Neurology Flashcards
Gullain Barre Syndrome:
What are some common causes of it?
How does it present?
What investigations should you do?
What is the treatment?
Causes:
Campylobacter Jejunum
Mycoplasma Pneumonia
EBV
Hep E - Genotype 3
**molecular mimicary
Presentation:
Symmetrical Weakness, proximal muslces affected.
- 20% devleop resipratory distress
Sensory changes
- Pain
- Distal Parasthesia
Weakness:
- Loss of reflexes
- Diploia
- Dysphasia
Autonomic dysfuncton
- postural hypotension
- Constipation
Investigations:
Nerve conduction studies
Peak Flow - to assess respiratory function - every 4 hrly.
Lumbar puncture:
- raised Protein
- Normal White cells
*if detioration admitt to ITU
Treatment:
IV immunoglobulins
Plasma Exchange
Respiratory Support
Pain management
Bell’s Palsy:
Lower Motor Neuron lesion of the fascial nerve.
Unkown eitology but thought to be associated with:
- latent HSV
*more common in pregnancy x3
*more common in DM x5
Clinical Features:
- abrupt onset - over night
- complete unilateral weakness
- ipsilateral pain around ear
- reduced taste (ageusia)
- hypersensitivity of sounds (stapedius palsy)
Differentials:
- Ramsay Hunt syndrome (VZV reactivation)
- Mengitits
- Braimstem lesions
- Cerebellopontine angle tumours - accoustic
- lymm disease (Borrelia)
Investigations:
To rule out other causes:
- VZV antibodies
- Borrelia antibodies
- ESR
- Glucose
*CT/MRI (tumours)
Mangagement:
within 72 hours - predisilone 60mg.
+72 hours - steroids but the evidence is not clear
**protection of th eye:
- dark glasses
- artificial tears
- use of tape on the eyes
- surgical eye closure if severe
Prognosis:
incomplete paralysis make full recover
- in a few weeks
complete paralysis - 80%
Myesthenia Crisis:
*Plasmaphresis
*Immunoglobulins
*ventilatory support
Myasthenia Gravis:
What can make this worse?
What is it associated with?
What investigations should be done?
How is it treated?
Autoimmune disease
-antibodies against nictonic receptor
Augmentors:
*climte change
* pregnancy
*hypokalamia
*gentamicin
*opiods
*Beta Blockers
Differentials:
Lambert- Eaton Syndrome
Polymyositis
Takayasu’s arteritis
botulism
Associations:
- SLE
- RA
Investigations:
- Anti- AChR antibodies
- Muscle Specific Tyrosine Kinase / MUSK antibodies
- Low density lipolipoprotein receptor related protein
- EMG studies
- CT for thyoma (as associated)
- Tensilon test (dangerous)
Treatment:
- Anti-cholinesterase (pyridostigamine)
- Immunosupression - steroids
- Thyectomy
Lambort Eaton Syndrome?
Compare and contrast with MG:
Neuromuscular disease that prevents the release of neurotransmitters on the pre-synptic membrane
- due to antibodies against the Ca2+ channel.
*associated with cancers
- small cell lung cancer
Clinical Features:
gait changes - this is well before changes to the muscles of the eye
Autonomic dysfunction
- dry eyes
- constipation
**weakness improves with exercise
this is contrasted with MG, which gets worse.
Treatment:
* cure underlying condition
* pyridostigamine
*Diaminopyridine
- this blocks K+ allowing Ca2+ to stay open for longer
*Immunoglobulins
Define Delierium:
A distrubanc of consciousness with reduced ability to focus, substain or shift attention.
It develops acutely (over hours to days) and tends to fluctate in its severity over that time
Evidence of a physiological cause induced by illness, trauma, medication or pyschological distress
Types:
* hypoactive
*hyperative
*mixed
What are some differentials to delierum?
And what are some common risk factors?
Dementia
Anxiety
Non- convulsive Status epilepticus
Primary mental illness - schizophrenia
Risk Factors:
>65 years old
Dementia
Hip fracture
Acute illness
Pyschological agitation (pain)
What is the management for Delerious patients?
Assessment:
*History
- any clues to underlying causes
*Examination
*Cognitive Assessment
- AMT
- MMSE
*Investigations
Investigations:
FBC
U&Es
Blood Glucose
ABG
Bone profile
- Ca2+
CRP
Spetic Screen
- urine dipstick
- CXR
- Blood cultures
- CT/ EEG
What is the management for delierum?
_**Resolve the causative factor_
_**Review medications_
_**Avoid constipation_
Reorientate the patient as best as possible
- clocks
- Calenders
Calm the patient with reassurance
Encourage physical movement
Maintain fluids
Sedation:
used only when patient is a risk to themselves and others:
1st line: Haloperidol
*avoid in parkinson’s
2nd line: Lorazepam
What is the Imaging investgiations can be done into Parkinson’s?
DAT SPECT scan
What is the treatment for cluster headaches?
100% oxgen. The to 80% as pain decreases
+
Triptans
Prophylaxis:
- verapmil
During a GCS assessment, the supraorbital is squeezed and the patient moves their arm to below their clavical, what does this count as?
M4 - normal flexition
it does not count as localisation as it is not above clavical
What are the treatment options for generalised seizures?
1st line:
- Sodium valporate
2nd line:
- Lamotrigrine
or - Carbamazepine
What are the treatment options for focal seizures?
1st line:
- Carbamezepine
- Lamotrigrine
- *2nd Line:**
- Sodium valporate
- Levetiracetum
What type of seizure is most associatted with Automatisms?
Complex focal seizure of temporal lobe
Automatisms include:
- lip smacking
- Dystonic limb movement
- undressing
- walking in circles
What are some typical features of a generalised seizure?
Photosensitivity - some people sensitivity to certain light frequency.
Usually with genetic in nature
Tend not to have the build up
Usually in early hours of the days
No Aura
If an EMG shows diminished respone to continual stimulation what is a likely diagnosis?
Mysthenia Gravis
How are migraines treated acutely?
1st line:
- Triptans
- NSAIDs - high dose aspirin
2nd line:
- Metaclopramide
- Non- oral NSAIDs
What is the propholyatic treatment for migraines?
Avoid triggers:
- caffiene
- Cholocate
- Hangovers
etc
1st:
- propranolol
or
- Topiramate
2nd:
- accupuncture - 10 courses
3rd:
- botulism injections
What is the diagnostic criteria for migraines?
Without aura:
>2 of the following:
- unilateral
- Pulsating
- Mod pain
- Aggrevated by activity
>5 attacks
Lasting 4-72 hours
N&V or Photophobia
With Aura:
>2 attacks
What are the antibodies investigated for in mysthenia gravis?
Acetlycholine Receptor
Muscle Specific Kinase - MuSK
Low Density Lipolipoproteins receptor related 4 - LRP4
How is Msythenia Gravis offocially diagnosed?
Autoantibodies
Edrophonium test
What type of ventilation is used in mysthenia gravis crisis?
BiPAP
or
Intubation
What are the most common causes of Guillian Barre syndrome?
Campylobacter
EBV
CMV
Hep E type 3
What is the criteria used for diagnosis of Guillian Barre syndrome?
and what additional tests can be done to support the diagnosis?
Brighton Criteria
- EMG studies - reduced signals
- LP rasied proteins
What is the management for Guillian Barre syndrome?
IV immunoglobulins
Plasma Exchange
Supportive care
VTE prophylaxis
+/-
Intubuation / ITU admission
What is the prognosis of Guillian Barre syndrome?
80% recover
15% have permenant neurological deficit
5% die
What is the investigation of choice into Cervical Spondylosis? and what is the treatment?
*MRI of Spine
- *Radiculopathy:**
- NSAIDs
- Physiotherpay
- Spinal Decompression
Myelopathy:
- Laminectomy
What is the genetic risk factor for developing MS?
HLA DR2
What are the types of MS?
Relasping Remitting
Secondary Progressive
Primary Progressive
Progressive Relasping
What are some syndromes that may progress into MS?
Optic Neuritis
Transvermylitis
Clinically Isolated Syndromes
Acute Disseminated Encephalomyelitis
What is the name of the electric shocks felt across the body related to MS?
Lhermitte’s Sign
What other things can cause optic neuritis?
DM
SLE
Sarcoidosis
Syphilus
What are some core investigatiosn into MS?
MRI T2 - galadonium
LP - Oligolonal bands
Visual Evoked Potentials
- slowed
Vitamin D levels
What are some differentials to MS?
B12 deficiency
Motor Neuron
Myelopathy due to Cervical Neuropathy
Sarcoidosis
How are relaspes treated in MS?
Methylprednisolone
What is the mangement for MS?
MDT
- neurologist
- MS nurse
- physiotherapist
- Occupational therapist
Drugs:
drugs consist of disease modifying agents and new biologics.
1st line:
- Interferon Beta
- Dimethyl fumerate
2nd Line:
- Natalizumab
3rd Line:
- Alemtuzumab
- *Flares:**
- Methylprednisolone
What are the causes of coma?
Metabolic:
- drugs, poisoning
- Hypoglycaemia
- Hypoxia
- septicaemia
- hepatic encephalopathy (Conn Score)
Neurological:
- Trauma
- infection
- Vascular
- Epilepsy
What type of CT should be done into a suspected stroke?
Non - contrast CT
What is the most commonly survived brainstem stroke and what are the symptoms and which artery is typically involved?
Lateral Medullary Syndrome
Facial loss of pain and contralateral loss of pain on body
+
Nystagmus + Ataxia
Right Posterior Inferior Cerebrallar Artery
How long following a diagnosis of epilepsy can a person return to driving?
1 year for normal drivers
*6 months for non - epileptic seizure
10 years for public drivers
If a person experiences a seizure with Jacksonian movements, where is the likely source of the seizure?
Frontal lobe
- focal seizure
Which drugs can exacerbate Myasthenia gravis?
Beta Blockers
Penicilliamine (Wilson’s disease drug)
Antibiotics
- Gentamcin
- Macrolides
- quinolones
- Tetracyclines
Phentyonin
What is the immediate management and long term management of cluster headaches?
Subcutaneous Triptans + 100% high flow O2
Prevention:
- verapamil
Why must levodopa not be stopped acutely?
Can cause neuroleptic malignant syndrome
Which hormone may be elevated following a true seizure?
Prolactin
Which clinical test can be done to assess for cervical myelopathy?
Hoffman’s Test
Lhermitte’s sign
- flexion of neck causes tingling down spine
What is the most likely diagnosis following Parkinson’s and how does it present?
Progressive Supranuclear Palsy
- affects occular nerves and thus these should always be investigated following parkinsons.
- Impaired upward gaze
- Falls
*always suspect if a person diagnosed with Parkison’s falls over shortly afterwards
How is Status epilepticus managed?
ABCDE
- Take bloods for electrolyte, glucose causes
1st line:
- Lorazepam (or diazepam or midazolam buccal)
x repeat 3-5 mins
*if evidence of hyoglycaemia
- 100ml Glucose 20%
*if evidence of Alcohol Give thiamine
- *2nd Line - within 30mins:**
- Phenytoin
3rd Line - >30 mins
GA
Monitor EEG
What are the clinical signs of parkinson’s disease?
Pill Rolling Tremor
Bradykinesia
Cog-wheeling
Low Blink Rate
Drooling
Postural Instability
Masked Face
Shuffling
Gait Stooped Posture
Conjugate Gaze Disorders (either jerky pursuit or falling short of intended target)
Hypophonia (↓volume of speech)
Hypokinetic Dysarthria (mumbling)
What may a patients family member tell you if they suspect parkinsons?
Change in writing
- micrographie
Change in walking
Difficultly turning
unsteady
Nightmares
What are some differentials to Parkinsons? and what are some risk factors?
Lewy Body dementia
Brain tumours
Vascular Parkinson’s
Parkinson’s plus syndromes
Head Injury
What drugs are associatted with developing Parkinson’s disease?
Metaclopramide
Anti-psychotics
What are some of the complications following a stroke and their treatments?
Chest infections
-Keep NIL by mouth
-Semi erect
-NG tube
Seizures
- Maintain cerebral oxygenation
- Avoid metabolic disturbances
Venous thrombosis
- Hydration
- Stocking
- Enoxaparin
Pressure sores
- Frequent turning
- Avoid urination on skin
Constipation
- Diet
- Movement
Depression and anxiety
- CBT
- Antidepressants
What other important investigations should be done the following day after a stroke?
Second head CT to assess for a rebleed.
List some modifiable risk factors for a stroke
Hypertension
Smoking
Diabetes
AF
Vavular disease
Lipids
Alcohol use
Cotting abnormalities
What are the clinical features of cervivical spondlylosis?
Cervical radiculopathy
Cervical Myelopathy
Neck pain
What is the treatment for cervical myleopathy?
Anterior disectomy
Laminectomy
What are the secondary drugs given for stroke following the 14 days of aspirin:
Clopidogrel
or
Aspirin + Dipyridamole
These are for life.
In the setting of a stroke due to AF, when should anti-coagulation take place?
14 days, following the aspirin
What is the defintive best management for a patient who has had a stroke?
Thrombolysis + thromboectomy
*thromboectomy is usually done within 6 hours
What is the absolute contraindications to thrombolysis?
Previous Intracranial haemorrhage
Seizure at onset of stroke
Intracranial neoplasm
SAH
Stroke in last 3 months
LP in last 7 days
G.I haemorrhage in last 3 weeks
Active bleeding
Pregnancy
Variceal ulcers
Uncontrolled hypertension
BP >200/120mmHg
What are the symptoms of myasthenia Gravis?
Ptosis
Diplopia
Dysphagia
Slurred speach
Jaw fatigue
Weakness of proximal muscles
- neck muscles
How can you examin someone with MG?
- what things can you do to elicit symptoms?
Repeated blinking
Upward gazing
- diplopia
Repeated abduction of one arm
- will cause unilateral weakness
What are the indications for an endartectomy following a stroke or TIA?
Ischemic stroke within the distruption of the internal carotid
>70% stenosis
What scoring system can be used to stratify which patients are at highr isk of having a stroke following a TIA, and should be referred?
ABCD2
>4 is severe and patients should be admitted and assessed by specialist within 24 hours
What does an ischemic stroke appear like on CT?
Low desnity area - black on the scan with surrounding white area owing to oedema
What question do you want to ask when someone has collasped/ fainted?
What were the doing before the epidosde?
- standing, watching TV
Palpatations?
Loss of consciouness?
How long did the episode last?
Any shaking?
Injuries?
- tongue biting
Loss of continecne?
Confusion afterwards?
- how did they person come about
Following a seizure, how long are you band from driving, and how does this change if there is EEG of epilepsy?
Seizure: 6 months
Epilepsy: 1 year
List several causes to a seizure:
Genetic
Alcohol withdrawal
Stroke
Withdrawal of Benzo’s
Tumour
Fever
Head injury
Hypoglycaemia and other metabolic abnormalites
Infection
What is the most useful investgiation to confirm epilepsy and what can be done to increase chance of detecting epileptic activity?
EEG
- EEG during sleep
- Hyperventilating patient
- Photic light stimulation
What test should be order into someone with seizures for the first time?
Bloods:
- FBC
- Coagulation
- U&Es
- LFTs
- Glucose
+/- Toxicology
+/- Anticonvulsant levels
What advice/ intervetions should be offerred to woman who are pregnant and have epilepsy?
To maintain and control seizure activity, as the risk of falling is dangerous to baby.
Switch from sodium valporate to a less tetraogenic agent.
Offer:
- folic acid supplements
- Alpha fetal protein screening
- 20 week scan for abnormalities
If amourosis fagux takes place, which artery has been occluded?
Retinal artery
What are some cardiac causes of a stroke?
AF
Patent Foramen ovale
Infective endocarditis
Prosthetic valves - metalic
Acute M.I with left venticular wall motion
What kind of drug is given alongside LDOPA?
DOPA decarboxylase inhibitor
*remember the DOPA part
If patient has a ABCD2 score of >4, what should happen?
Admitted
Seen at TIA clinic with 24 hours and assessment and treatment within 2 weeks.
Investigatiosn include:
- Doppler of carotids
- ECG
- CT angiography of brain
What are the cardiovascular causes to a stroke?
AF
Patent foramen ovale
Prosthetic valves - metalic
Infective Endocartitis
MI. with large ventricular wall dilation causing thrombous
What are the risk factors for Stroke?
Hypertension
smoking
DM
Alcohol
Previous TIA
AF
Family history
Sleep apnea
What are the differentials to a stroke?
Migraine
Seizure
Alcohol withdrawal - Wernicke’s
TIA
Tumour
Hypoglycaemia
In Status epilepticus what immediate investigations should be ordered?
Blood glucose
ABG
U&Es
Ca2+ levels
Consider:
- Anti-convulsant levels
- Toxicology
- LP
- Blood cultures
Where is the lesion in RAPD?
Anterior to the optic chiasm
What immediate things do you want to give to a patient in status?
Anticonvulsants
- Lorazepam
IV glucose
What are UMN signs?
Spasticity
Brisk Reflexes
Clonus
Hoffman’s sign
Up going plantars
No muscle wasting
What is the surgical intervention into Slipepd disc? and what are some of the complications?
Disectomy
- CSF leak
- Bleeding
- Infection
What investigations are done into CSF when mengitis is suspected?
WCC
White cell differentiation
Glucose to plasma
Protein
Cultures
Visual inspection
What assessment is used for muscle strength and what are the scores?
MRC score
0 - no muscle contraction
1 - muscle contraction but no limb movement
2 - Active movement but not against gravity
3 - active movement against gravity
4 - active movement against some resistance
5 - normal power
If a patient has a GCS of <8 what is one of the immediate things that should be done prior to any imaging?
Anaethetist and Intubation
- airway is unsecure at GCS 8
How will an old bleed on the brain present? and what is likely bleed?
HYPOdense
- Black
*usually a subdural bleed
If a person has ataxic gait without limb ataxia where is the lesion likely to be?
Cerebella Vermis
What is the wide based gait with loss of heel to toe action called?
Ataxic gait
What is the typical type of aura seen in migraines?
Jagged cresecent scotoma
What are some common myotomes?
Lower Limb:
S1-S2 button my shoe - ankle flexion
L3-L4 kick the door - knee extension
Upper Limb:
C5- Arm flexion
C6: wrist extension
C7: Finger extension
C8: Finger flexion
T1: finger abduction
What is a defining feature of neurofibromatosis type 1?
Freckles in the axillla
What are the symptoms of cervical spondylosis?
- *Radicuopathy:**
- Neck pain
- Headaches
- Paraesthesia
- Dermatomal Pain
**loss of dexterity and fine movement control in the hands
- Reduced reflexes**
Myelopathy:
- loss of dexterity
- Painful dermatomal
- Spascicity in lower limbs
- Gait changes
- Autonomic dysfunction
**positive hoffman’s sign
What occular dysfunction won’t be seen with a 3rd nerve palsy?
Miosis
- this is excessive constriction of pupil. This will not be present
List some causes of peripheral neuropathy?
- *Predominant motor loss:**
- Guillian Barre syndrome
- Charcot Marie tooth disease
- *Predominant sensory Loss:**
- Diabetes
- Uraemia
- B12
- Alcohol
What is the pneumonic that can help with the visual field defect seen with temporal or parietal lobe lesions?
PITS
Parietal - Inferior quad loss
Temporal - Superior quad loss
**both will be homologous heminopia
What is first line for trigeminal neuralgia?
Carbamezapine
Define syncope:
Global cerebral hypoperfusion resulting in loss of conciouness
What are some common causes of carpel tunnel syndrome?
Hypothyroidism
Pregnancy
Rheumatoid disease
Polymyalgia rheumatica
Amyloidosis
What are some differentials to Guillian Barre Syndrome?
MG
Botulism
Spinal cord compression
What investigations should be done into peripheral neuropathy?
Bloods:
- FBC
- ESR
- U&Es
- TFTs
- Glucose
- B12
- Protein Electrophresis
- *Orifices:**
- electrophresis (Bence Jones)
- *X-rays:**
- CXR
- *Special Test:**
- EMG
- Lumbar puncture
What are the risk factors for cluster headaches?
Male
Smoking
Alcohol can trigger
What are the differentials for SAH?
Migraine
Mengitis
Cerebral Venous Sinus Thrombosis
Cavernous Sinus Thrombosis
What are the clinical findings in SAH?
Kernigs sign
- Pain and resistance when knee is extended when hip is flexed
Meningisim
Terson’s sign
Diffuse T wave inversion
Lowered GCS / Coma
Photophobia
Irritated
What is the grading system used for the radiological findings of SAH?
Fisher’s grading
As soon as a bleed is confirmed via CT, what investigation next investigation should be done into SAH?
CT angiogram
- to confrim the cause (berry aneurysm/ AVM)
- to allow for thearaputic intervention
What is the management of SAH?
Surgerical:
Neurosurgery Coil to plug the Aneurysm
Clipping
Medical:
Bed rest
- avoid straining
Fluid resuscitation
Nimodipine
- avoid intracerebral vasospasm
VTE
Controlled blood pressure
Analgesia
+/- Ventricular stent
- off load hydrocephalus
What are the different types of MND?
ALS
- UMN
- LMN
Progressive bulblar Pasly
- Cranials IX- XII
Progressive muscle atrophy
- LMN
Primary Lateral Sclerosis
- UMN
What is the diagnostic criteria for MND?
Revised El Escorial Diagnostic criteria
- UMN signs + LMN in >3 regions
**less than this is probable
What investigations do you want to do into peripheral neuropathy?
Bloods:
- FBC
- Glucose
- U&Es
- B12
- Electrophresis
- ANCA
- ANA
Orfices:
- Urine electrophresis
- Glucose
Special Tests:
- EMG
- *Consider looking for specifcs:**
- Lead
- Antiganglioside antibodies
What are some of the causes of Carpel tunnel syndrome?
Myoxoedma
- Hypothyroidism
Acromegaly
Pregnancy
Sarcoidosis
Excessive dialysis
RA
Polymyalgia Rheumatica
What two examination tests can be done into carpel tunnel syndrome?
Phalen’s test
Tinnel’s test
Which muscles are implicated in Carpel tunnel syndrome?
Lumbricals
Oppensens policis
Abductor Pollicis Brevis
Flexor Pollicis Brevis
LOAF
