Neurology Flashcards by Josiah Grant

What is Frank’s sign?

Diagonal earlobe crease – it is a sign of diabetes mellitus and cardiovascular disease

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List a surgical sieve that you can use to consider different types of causes of neurological symptoms

Vascular

Infection

Inflammation/Autoimmune

Toxic/Metabolic

Tumour/Malignancy

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Describe the main features of:
UMN lesions
LMN lesions

UMN
Hyperreflexia
Hypertonia
Upgoing plantars
Reduced power

LMN
Hyporeflexia
Hypotonia
Wasting
Reduced power
Fasciculations

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Where is the lesion likely to be in a patient with widespread bilateral derangement of motor function?

Neuromuscular junction

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Name an important condition that causes loss of motor function in which the lesion is at the level of the neuromuscular junction.

Myasthenia gravis – autoantibodies against nicotinic acetylcholine receptors

NOTE: Lambert-Eaton syndrome has similar symptoms but is caused by a defect in the calcium channel on the presynaptic membrane involved in vesicular exocytosis

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What is a major risk factor for botulism?

IV drug use

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Describe the test used to confirm a diagnosis of botulism.

Bioassay – two mice are injected with a serum sample from the patient, and one of the mice is given the botulinum antitoxin. If the mouse without the antitoxin dies, it is botulism

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Describe the neurological signs seen in the examination of a patient with botulism.

Signs of LMN lesion

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What are the six main features of cerebellar disease

D - dysiadochokinesia
A - ataxia
N - nystagmus
I - intention tremor
S - Slurred speech
H - Hypotonia

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Using the surgical sieve VIITT, list some causes of cerebellar disease

Vascular – bleed in the cerebellar fossa

Infection – TB, varicella zoster, cerebellitis

Inflammation – MS

Tumour – primary or metastases

Toxic/Metabolic – alcohol, phenytoin

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Describe how the anatomical level of a sensory lesion affects the area of which the abnormal sensation experienced.

Brain – hemisensory

Spinal cord – at spinal cord level (e.g. T10 = umbilicus)

Nerve root (radiculopathy) – dermatome

Mononeuropathy – specific area of skin

Polyneuropathy – gloves and stockings

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What is the most common cause of polyneuropathy?

Diabetes Mellitus

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What is duloxetine and what can it be used to treat?

Anti-depressant (SNRI)

It can be used to treat peripheral neuropathy and premature ejaculation

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Using the surgical sieve VIITT, list some causes of polyneuropathy.

Vascular – no common causes

Infection – HIV

Inflammation – Guillain-Barre syndrome

Toxic/Metabolic – diabetes, amyloidosis, CKD, alcohol, cisplatin, amiodarone, metronidazole, phenytoin, isoniazid, nitrofurantoin

Tumour – paraneoplastic syndrome

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Which other drug may be used to treat neuropathic pain?

Pregabalin

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List the main toxic/metabolic causes of peripheral neuropathy. Suggest investigations that may reveal clues about each of the causes

Drugs – history

Alcohol – history + high GGT + high MCV

B12 deficiency – low Hb + high MCV

Hypothyroidism – TFTs

Uraemia – U&Es

Amyloidosis – history of multiple myeloma or chronic infection/inflammation

Diabetes mellitus – history + blood glucose + HbA1c

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Explain why myeloma is associated with amyloidosis

Myeloma causes increased production of immunoglobulins, which have light chains

The light chains are a precursor to amyloid fibrils

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Explain why chronic inflammation/infection is associated with amyloidosis.

Inflammation leads to high levels of serum amyloid protein A (an acute phase protein)

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List some associated symptoms to ask patients presenting with neurological symptoms.

Impaired vision
Impaired hearing
Headache
Speech disturbance
Weakness
Sensory disturbance
Bowel continence
Urinary continence

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List some inflammatory/autoimmune causes of peripheral neuropathy

Vasculitis

Connective tissue diseases

Demyelinating polyneuropathy (e.g. Guillain-Barre syndrome)

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Describe the appearance of the feet in patients with long-term peripheral neuropathy.

High-arched foot (pes cavus)

Clawed toes

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What is amaurosis fugax?

Painless temporary loss of vision in one or both eyes

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List two causes of blurring of the optic disc margin and explain how you would differentiate between them.

Papilloedema – NO pain and NO blurring of vision

Papillitis – pain and blurring of vision

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What is papillitis?

Inflammation of the head of the optic nerve

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In which part of the spinal cord do you find the descending inhibitory tracts?

Corticospinal tract

What happens if the spinothalamic tract is compressed at a particular level?

Impaired/loss of sensation up until the level of the lesion

Define paraparesis

Partial paralysis of the lower limbs

State a vascular cause of spastic paraparesis

Obstruction of the anterior or posterior spinal arteries

State an infective cause of spastic paraparesis

TB of the spine (Pott’s disease)

State an inflammatory (demyelinating) cause of spastic paraparesis.

Transverse myelitis (may be associated with infections e.g. chest infections caused by Mycoplasma pneumonia)

What features of the history are necessary for a diagnosis of multiple sclerosis?

Two lesions separated in time and space

Which condition causes pain and paraesthesia on the anterolateral thigh and what is it caused by? Outline the treatment

Meralgia paraesthetica Compression of the lateral femoral cutaneous nerve Reassure the patient that it isn’t something serious Avoid tight garments Lose weight

Which pharmaceutical options might you consider if meralgia paraesthetica pain persist despite these treatment?

Carbamazepine Gabapentin

What is a radiculopathy?

Disease of the nerve roots

What is sciatica

Pain in the buttock, radiating down the leg below the knee It is caused by compression of the lumbosacral nerve roots

What can cause compression of the nerve roots?

Disc herniation Spinal canal stenosis

Describe the main features of Parkinson’s disease

Rigidity Bradykinesia Resting tremor Gait instability

List some other diseases that cause symptoms that are similar to Parkinson’s disease

Progressive supranuclear palsy Lewy body dementia

What is the key feature of progressive supranuclear palsy that helps distinguish it from Parkinson’s disease?

Limited upgaze

What is the underlying pathological process that causes Parkinson’s disease?

Depletion of dopaminergic neurons in the subtantia nigra

What is cogwheel rigidity caused by?

A tremor superimposed on increased tone

What is another name for progressive supranuclear palsy?

Steele-Richardson syndrome

What are the key features of Lewy body dementia?

Parkinsonism | Hallusinations

If there are no abnormalities seen on examination and imaging of a patient presenting with confusion, what is the likely cause?

Toxic/metabolic

What dangerous disease can cause confusion and chest pain?

CO poisoning

List four causes of confusion with reduced AMTS.

Post-ictal Dysphasia Dementia Progressive pseudodementia

List some causes of dementia.

Alzheimer’s disease Vascular dementia Lewy body dementia Alcoholism Inherited (e.g. Huntingdon’s disease)

What are some important features of the history that you should check in a dementia history?

History of ischaemic heart disease/peripheral vascular disease History/signs of alcohol abuse Other symptoms (e.g. Huntingdon’s chorea)

List a differential diagnosis for confusion and reduced consciousness

Hypoglycaemia Vascular (i.e. bleed) Infection Inflammation Malignancy Toxic/metabolic

What are some distinguishing features of a subdural haematoma?

Falls and fluctuating consciousness

What are the main symptoms of intracranial infection?

Neck stiffness | Headache

State an inflammatory cause of confusion with reduced consciousness.

Cerebral vasculitis

List some investigations you would perform to look for a toxic/metabolic cause of confusion with reduced AMTS.

Drug history U&Es LFTs Vitamin deficiencies Endocrinopathies

Which endocrine disease may present with confusion?

Cushing’s disease

What are the four main diseases that you need to think about when a patient presents in the emergency department with a headache?

Meningitis Giant cell arteritis Subarachnoid haemorrhage Migraine

List the main symptoms of meningitis

Headache Neck stiffness Fever Photophobia Kernig’s sign

What is Kernig's sign?

When the hip is flexed and the knee is at 90 degree, extension of the knee causes pain

Describe the presentation of subarachnoid haemorrhage

Sudden-onset worst headache ever

What is the first investigation that is performed in suspected SAH?

CT Head

What would you look for when doing a lumbar puncture of a patient with SAH?

Xanthochromia (yellow discolouration of the CSF due to the break down of haemoglobin)

List the main symptoms of giant cell arteritis

Headache Loss of vision Jaw claudication Scalp tenderness

Which disease is giant cell arteritis associated with?

Polymyalgia rheumatica

How do you treat giant cell arteritis?

High-dose prednisolone

List two investigations that you would perform in a patient with giant cell arteritis

ESR Temporal artery biopsy

Describe the features of migraine

Unilateral, throbbing pain around the eye

List examples of negative and positive auras

Negative – dark, black holes Positive – flashing lights

What is the window for thrombolysis in a patient with stroke?

Within 4.5 hours of onset of symptoms

Which investigation must you perform in stroke patients before giving any treatment?

CT Head – exclude haemorrhage

Describe the management of a stroke patient who presents > 4.5 hours after the onset of symptoms

CT head to exclude haemorrhage Aspirin (300 mg) Swallow assessment Maintain hydration, oxygenation and monitor glucose

At what point do you worry about the blood pressure of a patient with a TIA?

If the blood pressure rises > 220/120 mm Hg

Describe the management of a patient with TIA

Aspirin Risk factor modification

List some investigations that you would perform in a patient with a TIA

ECG Echocardiogram Carotid artery Doppler

Why is it important to monitor FVC in a patient with Guillain-Barre syndrome?

It can cause respiratory muscle weakness and reduce ventilation

How is FVC monitored?

Spirometry

What must you do if the FVC begins to drop?

Ventilate

Why is it important to set up a cardiac monitor for patients with Guillain-Barre syndrome?

Guillain-Barre syndrome is associated with autonomic neuropathy

How is Guillain-Barre syndrome treated?

IVIg

Construct a simple list of causes of collapse

Hypoglycaemia Cardiac – vasovagal, arrhythmia, outflow obstruction, postural hypotension Neurlogical – seizure