Neurology Flashcards
Functions of frontal lobe
- Motor cortex for contralateral side= precentral gyrus
- Broca’s area, speech output inferior frontal gyrus
- Emotions
Function of parietal lobe
- Sensory cortex for contralateral side = postcentral gyrus
Functions of temporal lobe
- Memory
2. Wernicke’s area, comprehension of speech = superior temporal gyrus
Function of occipital lobe
- Vision
UMN signs (CNS)
- inc tone (spasticity)
- weakness, no wasting
- brisk reflexes + clonus
- upgoing plantars
LMN signs (PNS)
- Reduced tone
- weakness, wasting, fasciculation
- reduced or absent reflexes
- normal plantar
Name and describe the motor tract
Corticospinal
UMN in motor cortex (precentral gyrus) -> medulla where it crosses to contralteral side -> spinal level of action -> ventral root (LMN) -> muscle
Name the 2 sensory pathways and what they transmit
- Spinothalamic- pain and temp (coarse)
2. Dorsal/posterior column- position and vibration (fine)
Describe the spinothalamic pathway
Nociceptors or thermoreceptors detect impulse -> dorsal root -> dorsal horn and crosses to contralateral side AT SAME SPINAL LEVEL -> post central gyrus sensory cortex
Describe the posterior/dorsal column pathway
proprioceptors or mechanoreceptors detect stimuli -> afferent to dorsal root ganglion/horn -> up to medulla and CROSSES TO CONTRALATERAL SIDE AT MEDULLA-> thalamus-> sensory cortex
Biceps reflex at level
C5
Supinator reflex at level
C6
Triceps reflex at level
C7
Knee Jerk at level
L4
Ankle reflex at level
S1
What is a negative symptom
Partial or complete failure of impulse conduction leading to loss/reduction of function
What are positive symptoms
Exaggeration of a physiological phenomenon eg seizure, tremor, trigeminal neuralgia
Hemiplegia
severe/complete loss of strength on one side of body
Hemiparesis
slight weakness on one side of body
Paraparesis
bilateral leg weakness
Spondylosis
AGE RELATED degeneration of intervertebral discs
Define MND
Progressive DEGENERATION of ANTERIOR horn cells- where UMN from motor cortex synapse and LMN begin -> muscle.
MND presentation
U+LMN signs Widespread fasciculations NO sensory signs Men > women Chronic and BILATERAL symptoms can include speech
DD for MND
Cervical myelopathy (spinal cord compression)
Spinal Shock
You get ACUTELY UNEXPECTED SIGNS before correct signs develop. IE flaccid paralysis with loss of sensation and then gradually -> spasticity and reflexes ie LMN -> UMN
Guillan-Barre Syndrome Definiton
Acute DEMYELINATION of PERIPHERAL nerve roots and nerves typically post viral infection.
GBS typical presentation
LMN signs ONLY
sensory deficit
ascending weakness
generalised, bilateral signs
Causes of peripheral neuropathy (7 categories)
- congenital
- metabolic (b12 deficiency)
- Toxic (alcohol, drugs)
- Endocrine (DM, thyroid)
- Inflammatory (GBS)
- Neoplastic
- Infective (HIV, Lyme)
Define Myasthenia Gravis
Autoimmune condition attacking components of NMJ-> weakness and fatigue of skeletal muscle
Typical presentation of Myasthenia
Variable incorrect eye movements
Fatiguability
Difficulty swallowing
ADD PIC
Define functional disorders
Symptoms appear not to be caused by PHYSICAL disease, no VISIBLE pathology.
Thought to be a disturbance of FUNCTION
Define Epilepsy
A CHRONIC disorder characterised by RECURRENT SEIZURES (2 or more without clear symptomatic provocation eg alcohol withdrawal)
DD of a blackout/sudden collapse
- Faint = vasovagal syncope
- Seizure
- Cardiac syncope
other: cataplexy (temp paralysis, no LOC) and hypoglycaemic attacks
Define vasovagal syncope
Sudden and temporary IMPAIRMENT of CONSCIOUSNESS with LOSS of TONE caused by reduction of blood/oxygen to brain.
Define seizure
Clinical phenomenon due to abnormal synchronous cortical discharges
Useful features to differentiate between faint and seizure(4)
- POST event CONFUSION >2min
- Deeply bitten lateral TONGUE
- LONG T+C phases >1min
- deep CYANOSOS
NB NOT:
twitching/jerking, incontinence, pallor, bitten tongue tip, fatigue
Causes of epilepsy in adults
- unknown
- anything effecting cortical brain eg:
- stroke
- trauma
- tumour
- infection
- degenerative
- congential/genetic
Classification of seizures
Focal or Generalised Generalised: - Absence - Tonic - Tonic-Clonic Atonic, myoclonic
Define status epilepticus (acute seizures) and their treatment.
seizures 5min+ OR
2+ discrete seizure with incomplete recovery of consciousness between them.
BENZODIAZIPINES ( lorazepam) and PHENYTOIN (block Na channel) nb phenytoin is teratogenic
Mood stabilising drugs in epilepsy
CarbaMezepine (block Na channel) and laMotrigine = safe (LLT for epilepsy)
Sodium valproate uses and se
pro - best overall drug for epilepsy but teratogenic! neurodevelopment delay
Newer anti-epileptics, safer profile LLT
Lamotrigine, Levetiracetam, Topiramate
3 types of pain
- Nociceptive- caused by stimulation of primary afferent nerves responding to nocious stimuli
- Neuropathic- ECTOPIC pain signal generation, often in the ABSENCE of ongoing noxious events,due to PATHOLOGY in the P/CNS
- Psychogenic- no apparent organic basis
WHO pain ladder 3 steps
1- non opiod eg paracetamol
2. weak opiod + non opiod eg codein + paracetamol
3. Strong opiod + non opiod
adjuvant analgesia eg anticonvulsant/depressant
Paracetamol benefits and dosage
Analgesic, antipyretic, NO anti inflam
uk tablets are 500mg. LESS for frail, underweight and taking other paracetamol products
NSAIDS mechanism of action eg ibruprofen or diclofenac, nb aspirin is antiplatelet nsaid
Inhibit prostaglandin synthesis via COX1 (GI lining) and COX2 (controls inflamm response)
-> anti inflamm but GI SE
NSAIDs max dose
2.4g
tablet is usually 400mg
take after food
NSAID SE
GI- gastritis, bleeding
CV. may give lansoprazole 15mg once a day (PPI)
Renal (COX2)
Hypersensitivity reactions like rashes, angioedema, bronchospam (ASTHMA contraindication if NSAID use causes attack)
Weak opiod examples, mechanism of action + SE
Codeine phosphate, dihydrocodeine.
alter perception of pain, no anti infalmm.
SE- nausea, constipation, adr long term
Codeine contraindications
children, adolescents, breast feeding women because toxic metabolites
Tramadol mechanism, Indications and SE
STRONG OPIOD (better than codeine, not as good as morphine)
Enhances serotonin and adrenergic pathways.
SE- N+V, drowsiness, resp despression,(SO) hypotension,(SO) abuse with SSRI
Strong opiod examples and mechanism of action
Morphine, fentanyl, oxycodone, pethidine
Act on Mu and kappa receptors in CNS
Tricyclic Antidepressants as adjuvant agents. Example, SE
Amitriptyline, nortriptyline, dosulepin
SE- sedation, antimuscarinic (dry mouth, urinary retention)
Antiepileptics as adjuvant agents for neuropathic pain. Examples
Gabapentin (not acc used in anti-epilepsy)
Carbamazepine- mood stabiliser in epilepsy
Anxiolytics - pain disorders and muscle spasm
Benzodiazepines eg diazepam
Define Multiple Sclerosis
Chronic AUTOIMMUNE condition of CNS leading to INFLAMMATION (RR), DEMYELINATION and NEURODEGENERATION (long).
Leads to functional disability that either worsens or has periods of R/R
Symptoms of MS
Sensory disturbance-numb, tingling (otoff and lhermitte)
Visual - especially 1 eye
Motor- UMN signs and walking difficult (slap)
Bladder and bowel problems
fatigue
pain
Epidemiology of MS
20-40year olds. Women >men. Further from equator
Lhermittes symptom MS
neck flexion- electric feeling down spine
Uhtoffs phenomenon MS
Transient functional disturbance when it’s hot/post excercise
Aetiology of MS
theory - T cell infiltration of CNS in RR stage then resident cns cells contribute to inflammation long term
Both genetic and env triggers likely (incidence > further from equator)
Primary Headache Syndromes- 3 types
- Tension headaches
- Migraine
- Trigeminal autonomic cephalagies ( pain on one side of the head in the trigeminal nerve area and symptoms in autonomic systems on the same side, such as eye watering and redness or drooping eyelids.Inc Cluster headache.)
Tension Headache
presentation
Site - bilateral O- episodic C- tight band R A T- chronic E- stress, caffeine, lack of sleep, dehydration, eyesight etc S- not debilitating/affecting AODL
Causes of tension headache
thought to be VASC IRR referred to muscles
May be:
- ANELGESIC OVERUSE but withdrawal can -> rebound headache
- need glasses/ other TRIGGERS
- ongoing migraine
- neck stiffness irritating occipital
Treating TTH (3)
- lifestyle factors
+ paracetamol, NSAID
2.analgesia withdrawal - neck physio if relevant
Migraine cause and presentation
cause - vasospasm S- unilateral O- Episodic, C- disabling R A- predrome, aura, nausea, inc sensitivity T- hours- days E- better when lie down, dark S- bad
Assd migraine features
- prodrome eg yawn, toilet, irritable aura- flashing lights - postdrome - feel shit days -Nausea photophobia phonophobia osmophobia = sensitivity!
Treating migraine- current (3)
- lifestyle changes
2. prophylaxis - beta blocker(propanolol) anticonvulsant/antiepileptic topiramate (teratogenic), antidepressant amitryptiline candesartan?
- RESCUE treatment=
IV antiemetic eg metaclopramide + NSAID+ TRIPTAN
NSAID for mild symptoms (aspirin, ibruprofen, naproxen)
Triptan for severe symptoms (sumatriptan)
CN1
Olfactory- smell
Px - change in smell
CN2
Optic
AFRO for examination
ADD pictures of visual fields
Absent direct and consensual light reflex =
optic nerve lesion (CN2)
Absent direct light reflex, consensual is present =
ipsilateral occulomotor nerve lesion (CN3)
CN3,4,6
Occulomotor, Trochlear, Abducens
All eye movement except superior oblique (down and out CN4) and lateral rectus (side CN6, squint)
So4Lr6
CN5
Trigeminal (V1 = Opthalmic, V2 = Maxillary, V3 = Mandibular)
sensation, corneal reflex, muscles of mastication
jaw swings to side of lesion
CN7
Facial
movement and taste ant 2/3 tongue
NB forehead is spared in UMN lesions like strokes because it receives motor innervation from both hemispheres
CN8
Vestibulocochlear
perform Webers and Rinnes test
Weber’s test (1st)
Hit tuning fork, place on forehead.
If heard louder on one side there is either :
a) conductive hearing loss (outer/middle) = on the side louder
or
b) sensorineural (inner ear deficit)= on the quieter side
Rinne’s test (2nd)
Hit tuning fork, place on mastoid of 1 ear.
should hear ringing.
place it outside the ear and should still hear ringing = +, normal
place it outside ear and no hearing = - Rinne, conductive hearing loss on that side.
CN9, 10
Glossopharyngeal, Vagus (sensory and motor func mix)
inspect for palate symmetry, cough, speech, swallow
taste post 1/3 = cn9
uvula deviation = away from side of lesion CN10
gag reflex
CN11
Spinal
SCM and trapezius
get patient to turn head and shrug shoulders against force and look for wasting
CN12
Hypoglossal
tongue movement
deviates to side of lesion
Causes that can affect any CN -> deficit (6)
DM, MS, tumour, vasculitis, infection, syphyilis
Define Trigeminal Neuralgia and 3 drugs used to treat
stabbing pain in one division of trigeminal nerve, without any known pathology.
Often treated with carbamezipine, gabapentin or phenytoin (anti-seizure meds)
Define TIA
SUDDEN onset of FOCAL NEUROLOGICAL DEFICIT
(usually dysphasia and hemiparesis)
caused by ischaemia.
the deficits are temporary and maximal at onset.
Lasts 5-15 mins.
traditionally <24 hours to define.
Risk factors for ischaemic stroke (9)
AF, CA stenosis,hypercholestrolemia,obesity, DM, hypertension, age, smoking, FH
all cv risk factors
Bamford/Oxford Classification of stroke (4)
NB most of the time these are ischaemic.
- TACS
- PACS
- LACS- lacunar
- POCs
Causes of ischaemic stroke
- Thrombotic occlusion due to large vessel disease - atherosclerosis
- Cardioembolism
- Dissection (CA -> intramural haematoma)
What is TACs criteria
- Higher function loss - speech, apraxia,neglect
- Homonomyous Hemianopia
- Hemi-losses sensory/motor, unilateral
3/3 = TACs
2/3 = PACs OR just number 1
What is Lacunar Syndrome
- Hemiplegia
2.Hemisensory loss - Upgoing plantar
NB - NO HIGHER FUNCTION LOSS OR HEMIANOPIA
SIgns of POC syndrome
Brainstem signs: CN involvement ipsilateral eg dizzy, vertigo, dysphagia, ataxia
Cerebellar signs: ipsilateral DANISH
Occipital signs: homonymous hemianopia (isolated), diplopia
CROSS HALLMARK:
contralateral motor weakness and upgoing plantar
Forms of POCS
- PCA stroke
- Basilar artery thrombosis
- Cerebellar stroke
- Brainstem stroke
PCA stroke MOA and typical symptom
PCA infarct or occipital haemorrhage
-> controlateral homonymous hemianopia
Cerebellar stroke- DANISH
Dysdiadochokinesia Ataxia Nystagmus INTENTION TREMOR Scanning dysarthria Heel Shin test incoordination
Basilar artery thrombosis symptoms
Bilateral/uni CN palsy severe quadriplegia bilateral upgoing plantar coma, resp arrest locked in syndrome
Brainstem stroke syndromes
- Lateral medullary/wallenburg
8 causes of hemorrhagic stroke
- Trauma
- Hypertension
- Vascular abnormalities
- Vasculitis
- Impaired coagulation
- Amyloid angiopathy
- Tumour
- Drug induced
Types of brain hemorrhage
- Intracerebral
- Subarachnoid
- Subdural
- Extradural
add pics
Differentials of acute secondary headaches
- SAH (sudden onset severe headache)
- Meningitis (rash, fever, neck stiff)
- Encephalitis (fever, fits, strange behaviour, reduced consciousness)
Headache warning signs
- Papilloedema
- Seizures, focal neurological signs, cancer, immunosuppression (HIV)
- Visual disturbance
- Postural change
- Pregnancy
- N+V
- Vasculitis history, DM
- Getting worse
- morning headache or wakes from sleep
CA Dissection signs 5
- recent trauma
- neck stiffness
- Horners
- TIA symptoms
- Thunderclap headache
VA Dissection signs
- recent trauma
- neck stiffness
- sudden onset vertigo or ataxia
- risk of POCS
Giant Cell Arteritis/ Temporal arteritis definition and presentation
Vasculitis (inflammation in lining of) temporal artery.
THINK in 50+
Generalised aches and pains and unilateral throbbing
May have palpable artery, scalp tenderness and jaw claudication.
if suspected, immediately START STEROIDS to avoid vision loss.
Differentials of subacute secondary headaches
- CVST
- GCA
- Tumour
- Intracanial hypertension (benign or malignant)
- Sinusitis
- Glaucoma
Expressive dysphasia
They don’t make sense when you ask them to name 3 objects.
- issue is with Broca’s area frontal lobe
Receptive dysphasia
can speak normally but cannot understand what you want them to do
- won’t perform a 3 stage command
- issue is with comprehension in Wernickes area in temporal lobe
Dysarthria
Slurred speech
- cannot articulate well when asked to say a tongue twister
- issue with muscles
Aphasia
cannot speak
Ischaemic stroke management
- Thrombolysis /Clot busting within 4.5 hrs = Alteplase
- Antiplatelet = Aspirin short term, clopidogrel
- Anticoagulants = Short term heparin, warfarin , long term apixaban etc
- BP control, cholestrol control if necessary
- Thrombectomy if anterior circulation stroke and feasible
