Neurology Flashcards
What is spontaneous intracranial hypotension?
Low CSF headaches
- Worse on standing
- Improve on lying flat
- Risk factors = Marfan’s syndrome
Ix: MRI with gadolinium
Rx: Usually conservative
A humeral shaft fracture - which nerve is mostly likely to be damaged and what is the presentation?
Radial nerve
Wrist drop + sensory loss to small area between dorsal aspect of 1st and 2nd metacarpals
Tricep paralysis
Out of sodium valproate, carbamazepine and phenytoin which one is most likely to cause megaloblastic anaemia?
Phenytoin
by altering folate mechanism
What blood vessel is subdural haemorrhages mostly due to?
What shape is it on CT?
Who are more at risk?
Bridging veins between cortex and venous sinuses
Crescent shape
Alcoholics & elderly
What are the functions of the dorsal column?
Fine touch, proprioception, vibration
Condition called Neurosyphilis (tabes dorsalis) is due to just dorsal column lesion
What is the first line antiplatelet for secondary prevention following stroke?
Clopidogrel
Parkinsonism with associated autonomic disturbance (atonic bladder, postural hypotension) points towards…
Multiple system atrophy
Features
- parkinsonism
- autonomic disturbance
- erectile dysfunction: often an early feature
- postural hypotension
- atonic bladder - cerebellar signs
Treatment for idiopathic intracranial hypertension (2)
Acetazolamide
- a carbonic anhydrase inhibitor that is used in IIH to reduce the production of cerebrospinal fluid in order to reduce intracranial pressure
Topiramate
Features of vestibular schwannoma (acoustic neuroma)
cerebellopontine angle tumour
cranial nerve VIII: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
cranial nerve V: absent corneal reflex
cranial nerve VII: facial palsy
What is the Neuroleptic malignant syndrome tetrad?
hyperthermia/ pyrexia, muscle rigidity, autonomic instability, altered mental status
A raised creatine kinase is present in most cases. Acute kidney injury (secondary to rhabdomyolysis) may develop in severe cases - deranged U&Es. A leukocytosis may also be seen
What blood test is used to differentiate between a true seizure and a pseudoseizure
Prolactin
A 30-year-old man with a family history of early blindness is concerned that he is developing ‘tunnel vision’.
This is a common presentation of retinitis pigmentosa. Extensive pigmentation would normally be noted on fundoscopy.
(tunnel vision - macular sparing also happens in glaucoma)
upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a….
pituitary tumour
lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a…
craniopharyngioma
What two features suggests the development of Korsakoff’s syndrome
An inability to acquire new memories (amnesia) and confabulation (disturbance of memory/ production of fabricated, distorted or misinterpreted memories)
Features of Wernicke’s encephalopathy
Ix?
Tx?
CAN OPEN Confusion Ataxia Nystagmus Ophthamoplegia PEripheral Neuropathy
Ix:
- decreased red cell transketolase
- MRI
Tx: Pabrinex/ Thiamine (B1) replacement
High stepping gait is due to…
compensate for foot drop
Unilateral - usually due to common peroneal nerve lesion
Bilateral foot drop - peripheral neuropathy
What artery supplies both the Wernickes and Broca’s areas of the cortex?
What location are each area in?
Middle cerebral artery
- usually dominant hemisphere which is the LEFT usually
Brocas - inferior frontal gyrus - speech issues
Wernickes - superior temporal gyrus - comprehension issue
How do lacunar infarcts present?
involves perforating arteries around the internal capsule, thalamus and basal ganglia
presents with 1 of the following:
1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
2. pure sensory stroke.
3. ataxic hemiparesis
How does lateral medullary syndrome present?
(posterior inferior cerebellar artery)
aka Wallenberg’s syndrome
ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner’s
contralateral: limb sensory loss
Subacute combined degeneration of the cord
Subacute combined degeneration of the cord involves degeneration of the posterior and lateral columns of the spinal cord, often due to vitamin B12 deficiency.
Damage to the posterior columns - loss of proprioception, light touch and vibration sense (sensory ataxia and a positive Romberg’s test).
Damage to lateral columns - spastic weakness and upgoing plantars (UMN signs).
Damage to peripheral nerves - absent ankle and knee jerks (LMN signs).
When there is a mix of UMN and LMN signs in a patient, always consider SCDC.
Replacing folate without vitamin B12 (hinted at in this case) can precipitate subacute combined degeneration of the cord in a patient who is vitamin B12 deficient. Always ensure vitamin B12 levels are checked (and replenished) before giving folate for a macrocytic anaemia.
Amyotrophic lateral sclerosis is a subtype of motor neurone disease. This may present with mixed UMN and LMN signs but no associated sensory deficits.
First line Tx for restless leg syndrome
dopamine agonists such as ropinirole
common peroneal palsy can cause…
weakness of foot dorsiflexion and foot eversion
sensory loss over the 1st and 2nd toes
What is the Ramsey Hunt Syndrome?
Features?
Tx?
caused by the reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve.
Features
auricular pain is often the first feature
facial nerve palsy
vesicular rash around the ear
other features include vertigo and tinnitus
Management
oral aciclovir and corticosteroids are usually given
An 18-year-old is found unresponsive and lying on the floor. He slowly regains consciousness, is confused and has a right-sided weakness of their arm and face. On arrival, the paramedics notice that he has a medical bracelet with a long-term condition stated on it.
What condition does this patient most likely have?
Patients with focal seizures may experience post-ictal weakness (Todd’s paresis)
Frontal lobe
What is the management for acute relapse of MS?
high dose steroids
Brown-Sequard syndrome
Unilateral spastic paresis and loss of proprioception/vibration sensation with loss of pain and temperature sensation on the opposite side -
Acute Tx or cluster headache
Prophylaxis tx
O2 + subcut triptan
verapamil
Lip-smacking and post-ictal dysphasia focal seizure is from which lobe location?
Temporal lobe
What does DANISH stand for?
D - Dysdiadochokinesia, Dysmetria (past-pointing), patients may appear ‘Drunk’
A - Ataxia (limb, truncal)
N - Nystamus (horizontal = ipsilateral hemisphere)
I - Intention tremour
S - Slurred staccato speech, Scanning dysarthria
H - Hypotonia
What is autonomic dysreflexia?
Occurs in patient who had a spinal cord injury at, or above T6.
Get symptoms such as severe hypertension, flushing, sweating without a congruent response in heart rate
Why is COCP contraindicated in migraines?
due to significantly increased risk of stroke
Symptoms of progressive supranuclear palsy?
Parkinsonism features +
- dysarthria (slow speech)
- vertical gaze palsy
Painful third nerve palsy, what artery aneurysm must be urgently checked?
Posterior communicating artery aneurysm
- can also have pupil dilation
What is weber’s syndrome?
Ipsilateral III palsy + contralateral weakness (hemiplegia)
Parkinsonism with symmetrical tremor
Drug induced Parkisonism
Examples of dopamine agonist?
Parkinson’s disease drugs eg Bromocriptine, ropinirole, cabergoline
Examples of dopamine antagonist drugs
Antipsychotics e.g. haloperidol
Anti-emetics (e.g. metoclopramide/ domperidone)
Treatment of neuroleptic malignant syndrome
IV fluids
Dantrolene
bromocriptine, dopamine agonist, may also be used
Drugs that increase the risk of idiopathic intracranial hypertension
COCP, steroids, tetracycline, vit A, lithium
What is hoffmans sign
a sign of UMN dysfunction
GCS less than ___- –> what is next step
8
intubate and ventilate
A low pressure headache commonly develops following a lumbar puncture - what is the treatment?
Caffeine and fluids
Reflexes for ankle, knee, biceps, tricepts
S1, S2,
L3, L4
C5, C6
C7, C8
-Ed
Miosis means
excessive constriction
what is the first line tx for neuropathic pain?
amitriptyline, duloxetine, gabapentin or pregabalin
What is the criteria for total anterior circulation infarct?
- unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphasia
Total anterior circulation infarcts (TACI, c. 15%)
involves middle and anterior cerebral arteries
all 3 of the above criteria are present
Symptoms of uncal herniation
3rd nerve gets compressed - dilated ipsilateral pupil
- ophthalmoplegia
Is gait ataxia caused by cerebellar hemisphere or cerebellar vermis?
cerebellar vermis
Cerebellar hemisphere lesions cause peripheral (‘finger-nose ataxia’)
Cerebellar vermis lesions cause gait ataxia
Klumpke’s paralysis affecting which roots
brachial trunks C8-T1
Erb’s palsy affects which roots
C5-C6
Why is it important to not acutely stop levodopa?
To prevent acute dystonia
What is refeeding syndrome
It is when there are metabolic abnormalities which occur on feeding a person following a period of starvation
- hypophosphataemia
- hypokalaemia
- hypomagnesaemia
- abnormal fluid balance
What is first line ix for MS
mri with contrast
What is the cushing reflex?
Response to increased ICP that results in hypertension and bradycardia
What is the long term prophylaxis of cluster headaches
verapamil
What should you prescribe to a 17 year old girl with tonic clonic seizures
Lamotrigine
(Sodium valproate is usually first line but should not be prescribed to female children, adolescents, childbearing age, pregnant woman)
What makes essential tremor better?
Alcohol and propranolol
how to define postural hypotension
Postural hypotension is defined as a fall in blood pressure (BP) of at least 20 mmHg systolic and 10 mm Hg diastolic within three minutes in the upright position
What is the treatment of a myasthenic crisis?
plasmapheresis, IV immunoglobulins, ventilatory support
patient with unilateral hearing loss who presents with reduced facial sensation and balance problems…
First line Ix?
Acoustic neuroma
Gadolinium enhanced MRI
Audiogram
