Neurology Flashcards
1
Q
What questions should be asked prior to an MRI scan?
A
- Do you have a pacemaker inserted?
- Do you have any known shrapnel?
- Have you ever had brain surgery?
- Do you have any metal in your body that you know about?
2
Q
What is a potential acute analgesia for a migraine?
A
Metaclopromide + diclofenac
3
Q
What are some causes of seizures?
A
- epilepsy
- intercranial - space-occupying lesion
- meningitis/encephalitis
- alcohol withdrawal
- electrolyte abnormalities (low sodium, low calcium, low magnesium)
- drug overdose
- head injury
4
Q
What do you give a patient in status epilepticus?
A
IV lorazepam 4mg STAT
OR
PR diazepam 10mg STAT (only really buccal in community)
You can repeat, if not working then start a phenytoin infusion
5
Q
What do you see in LP in a patient with viral meningitis?
What about bacterial or fungal?
A
Viral - raised lymphocytes, normal glucose, normal protein
Bacterial - raised neutrophils, low glucose, high protein
Fungal - low glucose, lymphocytes, normal protein (TB same as fungal but may be monocytes)
6
Q
What is your immediate management of a patient presenting with a TIA?
A
- Give aspirin 300mg immediately. If bleeding disorder or on anticoagulant then admit to exclude haemorrhage, if contraindicated seek specialist advice
7
Q
How does subacute degeneration of the cord present?
A
Damage to the posterior columns – loss of proprioception, light touch and vibration sense (sensory ataxia and positive romberg’s)
Damage to the lateral columns – spastic weakness and upgoing plantars (UMN signs)
Damage to peripheral nerves – absent ankle and knee jerks (LMN signs)
A mix of UMN and LMN consider ACDC. Joint position and vibration sense is lost first, then distal paraesthesia
B12 needs replacing
8
Q
What diet is supposed to be helpful in children with epilepsy?
A
Ketogenic diet - high fat, low carbohydrate
9
Q
What are some non-epileptic causes of seizures?
A
Febrile convulsions
Alcohol withdrawal seizures
Psychogenic non-epileptic seizures
10
Q
What are the three types of seizures?
A
Focal - start in one part of the brain, awareness varies, can divide into motor, non-motor
Generalised - involve both sides of the brain, LOC, divided into motor (tonic-clonic) and non-motor (abscence)
Unknown onset
11
Q
What are the names of epilepsy recognised in children?
A
West’s Syndrome
Lennox-Gastaut Syndrome
Benign Rolandic EPilepsy
Juvenile Myoclonic Epilepsy
12
Q
What are two classical features of epilepsy?
A
Urinary incontinence
Tongue biting
13
Q
What groups of patients with epilepsy need extra information?
A
Drivers (must be seizure free for 1 year with established epilepsy, or 6 months if unprovoked single attack)
Woman - pregnant or trying to get pregnant
Contraception
14
Q
What are two serum antibodies tested for in myasthenia gravis?
A
Anti-Acetylcholine-Receptor Anti-MuSc Receptor
15
Q
Give 4 treatments for myasthenia gravis.
A
Anticholinesterases – pyridostigmine, Immunosuppressants – azathioprine, mycophenolate, thymectomy, plasmapheresis and IV immunoglobulin
16
Q
What is the eventual cause of death in MND?
A
Respiratory failure
17
Q
What are the 4 kinds of MND and their key features?
A
Amyotrophic Lateral Sclerosis, Primary Lateral Sclerosis, Bulbar Onset, Progressive Muscular Atrophy
18
Q
List 7 symptoms of MND?
A
Mixed UMN and LMN, no sensory deficit, leg weakness, arm weakness, trouble with buttons, urinary incontinence, wasting, fasciculations, nystagmus, dysarthria
19
Q
What is the only medication licensed specifically for MND?
A
Riluzole
20
Q
What supportive treatment exists for MND?
A
NG tube, pain management, mouth care, oral hygiene, baclofen for spasticity
21
Q
What is affected in Duchenne’s muscular dystrophy?
A
Dystrophin protein in the muscles, used for structure, failure leads to cell and muscle death
22
Q
What marker is raised in Duchenne’s Muscular Dystrophy?
A
Creatinine kinase
23
Q
What is Gower’s Sign?
A
Inability to stand without using their hands to ‘walk up’
24
Q
How is Duchenne inherited?
A
X-linked recessive, only occurs in males or females with turner’s syndrome
25
What are the symptoms of Myasthenia Gravis?
Fatiguability on repeated movements, ptosis, easily tired, proximal limb weakness
26
What investigations require doing and what do you find?
Antibody screen for Anti-MuSK and anti-AChR, EMG, tensillon test
27
How is it treated?
Pyridostigmine
28
Name 2 radiological areas of the brain where lesions are commonly found on MRI of a patient with multiple sclerosis.
Cortex, ventricles – there is focal inflammation and demyelination
29
Name 2 first line therapy agents used in MS.
Prednisolone, Beta-Interferon (to reduce relapse rate and in secondary progressive disease), Natalizumab (in severe relapsing and remitting disease)
30
Give 5 non-medical treatments for MS?
Physiotherapy for spasticity, intermittent self-catheterisation, support with fear and depression, advise on work and home alterations, infection treatment
31
Describe the lesions seen in a CT of the brain in a patient with MS?
Demyelinating plaques, discrete borders, elliptical, focal inflammation
32
What do you find in the CSF of patients with MS?
Oligoclonal bands
| Raised cell count
33
What is an early sign of MS?
Optic neuritis
34
What is the most common cause of encephalitis in the UK?
Herpes Simplex Virus, other causes include varicella zoster virus, EBV, enteroviruses
35
What do you use to treat meningococcal sepsis?
Cefotaxime/Ceftriaxone
36
What is given in meningitis prophylaxis?
Ciprofloxacin
37
What might you see on LP in bacterial meningitis?
Raised WCC, reduced glucose, viral: raised glucose, raised WCC
38
When are the vaccines given to children?
Men B 2, 3, 4 months, Men ACWY 18 years, Men C, 18 months
39
Quadrad of Parkinsonian symptoms?
Rigidity
Bradykinesia
Slow, shuffling gait with reduced arm swing
Resting tremor (unilateral, improves with voluntary movement)
40
3 drugs that can be used for PD?
Levodopa, Carpadopa, Cabergoline, amantidine
41
What chromosome is the CAG triplet repeat found on in HD?
4
42
What is a typical pathological finding in PD?
Loss of dopamine producing neurons in the substantia nigra
43
What scan can be used for diagnosis?
DatSCAN, MRI
44
How is Parkinson's Disease managed?
Dopamine precursors, Dopamine agonists
45
What are the 3 types of tremor and when do they occur?
Essential, Action, Resting
46
How does Huntington’s present?
Chorea, personality changes, dementia, nystagmus,
47
How is HD managed?
No cure, managed through support, family therapy, supportive treatment for symptoms
48
What is the genetic abnormality in HD and what does it result in?
CAG triple repeat, results in mistranslation of the Huntingtin’s Protein
49
What is the genetic abnormality in HD and what does it result in?
CAG triple repeat, results in mistranslation of the Huntingtin’s Protein
50
Where is Broca’s area located and what does it control?
Frontal lobe, dominant hemisphere, 95% and 60% left side, controls expression, Wernicke’s located in temporal lobe and deals with reception
51
What do Type A nerve fibres control/sense? What do the unmyelinated fibres deal with?
Type A are myelinated, control and sense sharp, immediate pain, large fibres, loss of them results in loss of vibration, touch and proprioception. Type C are unmyelinated small slow fibres that deal with dull prolonged pain.
52
What are the 5 signs of an UMN lesions? A LMN lesion?
UMN – hyperreflexia, upward plantars, increased tone, no muscle wasting, weakness. LMN: muscle wasting, decreased tone, hyporeflexia, fasciculations, weakness. UMN lesions present with pyramidal pattern of weakness (arm extensors, leg flexors)
53
What is the corticospinal tract?
Tract responsible for co-ordinated purposeful movement
54
Explain Brown-Sequard Syndrome?
This is a rare partial incomplete lesion of the spinal cord. There is ipsilateral loss of fine touch, proprioception, vibration and sensation below the level of the lesion (as the dorsal column tract decussated back in the medullary pyramids) and contralateral loss of pain and temperature about 3 vertebrae below the lesion. There is spastic paralysis below the lesion.
55
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What do these neurological terms mean?
Ataxia?
Apraxia?
Aphasia?
Agnosia?
```
Ataxia – lack of co-ordination/balance, caused by lesions of the vermis
Apraxia – inability to perform conscious movement
Aphasia – complete absence of speech, dysphagia is partial
Agnosia – a change in a sense such as smell or vision
56
A sudden chance in neurology over a slow one indicates?
A sudden change indicates a vascular pathology while a slow one indicates inflammatory
57
What does white show on a CT scan?
White indicates blood (recent bleed, bone or calcium, grey indicates old bleeds
58
When should a CT be performed before a LP?
If there are any signs of raised intercranial pressure (papilloedema), >60, seizures, decreased GCS
59
What is xanthochroid?
Bilirubin found in LP
60
What does a small response on NCS indicate? (Nerve conduction study)
Axonal loss
61
What is normal pressure hydrocephalus?
Hydrocephalus (ataxic gait, apraxia, cognitive impairment, raised ICP may be incontinence), differentials include dementia, parkinsonism. Responds to a VP shunt.
62
What are some causes of raised ICP?
Brainstem tumours, SAH, trauma
63
What are the 3 triad features in NPH?
Urinary incontinence, gait unsteadiness, dementia
64
What are the 3 components of GCS and their score?
Motor (6), Verbal (5), Eye response (4)
65
What are the five features required in order to diagnose someone as brain dead?
Pupils non-reactive to light, no pain response, no RR, no HR
66
What is Guillain-Barre?
Acute immune-mediated inflammatory demyelinating polyradiculoneuropathy
Post-viral/bacterial infection, often GI
Progressive ascending weakness of all 4 limbs, flaccid paralysis, proximal before distal, legs before arms
Investigate with LP (normal WBC, high protein), NCS
Treat with IV Ig
67
What are the 3 key features of Horner’s Syndrome?
Unilateral facial sweating, ptosis, miosis
68
What is the main difference between simple and complex partial seizures?
Simple partial seizures do not involve a loss of consciousness, complex ones do
69
What are some epilepsy differentials in children?
Juddering attack, febrile seizures, cataplexy, juvenile myoclonic epilepsy, toddler seizures
70
Describe mass effect and state what kind of tumour leads to it?
Pressure of optic chiasma leading to bitemporal hemianopia, pituitary tumours
71
Describe 5 symptoms of raised intracranial pressure?
Headache, blurred vision, vomiting, ataxia, diplopia, papilledema
72
Name 3 types of primary brain tumour?
Gliomas (intrinsic tumours), Meningiomas (extra-axial tumours and Pituitary Tumours
73
A well-circumscribed non-contrast enhancing brain tumours in a 12-year-old presenting with seizures is likely to be what?
Glioma – either fibrillary astrocytoma or pilocytic astrocytoma
74
What is an acoustic neuroma?
It is best visualised with an MRI of the cerebellopontine angle. It is a benign schwannoma (primary intracranial tumour) that causes symptoms by affect CNVIII. It accounts for 5% of intracranial tumours. Bilateral acoustic neuromas are seen in neurofibromatosis T2.
75
What is tuberous sclerosis?
This is a genetic AD condition, features depigmentation, café au lait spots, fibromatoma beneath nails, developmental delay, epilepsy, intellectual impairment
76
What are some acute causes of headache?
Meningitis (fever, meningism, neck stiffness, photophobia, purpuric rash), Encephalitis (behaviour change, fever, loss of consciousness, seizures), SAH (thunderclap headache, worst ever headache), extradural (trauma hx, lucid interval), venous sinus thrombosis (sudden headache with papilledema), Sinusitis (dull headache, tenderness over sinuses, worse bending down, coryzal symptoms).
77
What are your differentials of a headache? What are their defining features?
Migraine, cluster headache, trigeminal neuralgia (tingling electric shocks when brushing hair, first line tx carbamazepine), medication induced headache, GCA, SAH, SDH, EDH, meningitis, VTE,
78
What are some chronic causes of headaches?
Migraine (unilateral, 4-72hrs, throbbing, photophobia, aura, n+v), cluster headaches (unilateral, pain around eye, frequent attacks), trigeminal neuralgia (tenderness of scalp when brushing hair, lightning shocks), raised ICP (worse lying or bending forwards, vomiting, papilledema, focal signs, seizures), GCA (worse on scalp, jaw claudication, pulseless temporal artery), medication headache (Hx of medication use including paracetamol, opiates, triptans)
79
What are the first- and second-line treatments of migraine?
1st: amitriptyline, propranolol, topiramate. 2nd Sumatriptan, pregabalin, valproate, carbamazepine, pzotifen, gabapentin
80
What can trigger migraines? Give 7
Chocolate, orgasms, alcohol, hangover, cheese, COCP, lie-ins
81
What are some secondary causes of headaches?
Space-occupying lesion, dehydration, meningitis, SAH, GCA, medication
82
What are some sinister signs of a headache?
Vomiting more than once, new neurological deficit, reduction in conscious levels, fever, sudden onset, papilledema
83
What investigations do you do for GCA and what do they show?
Temporal artery biopsy
84
What is teichopsia?
Zig-zag lines seen during migraine aura
85
What can be prescribed in an acute migraine?
Triptan + NSAID or triptan + paracetamol, prophylaxis = topiramate or propralolol
86
What are the red flags for cauda equina syndrome?
Saddle anaesthesia/loss of sensation, loss of anal tone, incontinence, foot drop,
87
What does mononeuritis multiplex present with?
Loss of both sensory and motor function, it involves involvement of sequential nerves or simultaneous nerves, often asymmetrical on initial presentation
88
What is transverse myelitis?
This is loss of motor, sensory and autonomic function below the level of a lesion – inflammation of the spinal cord
89
What do you see in a III nerve palsy?
Difficulty looking down and out, unilateral ptosis, dilated fixed pupil. CN VI would have defective eye abduction and horizontal diplopia
90
What can cause carpal tunnel syndrome?
Nerve compression due to occupation (drilling), 3rd trimester pregnancy, rheumatoid arthritis, hypothyroidism
91
Give 5 risk factors of strokes.
Diabetes, Obesity, High cholesterol, age, family history, smoking, hypertension
92
What is a lacunar infarct?
An infarct occurs in small blood vessels, commonly in HTN
93
Lacunar strokes present with?
Unilateral motor disturbance affecting the face, arm or leg, complete one-sided sensory loss, ataxia hemiparesis
94
Where is the source of the bleed for a CT scan showing a crescent-shaped white-grey discrete lesion located proximal to the right parietal cortex in keeping with haemorrhage, no midline shift or ventricular enlargement?
Subdural haemorrhage is caused by damage to bridging veins between cortex and venous sinuses
95
What is the most common cause of strokes?
Ischaemic/ embolic
96
Common presentation of a posterior circulation stroke?
Homonymous hemianopia, ataxia
97
What are areas of poor perfusion called and why do they occur?
Watershed areas, areas between vascular territories
98
How is an ischaemic stroke managed?
Alteplase within 4.5 hours, 300mg aspirin for 2 weeks, long-term clopidogrel 75mg and statin
99
What is Todd’s Palsy?
Post-ictal weakness that is sometimes mistaken as a stroke
100
What is coning and when does it occur?
Coning is when the lower brainstem is forced through the foremen magnum resulting in compression of the medullary pyramids and respiratory centre
101
What are some primary and secondary causes of haemorrhagic stroke?
Falls, AVM, tumours, cerebral aneurysms, HTN. Management for haemorrhagic stroke is to reduce blood pressure, consider a platelet transfusion, maintain fluids
102
What do you see on CT for a SAH, SD and ED?
SD – sickle shaped, ED – bulging lense, SAH – star-sign
103
Where do subdural occur?
Between the dura and pia, the dura and skull is the ED
104
What is the name of transient unilateral visual loss?
Amaurosis fugax
105
What score is used to assess stroke risk post-TIA and what steps are taken in prophylaxis?
ABCD2, regardless prescribe aspirin, if over 4 urgent neuro referral within 24 hours
106
What investigations do you do in a suspected stroke?
CT Head, Carotid Doppler, cardio angio, Echo, ECG
107
What symptoms occur in a stroke and how does changing the location of the infarct affect symptoms?
ASA – hemiplegia, unless one sided in which case the opposite side will have weakness and sensation loss.
108
What is the definition of a TIA?
A transient ischaemic attack – a brief episode of neurological dysfunction due to microinfarcts or embolisms lasting less than 24 hours
109
What is your management of an acute seizure?
Airway, O2, recovery position
| Rectal diazepam 10mg - if prolonged
110
A lucid period following a head injury may indicate a...?
Extradural haemorrhage
Biconvex shape on CT
Bleed from the middle meningeal artery
111
What is your management for neuralgia?
Amitriptyline
Duloxetine
Gabapentin
Pregabalin
Opioid recommended is tramadol
Can use topical capsaicin
112
Double vision occuring later int he day may indicate what?
Myasthenia gravis - occular
| Treat with pyridostigmine
113
What does pabrinex contain?
Vitamin B1 - thiamine
114
What are some causes of status epilepticus and which is the most important to rule out first?
Hypoxia
Hypoglycaemia
Also: alcohol withdrawal, infection, SDH
115
What is the acute treatment for cluster headaches and how do they present?
Subcutaneous sumatriptan + 100% O2
| Severe unilateral headache, recurrent over a few weeks, redness of affected eye, rhinorrhoea and miosis association
116
Ulnar nerve weakness presents with?
Wasting of hypothenar eminence
Weakness of finger abduction
'Claw hand'
Sensory loss to medial 1 1/2 fingers
117
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What are the nerve roots of the following reflexes?
Ankle
Knee
Biceps
Triceps
```
Ankle S1-2
Knee L3-4
Biceps C5-6
Triceps C7-8
118
What is autonomic dysreflexia?
Occurs in patients with spinal injuries above T6
A noxious stimulus or full bladder - stimulates sympathetic response - vasocontriction - uncontrolled by brain due to spinal cord lesion - sudden onset headache, bradycardia and hypertension
Treat by sitting patient up slowly and giving a GTN spray, treat the underlying cause
119
What is Lambert-Eaton Syndrome?
```
Voltage-gated calcium channel antibodies
Weakness improves after exercise
Proximal muscle weakness, presents in later life
Limb girdle weakness, hyporeflexia
Association with SCLC (smoking history)
```
120
What is Arnold-Chiari malformation and what can it cause in newborn babies?
Herniation of the cerebellar tonsils through the foramen magnum
Can cause hydrocephalus
Headache
Syringomyelia
Can occur in later life through trauma
121
What investigations do you do in someone post-stroke?
Autoimmune and thrombophilia screen - in a young person with no obvious cause
CT head - first line radiological investigation
MRI head
Carotid artery doppler
122
What level do you do a lumbar puncture?
L3/4
123
What investigations do you do in MS and what do you see?
LP – oligoclonal IgG bands
| MRI – plaques in the periventricular region
124
What drugs might cause postural hypotension?
Thiazide diuretics, loop diuretics
125
What medication is used in Parkinson’s Disease?
L-dopa, carbidopa-levodopa, co-benyldopa
126
What advice can you give for someone experiencing dizziness as a result of postural hypotension?
Sit up slowly for 5 minutes before standing
Raise and low arms 5 times before standing
TED stockings, raise the head of the bed at night
127
What is the inheritance pattern for Alzheimer’s thought to be and what is the chance that it is passed to children?
AD
| 10-20%
128
What is degenerative cervical myelopathy?
Loss of fine motor function in upper limbs, symptoms vary, progressive condition, positive Hoffman’s sign
MRI is diagnostic
129
What are some absolute contraindications for thrombolysis post-stroke?
- Previous intracranial haemorrhage
- Seizure at onset of stroke
- Intracranial neoplasm
- Suspected subarachnoid haemorrhage
- Stroke or traumatic brain injury in preceding 3 months
- Lumbar puncture in preceding 7 days
- Gastrointestinal haemorrhage in preceding 3 weeks
- Active bleeding
- Pregnancy
- Oesophageal varices
- Uncontrolled hypertension >200/120mmHg
130
What is your post-stroke management?
If within window for ischaemic stroke – alteplase (4.5hrs) and no contraindications
AF – aspirin after 14 days (earlier may exacerbate haemorrhage)
Acute 300mg aspirin if haemorrhagic excluded, clopidogrel now preferred, aspirin + dipyridamole if anything contraindicated
High cholesterol – statin
131
Define a sub-arachnoid haemorrhage?
Bleeding inthe subarachnoid space between the arachnoid membrane and the pia mater
132
What is the treatment for a SAH?
Clipping of aneurysm is definitive
Management until then - prevent vasospasms with nimodipine (CCB), hydrocephalus with an external ventricular drain or VP shunt
133
What investigations do you do in a SAH?
CT Head
LP - xanthochromia - used to confirm or rule out SAH if CT is negative, perform at 12 hours following symptoms to allow for xanthocromia development
134
What might you see on histological examination of the MRI in a patient with MS?
Demyelination Variable oligodendrocyte loss Hypercellular plaque edge due to infiltration of tissue with inflammatory cells Perivenous inflammatory infiltrate (mainly macrophages and T-lymphocytes) Older plaques may have central gliosis
135
What is your post-stroke management?
Aspirin 300mg OD two weeks
Clopidogrel 75mg thereafter
If AF consider apixaban
136
What are some causes of a facial nerve palsy?
```
Bell's Palsy
Trauma
Stroke
Acoustic neuroma
Guillaine Barre
Birth Trauma
Infection
```
137
What part of the brain is first affected by Alzheimer’s Disease?
Temporal
138
What are classic symptoms of a raised intracranial pressure headache?
```
Severe throbbing headache
Worse first thing in the morning
Vomiting
Blurry vision
Blurring of optic disc margin on fundoscopy – papilloedema
```
139
A visual field in the left temporal lobe results in what defect?
Right superior homonymous quadrantopia
| PITS – parietal = inferior, temporal = superior
140
If clopidogrel is contraindicated in a patient post-stroke, what is your alternative medication?
Apirin and modified-release dipyridamole
141
What vitamin is thiamine?
B1
142
What is supranuclear palsy and what is it a differential for?
Parkinsonism
| Dysarthria, reduced vertical eye movements, resting tremor, bradykinesia, postural instability, rigidity,
143
What are some risk factors in Degenerative Cervical Myelopathy?
Smoking, genetics, occupation
144
What are some differentials for Parkinson’s?
Drug-induced (antipsychotics, metoclopramide)
Progressive supranuclear palsy
Multiple system atrophy
145
Migraine management?
Acute: triptan + NSAID or Triptan + paracetamol
Prophylaxis: Topiramate or propranolol
146
Common symptoms of multiple sclerosis include?
Visual: optic neuritis, optic atrophy, Uhthoff’s (worsening of vision following rise in body temperature)
Sensory: pins/needles, numbness, trigeminal neuralgia, Lhermitte’s syndrome (paraesthesia in limbs on neck flexion)
Motor: spastic weakness
Cerebellar: ataxia, tremor
Others: urinary incontinence, sexual dysfunction
147
How might degenerative myelopathy present?
Causes: disc prolapse
Pain, loss of sensation (paraesthesia), weakness, autonomic function loss, Hoffman’s sign positive
Ix: MRI spine
Management: urgent spinal assessment, decompressive surgery
