Neurology Flashcards
1
Q
Seizure classification
A
- Focal or generalised
- Aware or impaired awareness (focal only)
- Motor vs non-motor
- Provoked (reversible CNS insult) or unprovoked (genetic, structural, metabolic, immune, infectious causes of epilepsy).
2
Q
Hippocampal sclerosis is seen in what type of epilepsy
A
Mesial Temporal lobe epilepsy
3
Q
In epilepsy idiopathic seizures are caused by
A
idiopathic seizure = genetic cause
4
Q
Location of haemorrhage causing focal jerking
A
Motor cortex
5
Q
Seizuregenic neurotransmitter
A
- Na
- Glutamate
- NMDA
- AMPA
6
Q
Anti-seizure neurotransmitters
inhibitory
A
- GABA
- K
7
Q
Management of Juvenile Myoclonic epilepsy
A
Sodium Valproate
8
Q
Management of focal epilepsy
A
Carbamazepine
9
Q
Management of absent seizures
A
Ethosuxamide
10
Q
Antiepileptic which interact with OCP
A
Lamotrigine
11
Q
Cause of further seizure while on anti-epileptics
A
Can be caused by anti-epileptics themselves. Particularly Carbamazepine.
12
Q
Interaction of Valproate and Lamotrigine
A
Lamotrigine levels increase when used with Sodium Valproate due to enzyme inhibition.
Symptoms - cerebellar signs.
13
Q
Best anti-epileptic for pregnancy
A
Lamotrigine
Levetriacetam
*DO NOT USE VALPROATE - highly teratogenic.
14
Q
Carbamazepine and Steven Johnsons HLA associations
A
HLA 1502- asians
HLA
15
Q
holepunch brain
A
neurocysticicosis
16
Q
Herpes encephalitis EEG
A
Periodic lateralized epileptiform discharges (PLEDS)
17
Q
Headache, hemiparesis and seizure in post-partum
A
Cerebral venous thrombosis.
Imaging - CT venogram or MR venogram
18
Q
Anti-epileptics causing visual fields defects
A
Vigabatrin (blind as a bat)
Topiramate (Pirate eye patch)
19
Q
Drugs which exert an effect on the CNS without crossing the blood-brain barrier
A
Domperidone
20
Q
Antibody in stiff person syndrome
A
Anti-GAD65 (same as T1DM)
21
Q
Features of Gertsmans syndrome (Dominant parietal lobe stroke)
A
Acalculia, Finger agnosia, Agraphia, L-R disorientation
22
Q
Pathway of the sympathetic chain by neurons
A
1st order neuron - from posterolateral hypothalamus, through the midbrain and pons to the ciliospinal centre of budge at C8-T2
2nd order neuron - From T1 into sympathetic chain over apex of lung to the superior cervical ganglion at the level of the bifurcation of the carotid artery.
3rd order neuron- from superior cervical ganglion along the internal carotid artery to supply the eye.
23
Q
Disease which is caused by JC virus
A
Progressive multifocal leukoencephalopathy
24
Q
Management of PML
A
Cease biologic drugs (natalizumab/rituximab) + start plex.
commence hydrocortisone if IRIS develops.
Give Pembrolizumab
25
Unilateral temporal lobe enhancement on MRI
HSV encephalitis
| Limbic encephalitis
26
Hummingbird sign on MRI
progressive supranuclear palsy
27
CJD symptoms
rapid onset dementia, behavioural changes, myoclonus.
28
CJD EEG and MRI findings
EEG - sharp wave pattern
| MRI - cortical ribboning. Diffusion restriction in cortex and basal ganglia
29
Management of venous sinus thrombosis
Anticoagulate (even if there has been haemorrhage)
| Use clexane/warfarin - no evidence for NOAC
30
What is the rule of 4's
1. 4 CN in the medulla, 4 in the Pons, 4 above the Pons
2. 4 midline structures starting with M- medial longitudinal fasciculus, medial lemniscus, motor neuron bodies 3,4,6,12. Motor pathway.
3. 4 side structures starting with S - sympathetic chain, sensory body of CN5, spinothalamic tract, spinocerebellar tract
4. 4 motor nucleuses are factors of 12.
31
In nerve conduction studies reduced amplitude is due to
axonal loss
| can also be issues with NMJ or muscle
32
In nerve conduction studies reduced velocity/ increased latency is due to
demyelination
33
Nerve lesions that cannot be tested in NCS
pre-ganglionic sensory nerve lesions
34
In nerve conduction studies reduced f-waves is due to
defect anywhere along the neuron
35
Interferon beta MOA and SE
Decreases T and B cell function by decreasing matrix metalloproteinases
SE - flu like symptoms, leukopenia, LFTs, thyroid.
36
Glatiramer acetate MOA and SE
Ligand for MHC II, stimulates Tregs
SE: injection reactions
37
Teriflunomide MOA and SE
Inhibits pyrimadine synthesis
SE - hair thinning, GI, teratogenic
38
Dimethyl fumarate MOA and SE
Lowers lymphocyte count
SE - flushing, diarrhoea.
Risk of PML
39
Fingolimod MOA and SE
Sphingosine 1 phosphate receptor modulator
Traps T cells in lymphnodes
SE - bradycardia, macular oedema, shingles.
40
Cladribine MOA and SE
Purine antimetabolite - causes DNA strand breakage and activates p53
SE- headache, shingles, malignancy.
41
Natalizumab MOA and SE
Targets a4b1 integrin, stops leukocytes crossing the BBB.
SE: PML, pharyngitis, peripheral oedema
42
Alemtuzumab MOA and SE
Targets CD52 - causes lymphopenia
SE: autoimmune disease
43
Ocrelizumab MOA and SE
Targets CD20
44
MS drugs in pregnancy
Interferron beta
Glatiramer acetate
All biologics
45
Pathophysiology of migraine
Cortical spreading depression(of Leao)
| Self propagating wave of neuronal and glial depolarisation
46
Cause of headache in migraine vs cause of aura
Aura = due to cortical spreading neuronal and glial depolarisation
Headache = activation of trigeminal afferent nociception.
47
Molecular cascade in migraine
Neuronal pannexin 1 -> Caspase 1 -> kappa B - > pro-inflammatory mediators -> calcitonin gene related peptide.
48
Acquired loss of color vision, dyschromatopsia, indicates injury/pathology in which vessel/part of the eye.
Optic nerve! - this is caused by optic neuropathy.
49
Types of optic neuropathy
Anterior - ie involving the optic disc. Optic disc appears inflamed. Can be non-arteritis or srteritis (associated with GCA). NAION will typically have some or all of the signs of an optic neuropathy including decreased visual acuity, dyschromatopsia, an RAPD, a swollen optic nerve with splinter hemorrhages and a visual field defect.
Posterior ischemic optic neuropathy (PION) encompasses those conditions that result in ischemia to any portion of the optic nerve posterior to the optic disc.
50
How to differentiate Conus Medullaris from Cauda equina
Conus medullaris - both upper and lower motor signs.
| Cauda equina - lower motor only
51
Difference between post-ictal and inter-ictal psychosis
Postictal psychosis usually begins within 48 to 72 hours of a seizure or cluster of seizures, following a lucid interval. Postictal psychosis is often associated with positive symptoms including paranoid or referential delusions, hallucinations, and aggression
interictal psychosis may be more likely to manifest with disorganization and negative symptoms.
52
3rd nerve palsy cause if pupil is involved
Aneurysm compressing the 3rd nerve intracranially - can be posterior communicating artery.
53
3rd nerve palsy cause if pupil spared.
GCA
Ischaemic injury.
Needs MRI.
54
Type of patient who gets idiopathic intracranial hypertension
overweight young female
55
Risk factors for idiopathic intracranial hypertension
Overweight, OCP, Vit A use, tetracyclines.
56
Mx of idiopathic intracranial hypertension
Weight loss
| Acetazolomide
57
Small fibre nerves
C- fibres - pain and temperature
58
Neurological effect of EtOH and EtOH withdrawal
EtOH use - releases GABA, causes GABA receptor upregulation.
Inhibits NMDA receptors, causes NMDA receptor upregulation.
EtOH withdrawal - Low levels of GABA, Increased NMDA and high NMDA receptors.
59
Neurological effect of Nicotine.
binds stereo-selectively to nicotinic-cholinergic receptors.
stimulating effect = locus ceruleus
reward effect = limbic system
60
Examination sign of poor prognosis in subarachnoid haemorrhage
Terson syndrome (preretinal hemorrhages) may be seen and implies a poorer prognosis.
61
Driving limitation on seizures
Standard - 12 months
| Variation - 6 months if clear trigger or first seizure now treated.
62
Adrenal disease and progressive spastic paresis
X-linked adrenoleukodystrophy and adrenomyeloneuropathy - peroxisomal disorder of beta-oxidation that results in accumulation of very long-chain fatty acids (VLCFAs) in all tissues. Accumulation of abnormal VLCFAs in affected organs (central nervous system, Leydig cells of the testes, and the adrenal cortex) is presumed to underlie the pathologic process of ALD/AMN
63
Test for X-linked adrenoleukodystrophy and adrenomyeloneuropathy
ABCD1 mutation
64
Symptoms of X-linked adrenoleukodystrophy and adrenomyeloneuropathy in men
spastic paraparesis, abnormal sphincter control, neurogenic bladder, sexual dysfunction. Numbness and pain from polyneuropathy. Adrenal insufficiency.
65
Symptoms of X-linked adrenoleukodystrophy and adrenomyeloneuropathy in women
peripheral neuropathy and myelopathy, often with a gait disorder and fecal incontinence and sometimes with mild spastic paraparesis
66
Management of contraception with AED use
1. Mirena
| 2. Increase oestrogen dose in OCP
67
Endocrine function of the hypothalamus
supraoptic and paraventricular nuclei secrete ADH. The paraventricular nucleus also
secretes oxytocin.
68
Interaction of Lamotrigine and Carbamazepine
Lamotrigine levels decrease (unlike the increase seen with sodium valproate) - this is because Carbamazepine is an enzyme inducer.
69
Drugs which lower the seizure threshold
```
Propofol
Beta-Lactam Abx
Amphotericin
Antidepressants
Clozapine
Theophylline
Cyclosporine
Pethidine
```
70
Role of Nimodipine in Subarachnoid haemorrhage
Theoretically to prevent vasospasm.
| goal = to decrease neurological deficits that develop as a result of distal infarction of brain from site of vasospasm
71
Which AEDs reduce concentration in pregnancy due to reduced protein binding?
Phenytoin, Phenobarbital, Valproate
72
Which AED has the most stable levels in pregnancy
Carbamazepine
73
AEDs with the least stable levels in pregnancy
Levetiracetam, Lamotrigine, Oxcarbazine
74
Stroke causing loss of Ant 2/3 tongue taste
Marie Foix - AICA stroke - Facial nuclei involved rather than just facial nerve
75
How to differentiate medial medullary syndrome from lateral medullary syndrome
Medial = motor loss, tongue motor palsy, medial lemniscus (vibration + proprioception).
Lateral (side) = sensory loss, side nuclei - CN 9,10,11, Sympathetic chain.
76
Types of nerve fibres and function
Aa fibres - myelinated 15mm - muscle spindles (proprioception) + alpha motor
Ab fibres - myelinated 8mm - mechanoreceptors
Ac (gamma) fibres - myelinated 5mm - muscle spindles (proprioception)
Ad fibres - myelinated 3mm - pain (rapid response), temp.
B fibres - moderately myelinated 2mm - preganglionic sympathetic
C fibres - unmyelinated 1mm - pain
77
Nerve fibre most affected by hypoxia
b- fibres - therefore hypoxia causes autonomic effects
78
Nerve fibre most affected by pressure
a- fibres - eg carpal tunnel
79
Nerve fibre most affected by anaesthetic
c-fibres
80
CN with parasympathetic activity
3 - pupil parasympathetics
7 - lacrimal gland, sublingual gland, submandibular gland
9 - parotid gland
10 - vagus
81
Miller Fishcer triad and Ab
ophthalmoplegia with ataxia and areflexia
| GQ1B
82
Biggest RF for SUDEP (unexplained death in epilepsy)
frequency of GTCS
83
4 symptoms of PRES syndrome
- CCCV = confusion, cephalgias, convulsions, visual disturbance
84
Treatment for NMO
Eculizumab -prevention
| Methyl pred- acute attack
85
Risk Factors for PRES
- severe HTN
- Pre-eclampsia
- Immunosuppression - Tac, cyclo, cisplatin, VEGF
- renal failure
- autoimmune disease
86
PRES MRI finding
vasogenic oedema in bilateral posterior hemispheres.
87
What does each part of the HINTS exam test?
Head impulse - POSITIVE IF PERIPHERAL - abnormal due to disease with the 8th cranial nerve (vestibulocochlear nerve). Lesion of vestibulocochlear nerve should be unilateral, and patient will correct with saccade if peripheral.
Nystagmus - BIDIRECTIONAL/ VERTICAL = CENTRAL.
UNIDIRECTIONAL = PERIPHERAL
Test of skew - If present = CENTRAL
88
Trigeminal autonomic cephalgias
1. SCUNT/SUNA - 60secs
2. Paroxysmal hemicrania - 15mins
3. Cluster headache - 1hr
4. Continuous hemicrania - days
Have unilateral autonoic signs - tearing, nasal drip, miosis, ptosis, tinnitus
89
Condition that cluster headaches and Trigeminal autonomic cephalgias are associated with
Pituitary adenomas
90
Management of Cluster headaches
- Triptans
- Occipital nerve injection
- Steroids
- Verapamil
NOT indomethicin
91
Management of Paroxysmal hemicrania/ continuous hemicrania
Indomethacin
92
Management of SCUNT/SUNA - acute and preventer
Acute - Lignocaine
| Lamotrigine is preventer for SCUNT/SUNA
93
Migraine preventers
- propanolol
- pizotifen
- topiramate
- valproate
- verapamil
- clonidine
- candesartan
- amitriptyline
94
CGRP mabs (name 3)
- Fremanezumab
- Galcanezumab
- Erenumab
95
Target of Ergots and triptans
- 5HT
96
Stroke syndromes:
- Contralateral weakness and sensory loss more marked in the upper limbs and lower half of the face than in lower limbs
- Gaze deviates toward the side of infarction
- Contralateral homonymous hemianopia without macular sparing
- Aphasia if in dominant hemisphere
- Broca aphasia (lesion to inferior frontal gyrus)
- Wernicke aphasia -Occurs in lesion to superior temporal gyrus
- Conduction aphasia
- Hemineglect if in nondominant hemisphere
- Sensory neglect
MCA
97
Stroke syndromes:
- Contralateral weakness and sensory loss in the lower limbs more marked than in upper limbs
- Abulia (lack of will)
- Urinary incontinence
- Dysarthria/ Transcortical motor aphasia
- Frontal release signs
- Limb apraxia
ACA
98
Stroke syndromes:
- Contralateral homonymous hemianopia with macular sparing due to occipital lobe involvement
- Contralateral sensory loss due to lateral thalamic involvement: light touch, pinprick, and positional sense may be reduced.
- Memory deficits
- Vertigo, nausea
PCA
99
Stroke syndromes:
- Ipsilateral bulbar palsy (dysphagia, dysphonia, hiccups, decreased gag reflex)
- Ipsilateral nystagmus and vertigo (vestibular nuclei)
- Pain and temperature - contralateral to body and ipsilateral to face.
- limb ataxia
- Horners syndrome
PICA = lateral medulla affected
100
Stroke syndromes:
- Contralateral body pain and temp loss
- ipsilateral ataxia
- ipsilateral face pain + temp loss - 5thCN
- ipsilateral weakness - 7th CN
- Loss of anterior 2/3 tongue sensation
- Ipsilateral horners and vestibular nuclei
AICA
101
Stroke syndromes:
- Locked in syndrome
-
Basilar
102
Stroke syndromes:
| Amaurosis Fugax
Internal carotid
103
Stroke syndromes:
| Horner's syndrome alone
Common carotid
104
Area of brain causing hemibalismus
Subthalamic nucleus
105
Stroke syndromes:
- Ipsilateral internuclear ophthalmoplegia
- Ipsilateral facial muscle weakness
- Contralateral hemiparesis
Medial pontine - supplied by paramedian branches of the basilar
106
Stroke syndromes:
Contralateral hemiplegia and paresthesia
Gaze palsy and ipsilateral deviation of the eyes
Stupor and coma
Putamen
107
Stroke syndromes:
Contralateral hemiparesis and paresthesia
Miotic and unreactive pupils, upgaze palsy with gaze deviation away from the side of the lesion (wrong way eyes)
Thalamus
108
VGKC disease and presentation
- Includes LGI1 and CASPR2 encephalitis
- faciobrachial dystonic seizures
- hyponatremia
- REM sleep disorder
- severe impairment of short-term memory
- neuromytonia - muscle twitching at rest
- associated with lung, breast and thymus cancers.
109
LGI1 disease and presentation
LGI1 encephalitis
- faciobrachial dystonic seizures
- hyponatremia
- REM sleep disorder
110
LGI1 disease and presentation
LGI1 encephalitis
- faciobrachial dystonic seizures
- hyponatremia
- REM sleep disorder
111
CASPR2 disease and presentation
limbic encephalitis
- severe impairment of short-term memory
- neuromytonia - muscle twitching at rest
Associated with thymoma
112
AMPA disease and presentation
AMPA encephalitis
- females, with a median age of onset of 50 to 60 years
- limbic encephalitis
113
VG calcium channel disease and presentation
Lambert-Eaton myasthenia
| recovery of lost deep tendon reflexes or improvement in muscle strength with vigorous, brief muscle activation.
114
MND/ALS pattern
both UMN and LMN disease with patchy involvement and both acute and chronic denervation. Can get split hand syndrome or isolated foot drop etc. Needs evidence that there isn't structural compression.
115
EMG findings for acute denervation
Fibrillations and positive sharp waves with increased insertional activity.
116
EMG findings for chronic denervation
Large amplitude, long duration complex motor unit action potentials with neurogenic recruitment.
117
Which disease does ALS/MND have overlap with?
Frontotemporal dementia
118
Genes associated with ALS
- SOD1
- C9ORF72
- FUS
119
Histology in ALS
TDP-43 accumulation and inclusion formation is observed in most sporadic cases of ALS and fronto-temporal dementia.
120
Mechanism of central sensitization
- increased c-fibre stimulus leads to upregulation of NMDA and glutamate in the spinal cord.
- Dorsal horn becomes disorganised.
- Increased substance P production - lowers nociception threshold.
- can cause sympathetic responses due to disorganised/crossed fibres.
121
Hockey stick sign on brain imaging
CJD
122
CJD finding in CSF
CSF 14-3-3 protein
123
CJD EEG
periodic synchronous bi- or triphasic periodic sharp wave complexes
124
GBS antibodies
- GM3 - motor axonal
- GM1 - Multifocal motor neuropathy and dementia
- GQ1b - Miller Fischer syndrome - ataxia, ophthalmoplegia, areflexia.
125
Symptoms of normal pressure hydrocephalus
Ataxia, Cognitive impairment, urinary incontinence.
126
Effect of extending thrombolysis time frame to 9 hours.
Increased proportion of patients with regained function. Increased cerebral haemorrhage
