour
111
Investigations for encephalitis
```
Lumbar puncture + CSF studies (increase in protein level, decreased glucose)
FBC
Throat swabs, stool culture
CT/MRI scan
EEG
```
112
Management for encephalitis
Viral - Acyclovir
113
Define Huntington's disease
An autosomal dominant, progressive neurodegenerative disorder
114
Pathophysiology of Huntington's
Autosomal dominant
Mutation in chromosome 4, repeated expression of CAG
Cerebral atrophy with loss of neurones in the caudate nucleus and putamen of the basal ganglia
Decreased ACh synthesis and GABA in striatum
115
Signs and symptoms of Huntington's
Prodrome
Chorea - jerky, explosive, figidity movements
Rigidity, writhing and abnormal posture
Dysarthria, dysphagia and abnormal eye movements
Behavioural change - aggression, addictive behaviour, depression/anxiety
Dementia
Seizures
Clonus
116
Investigations for Huntington's
Diagnosis is clinical
CT/MRI
Genetic testing
117
Management for Huntington's
No treatment to prevent progression
| Management of chorea = benzodiazepines, valproic acid
118
Define motor neurone disease
A sporadic or hereditary disease affecting upper and/or lower motor neurones - characterised by progressive degeneration of motor neurone in the spinal cord (anterior horn), cranial nerve motor nuclei and within the cortex
119
Risk factors for motor neurone disease
Genetic
120
Upper motor neurone signs
Weakness
Hypertonia
Upgoing plantars (positive Babinski)
Clonus
121
Low motor neuron signs
```
Weakness
Depressed/absent reflexes
Decreased tone
Wasting
Fasciculations
```
122
Name the four types of MND
Amyotrophic lateral sclerosis (ALS)
Primary lateral sclerosis (PLS)
Progressive muscular atrophy (PMA)
Progressive bulbar palsy (PBP)
123
Investigations for MND
Clinical findings
| Nerve conduction studies
124
Management for MND
Riluzole - not a cure, extends life by 3 months
MDT approach
Baclofen for spasms
125
Define multiple sclerosis
A chronic inflammatory disorder of the central nervous system associated with progressive disability
126
Risk factors for multiple sclerosis
EBV
MMR
Higher prevalence in the north and south hemispheres - lowest rates around the equator
127
Pathophysiology of multiple sclerosis
Immune-mediated demyelination at multiple CNS sites occurs as discrete plaques. Thought to be T-cell mediated: T-cells activate B cells to produce auto-antibodies against myelin. Repeat demyelination leads to axonal loss and incomplete recovery between attacks
128
Name the subtypes of multiple sclerosis
Relapsing-remitting (80%)
Secondary progressive
Primary progressive
129
Symptoms and signs of multiple sclerosis
Unilateral optic neuritis, diplopia, ataxia, vertigo, bladder/sexual dysfunction, fatigue, UMN signs
Symptoms worsen with heat/exercise - Uhthoff's phenomenon
130
Investigations for multiple sclerosis
Electrophysiology - delayed nerve conduction studies suggests demyelination
MRI
Lumbar puncture - increased protein, OLIGOCLONAL bands of increased immunoglobulin concentration
>2 CNS lesions disseminated in time and space
131
Management for multiple sclerosis
Oral methylprednisolone
| Natalizumab
132
Risk factors for brain tumours
Family history
Exposure to ionising radiation
Immunosuppression
133
Types of tumours
High grade - Gliomas (astrocytomas or oligodendromas)
Low grade - Meningioma (benign), neurofibromas, pituitary tumour, pineal tumour
Metastases
134
Where can a tumour metastasis from
lung, breast, prostate, colorectal, melanoma and kidney
135
Signs and symptoms of tumours
Increased ICP
Nausea and vomiting
Seizures
Personality change, confusion, papilloedema
136
Investigations for tumours
CT or MRI scan
137
Management for tumours
Neurosurgery
138
Where is the most common site for disc herniation
L4/L5
139
What is spinal cord compression
Myelopathy with UMN signs
140
What is spinal root compression
Radiculopathy with LMN signs
141
Causes of spinal cord compression
Secondary malignancy
Disc herniation
Intervertebral disc prolapse
142
Investigations for spinal cord compression
MRI - gold standard
143
Management for spinal cord compression
Neurosurgery
| Epidural steroid injection
144
Signs and symptoms at L5/S1
SCIATICA
| Sensory loss/pain - back of thigh, leg, lateral aspect of little toe
145
Signs and symptoms at L4/L5
Sensory loss/pain - lateral thigh/lateral leg
146
Pathophysiology of cauda equina syndrome
Nerve root compression caudal to the termination of the spinal cord
Usually large central disc herniation at L4/L5 or L5/S1 levels
147
Causes of cauda equina syndrome
Disc herniation
Tumours/metastasis
Trauma
Congenital e.g. spinal bifida
148
Signs and symptoms of cauda equina syndrome
```
Bilateral/unilateral pain in legs
Vairable leg weakness
Saddle anaesthesia
Poor anal tone
Erectile dysfunction
Bladder/bowel dysfunction
```
149
Investigations for cauda equina syndrome
MRI
150
Management for cauda equina syndrome
Neurosurgery - MEDICAL EMERGENCY
