Neurology Flashcards
1
Q
What does meningism refer to?
A
set of 3 symptoms:
stiffness of the neck, photophobia, severe headache
2
Q
Patients with viral or bacterial meningitis generally have?
A
Fever, malaise, rash (typically haemorrhagic in meningococcoal meningitis)
3
Q
Viral causes of meningitis (HELP Me)
A
Herpes simplex virus Enteroviruses Lymphocytic chorio meningitis virus Poliovirus Mumps virus
4
Q
Bacterial causes of meningitis in neonates?
A
E.Coli, group B streptococcus, listeria monocytogenes
5
Q
Bacterial causes of meningitis in infants?
A
Neisseria meningitidis, Steptococcus pneumoniae, haemophilius influenzae
6
Q
Bacterial causes of meningitis in young adults?
A
Neisseria meningitidis, S.pneumoniae
7
Q
Bacterial causes of meningitis in the elderly
A
S.pneumoniae, Neisseria meningitidis, Listeria monocytogenes
8
Q
What is encephalitis? Clinical symptoms?
A
inflammation of the cerebral cortex (generally viral)
fatigue, decreased consciousness, fever, fits
9
Q
Meningo-encephalitis
A
If a patient with encephalitis also has meningism
10
Q
Viral causes of encephalitis
A
Herpes simplex virus, varicella zoster virus, HIV, mumps, measles, parvoviruses
11
Q
Procedure to test CSF?
A
lumbar puncture
12
Q
Lumbar puncture
A
Needle that pierces the dura and arachnoid mater to enter the subarachnoid space
13
Q
Early signs of meningitis in a lumbar puncture
A
Low glucose, high protein, WCC
14
Q
Difference between lumbar and epidural?
A
Different needle, epidural, need to stay OUTSIDE the dura, therefore bent and blunt needles used for epidural (not sharp). Once reaches the dura, pushes dura away, can feed tube into needle and inject anaesthesia
15
Q
If the predominant kind of WBC in the CSF are neutrophils, does this indicate viral or bacterial infection?
A
bacterial (neutrophils are professional phagocytes that respond to bacteria)
16
Q
Why do you get reduced glucose in the CSF with an inflammatory response to a bacterial infection?
A
neutrophils are metabolically active and use glucose
17
Q
Why is there increased protein in the CSF in a bacterial infection?
A
Dying bacteria, antibacterial proteins and antibodies all contribute to the elevated CSF
18
Q
Empirical antibiotics given for CNS bacterial infections?
A
IV cefotaxime, ceftriaxone
19
Q
Adjunctive therapy alongside antibiotics for CNS infections?
A
IV dexamethasone (corticosteroids) - reduce the risk of long-term neurological complications from some bacterial causes of meningitis
20
Q
CSF from lumbar puncture with a viral infection?
A
WCC predominantly lymphocytes (not neutrophils), moderately raised protein
21
Q
Meninges blood supply
A
meningeal vessels (branches of the internal carotid) run in the extradural (epidural) space, bridging veins across the subdural space, circle of Willis lies in the subarachnoid space, there are no vessels deep to the pia mater, the pia forms part of the BBB
22
Q
Stroke definition
A
Infarction or bleeding to the brain which manifests with sudden-onset focal CNS signs, lasting over 24hours
23
Q
Risk factors for stroke
A
HTN, DM, age, smoking, heart disease, raised PCV, polycythaemia, clotting disorders, combined oral contraceptive pill
24
Q
Two types of stroke
A
Ischaemic (85%) - cerebral infarction due to thrombosis or arterial embolism
Haemorrhagic (15%) - subarachnoid or intracranial, blood leaks into brain
25
Causes of ischaemic stroke?
Thrombosis or arterial embolism blocks a blood vessel
26
Causes of haemorrhagic stroke
Trauma, aneurysm rupture, thrombolysis, anticoagulation, carotid artery dissection
27
Differential diagnosis for stroke?
Hypoglycaemia, migraine aura, focal epilepsy, syncope
28
Clinical presentation of anterior cerebral artery (ACA) ischaemic stroke (DISTAL)
```
Drowsiness
Incontinence
Sensory leg disturbances
Truncal ataxia
Akinetic mutism
Leg weakness
```
29
Clinical presentation of middle cerebral artery (MCA) ischaemic stroke (CHAFD)
```
Contralateral arm/leg weakness
Hemianopia
Aphasia
Facial droop
Dysphasia
```
30
Clinical presentation of posterior cerebral artery (PCA) ischaemic stroke (CCCUPV)
```
Contralateral homonymous hemianopia
Cortical blindness
Colour naming and discrimination difficulties
Unilateral headache
Prosopagnosia
Visual agnosia
```
31
Stroke Ix
1. Urgent CT/MRI (to identify ischaemic or haemorrhagic)
2. Pulse, BP, ECG - to look AF/MI
3. FBC - thrombocytopenia, polycythaemia, exclude hypoglycaemia
32
1st step of stroke Mx
Maximise reversible ischaemic tissue - hydration and oxygen
33
Stroke Mx - ischaemic
1. Thrombolysis - give tissue plasminogen activator (IV altepase) and start antiplatelet therapy
2. If time of onset is known, give daily aspirin for 2 weeks and lifelong clopidogrel
34
Stroke Mx - haemorrhagic (MC MARS)
```
Monitor GCS
Control HTN
Manual decompression of raised ICP or give diuretics
Antiplatelets contraindicated
Reverse anticoagulation
Surgery may be required
```
35
Transient ischaemic attack
Ischaemic neurological event with symptoms lasting <24hours, without intervention 1 in 12 patients will have a stroke within a week
36
Risk factors for TIA
(same for stroke), age, HTN, DM, smoking, raised PCV, polycythaemia
37
Causes of TIA?
1. atherothromboembolism (from the carotid)
2. cardioembolism (microemobil from mural thrombus post-MI, AF)
3. hyperviscosity (raised PCV, polycythaemia)
38
Distribution of TIA
Anterior circulation (90%) - carotid, posterior (10%) - vertebrobasilar
39
TIA symptoms - anterior circulation (HOAD)
Hemiparesis
Occlusion may cause weak contralateral arm/leg
Amaurosis fugax
Dysphagia
40
TIA symptoms - posterior circulation (Don'T CHAV)
Diplopia, tetraparesis, choking, hemianopia vision loss, ataxia, vertigo/vomiting
41
Ix for TIA
Bloods - FBC (polycythaemia), glucose (hypoglycaemia), cholesterol
Diffusion weighted MRI (if ABCD2 >4)
Carotid artery doppler US
ECG (AF)
42
Tx for TIA
1. ABCD2 score for stroke risk
2. Control CDV risk factors (HTN = ACE-i/ARBs, cholesterol = statins)
3. Antiplatelet drugs - aspirin then clopidogrel
4. Anticoagulation - e.g. warfarin, if have AF, mitral stenosis
43
What driving precautions should be taken after TIA?
Do not drive for 4 weeks after a TIA
44
Clopidogrel
P2Y12 inhibitor, antiplatelet drug. Works by binding to the P2Y12 receptors on platelets to prevent platelet aggregation
45
Subarachnoid haemorrhage (SAH)
Bleeding in the subarachnoid space (arachnoid and pia mater)
46
Risk factors for SAH?
HTN, age, smoking, previous aneurysmal SAH, FHx
47
Causes of SAH
Berry aneurysm rupture (80%), arteriovenous malformations (15%) - fistula between arterial and venous symptoms causing high blood flow between AVM, idiopathic otherwise
48
Ix for SAH
CT scan
Lumbar puncture (bilirubin, oxyhaemoglobin)
MR angiography
49
Tx for SAH
Immediate referral to neurosurgeon
Re-examine CNS often - BP, GCS
Maintain cerebral perfusion by keeping well hydrated
CCB (nimodipine) to reduce vasospasm
Surgery - endovascular coiling or surgical clipping
50
Complications of SAH?
Re-bleeding, hyponatraemia, cerebral ischaemia due to vasospasm, hydrocephalus
51
Subdural haemorrhage (SDH)
accumulation of blood in the subdural space (between dura and arachnoid) following the rupture of a bridging vein
52
Who are vulnerable to SDH and why?
Alcoholics, those with dementia - brain size < skull, bridging veins more vulnerable to rupture
53
Causes of SDH
Most due to trauma, but can be 9 months previously
54
Pathophysiology of SDH
Bleeding from bridging veins, stops due to low pressure, forms clot, after time clot lyses and increased clot fragments in blood increases osmotic pressure, draws in water which increases ICP, leads to shift of the midline structures to the side, eventual coning
55
What is meant by coning?
As the ICP rises the brain pushes through the foramen magnum
56
Clinical presentation of SDH
Latent period --> headache, drowsiness, unsteadiness, mood change
57
Ix of SDH
CT scan, MRI
58
Tx for SDH
Reverse clotting abnormalities, refer to neurosurgeon, IV mannitol (diuretic) to reduce ICP
59
Extradural haemorrhage
Collection of blood between the dura mater and bone, most commonly due to trauma --> skull fracture --> laceration of the middle meningeal artery
60
Clinical presentation of extradural haemorrhage
Characteristic history of head trauma, followed by brief period of unconsciousness/drowsiness --> lucid interval (hours/days)
Severe headache, nausea, vomiting, confusion, rapid ICP increase, ipsilateral pupil dilates, decreased GCS, coning
61
Ix for extradural haemorrhage
CT scan shows hyperdense haematoma in biconcave shape
| Skull X-ray may show fracture that crosses the middle meningeal artery
62
Tx for extradural haemorrhage
ABCDE, IV mannitol (diuretic to reduce ICP), referral to neurosurgery, maintain airway via intubation
63
Myasthenia gravis
Autoimmune condition mediated by antibodies against ACh receptors on the post-synaptic side of the NMJ
64
Causes of myasthenia gravis
- If <50, more common in women and associated with other autoimmune conditions e.g. SLE, RA
- If >50, more common in men, and associated with thymus atrophy/cancer
65
Clinical presentation of Myasthenia gravis?
Progressive muscle weakness (order of muscle weakness - extraocular, bulbar, facial, neck, trunk), ptosis (eyelid drooping), displopia, myasthenic snarl when smiling, tendon reflexes present, general respiratory difficulties
66
Order of progressive muscle weakness in myasthenia gravis? (Every Boy Finds Nice Trousers)
Extraocular, bulbar, facial, neck, trunk
67
Ix for myasthenia gravis
1. Anti-AChR antibodies
2. Electromyography (EMG) - decrement in muscle AP upon stimulation
3. CT of thymus
68
Mx for myasthenia gravis?
1. Symptom control (muscle weakness) - acetylcholinesterases (pyridostigmine)
2. Immunosuppression (prednisolone)
3. Thyectomy
69
Myasthenic crisis
Life-threatening weakness of the respiratory muscles during a relapse, monitor the FVC, treat with plasmapheresis (removal of AChR antibodies)
70
Lambert-Eaton Myasthenic syndrome (LEMS)
Autoimmune disorder of NMJ, impaired pre-synaptic release of ACh due to antibodies against the calcium voltage gated ion channels (P/Q subtype)
71
Risk factor for LEMS
Cancer - LEMS is paraneoplastic in 50% cases (in particular small cell cancer of the lungs)
72
Presentation of LEMS
Proximal muscle weakness, depressed tendon reflexes, gait difficulty, autonomic symptoms - dry mouth, constipation, postural hypotension
73
Ix for LEMS
EMG, CT scan/MRI of lungs, serum test for voltage gated calcium channel antibodies
74
Mx of LEMS
Pyridostigmine (improve muscle strength), prednisolone (steroid immunosuppression), IV Ig
75
What is epilepsy?
Condition that occurs due to excessive and uncontrolled neuronal activity in the brain, manifesting in seizures
76
Seizure criteria to be defined as epileptic?
>2 24hrs apart
77
Risk factors for epilepsy?
FHx, premature babies, abnormal blood vessels in brain, Alzheimers/dementia, drug use
78
Causes of epilepsy
1. Idiopathic
2. Cortical scarring - head injury, cerebrovascular disease
3. Stroke, tumour, Alzheimer's dementia
79
Focal/partial seizures
Originating in networks often linked to one hemisphere/lobe
80
generalised seizures
originating at some point within and rapidly engaging bilaterally distributed networks leading to simultaneous onset of widespread electrical discharge
81
Two types of focal/partial seizure
1. Simple/without loss of consciousness
| 2. Complex/loss of consciousness
82
Types of generalised seizures
Tonic-clonic, absence, atonic, myoclonic, infantile spasms
83
What is meant by tonic and clonic?
tonic = muscles stiffen, clonic = muscles jerk
84
Symptoms of simple focal seizure?
Focal motor, sensory, autonomic or psychic symptoms e.g. deja vu, hallucinations
NO post-ictal symptoms
85
Mx for focal seizures?
1. carbamazepine, lamotrigine
| 2. sodium valproate
86
Symptoms of complex focal seizures?
Impaired awareness, post-ictal confusion
87
Tonic-clonic seizure
Muscle stiffening followed by muscle jerking, may be associated with tongue biting, incontinence, groaning.
POST-ICTAL confusion and drowsiness
88
Mx for tonic-clonic seizures?
1. sodium valproate
| 2. carbamazepine, lamotrigine
89
Absence seizures
Typically occur in children, brief (<10s) pause, stare into space, then return to normal suddenly, unaware during episode
90
Mx for absence seizures
Sodium valproate
91
Atonic seizures
'Drop attacks', sudden lapse in muscle tone, may cause a fall, no loss of consciousness
92
Mx for atonic seizures
1. Sodium valproate
| 2. Lamotrigine
93
Myoclonic seizures (flying saucer seizure)
Sudden brief muscle contractions/jerking
94
Mx for myoclonic seizures
1. Sodium valproate
| 2. Lamotrigine
95
Infantile spasms
Clusters of full body spasms in infancy, rare disorder
96
Ix for epilepsy
1. Electroencephalogram (EEG)
2. MRI
3. CT
97
Mx of epilepsy
1. Anti-eplieptic drugs
2. Psychological therapies e.g. CBT
3. Surgical intervention
98
papilloedema
optic disc swelling, often a presentation of brain tumours
99
Why does raised ICP at the start of a brain tumour not cause a problem?
Brain is compliant, removes CSF from ventricles --> spinal cord to adjust for increasing ICP due to tumour, but there is a point when no more CSF can be relocated and there is a really sharp rise in ICP --> symptoms --> midline shift of brain
100
Commonest types of tumours to metastasise to the CNS?
Lungs, breast, renal cell carcinoma, melanoma, GI
101
Gliomas (in order of decreasing malignancy)
1. Astrocytomas (85-90%)
2. Oligodendrogliomas (5%)
3. Ependymomas
102
Most common form of primary brain tumour?
gliomas
103
meningiomas
tumours growing from cells in the meninges, often benign
104
If a pituitary tumour grows large enough and presses on the optic chiasm?
Bitemporal hemianopia
105
Acoustic neuroma
tumours of the Schwann cells surrounding the auditory nerve that innervates the inner ear, occurring around the cerebellopontine angle
106
Risk factors for primary brain tumours?
FHx, ionising radiation, vinyl chloride, affluent people, immunosuppression
107
Common pathway for malignant gliomas?
Mutation of IHD-1 --> excessive 2-hydroxyglutarate (glycolysis of glucose) --> triggers genetic instability in glial cells --> inappropriate mitosis --> cancer
108
Oligodendrgliomas
arise from oligodendrocutes, slow growing, grade II, cause seizures, all IHD-1 positive
109
4 cardinal symptoms of primary brain tumours
1. Raised ICP
2. Neurological deficits
3. Epilepsy/seizures
4. Lethargy/fatigue
110
Symptoms of raised ICP due to brain tumour? (Prince Died Very Peacefully)
1. progressive headache
2. drowsiness
3. vomiting
4. papilloedema
111
Frontal lobe neurological deficit symptoms due to primary tumour?
hemiparesis, personality change, Broca's dysphasia, lack of ability to plan
112
parietal lobe neurological deficit symptoms due to primary tumour?
hemisensory loss, dysphasia, reduction in 2 point-discrimination
113
temporal lobe neurological deficit symptoms due to primary tumour?
dysphasia, amnesia
114
occipital lobe neurological deficit symptoms due to primary tumour?
contralateral visual defects
115
cerebellar neurological deficit symptoms due to primary tumour?
```
Dysdiadochokinesia
Ataxia
Nystagmus
Intention tremor
Slurred speech
Hypotonia
```
116
Ix for primary brain tumorus
CT and MRI, bloods, biopsy (via skull burr-hole)
117
Mx for primary brain tumours
Surgery, radiotherapy, chemotherapy (temozolomide), oral dexamethasone (most powerful synthetic steroid which rapidly improves brain performance in all tumours)
118
Most common type of seizures in primary brain tumours?
Focal
119
Charcot-marie-tooth disease
peroneal muscle atrophy, heterogenous group of inherited peripheral neuropathies
120
Clinical presentation of Charcot-Marie-Tooth disease
- High foot arches (pes cavus)
- 'Inverted champagne bottle legs' due to distal muscle wasting
- Lower limb and hand weakness
- Foot drop
- Peripheral sensory loss
121
Gullain-Barré syndrome
Acute inflammatory demyelinating polyneuropathy, begins soon after infection, followed by recovery
122
Signs of Gullain-Barré syndrome
Symmetrical ascending muscle weakness following infection, reduced reflexes
123
Triggers for Gullain-Barré syndrome
Infections such as campylobacter jejuni, HIV, EBC, causes antibody production which can also attack nerves
124
Mx of Gullain-Barré syndrome
IV immunglobulin and plasmapheresis
125
Giant cell arteritis (temporal arteritis)
Granulmatous arteritis of the aorta and large vessels (affecting the head and neck), particularly affect the temporal artery
126
Pathophysiology of GCA
Granulomatous arteritis (arterial inflammation) in skip lesions along the artery, leading to endothelial damage and thus thrombus formation --> obstruction of blood flow --> ischaemia
127
Clinical presentation of GCA
- New onset severe headache
- Tenderness along the temporal artery
- Scalp tenderness
- Visual loss
- Jaw claudication
128
Ix for GCA
1. Temporal artery biopsy - diagnostic, need large section due to skip lesions
2. Raised ESR/CRP
3. Raised platelets
129
Mx of GCA
1. Begin high dose steroids (e.g. prednisolone) IMMEDIATELY
| 2. Bisphosphonates (osteoporosis prophylaxis)
130
What forms the carpal tunnel? what passes through
ligament and carpal bones, nine tendons and median nerve
131
Why does carpal tunnel syndrome occur more often in females?
smaller wrists but same size tendons
132
Clinical presentation of CTS?
- Aching pain in hand and arm (especially at night, can wake patient)
- Paraesthesia in thumb, index and middle fingers, relieved by dangling over the edge of the bed (wake and shake)
133
Ix for CTS
Phalen's test - maximal flexion of wrist for 1 min may induce pain
Tinel's test - tapping over nerve can induce tingling
134
Mx of CTS
Wrist splinting, local steroid injections, decompression surgery
135
Amaurosis fugax?
Unilateral vision loss 'like a curtain descending', occurs when the retinal artery is occluded
136
How does Paget's disease of bone affect the skull?
Overgrowth of bone can compress and damage the nerve, causing pain, weakness or tingling in an arm or leg or hearing loss
137
Huntington's disease
neurodegenerative disorder that causes chorea, characterised by the lack of GABA (inhibitory neurotransmitter)
138
Effect of lack of GABA in HD?
Less inhibition of glutamate release, therefore more thalamic stimulation --> jerky, semi-purposeful movements
139
What is meant by anticipation in HD?
The number of CAG repeats in each successive generation = earlier onset disease, more severe disease
140
Pathophysiology of HD?
Repeated expression of CAG, >35 repeats = HD, --> mutated huntingtin proteins have tendency to cluster and cause neurodegeneration in the brain therefore
141
Clinical presentation of HD
Chorea, muscle rigidity, dysarthria, dysphagia, cognitive symptoms (dementia)
142
Prodromal phase of HD
Irritability, confusion, incoordination
143
Medications for HD
Antipsychotics, diazepam, dopamine deleting agents (e.g. tetrabenazine)
144
What is Wernicke-Korsaoff syndrome?
Acute and reversible encephalopathy due to vitamin B1/thiamine deficiency
145
In which patients is WK syndrome common?
Alcohol abusers
146
Classic triad of symptoms in Wernickes encephalopathy?
confusion, ataxia and opthalmoplegia
147
Korsakoff's syndrome?
Late manifestation of the condition where Wernicke's encephalopathy is not treated adequately
148
How does chronic alcohol intake lead to thiamine/B12 deficiency?
- Inadequate intake
- Decreased absorption
- Impaired utilisation in the cells
149
Wernicke's Korsakoff's syndrome presentation COAT RACK
Confusion, ophthalmoplegia, ataxia, thymine deficiency
Retrograde amnesia
Anterograde amnesia
Confabulation
Korsakoff's psychosis
150
Myopathy
Primary disorder of muscles with gradual-onset symmetrical proximal muscle weakness
151
Differences between myopathy and neuropathy
Paraesthesia present in NP, not MP
NP = asymmetrical, MP = symmetrical
NP = distal, MP = proximal
Tendon reflexes, NP = diminished, MP = present
152
Muscular dystrophies
Progressive degeneration and weakness of specific muscle groups
153
Duchenne's muscular dystrophy (DMD)
Commonest muscular dystrophy, X-linked recessive condition, presents in early childhood and progresses, mutation in dystrophin gene --> absence of dystrophin protein
154
Ix of DMD
- Suspect in any boy that cannot walk by 18 months
- Serum creatinine kinase (high in DMD)
- Genetic analysis
- Muscle biopsy for dystrophin protein
155
Presentation of DMD
- Progressive proximal muscular dystrophy
- Pseudohypertrophy of calves
- Delay in motor milestones - inability to run, waddling gait
- Gower's sign - climbing up legs using hands when rising from the floor
156
Mx for DMD
genetic counselling, physiotherapy, corticosteroids (e.g. prednisolone) may improve muscle strength
157
Where does the spinal cord end? What is this tapered structure called?
L1-L2, conus medullaris
158
Cauda equina
bundle of nerves that arise from the end of the spinal cord
159
Spinal cord compression (SCC) occurs in 2.5% of patients presenting with?
metastatic cancer
160
Most common cause of spinal cord compression (SCC) (85%)
Metastases in the osseous vertebral column
161
What can happen to the intervertebral discs --> SCC?
Disc herniation - centre of disc moves out through the annulus and puts pressure on the nerve root, causing pain
162
Clinical presentation of SCC?
Back pain, motor pain, radicular pain, incontinence and bowel dysfunction
163
Ix for SCC
MRI scan
164
Mx of SCC
dependent on cause, malignancy (IV dexamethasone to reduce inflammation and oedema), refer to neurosurgery
165
Cauda equina syndrome
Medical emergency due to compression/spinal damage at or caudal to L2
166
Most common place of lumbar disc herniation for cauda equina syndrome?
L4/5 and L5/S1
167
Causes of cauda equina syndrome?
Herniation of lumbar disc, tumour, infection, trauma
168
Presentation of cauda equina syndrome?
Absent knee/ankle reflexes, saddle paraesthesia, loss of anal sphincter and bladder control, lower motor weakness
169
Ix for cauda equina syndrom
MRI, test lower limb reflexes
170
Mx of cauda equina syndrome
urgent referral to neurosurgeon
171
Syncope
Essentially fainting - caused by a temporary drop in the amount of blood that flows to the brain
Happens due to a sudden drop in BP, drop in HR, or changes in the amount of blood in areas of your body
172
Thalamus
Connection between cortex and brainstem and spinal cord
173
Main protein found in lewy body deposits?
alpha synuclein
174
What are lewy bodies?
Abnormal deposits/occlusions of protein that form within the brain in neurons affected by Parkinsons, Lewy body dementia, etc.
175
What is Parkinsons disease?
Common neurodegenerative disease where the clinical features result from progressive depletion of dopaminergic neurons in the substantia nigra, leading to excessive thalamic inhibition (less refined movement)
176
Differential diagnosis forr PD?
Benign essential tremor, Lewy Body dementia
177
Parkinsonian triad (TBH)
Tremor, bradykinesia, hypotonia
178
Tremor in PD
Worse at rest, improved by voluntary movement, most obvious in hands
179
Bradykinesia in PD
Slow to initiate movement and slow actions, decreased amplitude with repetition, hesitant gait (shuffling, hunched forward, no arm swinging), freezing at obstacles/doors, expressionless face
180
Hypotonia in PD
cogwheel rigidity
181
Clinical features in Parkinsons disease?
Neuropsychiatric symptoms - hallucinations, depression, dementia
Sleep disorders - insomnia
Fatigue
GI and autonomic disorders - drooling, sweating, constipation, dysphagia
182
Dx for PD?
Clinical diagnosis, signs invariably worse on one side is indicative, positive response to levodopa therapy
183
Mx for PD
1. Levodopa (combine with dopa-decarboxylase inhibitor)
2. Dopamine agonists - early onset PD
3. Monoamine oxidase B inhibitors
184
Enzyme that breaks down dopamine
Monoamine oxidase B
185
why does levodopa need to be combined with dopa-decarboxylase inhibitor?
So the L-dopa is not converted into dopamine peripherally, therefore more L-dopa is available to cross the BBB
186
SE of levodopa
nausea, vomiting, psychosis, hallucinations, wearing off effects
187
SE of dopamine agonists?
Impulse control disorders (gambling, hypersexuality, think wheelbarrows), drowsiness, nausea, hallucinations
188
Examples of Parkinsons's-plus syndromes
Dementia with lewy bodies, multiple system atrophy
189
What is benign essential tremor?
Common condition in the elderly, fine tremor affecting voluntary muscles, most notable in hands. It is SYMMETRICAL, MORE PROMINENT on voluntary movement, worse with caffeine/stress, improved by alcohol
190
Mx for benign essential tremor
Propanolol - non-selective beta blocker
191
Dementia
Clinical neurodegenerative condition with progressive decline in several cognitive domains, initial presentation is memory loss over months/years
192
Risk factors for dementia
FHx, age, Down's, high BP, obesity, hyperlipidaemia, DM
193
Alzheimer's disease
neuronal reduction in multiple areas of the brain, neurons affected develop surrounding neurofibrillary tangles, amyloid plaques and produce less ACh
194
Largest genetic risk factor for sporadic Alzheimer's disease?
Apolipoprotein E4 variant
195
Vascular dementia
Stepwise deterioration, followed by periods of stability, history of TIAs, presents with vascular pathology
196
Lewy-body dementia
Fluctuating condition with variation in alertness and attention, recurrent hallucinations, frequent falls
197
Frontal-temporal dementia
Specific degeneration of the frontal and temporal lobes. Loss of motivation, emotional unconcern, behaviour change, selfishness, neglecting personal hygiene, language problems, speaking slowly
198
Clinical presentation of Alzheimers?
1. Persistent, progressive and global cognitive impairment
2. Memory loss
3. Irritability, behaviour change
4. Psychosis
5. Agnosia
6. Anosognosia
7. Planning affected
8. Verbal difficulty
199
Ix for Alzheimers
History, MMSE, exclusion of differentials (e.g. hypothyroidism), bloods, MRI
200
Mx for dementia
1. Treat associated anxiety/depression
2. BP control
3. Acetylcholinesterase inhibitors (rivastigmine)
4. Antiglutamatergic treatment (memantine)
201
Motor neurone disease (MND)
umbrella term for neurodegenerative conditions characterised by selected loss of motor neurones (motor cortex, cranial nerve nuclei, anterior horn cells)
202
Muscles spared in MND
rectal and bladder sphincters, occulomotor muscles
203
Epidemiology for MND
males > females, median age onset - 60
204
Archetypal MND
Amyloidosis lateral sclerosis (80%)
205
ALS (UMN and LMN)
- Loss of motor neurons in motor cortex and anterior horn of cord
- Progressive weakness and UMN signs
- LMN muscle wasting
- Split hand sign
- Cramps
- Wrist and foot drop
206
UMN lesion signs
No/little muscle atrophy, weakness, hyperreflexia, positive Babinski sign, hypertonia
207
LMN lesion signs
Muscle atrophy, flaccid paralysis, diminished tendon reflexes, fasciculations, negative Babinski sign
208
Progressive bulbar palsy (LMN)
- Only affects CN 9-12
- Dysarthria, dysphagia, nasal regurgitation of fluids and choking
- LMN lesion of tongue and muscles of talking and swallowing
209
Progressive muscular atrophy (LMN)
Weakness, muscle wasting, fasciculations, affect distal muscles before proximal
210
Primary lateral sclerosis (UMN)
Least common, loss of Betz cells in the motor cortex, mainly UMN signs, marked leg weakness
211
Differentiate between MND and MS
MND NO sensory loss
212
Differentiate between MND and myasthenia gravis
MND does NOT affect occulomotor muscles
213
Ix for MND
clinical diagnosis, MRI, lumbar puncture (exclude inflammatory causes), EMG
214
Tx of MND
Riluzole
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Riluzole
used to improve survivla in MND, inhibitor of glutamate release and NMDA receptor antagonist
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5 types of primary headache? Which is the most common? Most disabling?
1. Migraine
2. Tension (most common)
3. Cluster (most disabling)
4. Sinus
5. Hormonal
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Causes of secondary headache?
meningitis, SAH, GCA, intracranial haemorrhage, medication over-use
218
Secondary headache red flags - SNOOP
Systemic symptoms (illness)
Neurological symptoms
Onset new (>40) or sudden (thunderclap)
Other associated symptoms e.g. papilloedema
Previous headache history with progression or change in attack character
219
Migraine
Disorder of recurrent attack, throbbing/pulsatile headache, often preceded by aura and other associated symptoms (nausea, vomiting, visual changes)
220
Migraine aura
Visual aura - zig-zags, shimmering, black holes
Sensory aura - paraesthesia, numbness
Motor aura - weakness, dysphasia
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Migraine presentation
1. Classically visual aura (15-30mins), followed by unilateral throbbing headache within 1hr
2. Isolated aura w/o headache
3. Episodic headache w/o aura, unilateral, with nausea, vomiting, photo/phonophobia
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Prodrome migraine aura
Cravings, yawning, mood change
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Partial triggers of migraine (CHOCOLATE)
Chocolate, hangovers, orgasms, caffeine/cheese, OCP, lie-ins, alcohol, travel, exercise
224
Dx of migraines
Clinical diagnosis, examine eyes, BP, head and neck, exclusion of SNOOP red flags
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Mx of migraine
1. Prophylactic treatment - propanolol (beta blocker) or topiramate (anti-convulsant)
2. During attack - oral triptan (sumatriptan) and NSAIDs
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presentation of tension headaches
bilateral pressure/tightness (band), non-pulsatile, no associated symptoms e.g. aura, vomiting, nausea, variation in duration
227
Mx of tension headaches?
Analgesia e.g. paracetamol
228
Cluster headaches
Most disabling primary headache, associated with trigeminal neuralgia
229
Cluster headaches - epidemiology
More common in males and smokers
230
Presentation of cluster headaches?
Unilateral pain around one eye, rapid onset, duration 15mins-->3hrs, episodic clusters, associated symptoms (ptosis, miosis, lacrimation, nasal discharge
231
Mx of cluster headaches?
Sumatriptan SC injection
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Sinus headache
Associated with sinusitis, dull constant ache over the frontal and maxillary sinuses, pain worse on bending over
233
Mx for sinus headache
analgesics, anti-emetics, ABx
234
Hormonal headache
Associated with decreased oestrogen concentration - beginning of periods, withdrawal of HRT
235
Medication over-use headaches
Common cause of headache due to overuse of painkillers/triptans taken regularly for headaches, stop medication to resolve
236
Common culprits for medication over-use headaches?
Codeine/co-codamol, sumatriptan (NSAIDs = unlikely)
237
Classic triad of meningitis
fever, headache, neck stiffness
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Symptoms of acute bacterial meningitis
sudden onset, photophobia, vomiting, deliriousness, drowsiness, papilloedema, non-blanching petechiae and purpuric rash
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Symptoms of viral meningitis
benign, self-limiting
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Ix for meningitis
Blood culture from lumbat puncture (at L4)
241
CSF findings for bacteria (cells protein, glucose)
Neutrophils, raised, decreased
242
CSF findings for virus (cells protein, glucose)
lymphocytes, normal/slightly raised, normal
243
Mx of meningitis?
start ABx immediately if suspected bacterial, confirmed bacterial - IV cefotaxime or ceftriaxone
244
What is encephalitis?
infection and inflammation of the brain parenchyma, most affects frontal and temporal lobes (responsible for emotion and memory change)
245
Viral causes of encephalitis?
HSV (1+2), varicella zoster, EBV, cytomegalovirus, HIV, mumps, measles
246
Presentation of encephalitis?
Fever, headache, brain dysfunction (behavioural change, decreased consciousness, confusion, drowsiness, seizures)
247
Ix for Meningitis
Blood culture, lumbar puncture, MRI, PCR CSF
248
Ix for encephalitis
CT and MRI scan, CSF analysis, viral serology of blood and CSF
249
Tx for encephalitis
Immediately treat with IV acyclovir, anti-seizure medication
250
What is herpes zoster-shingles?
Infection caused by the reactivation of the varicella zoster virus (VZV - chicken pox), usually within the dorsal root ganglia
251
Clinical presentation of herpes zoster infection?
Pain and paraesthesia in dermatomal distribution, malaise, fever, headache, rash consisting of papules and vesicles restricted to the same dermatome
252
Ix for herpes zoster? Mx?
Clinical diagnosis, oral anti-viral therapy (acyclovir), analgesia
253
Where do you get Borrelia from?
Ticks
254
Most common bacteria causing meningitis in neonates?
Group B strep
255
Most common bacteria causing meningitis in children
strep. pneumoniae
256
Most common bacteria causing meningitis in --> 50years
N.meningitidis, strep. pneumoniae
257
Most common bacteria causing meningitis in >50
strep. pneumoniae
258
Dx of bacterial meningitis
cloudy purulent fluid, increased WCC (neutrophils), high protein, low glucose, high lactate
259
When is a lumbar puncture contraindicated?
Raised ICP (risk of coning)
260
Empirical ABx for meningitis
ceftriaxone, cefotaxime
261
Prodrome phase in encephalitis?
fever, headache, nausea, vomiting, fatigue
262
Trigeminal neuralgia?
pain syndrome characterised by attacks of facial pain in the area of one or more branches of the trigeminal nerve
263
Px of trigeminal neuralgia
Unilateral facial pain, severe/shooting, electric shock like, lasts several seconds, typically shoots from mouth to angle of jaw
264
Bell's palsy
Acute, unilateral facial nerve palsy (peripheral - paralysis of ipsilateral eyelid, facial muscles)
265
Which nerve is damaged following wrist drop?
Radial
266
Tx for trigeminal neuralgia?
1st line - anticonvulsants e.g. carbamazepine
267
Dx of trigeminal neuralgia?
Clinical
268
Uhthoff's phenomenon
Paraesthesia in MS in heat (bath)
269
What lobe is Jacksonian march seizure associated with? What type of seizure is it?
Frontal, simple partial
270
What is a Jacksonian march seizure?
Phenomenon where a simple partial seizure spreads from the distal part of the limb toward the ipsilateral face, involve a progression of the location of the seizure in the brain, which leads to a "march" of the motor presentation of symptoms
271
Features of seizures in the temporal lobe
Motor phenomena, impaired awareness, lip smacking, dysphasia, deja vu, hallucinations
272
Features of seizures in the frontal lobe
Motor features, Jacksonian march, motor arrest, dysphasia, speech arrest
273
Features of seizures in the parietal lobe
Sensory disturbances, tingling, numbness, pain
274
Features of seizures in the occipital lobe
Visual phenomena e.g. spots, lines, flashes
275
Brown-sequard syndrome
ipsilateral haemiplegia with contralateral pain and temperature sensation deficits
276
Ix for Brown-sequard
MRI (gold standard)
277
Mx of Brown-sequard
Surgery to fix the cause, dexamethasone to reduce inflammation
278
Pharmacological therapy for MS
Oral prednisolone or IV hydrocortisone
279
What is Gullain-Barre syndrome?
Progressive onset of distal limb weakness, symmetrical, ascending
280
Mx of Gullain-Barre syndrome?
Vital capacity and ECG monitoring
281
What is neurofibromatosis?
Rare genetic disorder that causes typically benign tumours of the nerves, symptoms are variable, manifests itself at birth or in childhood
282
What is neurofibromatosis 1 characterised by?
Cafe-au-lait spots concentrated in the groin and armpits (light brown spots), scoliosis, tumours on the brain or spinal cord
283
Cafe-au-lait spots are typical of what?
neurofibromatosis
284
Causes of neurofibromatosis?
Mutations in the gene that controls production of neurofibromin protein (acts as a tumour suppressor)
285
Sleep stages
Non-REM stage 1 (N1), N2, N3, REM (rapid eye movement)
286
Acronym for EEG representations for each sleep stage
The Sleep Doctor's Brain
| Theta waves, Sleep spindles and K complexes, Delta waves, Beta waves
287
Sleep stage N1
light sleep, jerks
288
Sleep stage N2
Deeper sleep (50% of total sleep)
289
Sleep stage N3
Deep sleep - night terrors, nocturnal enuresis, sleepwalking
290
REM sleep stage
Dreaming, loss of muscle tone, erections
291
Gullain Barre syndrome is typically associated with?
Gastroenteritis caused by campylobacter jejuni, cytomegalovirus, or EBV
292
Gullain barre is like what neuropathy but just peripherally?
MS, attacks myelin
293
Most likely pathogen causing meningitis in pregnant women?
Listeria monocytogenes
294
CI for lumbar puncture?
raised ICP, focal neurology, infection at site of LP
295
Prophylactic Abx for meningitis contacts
Oral ciprofloxacin
296
Long term prophylaxis for cluster headaches?
Verapamil
297
How would you treat raised ICP?
IV mannitol
