Neurology Flashcards
(289 cards)
1
Q
what are 5 common causes of abnormal gait?
A
- stroke
- childhood hip disorders
- parkinson’s disease
- cerebral palsy
- multiple sclerosis
2
Q
what are 4 uncommon causes of abnormal gait?
A
- cerebellar disorder
- peripheral neuropathy
- myopathies
- guillain-barré syndrome
3
Q
what 2 clinical signs does difficulty rising from a chair point to?
A
- proximal weakness
2. difficulty initiating movements
4
Q
what clinical sign does a shuffling gait point to?
A
parkinsonism
5
Q
what 2 gait-related clinical signs other than a shuffling gait can point towards parkinsonism?
A
- postural sway
2. increased rate of walking
6
Q
what is a steppage gait?
A
the affected leg is lifted higher on walking and toes scrape the ground?
7
Q
what is the most common cause of a steppage gait?
A
foot drop
8
Q
what are 4 causes of foot drop?
A
- multiple sclerosis
- GBS
- peroneal nerve injury
- prolapsed intervertebral disc
9
Q
what are 2 conditions that can cause difficulty turning?
A
- cerebral defect
2. basal ganglia defect
10
Q
what does a widened base whilst walking suggest?
A
ataxia
11
Q
what is frontal ataxia?
A
a gait apraxia involving difficulty initiating movements despite normal power and co-ordination. gait is slow, shuffling and wide with hesitation and poor control
12
Q
what are 4 causes of frontal gait disorder/ ataxia?
A
- cerebral tumours
- subdural haematoma
- normal pressure hydrocephalus
- multiple lacunar infarcts
13
Q
what is the most common cause of a hemiparetic/ hemiplegic gait?
A
stroke/ CVA
14
Q
what is a hemiparetic/ hemiplegic gait?
A
asymmetry with flexors and extensors, affected side often shows increased flexion in upper limb and increased extension in lower limb. EG person walks with arm curled up and on one tiptoe
15
Q
what is the most common cause of scissor gait?
A
spastic cerebral palsy
16
Q
what is a scissor gait?
A
rigidity with excessive adduction of the legs when walking
17
Q
what is a trendelenburg gait?
A
the affected hip drops when the associated leg is raised from the ground
18
Q
what are 2 common causes of trendelenburg gait?
A
- L5 radiculopathy
2. hip abductor weakness/pain possibly due to superior gluteal nerve
19
Q
what is the most common cause of waddling gait?
A
proximal muscle weakness in the pelvic girdle
20
Q
what are three causes of proximal muscle weakness in the pelvic girdle?
A
- congenital hip dysplasia
- spinal muscular atrophy
- muscular dystrophies
21
Q
what are 2 common causes of disordered cognition/ deterioration of intellect?
A
- acute confusional state/ delirium
2. dementia
22
Q
what are 4 uncommon causes of disordered cognition/ deterioration of intellect?
A
- AIDS
- normal pressure hydrocephalus
- huntington’s disease
- vitamin deficiency
23
Q
what are 4 common causes of a coma?
A
- transient losses of consciousness (epilepsy/ syncope)
- primary cerebral conditions (haemorrhage, infection, trauma, tumours)
- hypoxia
- alcohol
24
Q
what 3 bits of information are important to find out with someone in a coma?
A
- immunosuppression
- recent travel
- past medical history
25
what are 5 components of an examination of someone in a coma?
1. normal obs
2. response to stimuli
3. survey of skin and mucous membranes
4. resp/abdo/cardiac/neuro exam
26
what does unilateral pupil dilation with no light response suggest?
uncal herniation of the temporal lobe trapping the 3rd nerve
27
what does fixed mid position pupils with a lack of response to light suggest?
midbrain lesion
28
what does small pupils with a response to light suggest?
pontine lesion
29
what is horner's syndrome?
usually unilateral meiosis, ptosis and anhydrosis
30
what does horner's syndrome suggest?
lesion in hypothalamus or brain stem, or an apical lung tumour (damage to sympathetic chain)
31
what do small pupils with a brisk response to light suggest?
metabolic cause
32
what are 6 common causes of dizziness?
1. benign positional vertigo
2. meniere's disease
3. vestibular neuronitis
4. brain stem stroke
5. TIA
6. postural hypotension
33
what are 2 uncommon causes of dizziness?
1. arrhythmia
| 2. multiple sclerosis
34
what is the pathophysiology of benign positional vertigo?
detached otoliths (calcite particles in the membrane of the inner ear) moving after the head has stopped moving, causing dizziness and vertigo
35
what are 3 causes of benign positional vertigo?
1. idiopathic
2. spontaneous labyrinth degeneration
3. chronic middle ear disease
36
what are 3 risk factors for benign positional vertigo?
1. women
2. older age
3. meniere's disease
37
what is the clinical presentation of benign positional vertigo?
vertigo worse on head movement and usually one side, sudden onset attacks for 20-30 seconds. nausea is common and often worse symptoms in the morning. hearing is not affected
38
what are 4 red flags in the examination of benign positional vertigo?
1. unilateral hearing loss
2. new onset headache
3. focal neurological signs
4. nystagmus
39
what is the management of benign positional vertigo?
1. reassurance
| 2. epley's manoeuvre
40
what is the pathophysiology of meniere's disease?
change in fluid volume in the labyrinth causing vertigo
41
what are 4 risk factors for meniere's disease?
1. allergy
2. autoimmunity
3. metabolic disturbance of sodium and potassium
4. viral infection
42
what are the 4 core symptoms of meniere's disease?
1. vertigo
2. tinnitus
3. fluctuating hearing loss
4. aural pressure
43
how long do attacks of meniere's disease last and what is their pattern of occurence?
2-3 hours, and usually occur in clusters
44
what do you examine for meniere's disease?
no diagnostic signs so do a cranial nerve, ear, c-spine exam and hallpike manoeuvre
45
what is the hallpike manoeuvre?
1. with the patient sitting up, turn head to 45 degrees
2. lie patient down with head overhanging the bead keeping the rotation and look for nystagmus
3. repeat on contralateral side, can be a sign of bpv
46
what is the medical treatment for vertigo attacks?
1. prochlorperazine, can also be used for nausea related to a migraine
2. local steroid injections
47
what is the pathophysiological of vestibular neuritis?
inflammation of the labyrinth and damage to vestibular and auditory end organs
48
what are 3 causes of vestibular neuritis?
1. reactivated herpes simplex type 1
2. autoimmune
3. microvascular ischaemic insults
49
what are 3 causes of cochlear trauma?
1. meniere's disease
2. meningitis
3. vertebrobasilar ischaemia
50
what is the clinical presentation of vestibular neuritis?
sudden incapacitating vertigo, not triggered by movement but worsened with movement. hearing loss can occur with labyrinthitis
51
what are 3 conditions to rule out with vestibular neuritis?
1. stroke
2. TIA
3. brain tumour
52
what are 7 important things to examine with vestibular neuritis?
1. cranial nerves
2. ear
3. gait
4. mastoid tenderness
5. weber's sign
6. head-impulse test
7. nystagmus type
53
what are 6 common causes of a headache?
1. non-organic pain syndromes
2. sinusitis
3. migraine
4. meningitis
5. subarachnoid haemorrhage
6. raised ICP
54
what is an uncommon cause of a headache?
encephalitis
55
what 5 things should a headache examination include?
1. optic fundi
2. blood pressure
3. temporal artery palpation (>50)
4. neuro exam
5. cognitive level
56
what is the 1st line treatment for acute tension headaches?
ibuprofen
57
what is the 1st line treatment for chronic tension headaches?
amitriptyline
58
what are 4 headache red flags?
1. papilloedema
2. new seizure
3. abnormal neurological signs
4. new onset cluster headache
59
how do you manage migraines?
1. simple analgesics like NSAIDs
2. prochlorperazine for nausea
3. triptans
60
what is the 1st line prophylactic treatment for migraines?
1. beta blocker
| 2. amitriptyline
61
what is the 2nd line prophylactic treatment for migraines?
sodium valproate
62
how do you treat a cluster migraine attack?
1. subcutaneous sumatriptan
| 2. oxygen
63
what is the 1st line prophylactic treatment for cluster headaches?
verapamil calcium channel blocker (2 weekly ECG monitoring necessary)
64
what is the 2nd line prophylactic treatment for cluster headaches?
lithium
65
what is the treatment for subarachnoid haemorrhage?
1. coiling or clipping
2. nimodipine to prevent cerebral ischaemia due to vasospasm
3. intubation and ventilation may be required
4. antiemetics and analgesia for conscious patients
66
what examination should be done for subarachnoid haemorrhage?
1. consciousness level
2. ophthalmoscopy
3. neck stiffness
4. full neuro exam
5. marked increase in BP
6. head CT
7. ECG
8. lumbar puncture if head CT is negative but symptoms suggest SAH
67
what are 4 common causes of movement disorder/ tremor?
1. parkinson's
2. benign essential tremor
3. drug induced (alcohol, neuroleptics, beta agonists)
4. thyrotoxicosis
68
what are 4 uncommon causes of movement disorder/ tremor?
1. huntington's
2. chorea
3. liver failure
4. wilson's disease
69
what is the first line treatment for benign essential tremor?
beta blocker (propranolol)
70
what are 4 neurological features of wilson's disease?
1. tremor (asymmetrical and variable)
2. difficulty speaking
3. excess salivation
4. ataxia
71
what are 6 causes of altered sensation?
1. peripheral neuropathy
2. CNS disorders (stroke, MS)
3. nerve root lesions
4. spinal cord compression
5. hyperventilation
6. circulatory disturbance (raynaud's, PVD, embolic disease)
72
what are 2 common causes of visual problems?
1. optic neuritis
| 2. papilloedema
73
what is optic neuritis and what is the triad of symptoms?
inflammation of the optic nerve presenting with eye pain, reduced vision and reduced colour vision
74
what is the clinical presentation of optic neuritis?
visual development over a period of hours to days that gets worse with a hot bath. presents with eye pain on movement, reduced vision and colour vision, and often light flashes and fatigue
75
what are 2 signs of optic neuritis?
1. decreased pupillary light reflex
| 2. papillitis in 1/3 of cases
76
how do you treat optic neuritis?
if the cause is demyelination, methylprednisolone can speed up acute recovery and interferon beta is considered
77
what tests should you do for optic neuritis?
1. fundoscopy
2. MRI
3. CXR if atypical for sarcoidosis
4. LP can be useful
78
what pathological phenomena causes papilloedema?
raised intracranial pressure
79
what are 3 causes of papilloedema?
1. non-arteritic anterior ischaemic optic neuropathy
2. optic neuritis
3. intracranial pathology
80
what are 3 common causes of unilateral papilloedema/
1. optic neuropathy
2. retinal vein occlusion
3. diabetic papillopathy
81
what are 2 common causes of bilateral papilloedema?
1. toxic optic neuropathy
| 2. malignant hypertension
82
what are 5 intracranial causes of papilloedema?
1. tumour
2. haemorrhage
3. trauma
4. infection/ abscess
5. respiratory failure
83
what is the clinical presentation of papilloedema caused by intracranial pathology?
increases over a period of hours to weeks, and can proceed to blind spot enlargement, blurred vision and vision obscurations
84
how do you treat papilloedema?
treat the underlying cause, iv mannitol can reduce intracranial pressure
85
what are 7 common causes of weakness?
1. upper/lower motor neurone lesions
2. hypocalcaemia
3. hypokalaemia
4. anaemia
5. post-viral syndrome
6. malignancy
7. guillain-barre
86
what are 3 uncommon causes of weakness?
1. myasthenia gravis
2. inflammatory myopathy
3. proximal myopathy (thyroid, cushing's, addison's)
87
what 2 disorders causing weakness can raise creatine kinase in the blood?
1. inflammatory myopathies
| 2. anterior horn cell disease
88
what is dysarthria?
a speech disorder caused by disturbance of muscle control
89
what is dysphagia?
impairment of language
90
what are 2 causes of dysarthria?
1. UMN lesions of cerebral hemispheres
| 2. LMN lesions of the brainstem
91
what are features of pseudobulbar palsy related to speech?
slurred and weak articulation, weak voice
92
what are features of cerebellar lesions related to speech?
slurred, staccato (stopping and starting through words) speech
93
what are features of parkinson's disease related to voice?
dysrhythmic, dysphonic (hoarseness) and monotonous voice
94
what are features of motor neurone disease related to voice?
indistinct articulation and hyper-nasality
95
what are 4 causes of dysarthria?
1. pseudobulbar palsy
2. cerebellar lesions
3. parkinson's disease
4. motor neurone disease
96
what are 3 causes of dysphasia?
1. stroke
2. dementia
3. head injury
generally caused by a lesion of the dominant hemisphere that affects broca's area or wernicke's area
97
what is receptive dysphasia and where in the brain is damaged?
language that is fluent in rhythm and articulation but does not make sense. wernicke's area
98
what is expressive dysphasia and where in the brain is damaged?
language that is NOT fluent in rhythm and articulation but the person understands what is being said. broca's area
99
what causes conduction dysphasia?
lesions in the arcuate fasciculus, posterior parietal and temoporal areas
100
what is conduction dysphasia?
speech that is quite fluent but words can be jumbled, speech is spontaneous and can be repetitive
101
what is the arcuate fasciculus?
a curved bundle of axons that connects broca's and wernicke's area. affected in conduction dysphasia
102
what are 4 neuro causes of incontinence?
1. stroke
2. multiple sclerosis
3. spinal cord injury
4. epileptic seizures
103
what are 7 causes of raised intracranial pressure?
1. localised mass lesions
2. neoplasm
3. abscesses
4. focal oedema secondary to infection or trauma
5. disturbance of CSF circulation
6. obstructed venous sinuses
7. idiopathic intracranial hypertension
104
what is the clinical presentation of raised intracranial pressure?
1. typically presents with headache, papilloedema and vomiting
2. headache worrying when nocturnal, early morning, or worse on coughing or moving the head
3. mental state changes early on can be tiredness, slow decision making, irritability, abnormal behaviour
4. other symptoms can include pupil changes, unilateral ptosis, hemiparesis, hypertension, slow irregular pulse
105
what investigations should be included in raised intracranial pressure?
1. CT/MRI
2. blood glucose
3. renal function
4. electrolytes
5. osmolality
106
in what 3 instances is ICP monitoring used?
1. severe head injury
2. abnormal CT
3. GCS 3-8
107
what are 2 treatment priorities for raised ICP?
1. maintaining arterial oxygen tension
| 2. maintaining normal vascular volume
108
what are some first line management strategies for raised ICP?
1. avoid pyrexia
2. manage seizures
3. CSF drainage
4. head off bed elevation
5. morphine for analgesia
6. IV propofol for sedation
7. neuromuscular blockade
8. iv mannitol to reduce cerebral hypertension
109
what is the last line strategy for raised ICP?
decompressive craniectomy
110
what is hydrocephalus?
increase in volume of CSF in the cerebral ventricles usually do to impaired absorption or increased secretion
111
what is the danger of hydrocephalus?
increased volume of CSF causes ventricular dilation, raised ICP and the CSF permeates periventricular white matter and can cause damage
112
what is non-communicative/obstructive hydrocephalus?
increases volume of CSF in the ventricles because there is obstruction to flow
113
what is hydrocephalus ex vacuo?
ventricular expansion secondary to brain atrophy
114
what are 4 causes of congenital hydrocephalus?
1. absence of antenatal care
2. maternal hypertension
3. pre-eclampsia
4. foetal alcohol use
115
what are 3 causes of acquired obstructive hydrocephalus?
1. supratentorial masses
2. intra-ventricular haematoma
3. tumours
116
what are 2 causes of communicating hydrocephalus?
1. thickening of the leptomeninges
| 2. increase in CSF viscosity
117
what are 2 signs of hydrocephalus in infants?
1. rapid increase in head circumference
| 2. increased limb tone
118
what are 4 signs of hydrocephalus in adults?
1. headache
2. vomiting
3. papilloedema
4. impaired upward gaze
119
what are 5 signs of gradual onset hydrocephalus?
1. cognitive deterioration
2. neck pain
3. nausea and vomiting
4. double vision
5. incontinence
120
how do you diagnose hydrocephalus?
CT scan with dilated ventricles
121
what does an abnormal 4th ventricle with regards to hydrocephalus mean in a CT scan?
posterior fossa mass
122
what does a normal 4th ventricle with regards to hydrocephalus mean in a CT scan?
aqueduct stenosis
123
what type of hydrocephalus is safe to use lumbar puncture?
communicating hydrocephalus
124
what is the common treatment for hydrocephalus?
insertion of a ventriculo-peritoneal shunt or an external ventricular drain
125
what is normal pressure hydrocephalus?
ventricular dilation in absence of CSF change
126
what are 3 symptoms of normal pressure hydrocephalus?
1. gait abnormality
2. urinary incontinence
3. dementia
4. pyramidal signs can be present and reflexes can be brisk
127
how do you diagnose normal pressure hydrocephalus?
1. MRI/CT shows ventricular enlargement
2. large volume LP shows normal CSF pressure
3. no papilloedema
128
how do you treat normal pressure hydrocephalus?
acetazolamide (carbonic anhydrase inhibitor) and ventriculo-peritoneal shunt insertion
129
what is a simple focal seizure?
motor or sensory disturbance with retained awareness
130
what is a complex focal seizure?
motor or sensory disturbance with impaired awareness
131
what are the 6 types of generalised seizures?
1. absence
2. tonic clonic
3. myoclonic
4. clonic
5. tonic
6. atonic
132
what are 5 non-idiopathic causes of epilepsy?
1. cerebrovascular disease
2. head injury
3. brain surgery
4. CNS infection
5. neurodegenerative disease
133
what are common features of the post-ictal phase?
1. drowsiness
| 2. headache
134
what is the clinical presentation of a generalised tonic clonic seizure
1. tonic and clonic phases
2. loss of consciousness
3. tongue biting
4. incontinence
5. usually last 1-3 minutes
135
what are 3 things that can cause a tonic clonic seizure?
1. sleep deprivation
2. alcohol
3. early morning seizures
136
what are 4 broad features of focal seizures?
1. motor (automatisms, lip smacking, plucking at clothes)
2. sensory (parasthesiae)
3. autonomic (epigastric sensation, nausea, abnormal taste)
4. psychiatric (deja vu, fear)
137
how do you diagnose epilepsy?
1. 2 seizures that are more than 24 hours apart
2. EEG abnormalities
3. MRI/CT
4. bloods
5. genetic testing
138
how often is epilepsy resistant to drug therapy?
1/3 of patients
139
how do you treat epilepsy?
1. tonic clonic- sodium valproate or lamotrigine
2. absence- ethosuximide or sodium valproate
3. tonic/atonic/myoclonic- avoid carbamazepine
4. focal seizures and focal seizures with secondary generalisation- carbamazepine 1st line, lamotrigine and sodium valproate 2nd line
5. try and treat with 1 drug and 1 main doctor
140
what is status epilepticus?
convulsive seizures that last for longer than 5 minutes, or convulsive seizures that occur one after another with no remission
141
what are 5 things that can cause status epilepticus?
1. drug withdrawal
2. intercurrent illness (disease occurring during current disease)
3. metabolic disturbance
4. alcohol intoxication
5. cerebrovascular accident
142
how do you treat status epilepticus?
1. protect the head and maintain the airway
2. IV lorazepam (0.1mg/kg) or buccal midazolam (10mg people over 10y/o, 7.5mg 5-10, 5mg 0-5)
3. IV phenytoin if necessary (1g if 60kg, 1.5g if 80kg, max 2g) do not use if bradycardic
4. IV diazepam if necessary
5. general anaesthesia if still refractory
143
what is the initial hospital management of a head injury?
1. involve neurosurgeons at an early stage
2. examine CNS, pulse, blood pressure, temperature, respirations and pupils every 15 minutes
3. assess anterograde and retrograde amnesia
144
what is the pre-hospital management for a head injury?
1. ABC
| 2. immobilisation of the cervical spine if indicated
145
when is cervical spine immobilisation indicated in a head injury?
1. neck pain
2. focal neurological deficit
3. paraesthesia
146
what are the indications for A+E referral with a head injury?
1. high energy head injury
2. loss of consciousness
3. amnesia
4. persistent headache
5. focal neurological signs
6. vomiting
7. seizures
8. visible trauma
9. suspected skull fracture
10. age over 65
11. history of bleeding
12. anticoagulation
13. drug or alcohol intoxication
14. suspicion of a non-accidental injury
147
what is the primary investigation for a head injury?
CT head
148
what are the indications for a CT head with a head injury?
1. gcs < 13 at any time
2. focal neurological signs
3. suspected open or depressed skull fracture (panda eyes, csf leak)
4. post-traumatic seizure
5. vomiting more than once
6. loss of consciousness COMBINED WITH-
age >65, coagulopathy, dangerous mechanism of injury, or anterograde amnesia of >30 minutes
basically anyone who needs to go to A+E also needs a head CT
149
what are the indications for a C-spine CT with a head injury?
1. GCS< 13
2. plain X-ray abnormal
3. patient intubated
4. suspicion
150
how can you treat a head injury in A+E?
1. high dose mannitol
2. prophylactic AED
3. early nutritional support
all depending on clinical signs
151
what is the immediate management plan for head injury in order?
1. ABC
2. oxygen with sats lower than 92% or hypoxia
3. stop blood loss, support circulation, if req treat for shock
4. treat seizures with lorazepam or phenytoin
5. assess level of consciousness and amnesia
6. rapid examination survey
7. investigations- u+e,, glucose, fbc, blood alcohol, toxicology, abg and clotting
8. neuro examination
9. brief history- when, where, how, had a fit, lucid interval, alcohol
10. evaluate face or scalp lacerations
11. check for csf leak from nose or ear and blood behind ear drum
12. palpate posterior neck for tenderness and deformity
13. radiology
152
what are 3 early common complications of head injuries?
1. extradural haemorrhage
2. subdural haemorrhage
3. seizures
153
what are 5 late onset complications of head injuries?
1. subdural haemorrhage
2. seizure
3. diabetes insipidus
4. parkinsonism
5. dementia
154
what is the clinical presentation of an extradural haemorrhage?
1. trauma that causes a loss of consciousness
2. headache
3. nausea and vomiting
4. seizures
155
what are some clinical signs of an extradural haemorrhage?
1. CSF otorrhoea/ rhinorrhoea
2. decrease in GCS
3. facial nerve injury
4. weakness of limbs
5. visual field defects
156
what is the clinical presentation of a haematoma in the spinal cord?
1. numbness
2. paraesthesia
3. alteration in reflexes
4. urinary incontinence
157
how do you treat an extradural haemorrhage?
1. maintain airway and perform a trauma assessment
2. treat with IV mannitol (osmotic diuretic) if ICP is raised
3. surgery might be needed to evacuate haematoma
158
what is the mortality rate for extradural haemorrhage?
30%
159
what are the 3 types of subdural haemorrhage?
1. acute
2. subacute (3-7 days)
3. chronic (2-3 weeks after injury)
160
what causes a subdural haemorrhage?
tearing of the bridging veins of the venous sinuses or bleeding from a damaged cortical artery. usually caused by blunt head trauma or aggressive shaking
161
what is the clinical presentation of a subdural haemorrhage?
1. presents shortly after a moderate-severe head injury and can involve a loss of consciousness
2. if it is chronic there is progressive anorexia, nausea, vomiting, and focal neurological deficit. can also manifest with sleepiness, headache, unsteadiness
3. fluctuating levels of consciousness are seen in 35% of cases
4. seizures may occur
162
what are four components of the examination for a subdural haemorrhage?
1. GCS evaluation
2. vital signs
3. neuro exam
4. external trauma exam
163
what investigations should be done for a subdural haemorrhage?
1. FBC, U+E, LFT, coagulation screen
| 2. CT head
164
what is the emergency management for subdural haemorrhage in severe trauma?
1. immobilise the cervical spine
2. assess ABC
3. intubate and ventilate
4. refer to neurosurgical team
5. IV mannitol if signs of raised ICP
6. treat coagulopathy
7. emergency craniotomy and clot evacuation
165
what are 5 complications fo a subdural haemorrhage?
1. cerebral oedema
2. raised ICP
3. recurrent haematoma
4. seizures
5. permanent neurological deficit
166
what are 4 causes of ischaemic stroke?
1. hypoperfusion
2. thrombus
3. embolus
4. cerebral venous sinus thrombosis
167
what are the two types of haemorrhagic stroke?
1. cerebral haemorrhage
| 2. subarachnoid haemorrhage
168
what are 4 causes of haemorrhagic stroke?
1. cerebral amyloid angiopathy
2. cerebral AV malformation
3. intracranial aneurysm
169
what are three classic features of a stroke?
1. facial weakness
2. arm drift
3. abnormal speech
170
what are 7 features of a stroke that involves the spinothalamic, corticospinal and dorsal columns?
1. hemiplegia
2. facial weakness
3. numbness
4. reduced sensation
5. reduced muscle tone leading to spasticity
6. hyperreflexia
7. tongue and sternocleidomastoid weakness
171
what nerves does a brainstem stroke affect?
the cranial nerves
172
what are 5 features of a stroke than involves the cerebral cortex?
1. aphasia
2. dysarthria
3. apraxia
4. visual field defect
5. memory loss
173
what are 3 features of a stroke that involved the cerebellum?
1. ataxia
2. co-ordination problems
3. vertigo
174
what vessels are mostly affected in the brain with large vessel disease?
1. common/ internal carotid arteries
2. vertebral arteries
3. circle of willis
175
what vessels are mostly affected in the brain with small vessel disease
1. middle cerebral artery
2. basilar artery
3. distal vertebral artery
176
what are two factors that can cause cerebral hypoperfusion?
1. cardiac arrest
| 2. arrhythmias
177
how does cerebral venous sinus thrombosis cause stroke
venous pressure will exceed arterial pressure so blood vessels break and leak blood into brain tissues
178
how do you diagnose a stroke?
history, examination and CT/MRI of the head
179
what investigations help you to determine the cause of a stroke?
1. ECG
2. ultrasound
3. angiogram
4. routine bloods
180
what are two procedures that remove atherosclerosis?
1. carotid angioplasty
| 2. carotid endarterectomy
181
what medicine can reduce the risk of future ischaemic strokes?
aspirin
182
what medicine can be given within 4.5 hours of the start of a stroke?
alteplase
183
how do you treat a venous stroke
LMW heparin and then warfarin, with oxygen if sats are less than 95%
184
what type of stroke might require a decompressive hemicraniectomy?
a middle cerebral artery stroke
185
what is the most common cause of a subarachnoid haemorrhage?
rupture of a berry aneurysm
186
what 3 genetic conditions have links to subarachnoid haemorrhage?
1. neurofibromatosis type 1
2. Marfan's
3. Ehlers-Danlos
187
where do 85% of berry aneurysms occur?
the circle of willis
188
what is the clinical presentation of a subarachnoid haemorrhage?
1. sudden explosive headache that may last for a few seconds
2. nausea and vomiting may occur
3. seizures may occur
4. meningism can present 6 hours after (headache, neck stiffness, photophobia)
5. following a head injury it causes headache, decreased consciousness and hemiparesis
189
what are symptoms of sentinel bleeds of a subarachnoid haemorrhage?
1. headache
2. diplopia
3. dizziness
4. orbital pain
often 3 weeks before subarachnoid haemorrhage
190
what should the examination for subarachnoid haemorrhage include?
1. consciousness level
2. ophthalmoscopy
3. neck stiffness
4. full neuro exam
5. marked increase in blood pressure
191
what does a subarachnoid haemorrhage in someone who has had seizures suggest?
arteriovenous malformation
192
how do you diagnose subarachnoid haemorrhage?
1. CT scan followed by an angiography
2. if CT is negative but symptoms are suggestive do a lumbar puncture and look for xanthochromia
3. ECG should be done
193
how do you treat cerebral ischaemia due to vasospasm in subarachnoid haemorrhage?
nimodipine
194
what treatments may be required for subarachnoid haemorrhage?
1. clipping/ obliteration
2. nimodipine
3. ventricular drainage or LP for hydrocephalus
4. intubation, ventilation and nasogastric feeding
5. analgesia and antiemetics
6. nitroprusside can be used for hypertension
195
what are 7 symptoms of meningitis?
1. severe headache
2. nuchal rigidity (inability to flex the neck forward)
3. sudden high fever
4. sudden altered mental status
5. photophobia
6. phonophobia
7. petechial rash
196
what is kernig's sign?
pain prevents passive extension of the knee
197
what is brudzinski's sign?
flexion of the neck causes involuntary flexion of the knee
198
what are 5 early complications of meningitis?
1. sepsis
2. DIC
3. gangrene
4. focal seizures
5. cranial nerve abnormality
199
what are 4 common viral causes of meningitis?
1. herpes simplex
2. varicella zoster
3. HIV
4. mumps
200
what are 3 non-infectious causes of meningitis?
1. sarcoidosis
2. SLE
3. malignant meningitis
201
what deficiency is common bacterial meningitis?
hyponatraemia
202
what are 3 prophylactic drugs for close contacts of people with meningitis?
1. rifampicin
2. ciprofloxacin
3. ceftriaxone
203
what antibiotic is given for meningococcal meningitis in primary care?
benzylpenicillin
204
what is the standard antibiotic given for meningitis?
cefotaxime (3rd generation cephalosporins)
205
what is given in paediatric H.influenzae meningitis?
corticosteroids
206
what is given in viral meningitis?
acyclovir
207
what is given in fungal meningitis?
amphotericin B
208
what is encephalitis?
sudden onset inflammation of the brain
209
what are 5 symptoms of encephalitis?
1. acute onset fever
2. headache
3. confusion
4. seizures
5. younger children may be irritable, feverish and have a poor appetite
210
what are 4 viral causes of encephalitis?
1. rabies
2. herpes simplex
3. polio
4. measles
211
what does an MRI of encephalitis show?
T2 hypersensitivity in median temporal lobes
212
what should investigations for encephalitis include?
MRI, EEG, LP, bloods, urinalysis
213
why are steroids used in encephalitis?
to reduce brain swelling
214
what are the symptoms of a frontal lobe tumour?
1. poor reasoning
2. personality change
3. inappropriate behaviour
4. poor planning
5. decreased speech production
215
what are the symptoms of a temporal lobe tumour?
1. loss of memory
2. loss of hearing
3. difficulties in language and comprehension
216
what are the symptoms of a parietal lobe tumour?
1. poor language interpretation
2. decreased sense of pain
3. poor visuospatial perception
217
what are the symptoms of an occipital lobe tumour?
poor vision or loss of vision
218
what are the symptoms of a cerebellar tumour?
1. poor balance
2. muscle movement
3. poor posture
219
what are the symptoms of a brain stem tumour?
1. altered blood pressure
2. swallowing difficulties
3. altered heartbeat
220
what is diagnostic for gliomas, meningiomas and brain mets and is seen on a CT/MRI?
disruption of the blood brain barrier
221
are meningiomas benign or malignant?
benign
222
what are the 5 most common original tumours to cause brain mets?
1. lung cancer
2. breast cancer
3. malignant melanoma
4. kidney cancer
5. colon cancer
223
what are 3 types of brain tumour and what are their prognoses?
1. medulloblastoma- good prognosis
2. glioblastoma- worse prognosis
3. oligodendroglioma- incurable and slowly progressive
224
what causes symptoms in parkinson's disease?
reduced dopamine in the pars compacta of the substantia nigra
225
what other abnormal body is found in the brain of someone with parkinson's disease?
lewy bodies
226
what are lewy bodies?
alpha-synuclein bound to ubiquitin in damaged cells
227
what are 3 genes that cause parkinson's disease?
PARK 1, 4, 5
228
what is the classic parkinsonian triad?
1. rigidity
2. bradykinesia
3. resting tremor
229
what are some other symptoms of parkinson's disease that are not the triad?
1. postural instability
2. shuffling gait
3. hallucinations
4. depression
5. sleep disturbance
6. cognitive dysfunction
7. reduced facial expressions
230
what is characteristic of the arms in a parkinsonian shuffling gait?
asymmetrical reduced arm swing
231
how do you diagnose parkinson's disease?
1. medical history and examination
| 2. patients can be given levodopa to see improvement which is diagnostic
232
how do you treat parkinson's disease medically?
1. dopamine analogue- levodopa
2. dopamine agonist- ropinirole
3. MAO inhibitors- selegiline
4. COMT inhibitors- entacopone
MAO and COM-T are enzymes that break down dopamine
233
what are some side-effects of dopamine agonists?
1. drowsiness
2. hallucinations
3. insomnia
4. nausea
234
what are some environmental causes of multiple sclerosis?
1. smoking
2. stress
3. toxins
4. diet
235
what is the pathophysiology of multiple sclerosis?
autoimmune disorder causing CNS plaques, inflammation and destruction of myelin sheaths. loss of oligodendrocytes
236
where in the central nervous system is white matter affected by lesions in multiple sclerosis?
1. basal ganglia
2. spinal cord
3. brainstem
4. optic nerve
237
what are 8 symptoms of multiple sclerosis?
1. loss of sensation
2. muscle weakness
3. blurred vision
4. hyperreflexia
5. muscle spasms
6. ataxia
7. dysarthria
8. depression
238
what of Uhthoff's phenomenon?
the worsening of multiple sclerosis symptoms in hot temperatures
239
what is Lhermitte's sign?
electrical sensation down back when bending the neck
240
how do you diagnose multiple sclerosis?
1. McDonald criteria
2. CT/MRI-periventricular lesions
3. LP- oligoclonal IgG bands
241
what are the 4 types of multiple sclerosis?
1. relapsing-remitting
2. primary progressive
3. secondary progressive
4. progressive-remitting
242
how do you treat multiple sclerosis medically?
1. treatment of relapses- methylprednisolone (steroid)
2. reduction of relapses- interferons and monoclonal antibodies (natalizumab)
3. fatigue- amantadine
4. spasticity- baclofen
5. emotional lability- amitriptyline
243
what are the three cause classification of spinal cord injury?
1. mechanical force
2. toxic
3. ischaemic
244
how is the level of injury defined in spinal cord injury?
the lowest level of full sensation and function
245
what is the clinical presentation of central cord syndrome?
1. weakness of arms
2. sparing in legs and spared sensation in areas supplied by sacral segments
3. loss of pain sensation, light touch and pressure below injury
246
what are the most common causes of central cord syndrome?
1. trauma to the neck due to mechanical injury
| 2. neck hyperextension in the elderly due to spinal stenosis
247
what is the clinical presentation of anterior cord syndrome?
lost motor sensation, pain and temperature sensation below the level of the injury
248
what are the most common causes of anterior cord syndrome?
1. compression of the anterior spinal artery
| 2. compression of the anterior spinal cord
249
what is the clinical presentation of posterior cord syndrome?
loss of proprioception and sense of vibration below the level of injury
250
what is the clinical presentation of brown sequard syndrome?
hemisection of the spinal cord causing loss of motor function, proprioception and vibration on the ipsilateral side and pain and temperature contralaterally
251
what is the clinical presentation of cauda equina syndrome?
1. leg weakness
2. saddle anaesthesia
3. back pain
4. sensory loss
5. decreased sphincter tone
252
what is guillain-barre syndrome?
autoimmune destruction of the peripheral nerve system, can be demyelinating or axonal
253
what typically causes guillain-barre syndrome?
gastroenteritis or respiratory tract infection
254
what are 5 viruses and bacteria that can cause guillain-barre syndrome?
1. campylobacter jejuni
2. influenza
3. epstein-barr virus
4. cytomegalovirus
5. varicella zoster
255
what is the clinical presentation of guillain-barre syndrome?
1. initial numbness, tingling and pain
2. progressive weakness of arms and legs (half a day to two weeks to reach maximum severity)
4. proximal muscles are more affected- trunk, respiratory, cranial nerves
5. BP fluctuations and arrhythmia
256
what are 3 complications of guillain-barre syndrome?
1. pneumonia
2. thrombosis
3. GI bleeding
257
how do you diagnose guillain-barre syndrome?
1. nerve conduction studies show slow conduction
2. increased protein in CSF
3. weakness and hyporeflexia on examination
4. CT/MRI
258
what is a potentially fatal symptom of guillain-barre syndrome?
respiratory muscle involvement causing respiratory distress
259
how do you treat guillain-barre syndrome?
1. plasmapheresis
2. IV immunoglobulins
3. mechanical ventilation
260
what is a radiculopathy?
damage to a spinal nerve root
261
what is the clinical presentation of radiculopathy?
1. sharp, shooting pain within the distribution of the nerve
2. weakness
3. loss of sensation
262
what is the clinical presentation of a proximal myopathy?
1. proximal weakness
| 2. stairs, hair and chairs- difficulty climbing stairs, brushing hair and rising from a chair
263
what are common causes of proximal myopathy?
1. steroids- in transplant, chemotherapy or severe respiratory disease
4. duchenne muscular dystrophy
264
what is the most common mononeuropathy?
carpal tunnel syndrome
265
what is the clinical presentation of carpal tunnel syndrome?
1. pain
2. numbness
3. paraesthesia
4. affects the thumb and first two fingers and can radiate up to the forearm
266
what never is compressed in carpal tunnel syndrome?
median nerve
267
how do you treat carpal tunnel syndrome?
carpal tunnel release surgery
268
what is the clinical presentation of peripheral neuropathy?
1. burning pain in feet
2. decreased vibration sensation
3. weakness
4. paraesthesia
5. numbness
6. all occurs in the peripheries
7. discordance between vibration and sensation
269
what is myasthenia gravis?
binding of autoantibodies to acetylcholine receptors that interfere with neuromuscular transmission (autoimmune destruction of post-synaptic acetylcholine receptors)
270
what is the clinical presentation of myasthenia gravis?
1. increased muscular fatigue
2. ptosis, diplopia and myasthenic snarl
3. voice fading on repeated talking
4. weakness
5. tone, reflexes and sensation are all normal
271
what are the common causes of myasthenia gravis?
1. other autoimmune diseases EG rheumatoid arthritis, SLE
| 2. thymic hyperplasia/ atrophy/ tumour
272
what is a myasthenic crisis?
worsening muscle weakness causing respiratory failure that required intubation and mechanical ventiliation, affecting 20-30% of patients within the first year
273
what 3 medications can aggravate myasthenia gravis symptoms?
1. antibiotics
2. anti-arrhythmics
3. beta-blockers
274
how do you diagnose myasthenia gravis?
1. anti-achR antibodies or MuSK antibodies
2. neurophysiological tests
3. clinical features and examination
4. thyroid function
5. MRI/CT head
6. Thymus CT
7. tensilon test
275
what is the tensilon test for myasthenia gravis?
giving the patient IV acetylcholinesterase inhibitor and observing muscle strength
276
how do you treat myasthenia gravis?
1. acetylcholinesterase inhibitor- pyridostigmine
2. immunosuppressants- prednisolone
3. thymectomy
4. IV Ig can be useful
277
what is the emergency management protocol for a coma?
1. ABC of life support
2. IV access
3. stabilise cervical spine
4. blood glucose fingerprick
5. control seizures
6. treat potential causes (EG IV glucose, thiamine, naloxone)
7. brief collateral history and examination
8. ABG, FBC, U+E, LFT, ESR, CRP, ethanol, toxicity, drug levels, blood cultures, urine cultures, malaria?
9. CXR, CT head
10. reassess situation
278
what are some common causes of acute confusional state?
1. PINCH ME- pain, infection (pneumonia, UTI, IV lines, encephalitis, meningitis), nutrition, constipation, hydration, medication (opiates, anticonvulsants, levodopa), environment
2. non-convulsive status epilepticus
3. head injury
279
what investigations should/could be done on a patient with acute confusional state?
1. FBC, U+E, LFT, glucose, ABG, septic screen, ECG, LP, EEG, CT/MRI
280
how do you treat acute confusional state?
1. reduce distress and prevent accidents
2. treat suspected cause
3. remove catheters if you can
4. augment self care
5. minimise medication, consider sedation if agitated and disruptive
281
what are 10 red flag symptoms for acute new headache?
1. first and worst headache
2. thunderclap headache
3. unilateral headache with eye pain
4. unilateral headache and ipsilateral symptoms
5. cough-initiated headache
6. worse in the morning or bending forward
7. persisting headache with scalp tenderness over 50
8. headache with fever or neck stiffness
9. change in pattern of usual headache
10. decreased consciousness
282
what is a first and worst, thunderclap headache likely to be?
subarachnoid haemorrhage
283
what 2 things is a unilateral headache with eye pain likely to be?
1. cluster headache
| 2. acute glaucoma
284
what 3 things is a unilateral headache with ipsilateral symptoms likely to be?
1. migraine
2. tumour
3. vascular
285
what 2 things are a headache that worsens on coughing, waking up and leaning forward likely to be?
1. raised ICP
| 2. venous thrombosis
286
what is a persistent headache and scalp tenderness in someone over 50 likely to be?
giant cell arteritis
287
what is a headache with fever or neck stiffness likely to be?
meningitis
288
what 6 things is a headache with decreased consciousness or localising signs likely to be?
1. stroke
2. encephalitis/ meningitis
3. cerebral abscess
4. subarachnoid haemorrhage
5. tumour
6. subdural haemorrhage
289
what 5 things can cause papilloedema with a headache?
1. tumour
2. venous sinus occlusion
3. malignant hypertension
4. idiopathic intracranial hypertension
5. prolonged CNS infection
