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Neurology Flashcards

1
Q

Retinal vein occlusion

Features
Causes

A

Sudden, painless visual loss

Flame haemorrhages radiating from swollen disc
Cotton wool spots
engorged Tortuous veins
= FCT

*Look for changes relating to cause: diabetic or hypertensive retinopathy

Causes: hypertension, hyperglycaemia (DM), hyperviscosity (myeloma), high intraocular pressure (glaucoma)

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2
Q

Retinal artery occlusion

Features
Causes
Treatment

A

Sudden, painless visual loss. Preceded by amaurosis fugax.

Pale, milky with thread like arteries and cherry red macula.

*Look for causes: AF, carotid bruit

Causes: embolic (carotid plaque rupture, cardiac mural thrombus w/ AF), GCA

Tx: embolism (aspirin, anticoag, endardarectomy) ,GCA (high dose steroids)

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3
Q

Sudden painless visual loss

Causes

A

Retinal vein occlusion (HTN, DM, myeloma, glaucoma)
Retinal artery occlusion (AF, GCA)
Retinal detachment (proliferative diabetic retinopathy, trauma)
Vitreous haemorrhage (proliferative diabetic retinopathy, vitreous/retinal detachment, trauma)

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4
Q

Sudden painful visual loss

Causes

A

Acute glaucoma
Endophthalmitis
Uveitis
Trauma

Binocular: migraine, vertebrobasilar insufficiency, stroke, PRES, optic neuritis

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5
Q

Retinitis pigmentosa

Features
Cause
Associated conditions

A 
White stick
Tunnel vision (reduced peripheral vision) starting with reduced night vision

Fundoscopy: bone spicule pigmentation with optic atrophy

Congenital: AR
Acquired: post inflammatory retinitis

Associated:
Freidrichs ataxia
Refsums disease (ataxia, deafness, icthyosis)
Kearns-Sayre syndrome (ataxic, deaness, ophthalmoplegia/ptosis, PPM)
Users disease (deafness)

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6
Q

Tunnel vision

Causes

A 
Retinitis pigmentosa
Papilloedema
Glaucoma
Choroidoretinitis
Migraine
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7
Q

Age related macular degeneration

Features
Risk factors
Treatment

A

Wet (neovascular, exudative)
Dry (atrophic)

Fundoscopy: drusen, atrophy, fibrosis, neovascularisation (wet)

Risk: age, white, fhx, smoking, CHD/CVE

Tx: ophthalm, wet AMD = intravitreal injections of anti-VEGF

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8
Q

Optic atrophy

Features
Causes

A

RAPD, optic disc pallor

PALE DISCS
Pressure (tumour, glaucoma)
Ataxia (friedreichs ataxia)
Lebers hereditary optic atrophy

Dietary (B12)
Degenerative (retinitis pigmentosa)
Ischaemia (central retinal artery occlusion)
Syphilis (and other infection i.e.CMV, toxo)
Cyanide (and other toxins, etoh, lead, tobacco)
Sclerosis (MS)

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9
Q

Horner’s syndrome

Features

A

Ptosis, miosis, anhydrosis

Damage to sympathetic tract:

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10
Q

Horners syndrome

Causes

A

First order/central:
Hypothalamus - stroke, tumour
Brainstem - stroke, tumour, MS
Spinal cord - tumour, MS, syringomyelia, trauma

Second order/pre ganglionic:
Apical lung - pancoasts tumour, cervical rib
Subclavian artery aneurysm
Thyroid tumour

Third order/post ganglionic:
Carotid artery - dissection, aneurysm
Skull base - tumour, trauma
Cavernous sinus - thrombosis, tumour

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11
Q

Holmes adie pupil

A

Tonic pupil
Dilated with sluggish constriction to accommodation, poor response to light
Absent reflexes
Benign

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12
Q

Argyll Robertson pupil

A

Small irregular pupil
Accommodates but no reaction to light

*look for tabes dorsalis/sensory ataxia as associated with syphilis

Causes: quaternary syphilis or diabetes
Tx: penicillin

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13
Q

Oculomotor nerve palsy

Features
Causes

A

Full ptosis
Down and out pupil

If dilated pupil = surgical (papillary fibres and superficial and easily impinged by surgical causes)
If normal pupil = medical

Surgical: communicating artery aneurysm, cavernous sinus pathology (tumour, thrombus), cerebral herniation

Medical: mononeuritis multiplex (DM), midbrain infarction, midbrain demyelination, migraine

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14
Q

Neurofibromatosis

Features
Inheritance
Associations
Complications

A

Features: ABCDEF
Axillary freckling / Acuity (optic glioma)
Blood pressure (hypertension - RAS and phaeo)
Cutaneous neurofibromas (>2) / Cafe au lait (>6)
lisch noDules (iris hamartomas)
Enlarged palpable nerves with neuropathy
Fine crackles (fibrosis)

Inheritance: AD
Type 1 = ch 17, classical
Type 2 = ch 22, CENTRAL, BL acoustic neuroma, sensorineural deafness, no skin lesions

Association - phaeo and RAS (HTN)

Complications: epilepsy, sarcomas, scoliosis, low IQ

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15
Q

Enlarged palpable nerves and neuropathy

Causes

A 
Neurofibromatosis 
Leprosy
Amyloidosis
Acromegaly
Refsums disease (RP, ataxia, deafness, anosmia, dry scaley skin, short digits)
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16
Q

Tuberous sclerosis

Features
Inheritance
Associations
Investigations

A

Features:
Skin: butterfly adenoma sebaceum, periungual fibromas, shagreen patch (lumbar, leathery) and ash leaf macule (trunk, depigmented)
Resp: cystic lung disease
Abdo: renal enlargement (PKD/angiomyolipomata), renal transplant, evidence of dialysis
Eyes: phakomas on retina (dense white)
CNS: cognitive defects, seizures (very common)

Inheritance: AD

Associations: ADPKD (genes near each other on ch 16), renal angiomyolipomas, RCC, cysts. therefore renal failure.

Ix: railroad track calcification on skull films, CT/MRI head = tuberous calcified masses in cortex, echo and abdo USS = hamartomas and renal cysts.

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17
Q

Myasthenia gravis

Features
Cause
Associations
Investigations
Treatment
A 
Bilateral fatigable ptosis
Ophthalmoplegia
Nasal speech, poor swallow
Fatigable proximal upper limb weakness
Normal reflexes
Thymectomy scar (sternotomy)
Check FVC

Cause: anti acetylcholine receptor antibodies reduce transmission

Associations: autoimmune diseases (DM, RA, thyrotoxicosis), thymomas

Ix: anti acetylcholine R antibody (90%), anti-MuSK if anti-AChR negative, EMG (decremented response to train of implses), tensilon test (edrophonium ACh-esterase inhibitor improves weakness but causes HB and asystole!!), CT/MRI thymus, TFTs (Graves)

Tx: avoid precipitating drugs (beta blockers, antibiotics i.e. fluoroquinolones, penicillin, steroids)
Acute = IVIG or plasmapheresis
Chronic = pyridostigmine (ACH-esterase inhibitor), immuosuppression (steroids, aza), thymectomy

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18
Q

Lambert Eaton myasthenic syndrome

Cause
Features
Association

A

Diminished reflexes -better after exercise
Lower limb proximal weakness

Cause: antibodies blocking pre synaptic calcium channels

Associations: SC lung Ca

EMG: second wind phenomenom on repetitive stimulation

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19
Q

Bilateral ptosis

A 
Congenital
Myasthenia gravis
Myotonic dystrophy
BL 3rd nerve/horners
Mitochondrial disorders i.e. Kearns-Sayres
20
Q

Unilateral ptosis

A

3rd nerve palsy

Horners syndrome

21
Q

Bilateral ophthalmoplegia

A

Myasthenia gravis
Graves disease
Mitochondrial disorders i.e. Kearns-Sayres

22
Q

Facial nerve palsy

Features
Cause

A

Unilateral facial droop, can’t raise eyebrows or tightly close eyes

Causes:
Bells palsy
Varicella Zoster/Ramsay hunt (vesicular rash in ear)
Mononeuropathy (DM, sarcoid, lyme)
Tumour (parotid, acoustic neuroma)
Trauma
MS
CVE
23
Q

Bells palsy

Features
Treatment

A

Facial nerve palsy. Rapid onset. HSV-1 implicated.

Tx: prednisolone within 72 hrs of onset, eye protection

70-80% full recovery

24
Q

Bilateral facial palsy

Causes

A 
GBS
Sarcoidosis
Lyme disease
Myasthenia gravis
Bilateral bells palsy
25
Friedrichs ataxia Features Inheritance Associations
``` Features: Young, wheelchair Ataxia, dysarthria, nystagmus LMN: leg wasting, weakness, absent reflexes UMN: upgoing plantars PC loss: vibration and proprioception MSK: pes cavus, kyphoscoliosis Eye and ears: optic atrophy, sensorineural deafness Cardiac: HOCM Diabetes ``` Inheritance: AR, 20yr from diagnosis Association: HOCM, dementia
26
Extensor plantars with absent reflexes
Freidriechs ataxia Sabacute combined degeneration of spinal cord (B12) MND Taboparesis Combined lesions i.e. cervical radiculopathy and peripheral neuropathy
27
Peripheral neuropathy Causes
Sensory: metabolic type DM, alcohol, drugs, vitamin deficiency (b12, thiamine) Motor: rare types GBS, lead toxicity, porphyria, HSMN (charcot marie tooth)
28
Mononeuritis multiplex Causes
``` DM CTD (SLE, RA) Vasculitis (PAN, Churg Strauss) Infection (HIV) Malignancy (paraneoplastic) ```
29
HSMN/Charcot Marie Tooth Features Types
Neuropathy - predominantly motor, with MSK effects Distal wasting of lower limbs, preserved thigh muscle bulk (inverted champagne bottles) Weakness distally Socking sensory loss Gait: high stepping (foot drop) and stamping (loss of proprioception) Hand muscle wasting Palpable nerves MSK: pes cavus Types: I (demyelinating) and II (axonal) most common AD inheritance Ix: NCS/EMG (demyelinating vs axonal) Tx: PT/OT, podiatry, genetic counselling
30
Parkinson's disease ``` Features Associated signs Causes Pathology Treatment ```
Expressionless face Tremor: coarse, pill rolling, asymmetrical Bradykinesia: oppose digits quickly Cogwheel rigidity: synkinesis enhances it (simultaneous movements of other hand tapping on leg) Gait: shuffling, reduced arm swing Speech: slow, quiet Associated signs: BP (MSA - postural drop, cerebellar and pyramidal signs) Eye movements (PSP - reduced up/down eye movements) Dementia (DLB) Drug history Causes: Idiopathic Parkinsons disease Parkinsons plus: MSA, PSP, CBD, DLB Drug induced Parkinsonism (phenothiazines) Pathology: degeneration of dopaminergic neurons in substantia nigra ``` Treatment: L dopa with dopa decarboxylase inhibitor (madopar) - nausea, dyskinesia, wear off, on/off motor fluctuation Dopamine agonist (pergolide) - less side effects, apomorphine is SC injection/infusion MAO-B inhibitor (selegiline) Anti cholinergic (reduce tremor) COMT inhibitor (entacapone) Amantadine (increase DA release) Surgery: DBS ```
31
Tremor Causes
Resting: Parkinsons (check eye movements, bradykinesia, cogwheel rigidity, BP) Intention: cerebellar (check eye movements, past pointing, dysdiadokokinesia, ataxia, hypotonia, dysarthria) Postural: benign essential tremor (better with alcohol), anxiety, thyrotoxicosis (thyroid examination), metabolic (CO2/asterixis)
32
MND ``` Features History Types Investigation Treatment Prognosis ```
Wasting, fasciculation Increased tone Weakness Absent knee with extensor plantar NORMAL SENSATION Speech: bulbar (nasal) or pseudobulbar (hot potato due to spastic tongue) Tongue: wasting and fasciculation (if bulbar), spastic (if pseudobulbar) History: asymmetrical, rapid, aggressive, behavioural/cognitive dysfunction (FTD = MND). MFMN = distal weakness Family history - Kenendys Types Axonal degeneration of upper an lower motor neurons AML: 1/2, CS tracts, spastic paraparesis PMA: 1/4, anterior horn cells, wasting/fasciculation/weakness. Best prognosis. PBP: 1/4, lower CN and suprabulbar nuclei (speech and swallow problems). Worst prognosis. Kennedys = tongue fasciculations SMA: LMN ** differentials: multifocal motor neuropathy with conduction block. Ix: EMG (fasciculation, fibrillations, in MFMN = demyelinating, conduction block), MRI brain and spine (exclude cord compression, myelopathy, brainstem lesions) Tx: supportive (PEG, NIV), MDT Riluzole (glutamate antagonist) - 3 months benefit, doesn't improve function or QoL Screen for FTD. Prognosis: 3 yrs from diagnosis due to pneumonia and resp failure
33
Wasting of hand muscles Causes
Anterior horn cell: MND, syringomyelia, cervical cord compression, polio Brachial plexus: trauma, pancoast's tumour, cervical rib Peripheral nerve: median and ulnar nerve lesions, peripheral neuropathy Muscle: disuse atrophy i.e. RA
34
Syringomyelia Features Cause Associations
UL: Weakness/wasting small hand muscles Areflexia upper limbs Dissociated sensory loss (pain and temp lost) with scars Charcot joint LL: UMN weakness with upgoing plantars Kyphoscoliosis, Horner's, if syringobulbia -> cerebellar/lower CN Cause: progressively expanding fluid filled cavity in cervical spinal cord spanning several levels Associations: arnold-chiari, spina bifida Ix: spinal MRI
35
Charcot joint Causes Treatment
Painless deformity and destruction of joint with new bone formation after repeated minor trauma secondary to loss of pain sensation (spinothalamic) Cause: tabes dorsalis (hip/knee), diabetes (foot/ankle), syringomyelia (elbow/shoulder) Tx: bisphosphonates
36
Biceps/supinator jerk Triceps jerk
C5/6 C7/8
37
Spastic paraparesis i.e. myelopathy Features Cause
``` Wheelchair/stick, ?scars (trauma), urinary catheter (?Spinal) Increased tone with clonus Weakness Hypereflexia and extensor planters Scissoring gait ?sensory level (spinal) ?signs of MS (cerebellar, optic atrophy) ``` Broadly: trauma, ischaemia, inflammation, neoplastic, infection, metabolic. Commonly: MS, spinal cord compression, cervical myelopathy, trauma, MND (normal sensation) Other: anterior Spinal artery thrombosis (dissociated sensory, DC preserved), syringomyelia (LMN signs in upper limb, UMN in lower limb, shawl sensory loss), HSP (fhx, stiff>weak), subacute combined degeneration of cord (absent reflexes, upcoming plantars), Friedrich ataxia (cerebellar, DC loss, UMN, MSK, eye, heart)
38
Cord compression Features Cause Investigation Treatment
Sensory level Spastic paraparesis Upgoing planters and clonus Weakness Causes: disc prolapse, trauma, infection (abscess, tb), malignancy Ix: mri spine Tx: surgical decompression, steroids/radio if malignancy
39
Wallenberg/lateral medullary syndrome Features Cause
IPSILATERAL: cerebellar signs, vertigo, horners, palatal paralysis, trigeminal pain and temp loss. CONTRALATERAL: loss of pain and temp Cause: occlusion of PICA
40
Stroke ``` Features Look for causes Definition CVE/TIA Investigation Management Bamford classification ```
Flexed upper limb/extended lower limbs Increased tone and clonus Weakness May have reduced coordination 2 to weakness or cerebellar involvement (PC) Brisk reflexes and extensor plantars Gait - tip toesing Look for - facial weakness, swallow, visual fields/neglect, higher cortical Look for causes: AF, carotid bruits, murmur, HTN Definition: CVE; rapid onset focal neurological deficit due to vascular lesion >24 hrs TIA; rapid onset focal neurological deficit <24 hrs Ix: bloods (inc CRP/ESR if young), glucose, renal function, ECG (AF), CXR (cardiomeg, aspiration), CTH (infarct, bleed) Consider: echo, carotid dopplers, MRI/MRA/MRV (dissection, venous sinus thrombosis), clotting, vasculitis screen if young Mx: Acute: thrombolysis <4.5 hrs and no CI in ischaemic Aspirin 300 2/52 then clopi, PPI, MDT on st unit, IPCS Chronic: secondary prevention (statin, ACEI), carotid endartarectomy (70-99% occlusion), anticoag if AF Bamford: TACS: hemiplegia, homonomous hemianopia, high cortical dysfunction (swallow, neglect) PACS: 2/3 Lacunar: pure hemisensoy/motor
41
Visual field defects Defect and location of lesion
Unilateral - ipsilateral optic nerve Bitemporal hemianopia - optic chiasm Homonymous hemianopia - contralateral optic tract Upper homonymous hemianopia - contralateral temporal optic radiation Lower homonymous hemianopia - contralateral parietal optic radiation Macula spared in posterior cerebral artery stroke Otherwise middle cerebral artery
42
Multiple sclerosis ``` Features Diagnostic criteria Investigations Treatment Prognosis Pregnancy ```
Wheelchair INO (can be bilateral - cant adduct, other eye nystagmus), optic atrophy, reduced acuity, any other CN pathology UMN with altered sensation - spastic paraparesis Cerebellar signs Autonomic features - bladder and bowel Uthoffs - heat worsens Lhermittes - lightening pain on neck flexion Diagnostic: CNS demyelination causing neurological impairment disseminated in space and time. Unknown cause. Ix: CSF (oligoconal bands), MRI (periventricular white matter plaques), VEPs (delayed velocity, normal amplitude - previous optic neuritis) Tx: MDT DMARD: IFN b, glatiramer reduce relapse rate. Monoclonal ab reduce progression (natalizumab). Symptoms: high dose steroids i.e. methylpred shortens relapse, antispasmodics, carbamazepine (neuro pain), manage bowel and bladder Prognosis: variable, majority ambulant 10 yrs Pregnancy: reduced relapse rate but increased in post partum
43
Cerebellar syndrome Features Cause
Dysarthria, rebound phenomenon, incoordination, hypotonia and hyporeflexia, nystagmus, broad based gait Ipsilateral limbs signs ``` Causes: Alcohol and drugs (PT) CVE SOL or paraneoplastic Inflammation: MS Endocrine: hypothyroidism Rare: Freidreichs, ataxic telangiectasia ```
44
Myotonic dystrophy Features Inheritance Investigations Management
Face: myopathic, frontal balding, temporalis wasting, BL ptosis, cataracts, dysarthria Hands: myotonia (delayed grip release, tapping on thenar eminence), wasting and weakness, areflexia Other: cardiomyopathy, heart block, PPM, diabetes, testicular atrophy Inheritance: AD. DM 1 = DMPK gene ch 19, DM 2 = ZNF9 gene ch 3 Anticipation in DM1 Ix: EEG (dive bomber), genetics Mx: resp and cardiac complications, PPM, PT for myotonia, avoid GA
45
Ulnar nerve lesion Features Causes
``` Wasting of hypothenar eminence and small muscles of hand ?scars Claw of 4th/5th fingers Normal tone Weakness finger abduction Altered sensation -ulnar border ``` **Mimic - C8-T1 radiculopathy, check for other muscles of hand (abductor pollicis brevis) and sensation T1. ``` Causes: Trauma - at elbow Surgical procedure Malignancy - paraneoplastic Mononeuritis multiplex (would likely get areflexia if inflammatory) ``` Ix: neuro-physiological testing, NCS to localise lesion, EMG for prognosis in terms of recovery Treatment Neuropathic pain - tricyclic antidepressant (amitriptyline), gabapentin/pregabalin, duloextine, capsacin
46
Main peripheral nerves of upper limb
Ulnar - finger abduction Median - abductor pollicis brevis Radial - wrist extension Posterior interossei nerve - finger extension

PACES MRCP (6 decks)

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