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neurology Flashcards

1
Q

What are the roots of the ulnar nerve

A

C7-T1

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2
Q

Causes of unilateral ptosis

A

Horners
3rd nerve palsy
Myasthenia

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3
Q

Causes of a proximal weakness

A

Unable to stand from a chair. Reduced power in shoulder abduction

Neurological - myasthenia, muscular dystrophy, ALS
Muscle disease - myopathy or myositis (Polymyositis and dermatomyositis)
Endo - diabetes, thyrotoxicosis, Cushings
Polymyalgia (apparent weakness due to stiffness and pain, not objectively weak)
Drugs - steroids, alcohol
Electrolyte disturbance
Malignancy
Renal failure
Osteomalacia
Rhabdomyolysis

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4
Q

How to distinguish between cerebellar disease and sensory ataxia

A

Cerebellar - will have eye signs (nystagmus) and speech change (scanning dysarthria)

Sensory ataxia - sensory change (vibration and joint position sense), pseudoathetosis, able to perform finger-nose testing with eyes open, but not eyes closed

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5
Q

Indications for surgery for carotid artery stenosis

A

Occlusion between 50-99%
Occlusion >70% according to ESCT criteria (S = seventy)
Occlusion >50% according to NASCET criteria

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6
Q

Inheritance of myotonic dystrophy

Mutation and chromosome

A

AD with anticipation

Due to trinucletide repeat expansion on chr19 - myotonin protein kinase gene

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7
Q

Jumping vision

A

Oscillopsia

Cerebellar disease

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8
Q 
Friedrich's ataxia
Features
Inheritance
Onset
Complications
A

Features
Cerebellar sx - cerebellar ataxia, scanning dysarthria, nystagmus
Dorsal column loss - Sensory ataxia, upgoing plantars with decreased reflexes, loss of proprioception and vibration sense
UMN signs - Leg wasting & spastic paraparesis
Pes cavus

Inheritance
AR
Onset during teenage years
Prognosis ~20yrs

Complications  
Cardiac disease - HOCM
Optic atrophy (30%)
Diabetes mellitus (10%)
Sensineural deafness
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9
Q

Holmes Adie pupil

A

Benign condition
Pupil dilated, but slowly accommodates to light and accommodation
Usually chronic, can be acute with photophobia and blurriness
Syphilis negative (vs Argyll Robertson)

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10
Q

Investigations for peripheral neuropathy

A

Bloods - FBC (macrocytosis - B12), LFTs for derangement (alcohol)
Immunoglobulins and serum protein electrophoresis (myeloma)
Vitamin deficiencies - B1/6/12
HbA1c

Nerve conduction studies and EMG - determine length-dependent nature and axonal vs demyelinating pattern

Demyelinating pattern and non-length dependence are more in keeping with an underlying inflammatory cause eg CIDP

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11
Q

Ddx of cerebellar gait

A

S - SOL, stroke, MS
Malignancy related - paraneoplastic
Alcoholic degeneration
Other cerebellar degeneration - Friedrich’s ataxia

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12
Q

What CN are affected in cerebellopontine angle tumours

A

V, VI, VII, VIII and cerebellum

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13
Q

Causes of sensory ataxia

A

Central
Friedrich’s ataxia

Spinal
Cervical myelopathy (compression at cervical level)
Subacute combined degeneration of the cord - B12 deficiency 
Tabes dorsalis (neurosyphilis) - check for A-R pupil (accommodates but doesn't react to light)

Peripheral neuropathy - Diabetic neuropathy, alcohol

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14
Q

Causes of nystagmus

A

Cerebellar (ipsilateral lesion)
Vestibular (contralateral lesion)
Peripheral vestibular - Meniere’s, acoustic neuroma, labyrinthitis, vestibular neuritis (vertigo without deafness or tinnitus)
Central vestibular - Stroke/SOL/MS, encephalitis

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15
Q

Investigations for a stroke

A

CT head for consideration of thrombolysis
ECG for AF (+/- 24hr tape for paroxysmal AF)
Echo for structural heart disease
Carotid doppler for stenosis and consideration of carotid endarterectomy

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16
Q

Contraindications for thrombolysis

A

Onset of sx >4.5hrs ago (unless also considering thrombectomy)
Seizures at presentation
Ischaemic stroke or head injury in the last 3 months
BP >180/110
Previous intracranial bleed
Active bleeding;
Surgery or major trauma (incl CPR) within last 2wks
Non-compressible arterial puncture within last wk
LP in prev 7/7

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17
Q

Causes of a proximal myopathy

A

Endocrine - Cushings

Polymyositis / dermatomyositis

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18
Q

Indications for thrombectomy

A

Thrombectomy with thrombolysis: sx onset of acute ischaemic stroke within past 6hrs and confirmed occlusion of proximal anterior circulation seen in CTA/MRA

Thrombectomy +/- thrombolysis: for people last known to be well within 6-24hrs with sx of acute ischaemic stroke and confirmed occlusion of proximal anterior circulation seen in CTA/MRA AND potential to salvage brain tissue as assessed by MRI DWI or CT

Those with previously good function (pre-stroke functional status of less than 3 on the modified Rankin scale and a score of more than 5 on the National Institutes of Health Stroke Scale (NIHSS))

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19
Q

Indications for a decompressive hemicraniectomy

A

Within 48hrs of sx onset for people with acute stroke who meet all of the following criteria:

large infarction in MCA territory (>50% on CT)
Score above 15 on the NIHSS

Decreased GCS (score of 1 or more on item 1a of the NIHSS (rousable by minor stimulation, or worse)

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20
Q

What are the features of Friedrich’s ataxia

A 
Cerebellar sx
Sensory ataxia 
Cardiac disease
Ophthalmoplegia 
Nystagmus
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21
Q

Unilateral foot drop
Causes
Other features to look for

A

Other features:
Pes cavus
Wasting
Areflexia

Levels - spine, sciatic, common peroneal, peripheral neuropathy

Causes:

L4/5 radiculopathy - weakness of inversion and eversion - trauma, disc herniation

Sciatic nerve damage - hip surgery

Common peroneal nerve palsy - trauma, compression, leprosy, polio

Peripheral neuropathy - DM, CIDP, GBS, Charcot Marie Tooth disease

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22
Q

Contraindications for rapid BP lowering in stroke

A

Underlying structural cause (for example, tumour, arteriovenous malformation or aneurysm)

GCS <6

are going to have early neurosurgery to evacuate the haematoma

have a massive haematoma with a poor expected prognosis

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23
Q

Roots of the median nerve

A

C6 - T1

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24
Q

Causes of a bilateral foot drop

Causes
Other features to look for

A

Other features:
Pes cavus
Wasting
Areflexia

Levels - spine, sciatic, common peroneal, peripheral neuropathy

Causes:
1 - peripheral neuropathy - DM, CIDP, Charcot Marie Tooth, leprosy

2 - neuromuscular - inclusion body myositis, MND, myotonic dystrophy - distal weakness

3 - Cauda equina

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25
Q

Mx of myasthenia

A

ACEi - pyridostigmine
SE - anticholinergic - dry mouth, urinary retention
Steroids followed by steroid sparing agents

Acutely - FVC monitoring with steroids +/- IV Ig

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26
Q

Features of ataxia telangiectasia

A

Ataxia - cerebellar
Telangiectasia
Delayed motor development

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27
Q

Causes of peripheral neuropathy

A

Diabetes mellitus
Alcohol
Drugs - nitrofurantoin, amiodarone, isoniazid, vincristine
Vitamin deficiencies - B1/6/12
Immune - CIDP, GBS, ANCA positive vasculitis,
Sarcoidosis
CTD - SLE, Sjogrens, RA
Amyloidosis
Paraneoplastic - either solid tumour or paraproteinaemia related (myeloma)
Hypothyroidism and uraemia
Rare / heritable causes - HSMN

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28
Q

Features of spinocerebellar ataxia

A

Cerebellar signs
Peripheral neuropathy
UMN signs
Ophthalmoplegia

AD inheritance - CAG trinucleotide repeat expansion

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29
Q

Ddx of chorea like movements

A 
Sydenhams chorea
SLE
Vasculitis
Huntingtons 
Hyperglycaemia
Polycythaemia
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30
Q

Causes of a bilateral LMN VIIth nerve palsy

What else should be checked for

A 
Bilateral Bells
GBS
Sarcoidosis
Myaesthenia gravis
MND
Lyme disease
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31
Q 
GBS
What antibody is present 
Causes
Pattern of CF
Important ix
Mx
A

Anti-GM1
Post-infection, malignancy, vaccination
Ascending weakness and parasthesiae, autonomic dysfunction

FVC
LP - normal WCC but raised protein
Nerve conduction studies

IVIg / plasma exchange acutely
Supportive mx

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32
Q

Features of Frierich’s ataxia

A 
Sensory loss due to loss of dorsal root ganglion cells and peripheral nerve fibres 
Motor impairment (loss of motor pathways) - bilateral spastic paraparesis
Cerebellar signs (degeneration of spinocerebellar tracts)
Young onset
Wasting, deformities - pes cavus
Broad gait 
Cerebellar features 
UMN signs due to spinal motor degeneration 
Sensory loss (dorsal columns)
Decreased reflexes with upgoing plantars

Other features:
Optic atrophy
HOCM - murmur

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33
Q

Causes of bilateral ptosis

A 
Myasthenia gravis
Myotonic dystrophy
Oculopharyngeal dystrophy 
Chronic progressive external ophthalmoplegia (a/w Kearns Sayre)
Congenital 
Bilateral Horners 
Syringomyelia
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34
Q

What is the distribution of signs in Wallenberg syndrome

Which vessel is affected

A

Lateral medullary syndrome
Posterior inferior cerebellar artery

Ipsilateral:
Horners - SNS loss
Facial sensation loss (CN5)
Vertigo (CN8)
Dysphagia (CN 9 and 10)
Ataxia (cerebellum)
Contralateral:
ST loss (decussates lower down)
35
Q

Causes of absent ankle reflex with upgoing plantars

A

SACD
Hereditary cerebellar ataxia - Friedrich’s
Spinocerebellar ataxias
MND
Taboparesis (neurosyphilis)
Mixed conditions - eg DM with cervical myelopathy

36
Q

What are the features of myotonic dystrophy

A

Long drooping face
Unilateral or bilateral ptosis
Frontal balding
Muscle wasting of the face and shoulders.
Cataracts
Slurred speech - dysphagia and dysarthria.

Poor ability to relax post contraction (myotonia)
Hypo-reflexia
Distal muscle weakness (although type II disease presents later with proximal weakness)

Cardiac features - heart block, cardiomyopathy
Diabetes mellitus
Gonadal atrophy with preserved secondary sexual characteristics

37
Q

Red flags for non-length dependence of peripheral neuropathy

A

Proximal weakness with preserved distal power
Asymmetry in sensation and motor function

Suggests inflammatory cause (GBS / CIDP) over length dependent processes such as alcohol or diabetes

38
Q

Causes of predominantly sensory peripheral neuropathy

A

D - diabetes
D - deficiencies (B vitamins)
D - drugs - linezolid, chemotherapeutics (vincristine)
D - drink (alcohol)

39
Q

What does weakness with normal reflexes indicate

A

Lesion at the level of the NMJ or muscle itself
NMJ - myasthenia
Muscle - myopathy

40
Q

What features can be looked for in the CN exam in support of myasthenia

A

Bilateral fatiguable ptosis

Complex ophthalmoplegia

41
Q

Name given to syndrome of ipsilateral CN3 palsy and contralateral hemiparesis

A

Webers

Mid-brain stroke

42
Q

Features of pseudo bulbar palsy

Causes

A 
Monotonous slurred speech, dysarthria
Dribbles from mouth
Cannot protrude tongue
Absent palatal movement 
Emotionally labile
Exaggerated jaw jerk
Causes:
Bilateral stroke of internal capsule (commonest)
MS
MND
SOL - brainstem tumour
Traumatic head injury
43
Q

Txs for Parkinsons disease

A

L-dopa in combination with peripheral DOPA decarboxylase inhibitors carbidopa or benserazide

Entacapone (peripheral COMT inhibitor)

DA agonists - ropinerole

MAOi - selegiline

For PD dementia - rivastigmine or amatadine

For tremor predominant PD - add on anticholinergic procyclidine

44
Q

Causes of chorea (5)

A

Rheumatic fever - syndenhams chorea (ask about sore throat)
Huntingtons - ask about FHx
Drugs - anti-psychotics
Vascular lesions / SOL in subthalamic nucleus (tends to be unilateral)
SLE

45
Q

Mx of MND

A

MDT - PT/OT and neurologist
Communication aids
SALT with assessment for feeding support
Spirometry and early morning ABG for respiratory support
Riluzole is only disease-modifying tx

46
Q

Causes of a unilateral LMN VIIth nerve palsy

What else should be checked for

A 
Bells palsy
Ramsay Hunt syndrome 
Acoustic neuroma / meningioma (look for involvement of Vth, VIth, VIIth, VIIIth nerves, cerebellar signs and loss of taste on anterior 2/3 of the tongue).
Parotid tumour
Pontine lesion

Any cause of mono neuritis multiplex - DM, vasculitis, sarcoid

Check ipsilateral ear for signs of Herpes Zoster

47
Q

Perioral fasciculations are pathognomonic of which condition

A

Kennedys disease
Hereditary spinomuscular atrophy due to X-linked recessive mutation in androgen receptor gene
LMN affected only - proximal weakness and fasciculation
May be signs of androgen insensitivity - gynaecomastia

48
Q

Causes of bulbar palsy

A

LMN lesion

MND
Syringobulbia
GBS
Poliomyelitis
SOL - skull base or retropharyngeal
49
Q

Investigations for myasthenia

A

Anti-AChR antibodies
If negative, anti-MUSK antibodies
Nerve conduction studies for decremental response

CT chest for thymoma

50
Q

Causes of wasting of the small muscles of the hands

Other features o/e

A

Wasting - thenar and hypothenar eminence
Ext at MCP joints, flexion at IP joints
Dorsal guttering

Causes:
Anterior horn cells of C8/T1: cord compression, MND, syringmyelia, CMT disease, old polio

Root lesion at C8/T1: Cervical spondylosis, tumour at C8/T1 (neurofibroma)

Brachial plexus: Cervical rib, Pancoast’s tumour, trauma (Klumpke’s palsy)

Combined ulnar and median nerve lesions
Arthritis causing disuse atrophy (RA)
Cachexia

51
Q

Features and causes of a spastic paraparesis

A

Bilateral increased tone and weakness
Hyper-reflexia, upgoing plantars and clonus

Brain
Cerebal palsy, parasaggital meningioma
Spinocerebellar degeneration

Spine
MS (and transverse myelitis)
Cord compression - SOL, disc
B12 deficiency - SACD 
Trauma
MND
Hereditary spastic paraparesis
Tropical spastic paraparesis (HTLV1)
52
Q

Causes of mono neuritis multiplex

A 
DM
Vasculitis - Churg Strauss, Wegener's
Sarcoid
Polyarteritis nodosa 
SLE
Amyloidosis
53
Q

Features of a common peroneal nerve palsy

A

Inspection
Wasting of anterior and peroneal parts of the leg

Motor
Achilles reflex spared (via S1)
Weak dorsiflexion - ask to walk on heels
Foot eversion lost, foot inversion spared
Weakness of first toe dorsiflexion - extensor hallux longus

Sensory
Anaesthesia over the anterior (dorsal) surface of the leg and foot (deep and superficial peroneal nerves)
Sparing of sensation over the medial side of the foot (saphenous branch of the femoral nerve) and lateral side of the foot (sural branch of the tibial nerve)

54
Q

Features of Miller Fisher syndrome

Antibody

A

Ophthalmoplegia
Ataxia (cerebellar)
Areflexia

Anti-GQ1b antibodies

55
Q

Ddx of isolated LMN signs with normal sensation

A

Motor neurone disease
Multifocal motor neuropathy (extremities tend to be affected first - anti-GM1 antibodies, treatable with IVIg)
Progressive muscular atrophy (distal weakness before proximal)
Hereditary spinal muscular atrophies
Kennedy disease (rare) - androgen insensitivity

56
Q

Acute mx of MS

A

High dose IV steroids

Consider SE - hyperglycaemia, gastric ulcer (give PPI), warn of sleep disturbance

57
Q

Causes of bulbar speech

A

MND
Bulbar palsy
Pseudo-bulbar palsy (incl vascular disease and MS)
Brainstem vascular disease and brainstem stroke

58
Q

Causes of an asymmetric spastic paraparesis

A

Looks for contralateral sensory change - consider Brown Sequard syndrome
Check for sensory level

Ddx:
Compression - disc profusion, tumour 
MS
Vasculitis - SLE, sarcoid
Trauma
MND
Infection - HIV
Nutrition - B12, Cu
Rare - hereditary spastic paraparesis
59
Q

What is the most important ddx for MND

A

Cervical cord compression

60
Q

What features are suggestive of Progressive Supranuclear Palsy

A

Axial rigidity and imbalance - falls (without postural hypotension)
Impairment of vertical saccades
Confusion / dementia

61
Q

Indications for rapid BP control in stroke

A

Haemorrhagic stroke with sx onset within last 6hrs - lower BP if >150

Haemorrhagic stroke with sx onset beyond last 6hrs

Aim systolic 130-140

62
Q

Symptoms of thalamic syndrome

What vessel is affected

A

Vessel: posterior cerebral artery

Signs:
Hemisensory loss of face and body contra laterally - all modalities
Increased pain sensation over the same distribution

63
Q

What are the causes of cerebellopontine angle syndrome

What is the correct ix

A

Acoustic neuroma - unilateral tinnitus or deafness
Meningioma

Ix - MRI

64
Q

Causes of Horners
What else should you examine for

Key ix

A

Sympathetic trunk damage causing Anhidrosis, ptosis, miosis

Causes:
Central (hypothalamic / brainstem) - stroke (Wallenberg syndrome), SOL, MS, trauma, encephalitis, syringomyelia
Will cause anhidrosis of the face, neck, arm and trunk

Neck (cervical cord and T1; pre-ganglionic) - trauma (to brachial plexus), cervical rib, Pancoast tumour, thyroidectomy
Anhidrosis of face only

Carotid (post-ganglionic) - aneurysm, endarterectomy, dissection, cavernous sinus thrombosis
No anhidrosis

What else to examine for:
Apical chest signs
Neck - scars, aneurysm
Hands - wasting

Key ix: MRI head and arotid

65
Q

What features in addition to Parkinsonism are suggestive of specific Parkinsons plus syndromes

A

Gaze paresis - PSP

Autonomic dysfunction and cerebellar signs - MSA

Cognition and visual hallucinations - LBD

66
Q

Causes of a predominantly sensory peripheral neuropathy

A

Diabetes
Toxic - alcohol
Drugs - abx, chemotherapy, antiviral
B vitamin deficiencies

67
Q

Ix to send in suspected myasthenia gravis

A 
Anti-AChR and anti-MUSK antibodies 
TFT
CK to exclude myopathies
Spirometry 
Nerve conduction / EMG
Imaging for thymoma
68
Q

Cervical myelopathy

A

Compression at cervical cord level causing mixed LMN and UMN in the upper limbs, depending on the level

Causes:
Cervical spondylosis
Spinal cord SOL

69
Q

Tx of MS

A

MDT approach

Symptomatic tx
Bladder - anticholinergics
Spasticity - baclofen 
Neuropathic pain
Depression
Fatigue
Disease modifying therapy 
Beta inferon
Glatiramer
Fingolimod
Natalizmab
Cladiribine
70
Q

Non motor sx of Parkinsons

A 
Anosmia
Sleep disturbance and REM sleep disorder
Constipation 
Autonomic symptoms - postural hypotension, erectile dysfunction, urinary incontinence 
Depression
71
Q

Features on examination to help diagnose cause of cerebellar ataxia

A

Associated PN - alcohol or spinocerebellar disease
Upgoing plantars - spinocerebellar disease
Vascular risk factors
Features of malignancy - paraneoplastic syndrome

Medications
FHx

72
Q

Causes of parkinsonism

A 
Drugs - antipsychotics, antiemetics 
Idiopathic Parkinson's disease
Progressive supra nuclear palsy
Multisystem atrophy
Lewy body dementia
73
Q

Features of a syringobulbia

A

Cerebellar signs - Nystagmus, ataxia
Facial dissociated sensory loss
Bulbar palsy - speech, dysarthria, wasted faciculating tongue, weakness of sternomastoids and trapezius

74
Q

Causes of a spastic paraparesis and features on examination

A 
Features:
Bilateral increased tone
Weakness
Hyper-reflexic and upgoing plantars 
Scissoring gait
Causes - brain and spinal cord:
Cerebal palsy
MS
Cord compression - check for sensory level, back pain, no signs above level
Cervical spondylosis
Trauma 
MND
Disc prolapse 
Rarer:
Spinal artery thrombosis 
HTLV - tropical spastic paraparesis
Hereditary spastic paraplegia
Vasculitis
75
Q

What are the modes of sensation and what do they sense

A

Spinothalamic - sharp touch / pain, temperature

Dorsal column - vibration and proprioception, light touch

76
Q

Completing PD exam

A

Cerebellar signs
Autonomic signs
Cognition - Lewy body dementia
Assess whether under or over medicated

77
Q

Causes / associations of carpel tunnel syndrome

A 
Idiopathic
Occupational 
RA and OA
Pregnancy
Acromegaly 
Hypo-thyroid and diabetes
Trauma
78
Q

Ix of carpel tunnel

A

Nerve conduction studies

HbA1c, IGF1, TFT

79
Q

Causes of a proximal weakness

A 
Polymyositis / dermatomyositis 
Cushings and steroid use
Malignancy associated 
Alcoholism
Diabetic amyotrophy 
Muscular dystrophy
80
Q

Multifocal motor neuropathy
Features
Tx

A

Features:
Progressive LMN signs, starting distally - demyelination
No sensory involvement

Responds to IV Ig and immunosuppression

81
Q

Kennedy disease

A

X-linked mutation in androgen receptor causing androgen insensitivity

Features:
LMN signs, classically affecting proximal and bulbar muscles
Perioral fasciculation
Signs of androgen insensitivity - gynaecomastia and testicular atrophy

82
Q

Primary lateral sclerosis

A

UMN signs only

83
Q

Primary muscular atrophy

A

LMN signs only, typically distally

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