Neurology Flashcards
1
Q
Patterns of Motor Loss Cortical Lesions (3)
A
Unexpected pattern of weakness of all movements of a hand or foot
Normal/reduced tone
Increased reflexes more proximally in the arm or leg will suggest an UMN rather than LMN
2
Q
Patterns of Motor Loss
Internal Capsule and Corticospinal Tract Lesions (3)
A
Cause contralateral hemiparesis
If occurs with epilepsy, reduced cognition or hoonymour hemianopia then lesion is in cerebral hemisphere
A cranial nerve palsy (III-XII) contralateral to a hemiplegia implicates the brainstem on the side of the cranial nerve palsy
3
Q
Patterns of Motor Loss Cor lesions (2)
A
Paraparesis (both legs) or quadriparesis/tetraplegia (all limbs)
Find lesion by finding a motor and reflex level- power is unaffected above the lesion, with LMN signs at the level of the lesion and UMN signs below the lesion
4
Q
Patterns of Motor Loss Peipheral neuropathies (4)
A
Most cause distal weakness eg. foot drop
In Guillain-Barre weakness if often proximal due to root involvement
Involvement of a single nerve (mononeuropathy) occurs with trauma or entrapment eg. carpal tunnel
Involvement of several nerves (mononeuritis multiplex) eg. DM/vasculitis
5
Q
Patterns of Sensory Loss
Tracts (2)
A
Pain and temp. travel along small fibres in peripheral nerves and the spinothalamic (anterolateral) tracts in the cord and brainstem
Joint-position and vibration sense travel in large fibres in peripheral nerves and the large dorsal columns of the cord
6
Q
Patterns of Sensory Loss
Distal Sensory Loss (3)
A
Suggests a neuropathy
May involve all sensory modalities or be selective, depending on size of involved fibre
Individual nerve lesions are identified by their anatomical territories, which are usually more sharply defined than dermatomes (root lesions)
7
Q
Patterns of Sensory Loss Sensory level (2)
A
Hallmark of a cord lesion- ie. decreased sensation below lesion, normal sensation above
Hemicord lesions cause a Brown-Sequard picture with dorsal column loss on the side of the lesion and contralateral spinothalamic loss
8
Q
Patterns of Sensory Loss
Dissociated sensory loss (3)
A
Occur in cervical cord lesions- loss of fine touch and proprioception without loss of pain and temp.
Lateral brainstem lesions show both dissociated and crossed sensory loss with pain and temp. loss on the side of the face ipsilateral to the lesion, and contralateral arm and leg sensory loss
Lesions above th ebrainstem give a contralateral pattern of generalised sensory loss
9
Q
Patterns of Sensory Loss
Dissociated sensory loss (3)
A
Occur in cervical cord lesions- loss of fine touch and proprioception without loss of pain and temp.
Lateral brainstem lesions show both dissociated and crossed sensory loss with pain and temp. loss on the side of the face ipsilateral to the lesion, and contralateral arm and leg sensory loss
Lesions above the brainstem give a contralateral pattern of generalised sensory loss
10
Q
Patterns of Sensory Loss Cortical lesions (1)
A
Sensory loss is confined to more subtle and discriminative sensory functions
11
Q
Cerebral Artery Occlusion Carotid artery (2)
A
At worst, internal carotid artery occlusion causes total fatal infarction of the anterior 2/3rd of its hemisphere and basal ganglia
More often, the picture is like middle cerebral artery occlusion
12
Q
Cerebral Artery Occlusion
Anterior cerebral artery (4)
A
Supplies the frontal and medial part of cerebrum
Occlusion may cause a weak, numb contralateral leg +/- similar (usually milder) arm symptoms
Face is spared
Bilateral infarction can cause akinetic mutism from damage to the cingulate gyri (also a rare cause of paraplegia)
13
Q
Cerebral Artery Occlusion
Middle cerebral artery (2)
A
Supplies lateral part of each hemisphere
Occlusion may cause contralateral hemiparesis, hemisensory loss (especially face and arm), contralateral homonymous hemianopia due to involvement of optic radiation, cognitive change including dysphasia with dominant hemisphere lesions + visuospatial disturbance with non-dominant lesions
14
Q
Cerebral Artery Occlusion
Posterior cerebral artery (2)
A
Supplies the occipital lobe
Occlusion gives contralateral homonymous hemianopia
15
Q
Cerebral Artery Occlusion Vertebrobasilar Circulation (4)
A
Supplies the cerebellum, brainstem + occipital lobes
Occlusion causes signs relating to any or all 3: hemianopia, cortical blindness, diplopia, vertigo, nystagmus, ataxia, dysarthria, dysphasia, hemi/quadri-plegia, unilateral or bilateral sensory symptoms, coma
Infarctions of the brainstem can cause vertigo, vomiting, dysphagia, nystagmus
Locked in syndrome is due to pontine artery occlusion (can’t move but aware)
16
Q
Causes of Acute Single Episodes of Headache
9
A
Meningitis (fever, photophobia, stiff neck, purpuric rash, coma)
Encephalitis (fever, odd behaviour, fits, reduced consciousness)
Subarachnoid haemorrhage (sudden onset)
Head injury (usually lasts 2 weeks but rule out subdural/extradural)
Venous sinus thrombosis (subacute/sudden, papilloedema)
Sinusitis (dull, constant ache over sinuses with tenderness, worse on bending)
Tropical illness (malaria)
Low pressure headache (CSF leak)
Acute glaucoma (elderly, constant ache around eye, reduced vision, cloudy cornea)
17
Q
Causes of Acute Single Episodes of Headache
9
A
Meningitis (fever, photophobia, stiff neck, purpuric rash, coma)
Encephalitis (fever, odd behaviour, fits, reduced consciousness)
Subarachnoid haemorrhage (sudden onset)
Head injury (usually lasts 2 weeks but rule out subdural/extradural)
Venous sinus thrombosis (subacute/sudden, papilloedema)
Sinusitis (dull, constant ache over sinuses with tenderness, worse on bending)
Tropical illness (malaria)
Low pressure headache (CSF leak)
Acute glaucoma (elderly, constant ache around eye, reduced vision, cloudy cornea)
18
Q
Migraine
Symptoms (6)
A
Visual or other aura lasting 15-30 mins followed by unilateral, throbbing headache Nausea Vomiting Photophobia Phonophoia Allodynia- all stimuli produce pain
19
Q
Migraine
Associations (2)
A
Obesity
Patent foramen ovale
20
Q
Migraine
Stages (4)
A
Prodrome: precedes headache by hours/days, yawning, cravings, mood/sleep change
Aura: precedes headache by mins
Headache
Postdrome: fatigue, cognitive changes, muscle pain
21
Q
Migraine
Triggers (9)
A
Chocolate Hangovers Orgasms Cheese Oral contraceptives Lie-ins Alcohol Tumult Exercise
22
Q
Migraine Differential diagnosis (4)
A
Cluster headache
Tension headache
Intracranial pathology
Sinusitis/otitis media
23
Q
Migraine Acute therapy (5)
A
Restrict to 2 days a week
Aspirin 900mg
Ibuprofen 400-600mg
Triptans: sumatriptan 1st choice (contraindicated if IHD, uncontrolled high BP; side effect arrhythmias)
Add antiemetic if vomiting: metoclopramide
24
Q
Migraine Preventative therapy (6)
A
Consider if migraine is disabling and reduced quality of life or prolonged severe attacks
Propranolol 1st
Topiramate (side effect reduced memory) 2nd
Amitriptyline/other TCA
Candesartan
Others: sodium valproate (not for young women), pizotifen
25
Cluster Headache
| Symptoms of attack (6)
Rapid onset of excrutiating pain
Around on eye, may become watery and bloodshot
Strictly unilateral (almost always affects same side)
Lasts 15-60 min
Occurs once/twice daily
Often nocturnal
26
Cluster Headache
| Symptoms of bout (2)
Clusters last 4-12 weeks
| Followed by pain free periods of months or even 1-2 years
27
Cluster Headache
| Treatment of acute attack (3)
100% O2
Sumatriptan SC
Zolmitriptan nasal spray
28
```
Cluster Headache
Preventative treatment (4)
```
Suboccipital steroid injections
Verapamil
Lithium
Melatonin
29
Trigeminal Neuralgia
| Symptoms (4)
Intense, stabbing pai
Lasts seconds
In trigeminal nerve distribution unilaterally (typically maxillary/mandibular)
Face screws up with pain
30
Trigeminal Neuralgia
| Triggers (4)
Washing affected area
Shaving
Eating
Talking
31
```
Trigeminal Neuralgia
Secondary causes (4)
```
Compression of trigeminal nerve root by aneurysmal intracranial vessels or a tumour
Chronic meningeal inflammation
MS
Skull base malformation
32
Trigeminal Neuralgia
| Investigations (1)
MRI to exclude secondary causes (approx. 14%)
33
Trigeminal Neuralgia
| Treatment (5)
```
Carbamazepine
Lamotrigine
Phenytoin
Gabapentin
Surgery if drugs fail
```
34
Giant Cell Arteritis
| Aetiology (3)
Elderly
Takayasu's if <55
Polymyalgia rheumatica
35
Giant Cell Arteritis
| Symptoms (5)
```
Headache
Temporal artery and scalp tenderness
Jaw claudication
Sudden blindness, typically in on eye
Extracranial symptoms: dyspnoea, moring stiffness, unequal/weak pulses
```
36
Giant Cell Arteritis
| Investigations (6)
```
ESR ++
CRP ++
Platelets +
Alk Phos +
Hb -
Temporal artery biopsy
```
37
Giant Cell Arteritis
| Treatment (2)
Prednisolone
| Typically a 2 year course then complete remission
38
Tension Headache
| Signs + Symptoms (3)
Bilateral
Non-pulsatile headache
+/- scalp tenderness
39
Tension Headache
| Treatment (2)
Massage
| Antidepressants
40
Raised Intracranial Pressure
| Aetiology (7)
```
Head trauma
Infections
Tumours
Stroke
Epilepsy/seizures
Hydrocephalus
Meningitis
```
41
Raised Intracranial Pressure
| Signs + Symptoms (6)
```
Headache worse on waking, lying, bending forward or coughing
Vomiting
Papilloedema
Seizures
False localising signs
Odd behaviour
```
42
Raised Intracranial Pressure
| Investigations (2)
Imaging to exclude a space-occupying lesion
| LP contraindicated until after imaging (measure pressure )
43
Raised Intracranial Pressure
| Treatment (4)
Head elevation to facilitate venous return
Reduce pressure by draining fluid through a shunt
Mannitol or hypertonic saline (remove fluid from body)
Sedation as anxiety raises BP which raises ICP
44
Medication Overuse Headache
| Aetiology (3)
Mixed analgesics (paracetamol + codeine/opiates)
Ergotamine
Triptans
45
Medication Overuse Headache
| Treatment (3)
Withdraw the analgesia- aspirin or naproxen may help rebound headache
Preventive may help once off other drugs (eg. tricyclics, valproate, gabapentin)
Limit use of over the counter analgesia (no more than 6 days/month)
46
Medication Overuse Headache
| Treatment (3)
Withdraw the analgesia- aspirin or naproxen may help rebound headache
Preventive may help once off other drugs (eg. tricyclics, valproate, gabapentin)
Limit use of over the counter analgesia (no more than 6 days/month)
47
Vasovagal Syncope
| Aetiology (1)
Due to reflex bradycardia +/- peripheral vasodilatation provoked by emotion, pain, fear or standing too long
48
Vasovagal Syncope
| Signs + Symptoms (8)
```
Onset over seconds
Often preceded by nausea, pallor, sweating and closing in of visual fields (pre-syncope)
It cannot occur if lying down
Unconscious approx. 2 mins
Brief clonic jerking of the limbs may occur (due to cerebral hypoperfusion leading to reflex anoxic convulsion)
Urinary incontinence rare
No tongue biting
Recovery rapid
```
49
```
Carotid Sinus Syncope
Carotid sinus (3)
```
A collection of baroreceptors
Dilated area at the base of the internal carotid artery just superior to the bifurcation
Baroreceptors sense pressure changes by responding to change in the tension of the arterial wall
50
Carotid Sinus Syncope
| Definition (1)
Hypersensitive baroreceptors cause excessive reflex bradycardia +/- vasodilatation on minimal stimulation eg. head turning, shaving
51
```
Epilepsy
Seizure elements (3)
```
Prodrome lasting hours/days may rarely precede the seizure
Aura is part of seizure of which the patient is aware, may be strange feeling in the gut, sense of deja vu or smells/flashing lights (implying a focal seizure, often from the temporal lobe)
52
```
Epilepsy
Seizure Classification (5)
```
Partial (focal) seizures: features referable to a part of one hemisphere, often structural disease
Primary generalised seizures: simultaneous onset of electrical discharge throughout cortex with no localising features referable to only one hemisphere, absence seizures, tonic-clonic seizures, myoclonic seizures
Absence seizures: brief (<10s) pauses, presents in childhood eg. suddenly stops talking mid-sentence then carries on where left off
Tonic-clonic: loss of consciousness, stiff limbs (tonic), then jerk (clonic), post-ictal drowsy
Myoclonic: sudden jerk of limb/face/trunk, may be thrown suddenly to the ground
53
Epilepsy
| Aetiology (5)
2/3 idiopathic (often familial)
Structural: cortical scarring (eg. head injuries), developmental, space occupying lesion, stroke
Non-epileptic: trauma, stroke, haemorrhage, increased ICP, alcohol, drugs (cocaine), infection (meningitis)
Metabolic disturbance: hypoxia, high/low Na, low Ca, high/low glucose
Trigges: alcohol, stress, fevers, flickering lights
54
Epilepsy
| Investigations (4)
EEG
MRI (structural lesions)
Drug levels
Bloods: Na, Ca, glucose
55
Epilepsy
| Treatment of generalised tonic-clonic seizures (2)
1st sodium valproate/lamotrigine
| 2nd carbamazepine/topiramate
56
Epilepsy
| Treatment of absence seizures (3)
Sodium valproate
Lamotrigine
Ethosuximide
57
Epilepsy
| Treatment of myoclonic seizures (2)
1st sodium valproate/lamotrigine
| Must avoid carbamazepine, which may worsen seizures
58
Epilepsy
| Treatment of focal seizures (2)
1st carbamazepine
| 2nd sodium valproate/lamotrigine/topirimate
59
Epilepsy
| Side effects of treatments (3)
Carbamazepine: blurred vision, impaired balance, drowsiness
Lamotrigine: maculopapular rash, Stevens-Johnson syndrome or TEN, blurred vision, photosensitivity
Sodium valproate: teratogenic, nausea v common, pancreatitis, weight gain
60
Acoustic Neuroma
| Definition (1)
Schwannoma arising from the vestibular nerve
61
Acoustic Neuroma
| Signs + Symptoms (3)
Often presents with unilateral hearing loss, vertigo occurs later
With progression- ipsilateral Vth, VIth, IXth and Xth nerves may be affected and ipsilateral cerebellar signs
Signs of increased ICP occur late and suggest large tumour
62
Gait Disorders
| Spastic (1)
Stiff, circumduction of legs +/- scuffing of the toes of the shoes
63
Gait Disorders
| Extrapyramidal (4)
Flexed posture, shuffling feet, slow to start, postural instability, apraxic
'Gluing to the floor' on attempting walk
Wide-based unsteady gait with a tendency to fall
Causes: normal pressure hydrocephalus, multi-infarct states
64
Gait Disorders
| Ataxic (4)
Wide-based
Falls
Cannot walk heel-to-toe
Causes: cerebellar lesions (eg. MS, posterior fossa tumours, alcohol), proprioceptive sensory loss (eg. reduced B12)
65
Gait Disorders
| Myopathic (2)
Waddle (hip girdle weakness)
| Can't climb steps or stand from sitting
66
Gait Disorders
| Psychogenic (2)
Often a bizarre gait not conforming to any pattern of organic gait disturbance
Suspect if profound gait disturbance but without any signs on couch examination
67
Dyskinesia
| Definition (2)
Abnormal involuntary movements
| Impaired planning, control and execution of movement
68
Dyskinesia
| Tremor (4)
Rest tremor: abolished on voluntary movement, caused by Parkinsonism
Intention tremor: irregular, large-amplitude, worse at end of purposeful acts eg. finger pointing, caused by cerebellar damage (eg. MS, stroke)
Postural tremor: absent at rest, present on maintained posture (arms outstretched) and may persist (but isn't worse) on movement, caused by benign essential tremor (autosomal dominant), hyperthryoidism, anxiety
Re-emergent tremor: postural tremor developing after delay of approx 10 seconds (eg. Parkinson's)
69
Dyskinesia
| Chorea (2)
Non-rhythmic, jerky, purposeless movements flitting from one place to another, eg. facial grimacing, raising shoulders, flexing/extending fingers
Causes: Huntington's disease
70
Dyskinesia
| Hemiballismus (2)
Large amplitude, flinging hemichorea (affects proximal muscles) contralateral to a vascular lesion of the subthalamic nucleus (often elderly diabetics)
Recovers spontaneously over months
71
Dyskinesia
| Athetosis (3)
Slow, confluent, purposeless movements (especially digits, hand, face, tongue)
Hard to distinguish from chorea
Causes: cerebral palsy
72
Dyskinesia
| Tics (3)
Brief, repeated, stereotyped movements which patients may suppress for a while
Common in children and usually resolve
Common in Tourette's (motor and vocal)
73
Dyskinesia
| Myoclonus (2)
Sudden involuntary focal/general jerks arising from cord, brainstem or cerebral cortex
Seen in metabolic problems (low Na, high CO2) neurodegenerative disease and myoclonic epilepsies (infantile spasms)
74
```
Dyskinesia
Tardive Syndromes (4)
```
```
Tardive means 'delayed onset'
Common after chronic exposure to dopamine antagonists (eg. antiemetics, antipsychotics)
Tardive dyskinesia (movements)
Tardive dystonia (muscle spasms, twisting/turning character)
```
75
Dystonia
| Definition (1)
Prolonged muscle contractions causing abnormal posture or repetitive movements
76
Dystonia
| Idiopathic generalised dystonia (2)
Onset in childhood
| Often starts with dystonia in one leg, spreading to that side of the body
77
```
Dystonia
Focal dystonias (3)
```
Confined to one part of the body eg. writer's cramp
Rarely generalise
Worsened by stress
78
```
Dystonia
Acute dystonia (3)
```
May occur on starting neuroleptics and some antiemetics
May mistake for tetanus or meningitis
Rapidly disappear after a dose of anticholinergic
79
Stroke
| Definition (1)
Rapidly developing clinical signs of focal (or global) disturbance of cerebral function, with symptoms lasting >24 hours
80
Stroke
| Pathophysiology (2)
Ischaemic 85%
| Haemorrhagic 15% (70% primary intracerebral haemorrhage, 30% secondary haemorrhage eg. SAH)
81
Stroke
| Causes (5)
Small vessel occlusion
Cardiac emboli: AF, MI
Atherothromboembolism eg. from carotids
CNS bleeds: high BP, trauma, aneurysm rupture, anticoagulation, thrombolysis
Carotid dissection (spontaneous or from neck trauma)
82
Stroke
| Blood supply to the brain (2)
Carotid system supplies most of the hemispheres and cortical deep white matter
Vertebro-basilar system supplies the brainstem, cerebellum and occipital lobes
83
Stroke
| Non-modifiable risk factors (4)
Previous stroke
Age
Male
Family history
84
Stroke
| Modifiable risk factors (8)
```
High BP (exacerbates atheroma and increases involvement of smaller distal arteries)
Smoking
Diabetes
The pill
Sedentary lifestyle
Lipids
Heavy drinking
AF
```
85
Stroke
| Total anterior circulation syndrome (TACS) (5)
```
Complete hemiparesis/numbness
Loss of vision on one side (hemianopia)
Loss of awareness on one side (inattention)- non dominant
Main artery to one hemisphere
Dysphasia on its own
```
86
Stroke
| Partial anterior circulation syndrome (PACS) (4)
Branch of main artery
2 of the 3 TACS criteria
Or one higher cortical deficit: inattention or dysphasia
Or monoparesis
87
```
Stroke
Lacunar syndrome (LACS) (5)
```
Small perforating artery (basal ganglia, internal capsule, thalamus, pons)
Weakness/numbness of: face + arm + leg OR face + arm OR arm + leg
May have dysarthria
Ataxic hemiparesis
No affect on higher function (no dysphasia, inattention or hemianopia)
88
Stroke
| Posterior circulation syndrome (POCS)
```
Any posterior artery
Loss of balance/coordination
Vertigo
Double vision
Dysarthria
Visual loss (hemianopia)
```
89
Stroke
| Outcomes at 12 months (4)
TACS: 60% mortality at 1 year, 6% recurrence rate at 1 year
PACS: 16% mortality at 1 year, 17% recurrence rate at 1 year (common early)
LACS: 11% mortality at 1 year, 9% recurrence rate at 1 year
POCS: 19% mortality at 1 year, 20% recurrence rate at 1 year
90
```
Stroke
Differential diagnoses (6)
```
```
Seizures
Syncope
Sugar (hypo or hyper)
Sepsis (+ previous stroke)
Severe migraine
Space occupying lesions
```
91
Stroke
| Investigations (8)
```
CT head: haemorrhagic- hyperdense lesion, ischaemic- normal/parenchymal darkness, loss of grey-white matter difference, hyperattenuation of artery (clot inside)
FBC: exclude anaemia + thrombocytopenia
U+E + creatinine: exclude electrolyte disturbance
Glucose: exclude hypo/hyper
Troponin: exclude MI
Clotting screen
ECG: exclude MI + AF
Carotid doppler ultrasound
```
92
Stroke
| Treatment of ischaemic stroke (4)
Thrombolysis (eg. tissue plasminogen activator- alteplase) if within 4.5 hours
Anti-platelet: aspirin
Secondary prevention: statin, anticoagulation if in AF (warfarin/DOAC), antiplatelet (clopidogrel)
Carotid endarterectomy
93
Stroke
| Contraindications to thrombolysis (8)
```
Previous inrtacranial haemorrhage
Seizure at stroke onset
Intracranial neoplasm
Lumbar puncture within 7 days
Pregnancy
Active bleeding
Oesophageal varices
Require CT 24 hours after to assess for haemorrhage
```
94
Stroke
| Treatment of haemorrhagic stroke (3)
Rapid BP control if within 6h and systolic 150-220, aiming 130-140 within 1h
Neurosurgical opinion
Stop anticoagulants and antiplatelets
95
Stroke
| Locating the infarct (4)
Ant. cerebral artery: supplies frontal + medial cerebrum, causes contralateral motor/sensory loss in legs > arms with face sparing
Middle cerebral artery: supplies lateral hemisphere, causes motor/sensory loss in face + arms > legs, contralateral homonymous hemianopia due to optic radiation involvement and cortical changes (dysphasia if dominant hemisphere; hemisensory neglect/apraxia if non-dominant)
Posterior cerebral artery: supplies occipital lobe causing contralateral homonymous hemianopia with macular sparing
Vertebrobasilar circulation: supplies brainstem, cerebellum + occipital lobe, causes hemianopia/cortical blindness, CN lesions, quadriplegia + sensory symptoms
96
Transient Ischaemic Attack
| Definition (3)
Sudden onset of focal CNS phenomena due to temporary occlusion of part of the cerebral circulation
Usually embolic
Symptoms <24 h
97
Transient Ischaemic Attack
| Aetiology (2)
Atherosclerotic thromboembolism (usually from carotids)
Cardioembolism (post mI, AF, valve disease)
Hyperviscosity (polycythaemia, sickle cell disease, myeloma)
98
Transient Ischaemic Attack
| Signs + symptoms (3)
```
Mimic stroke in same arterial territory
Global events (eg. syncope, dizziness) not typical
Emboli may pass to the retinal artery, causing amaurosis fugax (one eye's vision is progressively lost)
```
99
```
Transient Ischaemic Attack
Differential diagnoses (4)
```
Hypoglycaemia
Migraine aura (symptoms spread over seconds, often visual)
Focal epilepsy (symptoms spread over seconds, often twitching/jerking)
Retinal bleeds
100
Transient Ischaemic Attack
| Investigations (6)
```
Bloods: FBC, U&E, ESR, glucose, lipids, clotting
CXR
ECG: exclude MI/AF
Echo: valvular disease
Carotid doppler
CT/MRI
```
101
Transient Ischaemic Attack
| Treatment (4)
Immediate anti-platelet: aspirin or clopidogrel
Carotid endarterectomy: if >70% stenosis
Anticoagulation eg. warfarin: if cardiac emboli eg. AF
Control cardiovascular risk factors: antihypertensives, statin, diabetic control, stop smoking
102
Subarachnoid Haemorrhage
| Aetiology (3)
Berry aneurysm rupture (80%): usually at junction of posterior communicating artery with the internal carotid artery or anterior communicating artery with anterior cerebral artery or MCA bifurcation, berry aneurysms are associated with polycystic kidneys, coarctation, Ehlers-Danlos
Arterio-venous malformation
No cause is found in <15%
103
```
Subarachnoid Haemorrhage
Risk factors (5)
```
```
Smoking
Alcohol misuse
Hypertension
Bleeding disorders
Post-menopausal
```
104
Subarachnoid Haemorrhage
| Signs + symptoms (8)
```
Sudden (thunderclap) occipital headache
Vomiting
Collapse
Seizures
Coma
Neck stiffness
Terson's syndrome: retinal,macular and vitreous bleeds
Kernig's sign: severe stiffness of hamstrings causes inability to straighten leg when hip flexed to 90 degrees
```
105
```
Subarachnoid Haemorrhage
Differential diagnoses (4)
```
Meningitis
Migraine
Intracerebral bleeds
Cortical vein thrombosis
106
Subarachnoid Haemorrhage
| Investigations (6)
```
CT: detects 90% in first 48h
LP: if CT -ve and no contraindications 12h after headache onset, CSF is bloody early then becomes xanthochromic (yellow) due to breakdown of haemoglobin to bilirubin
FBC: leucocytosis
Clotting: raised prolonged INR and PT
U&E: hyponatraemia
Troponin: elevated
```
107
Subarachnoid Haemorrhage
| Treatment (4)
Immediate neurosurgery referral
Maintain cerebral perfusion by keeping well hydrated and aim SBP >160 (only treat BP if very severe)
Nimodipine: reduces vasospasm
Endovascular coiling > surgical clipping
108
Subarachnoid Haemorrhage
| Complications (4)
Rebleeding commonest cause of death, usually in first few days
Cerebral ischaemia due to vasospasm and causes permanent CNS defect
Hydrocephalus due to blockage of arachnoid granulations
Hyponatraemia is common but shouldn't be managed with fluid restriction
109
Intracranial Venous Thrombosis
| Dural venous sinus thrombosis (3)
Most commonly sagittal/transverse sinus thrombosis
Symptoms come on gradually over days/weeks
Thrombosis within a dural venous sinus may extend into the cortical veins and cause infarction within a venous territory
110
Intracranial Venous Thrombosis
| Cortical vein thrombosis (5)
Often causes venous infarcts
Stroke-like focal symptoms that develop over days
May have an associated thunderclap headache
Seizures are common and focal
Usually occurs with sinus thromboses
111
Intracranial Venous Thrombosis
| Aetiology (4)
Common: pregnancy, OCP, head injury, dehydration, recent LP
Systemic: hyperthyroidism, heart failure, SLE, nephrosis, ketoacidosis
Infections: meningitis, TB, cerebral abscess, septicaemia
Drugs: androgens, antifibrinolytics, infliximab
112
Intracranial Venous Thrombosis
| Signs + symptoms (4)
Sagittal sinus: headache, vomiting, seizures, reduced vision, papilloedema
Transverse sinus: headache +/- mastoid pain, seizures, papilloedema, focal CNS signs
Sigmoid sinus: cerebellar signs, lower cranial nerve palsies
Cavernous sinus: often due to spread from facial pustules/folliculitis, headache, oedematous eyelids, fever
113
```
Intracranial Venous Thrombosis
Differential diagnoses (3)
```
Subarachnoid haemorrhage
Meningitis
Encephalitis
114
Intracranial Venous Thrombosis
| Investigations (3)
Must rule out SAH and meningitis
CT/MRI venography: absence of sinus
Lumbar puncture: raised opening pressure indicates venous thrombosis if there is a persistent headache and SAH is excluded
115
Intracranial Venous Thrombosis
| Treatment (2)
LMWH then warfarin once INR 2-3
| Fibrinolytics eg. streptokinase
116
Subdural Haemorrhage
| Aetiology (3)
Trauma (can be delayed)
Intracranial hypotension
Dural metastases
117
Subdural Haemorrhage
| Pathology (3)
Bleeding from bridging veins between cortex and venous sinuses (vulnerable to deceleration injury)
Blood accumulates between arachnoid and dura matter
Gradually increases ICP shifting midline sutures away from side of clot
118
```
Subdural Haemorrhage
Risk factors (3)
```
Elderly (cerebral atrophy makes bridging veins vulnerable)
Falls (epilepsy, alcohol)
Anticoagulation
119
Subdural Haemorrhage
| Signs + symptoms (7)
```
Fluctuating level of consciousness
Headache
Personality change
Unsteadiness
Increased ICP
Seizures
Localising neurological symptoms (eg. unequal pupils, hemiparesis) occur late after injury
```
120
Subdural Haemorrhage
| Investigations (1)
CT shows crescent cell shaped haematoma over 1 hemisphere +/- midline shift
121
```
Subdural Haemorrhage
Differential diagnoses (3)
```
Stroke
Dementia
CNS masses (eg. tumours, abscess)
122
Subdural Haemorrhage
| Treatment (2)
Irrigation and evacuation with Burr-hole craniostomy 1st line
Craniotomy 2nd line if clot has organised
123
Extradural Haemorrhage
| Aetiology (1)
Fractured temporal or parietal bone causing laceration of middle meningeal artery and vein, typically after trauma to a temple (blood accumulates between bone and dura)
124
Extradural Haemorrhage
| Signs + symptoms (3)
Lucid interval: head injury with no loss of consciousness, may last a few hours --> days
Subsequent features: reduced GCS (from rising ICP), severe headache, vomiting, confusion, fits +/- hemiparesis with brisk reflexes and upgoing plantars
Bleeding continues: dilation of ipsilateral pupil, GCS decreases more, bilateral limb weakness
125
Extradural Haemorrhage
| Investigations (2)
CT: biconvex/lens shaped haematoma
| Skull X-ray may show fracture lines across course of middle meningeal vessels
126
Extradural Haemorrhage
| Treatment (1)
Craniotomy with clot evacuation +/- bleeding vessel ligation
127
Delirium
| Epidemiology (3)
20-30% hospital inpatients
50% post-op
85% of patients in last weeks of life
128
Delirium
| Aetiology (10)
Systemic infection: pneumonia, UTI
Intracranial infection: encephalitis, meningitis
Drugs: opiates, anti-convulsants, sedatives, levodopa
Withdrawal: alcohol, drugs
Metabolic: uraemia, high/low Na, high/low glucose
Hypoxia: resp/cardiac failure
Vascular: stroke, MI
Increased ICP: head injury, SOL
Epilepsy: post-ictal state
Nutritional: thiamine/B12 deficiency
129
Delirium
| Symptoms (8)
```
Impaired attention
Anterograde memory impairment
Disorientation in time, place or person
Fluctuating levels of arousal
Disordered sleep/wake cycle
Disorganised thinking (rambling/incoherent)
Perceptual distortions eg. illusions, hallucinations
Mood changes
```
130
Delirium
| Signs (7)
```
Acute onset and fluctuant
Disturbed consciousness
Change in cognition
Delusions
Emotional disturbance
Sleep/wake cycle disturbance
Psychomotor function disturbance
```
131
Delirium
| Investigations (3)
4AT (>4 = possible delirium/cognitive impairment, 1-3 = possible cognitive impairment, 0 = both unlikely)
FBC, U&E, LFT, glucose
Septic screen: urine dipstick, CXR, blood cultures
132
Delirium
| Treatment (2)
Exclude and treat possible triggers (sepsis, blood glucose, medications, retention/constipation)
Drug management not usually necessary but if disruptive may need haloperidol for sedation
133
Dementia
| Aetiology (5)
```
Alzheimer's disease (50%)
Vascular dementia (25%)
Lewy body dementia (15-25%)
Fronto-temporal dementia
Others: alcohol and drug abuse, repeated head trauma, Whipple's disease, Huntington's
```
134
```
Dementia
Reversible causes (7)
```
```
Hypothyroidism
B12/folate deficiency
Syphilis
Subdural haemorrhage
Parkinsons
HIV
Normal pressure hydrocephalus
```
135
Dementia
| Investigations (4)
MMSE/MOCA
Bloods: FBC, ESR, U&E, Ca, LFT, TSH, B12, folate
CT/MRI: vascular damage, haemorrhage, structural pathology
Functional imaging: FDG, PET, SPECT
136
```
Dementia
Diagnostic criteria (3)
```
```
Present for >6 months
Functional decline in ADLs
Memory impairment +1 of:
-dysphagia (expressive/receptive)
-dyspraxia (motor skills)
-dysgnosia (difficulty recognising objects)
-dysexecutive functioning
```
137
Alzheimer's Disease
| Aetiology (2)
Accumulation of B-amyloid peptide results in neuronal damage, tangles, increased amyloid plaques + loss of acetylcholine
Usually temporal lobes affected first
138
```
Alzheimer's Disease
Risk factors (7)
```
```
1st degree relative affected
Down's syndrome
Vascular risk factors: high BP, AF, diabetes
Smoking
Alcohol
Reduced physical and cognitive activity
Depression and loneliness
```
139
Alzheimer's Disease
| Signs + symptoms (7)
Enduring, progressive and global cognitive impairment (unlike other dementias which may affect certain domains but not others)
Reduced visuospatial skill (get lost)
Reduced memory
Reduced verbal abilities
Reduced executive functioning
Anosognosia (lack of insight into the problems caused by the disease)
Later on: irritability, mood disturbance, behavioural change (eg. disinhibition), psychosis
140
Alzheimer's Disease
| Treatment (2)
Acetylcholinesterase inhibitors eg. donepezil, galantamine, rivastigimine- SE: D+V, cramps, incontinence, dizziness, insomnia
Antiglutamatergic: memantine (NMDA antagonist) for late stage disease- SE: hallucinations, confusion, hypersexuality
141
Vascular Dementia
| Aetiology (1)
Cumulative effects of many small strokes
142
```
Vascular Dementia
Risk factors (5)
```
```
Diabetes
Previous strokes
Hypertension
Peripheral vascular disease
Ischaemic heart disease
```
143
Vascular Dementia
| Signs + symptoms (2)
Stepwise deterioration
| Often predominant executive dysfunction and gait abnormalities
144
Lewy Body Dementia
| Signs + symptoms (7)
```
Fluctuating cognitive impairment
Detailed visual hallucinations
Parkinsonism later
Amnesia not prominent
REM sleep disorder
Falls + syncope
Frontal-executive and visuospatial defects
```
145
Fronto-Temporal Dementia
| Signs + symptoms (5)
Younger onset
Behavioural disorder (personality change)
Early preservation of episodic memory and spatial orientation
Disinhibition
Speech disorder
146
Parkinson's Disease
| Aetiology of Parkinsonism (2)
Idiopathic (Parkinson's Disease)
| Drugs (neuroleptics, prochloperazine)
147
Parkinson's Disease
| Pathology (3)
Mitochondrial DNA dysfunction causes degeneration of dopaminergic neurones in substantia nigra
Reduced input to striatum
Reduced dopamine levels
148
Parkinson's Disease
| Signs + symptoms (7)
Tremor: worse at rest, pill-rolling of thumb over fingers
Rigidity: with tremor gives cogwheel rigidity
Bradykinesia: slow initiation of movement and slow repetitive actions
Postural instability
REM sleep disorders
Reduced sense of smell
Poor executive functioning
149
Parkinson's Disease
| Treatment (6)
Levodopa + co-beneldopa (dopa-decarboxylase inhibitor), but efficacy reduces over time
Dopamine agonists eg. ropinirole can delay starting levodopa
Anticholinergics can help tremor but cause confusion in the elderly
MAO-B inhibitors eg. selegiline, as alternative to dopamine agonists
COMT inhibitors
Deep brain stimulation
150
Multiple Sclerosis
| Aetiology (5)
Discrete plaques of demyelination at multiple CNS sites due to T-cell mediated immune response
Demyelination heals poorly, causing relapsing and remitting symptoms
Prolonged demyelination causes axonal loss and clinically progressive symptoms
Lack of sunlight and vit D exposure
Genetic
151
Multiple Sclerosis
| Presenting signs + symptoms (5)
```
Usually monosymptomatic
Unilateral optic neuritis (pain on eye movement and rapid reduction in central vision)
Limb paraesthesia
Brainstem/cerebellar: ataxia, diplopia
May worsen with heat and exercise
```
152
Multiple Sclerosis
| Progresssive signs + ymptoms (9)
Sensory: pins + needles, reduced vibration sense
Motor: spastic weakness, myelitis
GU: erectile dysfunction, retention, incontinence
GI: swallowing disorder, constipation
Eyes: diplopia, hemianopia, pupillary defect
Cerebellum: trunk/limb ataxia, intention tremor, falls
Cognitive/visuospatial decline: amnesia, mood disturbed
Transverse myelitis: loss of motor, sensory, autonomic reflex and sphincter function below level of lesion
L'hermitte's sign: neck flexion causes electric shock in trunk and limbs
153
Multiple Sclerosis
| Poor prognostic signs (4)
Older male
Motor signs at onset
Many relapses early on
Many MRI lesions and axonal loss
154
Multiple Sclerosis
| Investigations (4)
McDonald criteria
MRI
CSF: oligoclonal bands of IgG on electrophoresis that are not present in serum suggests CNS inflammation
Bloods: FBC, TFT, B12, U&E to exclude other causes
155
```
Multiple Sclerosis
Differential diagnoses (5)
```
```
SLE
HIV
Tumour
Stroke
Vasculitis
```
156
Multiple Sclerosis
| treatment of acute relapses (2)
Steroids: IV methylprednisolone (don't use more than 2x/year)
Plasma exchange if severe
157
```
Multiple Sclerosis
Ongoing treatment (3)
```
Interferons (IFN-1B + IFN-1a): reduce relapses by 30% in active relapsing remitting disease and reduce lesion accumulation
Monoclonal antibodies: eg. alemtuzumab, natalizumab for relapsing remitting
Azathioprine for relapsing remitting
158
Multiple Sclerosis
| Palliation (3)
Spasticity: baclofen, diazepam
Tremor: botulinum injection
Urgency/frequency: self catheterisation
159
Space Occupying Lesions
| Primary brain tumours (7)
Astrocytoma: low grade tumour of CNS supporting cells, low grade diffuse tumours tend to occur in young people
Glioblastoma multiforme: high grade tumour of CNS supporting cells, may arise from pre-existing astrocytoma, v. aggressive, most common adult brain tumour
Oligodendroglioma: arise rom myelin sheath
Ependymoma: ventricular tumour in children
Medulloblastoma: neuroectoderm tumour that tends to occur in children in the brainstem
Primary CNS lymphoma: usually diffuse large B cell
Meningioma non-invasive but locally advanced, arise from arachnoid cells
160
Space Occupying Lesions
| Secondary brain tumours (3)
Lung
Breast
Melanoma
161
Space Occupying Lesions
| Signs + symptoms (4)
Increased ICP: headache worse on waking, lying down, bending forward or with coughing, vomiting, papilloedema
Seizures
Evolving focal neurology: VIth nerve palsy commonest due to long intracranial course
Subtle personality change
162
Space Occupying Lesions
| Investigations (3)
CT
MRI good for posterior fossa masses
Consider biopsy
163
Space Occupying Lesions
| Treatment (3) Prognosis (1)
Treatment:
- Benign: surgical excision unless inaccessible
- Malignant: surgical excision and adjuvant radiotherapy
- Lone chemo-radiotherapy if inoperable
Prognosis:
- <50% 5 year survival
164
Space Occupying Lesions
| Localising the lesion (5)
Temporal lobe: dysphasia, contralateral homonymous hemianopia, amnesia
Frontal lobe: hemiparesis, personality change, Broca's dysphasia
Parietal lobe: hemisensory loss, dysphasia
Occipital lobe: contralateral visual field defects
Cerebellar: DANISH- Dysdiadokinesis (inability to perform rapidly alternating movements), Ataxia, Nystagmus, Intention tremor, Slurred speech, Hypotonia
165
Bell's Palsy
| Definition (1)
Idiopathic facial nerve palsy
166
Bell's Palsy
| Other causes of VIIth nerve palsy (7)
```
Ramsay Hunt syndrome
Lyme disease
Meningitis
Stroke
Tumour
MS
Guillain-Barre
```
167
Bell's Palsy
| Signs + symptoms (8)
```
Abrupt onset
Complete unilateral facial weakness
Ipsilateral numbness/pain around ear
Reduced taste
Drooling
Food trapped between gum and cheek
Speech difficulties
Ask to wrinkle forehead and close eyes forcefully (under bilateral cortical control so spared in uMN lesion)
```
168
Bell's Palsy
| Investigations (2)
Blood: ESR, glucose, increased Borrelia antibodies in Lyme disease (indistinguishable from Bell's clinically), increased VZV antibodies in Ramsay Hunt
MRI: space occupying lesion, stroke, MS
169
Bell's Palsy
| Treatment (3)
Prednisolone within 72h of onset
May need plastic surgery if eye closure remains a problem and to straighten drooping face
Botulinum toxin can augment facial symmetry
170
```
Mononeuropathies
Definition (2)
```
Lesions of individual peripheral/cranial nerves, usually caused by trauma or entrapment (eg. tumour), except for carpal tunnel syndrome
Mononeuritis multiplex is when 2+ nerves are affected, causes tend to be systemic eg. AIDS, RA, diabetes
171
```
Mononeuropathies
Median nerve (5)
```
C6-T1
Nerve of precision grip
LOAF: 2 Lumbricals, Opponens pollicis, Abductor pollicis brevis, Flexor pollicis brevis
Trauma (lacerations) or carpal tunnel
Weakness of abductor pollicis brevis and sensory loss over radial 3.5 fingers and palm
172
```
Mononeuropathies
Ulnar nerve (3)
```
C7-T1
Vulnerable to elbow trauma
Wasting/weakness of medial wrist flexors, interossei and medial two lumbricals (claw hand), hypothenar wasting
173
```
Mononeuropathies
Radial nerve (5)
```
C5-T1
Nerve that opens the fist
Damaged by compression against the humerus
Wrist and finger drop
Muscles: BEST- Brachioradialis, extensors, Supinator, Triceps
174
```
Mononeuropathies
Phrenic nerve (3)
```
C3-5 (C3, 4, 4 keeps the diaphragm alive)
Consider phrenic nerve palsy if orthopnoea with raised hemidiaphragm on CXR
Causes: lung cancer, myeloma, thymoma, thoracic surgery, MS, HIV
175
```
Mononeuropathies
Sciatic nerve (3)
```
L4-S3
Damaged by pelvic tumours/fractures to pelvis/femur
Lesions affect hamstrings and all muscles below the knee (foot drop), with loss of sensation below the knee
176
Mononeuropathies
| Common peroneal nerve (5)
```
L4-S1
Originates from sciatic nerve just above knee, often damaged as it winds round the fibular head
Foot drop
Weak ankle dorsiflexion/eversion
Sensory loss over dorsum of foot
```
177
```
Mononeuropathies
Tibial nerve (4)
```
L4-S3
Originates from sciatic nerve just above knee
Lesions lead to inability to stand on tiptoe (plantar flexion), invert foot, flex toes
Sensory loss over the sole
178
Polyneuropathies
| Definition (1)
Disorders of peripheral/cranial nerves, distribution is symmetrical and widespread, often with distal weakness and sensory loss ('glove and stocking')
179
Polyneuropathies
| Aetiology (5)
Metabolic: diabetes and renal failure (mostly sensory)
Vasculitides: RA, Wegener's
Inflammatory: Guillain-Bare syndrome (mostly motor)
Infections: leprosy (mostly sensory), HIV, syphilis
Alcohol
180
Polyneuropathies
| Signs + symptoms of sensory neuropathy (5)
Numbness
Pins and needles/burning
Affects extremities 1st (glove and stocking distribution)
Difficulty handling small objects like buttons
Trauma/joint deformity
181
Polyneuropathies
| Signs + symptoms of motor neuropathy (5)
```
Often progressive
Weak/clumsy hands
Difficulty walking (falls, stumbling)
Difficulty breathing
LMN lesion signs
```
182
Polyneuropathies
| Signs + symptoms of cranial neuropathy (2)
Swallowing/speaking difficulties
| Diplopia
183
Polyneuropathies
| Signs + symptoms of autonomic neuropathy (5)
```
Sympathetic and parasympathetic neuropathies may be isolated or part of generalised sensorimotor peripheral neuropathy
Postural hypotension
Erectile dysfunction
Reduced sweating
Constipation and urinary retention
```
184
Guillain-Barre Syndrome
| Pathology (4)
Acute inflammatory demyelinating polyneuropathy
Triggered by Campylobacter jejuni, CMV, HIV, EBV
Trigger causes antibodies which attack nerves but very often no cause is found
May advance quickly and cause paralysis, unlike other neuropathies, proximal muscles are more affected (trunk, respiratory, cranial nerves)
185
Guillain-Barre Syndrome
| Signs + symptoms (4)
A few weeks after infection a symmetrical ascending muscle weakness starts (progression over days-weeks)
Pain common
Autonomic dysfunction: sweating, tachycardia, BP changes, arrhythmias
Areflexia
186
Guillain-Barre Syndrome
| Investigations (2)
Nerve conduction studies: slow conduction
| CSF: high protein, normal WCC
187
Guillain-Barre Syndrome
| Treatment (3)
Ventilate with respiratory involvement
IV immunoglobulin
Plasma exchange
188
Guillain-Barre Syndrome
| Prognosis (3)
85% make complete or near complete recovery
10% unable to walk 1 year
Mortality 10%
189
Motor Neuron Disease
| Definition (2)
Cluster of major degenerative diseases characterised by selective loss of neurons in motor cortex, cranial nerve nuclei and anterior horn cells
Upper and lower motor neurons are affected but there is no sensory loss/sphincter disturbance
190
Motor Neuron Disease
| Classification (4)
ALS: loss of motor neurons in motor cortex and the anterior horn of the cord, so weakness and UMN signs + LMN signs
Progressive bulbar palsy: only affects cranial nerves IX-XII (LMN lesion of tongue and muscles of talking/swallowing, can also be caused by Guillain-Barre, myasthenia
Corticobulbar palsy: UMN lesion of muscles of swallowing/talking, due to bilateral lesions (increased jaw jerk, slow speech, also see in MS/stroke)
Progressive muscular atrophy: anterior horn lesion only, thus no UMN signs
191
Motor Neuron Disease
| Signs + symptoms (7)
```
Stumbling spastic gait
Foot drop
Proximal myopathy
Weak grip
Shoulder abduction
UMN signs
LMN signs
```
192
Motor Neuron Disease
| Treatment (3)
Antiglutamatergic drugs may prolong life
Treat symptoms such as drooling, dysphagia, spasticity, joint pain
Non-invasive ventilation
193
Duchenne Muscular Dystrophy
| Pathology (1)
X-linked recessive mutation in dystrophin gene results in near-total loss of dystrophin (muscles get replaced by fibroadipose tissue)
194
Duchenne Muscular Dystrophy
| Signs + symptoms (4)
Boys aged 1-6
Waddling, clumsy gait
Gower's manoeuvre: on standing, he uses his hands to climb up his legs
Wheelchairs required by 9-12
195
Duchenne Muscular Dystrophy
| Investigations (2)
```
CK increases (measure in all boys not walking by 1.5 years)
Muscle biopsy (abnormal fibres surrounded by fat and fibrous tissue)
```
196
Duchenne Muscular Dystrophy
| Prognosis (3)
Prednisolone slows decline in muscle strength and function in short term
Mechanical ventilation improves longevity
Median age at death 31 years
197
Myasthenia Gravis
| Pathology (3)
Autoimmune disease mediated by antibodies to acetylcholine receptors (AChR)
Interfering with the neuromuscular transmission via depletion of working post-synaptic receptor sites
Both B+T cells implicated
198
Myasthenia Gravis
| Signs + symptoms (5)
```
Increasing muscular fatigue
Muscle groups affected in order: extraocular --> bulbar (swallowing, chewing) --> face --> neck etc.
Ptosis
Diplopia
On counting to 50 the voice fades
```
199
Myasthenia Gravis
| Associations (2)
If under 50 commoner in women and associated with other autoimmune diseases and thymic hyperplasia
If over 50 commoner in men and associated with thymic atrophy/tumour
200
Myasthenia Gravis
| Investigations (3)
Anti-AChR antibodies
Neurophysiology
CT thymus
201
Myasthenia Gravis
| Treatment (3)
Symptom control: anticholinesterase
Immunosuppression: treat relapses with prednisolone (may combine with azathioprine/methotrexate)
Thymectomy
202
Spinal Cord Injury
| Aetiology (5)
```
Most due to trauma, especially RTAs
Falls in elderly population
Tumours
Prolapsed discs
Inflammatory disease
```
203
Spinal Cord Injury
| Assessment (8)
ATLS principles
Log-roll technique for movement
C-spine immobilisation
Prevent and treat hypotension (due to neurogenic shock)
Restore intravascular volume (don't overload)
Monitor and treat symptomatic bradycardia
Monitor and regulate temp.
Perform serial neurological examinations
204
Spinal Cord Injury
| Root lesion tests (10)
```
C5: shoulder abduction
C6: elbow flexion
C7: elbow extension
C8: finger flexion (grip)
T1: finger abduction
L2: hip flexion
L3: knee extension
L4: ankle dorsiflexion
L5: great toe extension
S1: ankle plantarflexion
```
205
Spinal Cord Injury
| Consequences (5)
Injury to cervical spine causes tetraplegia but injury above level of phrenic nerve (C3-5) results in paralysis of diaphragm
Thoracic spine: paraplegia
Lumbar spine: cauda equina
Respiratory insufficiency: from neurological dysfunction and associated trauma
Hypotension below lesion (sympathetic interruption and resultant neurogenic shock- low BP + HR)
206
Spinal Cord Injury
| Treatment (5)
```
Early transfer to spinal injuries unit
Steroids
Early surgical decompression and stabilisation
Traction for cervical injuries
Anticoagulation: v high risk of VTE
```
207
Brown-Sequard Syndrome
| Definition (1)
Hemisection (lesion in one half) of spinal cord
208
Brown-Sequard Syndrome
| Aetiology (1)
Penetrating injuries
209
Brown-Sequard Syndrome
| Signs + symptoms (4)
Ipsilateral UMN weakness below lesion (severed corticospinal tract causing spastic paraparesis, brisk reflexes, extensor plantars)
Ipsilateral paralysis
Ipsilateral loss of proprioception and vibration (1 dorsal column severed)
Contralateral loss of pain and temp. (severed spinothalamic tract which is crossed over)
210
Spinal Shock
| Definition (1)
Transient physiological loss of function, often due to haemorrhage
211
Spinal Shock
| Signs + symptoms (5)
Anaesthesia
Flaccid paralysis below the level
Urinary retention
Over time flexion at hip and knee may be induced by stimuli (cold) and reflexes return
Overall, temporary loss of sensory and motor function tends to recover
212
Spinal Cord Compression
| Aetiology (5)
```
Bone displacement
Disc prolapse
Local tumour (secondary malignancy- breast, lung, prostate)
Abscess
Haematoma
```
213
Spinal Cord Compression
| Signs + symptoms (6)
Spinal/root pain
Leg weakness
LMN signs at level of lesion
UMN signs and sensory changes below lesion (spastic weakness, brisk reflexes, upgoing plantars, loss of coordination, joint position sense and vibration sense)
Joint position and vibration affected on same side
Pain and temp affected on other side
214
```
Spinal Cord Compression
Differential diagnoses (5)
```
```
Transverse myelitis
MS
Trauma
Guillain-Barre
Cord vasculitis (eg. syphilis)
```
215
Spinal Cord Compression
| Investigations (4)
MRI
Biopsy/surgical exploration may be needed to identify nature of mass
Bloods: FBC, ESR, syphilis serology, U&E, LFT, PSA
CXR: primary lung malignancy or secondaries
216
Spinal Cord Compression
| Treatment (2)
If malignancy: IV dexamethasone while considering chemo/radio +/- decompressive laminectomy
If epidural abscess: surgical decompression and antibiotics
