Neurology Flashcards
what are some red flags in a headache history?
- new onset headache + history of cancer
- cluster headache
- seizures
- altered conciousness/ memory/ confusion/ coordination
- papilloedema
- abnormal neurological examination
features of a migraine
- 4-72 hours
- must occur at least 5 times for diagnosis
- painful, unilateral, pulsating, aggravated by routine physical activity
- associated with nausea, photophobia, phonophobia
features of a tension headache
- 30 mins- 7 days
- bilateral pressing pain, not aggravated by routine physical activity
- no nausea/ vomiting
features of a cluster headache
- 15-180 minutes
- severe unilateral orbital/ supraorbital pain
- accompanied by ipsilateral cranial autonomic features and a sense of restlessness/ agitation
- attacks occur in a ‘cluster’ then are separated by a ‘pain free’ period
features of trigeminal neuralgia
- unilateral face pain in the distribution of the trigeminal nerve
- lasts up to 2 minutes
- like an electric shock
which headaches are classed as primary headaches?
migraine, cluster and tension
how are primary headaches treated?
- lifestyle modification pharmacological: - oral triptans- NSAIDS/ paracetamol - anti-emetics - topiramate/ propanolol - botulinum toxin injections
features of idiopathic intercranial hypertension?
- pain is worse on walking, coughing, sneezing and straining
- nausea and vomiting
- pappiloedema
how is idiopathic intercranial hypertension treated?
acetazolamide
topiramate
diuretics
features of GCA
new onset headache localised pain tenderness jaw claudication visual disturbance
treatment of giant cell arteritis
prednisolone
features of medication overuse headache
- headache present over 15 days/ month
- caused by regular use of drugs (more than 3 months)
- headaches worse during drug use
clinical features of MS
- more common in females (usual age around 30)
- monosymptomatic- most commonly optic neuritis
- symptoms worsen on heat/ exercise
- relapsing/ remitting- monosymptomatic followed by a period of no symptoms
diagnosis of MS
- clinical
- lesions disseminated in time and space attributed to no other known cause
- MRI- identifies plaques
- CSF- oligoclonal bands of IgG on electrophoresis
treatment of MS
- vitamin D supplements
- methylprednisolone to treat relapses
- IFN- 1b and IFN 1a to decrease relapses
- monoclonal antibodies- alemuzumab/ rituximab
what is myasthenia gravis?
autoimmune disease in which antibodies to nicotinic acetylcholine receptors are produced
clinical presentation of myasthenia gravis?
- muscular weakness/ fatigue
- ‘moves down’ e.g. symptoms begin extra ocularly and progress down the body towards the trunk
- ptosis, diplopia, myasthenic snarl
- voice fades on counting to 50
how is myasthenia gravis diagnosed?
- anti-AChR antibodies found in 90%
anti- muscle specific Kinase (MuSK) antibodies
Large thymus/ clusters of immune cells in thymus - Thymomas (tumours)
treatment of myasthenia gravis?
- symptom control- anticholinesterase medication= pyridostigmine
- treat relapses with prednisolone +azathioprine/ methotrexate
what can exacerbate symptoms in myasthenia gravis?
- pregnancy
- hypokalaemia
- infection
- drugs- tetracycline, quinine, B-blockers
how is MND distinguished from MS and polyneuropathies?
affects UMN and LMN, but NO sensory loss or sphincter disturbance
clinical presentation of amyotrophic lateral sclerosis (ALS)
- loss of motor neurons in motor cortex and anterior horn of spinal cord
- weakness + UMN signs (upgoing plantars etc) +LMN wasting/ fasciculations
- split hand sign- thumbs side of the hand seems to separate from the rest due to excessive wasting
clinical presentation of progressive bulbar palsy
- cranial nerves IX-XII
- LMN lesion of the tongue and muscles and talking -results in a flaccid, fasciculating tongue, absent jaw jerk, speech changes- quiet, horse, nasal
clinical presentation of progressive muscular atrophy
- anterior horn cell lesions only
- LMN only
- affects distal muscle groups before proximal
clinical presentation of primary lateral sclerosis
- loss of betz cells in motor cortex
- UMN signs
- spastic leg weakness and pseudo-bulbar palsy
- no cognitive decline
How is MND generally diagnosed?
clinical findings and EMG/ nerve conduction studies
what is the El Escorial Criteria for the diagnosis of ALS?
- signs of LMN and UMN degeneration
- progressive spread of signs together with the ABSENCE of:
- elctrophysiological evidence of other disease processes that may explain the signs
- neuroimaging evidence of other disease pocess that may explain the observed signs
management of MND
- riluzole- extends life by around 3 month
- baclofen for spasms
- PEG tube for feeding if needed
UMN signs
weakness brisk reflexes hypertoni upgoing plantars (positive babinski) clonus
LMN signs
weakness depressed/ absent reflexes decreased tone wasting fasciculations
what is Guillain-Barre syndrome?
acute, inflammatory, demyelinating, ascending polyneuropathy that affects the PNS following an upper respiratory tract infection/ GI infection
what are some common infections that can trigger GBS?
- campylobacter jejuni
- CMV
- herpes zoster
- EBV
- HIV
clinical features of GBS
- post infection
- symmetrical, ascending muscle weakness, begninning in the distal limb muscles and progresses proximally
- loss of reflexes, neuropathic pain and autonomic dysfunction
- can also affect respiratory muscles
diagnosis of GBS
- nerve conduction studies
- lumbar puncture- CSF- high proteins, normal WCC
how is GBS managed?
- IV immunoglobulin (IVIg) for 5 days
- monitor ventilation
clinical features of Huntingtons
- chorea- jerky, explosive, figidity movements
- dysarthria, dysphagia, abnormal eye movements
- dementia
what is the difference between spinal cord and spinal root compression?
spinal cord compression- myelopathy with UMN
spinal root compression- radiculopathy with LMN
Clinical features of a subarachnoid haemorrhage
- thunderclap headache/ sudden onset severe headache
- vomiting
- collapse
- seizures
clinical signs of a subarachnoid haemorrhage
- neck stiffness (Kernigs sign)
- retinal bleeds
- photophobia
diagnosis of SAH
star on CT
management of SAH
- surgery- endovascular coiling
- maintain cerebral perfusion
- nimodipine
features of a subdrual haematoma
- fluctuating conciousness
- bleeding from bridging veins
- symptoms occur late- a while after the initial injury
features of an extradural haematoma
- traumatic skull fracture
- lucid internal for a few days after injury
what is Lhermitte’s phenomenon?
Neck flexion brings on a sudden sensation of an electric shock running down your spine
Sign of MS
What is Uhthoffs phenomenon?
Temporary worsening of symptoms caused by an increase in temperature
(e.g. - MS patient in hot bath)
what is clinically located syndrome?
First episode of MS characteristics that must last 24 hours.
first attack of demyelination
A diagnosis of MS can be made afterwards if the MRI shows lesions similar to those of MS
what is secondary progressive MS?
SPMS follows relapsing remitting. Relapsing remitting will transition into progressive worsening of neurological functioning
what is primary progressive MS?
Worsening of neurological functioning from the onset of symptoms, without early relapses or remissions
15% of diagnosis
What is relapsing remitting MS?
clearly defined attacks of new or increasing neurologic symptoms.
These attacks – also called relapses or exacerbations – are followed by periods of partial or complete recovery (remissions).
During remissions, there may be no symptoms, and no apparent progression of the disease
describe GCS scoring
Eye Opening (E)
4 = spontaneous 3 = to sound 2 = to pressure 1 = none NT = not testable
Verbal Response (V)
5 = orientated 4 = confused 3 = words, but not coherent 2 = sounds, but no words 1 = none NT = not testable
Motor Response (M)
6 = obeys command 5 = localizing 4 = normal flexion 3 = abnormal flexion 2 = extension 1 = none NT = not testable
what condition is due to a CCG repeat?
fragile X syndrome
headache red flags
1) Sudden onset + severe
2) Age >50
3) Neck pain/stiffness, photophobia
4) Fever
5) Papilloedema
6) New onset neuro deficit
7) Vomiting
8) Dizziness and visual disturbances / atypical aura (over an hour)
what is giant cell arteritis?
Granulomatous medium/large vessel vasculitis
large vessel vasculitis of the head, scalp, arms, neck
what is a common association with GCA?
Polymyalgia Rheumatica - (neck, shoulders,back,hip)
1) Stiffness
2) Aching
3) Pain
Jaw/ Tongue claudication
Fever
Headache
what anaemia is seen in GCA?
normocytic normochromic
what is the difference between a facial palsy caused by an upper or lower motor neurone lesion?
Upper motor neurone lesion spares the upper head e.g ‘wrinkle forehead/ raise eyebrows’
what is Bells palsy?
Lower motor neurone palsy of the facial nerve (7th)
Causing:
1) Facial droop on one side of the face
2) Cant close one eyelid
3) flat wrinkles on one side of forehead
how is Bells palsy diagnosed?
diagnosis of exclusion- rule out other possible causes
management of Bells palsy
- eye drops
- wear sunglasses
- corticosteroids- prednisolone
median nerve palsy
C6-T1
carpal tunnel syndrome
ulnar nerve palsy
C7-T1
claw hand
weakness/ wasting of medial wrist flexors
radial nerve palsy
C5-T1
wrist and finger drop
Lat. cutaneous nerve of the thigh palsy
L2-L3
meralgia paraesthesia- lateral burning thigh pain
sciatic nerve palsy
L4-S3
foot drop
common peroneal nerve palsy
L4-S1
foot drop, weak dorsiflexion, sensory loss
tibial nerve palsy
L4-S3
failure of plantarflexion (tiptoes)
in which type of myopathy does spontaneous pain at rest occur?
inflammatory myopathy
which types of myopathy have a rapid onset?
toxic, drug or metabolic myopathies
what myopathy does pain on exercise relate to?
- ischeamia/ metabolic myopathy (McArdle’s disease)
what myopathy does ‘firm; muscles imply?
pseudo-hypertrophic muscular dystrophies (Duchenne’s)
how does Duchene’s muscular dystrophy present?
- young (around 4)
- clumsy walking
- diffuclty in standing
- progresses to respiratory failure
- pseudohypertrophy is also seen- in the calves
what marker is significantly raised in Duchennes?
serum creatinine kinase (over 40 times)
what is the inheritance pattern seen in duchenne’s and beckers’ muscular dystrophy?
x- linked recessive
how does myotonic dystrophy present?
- 20-40 years old
- distal weakness (hand/foot drop)
- weak sternocleidomastoids
- facial weakness
- cataracts
- develop respiratory and cardiac problems
clinical presentation of inflammatory myopathies
- weakness of quadriceps, finger flexors
- poor response to therapy
drug causes of myopathy
alcohol, statins, steroids, chloroquine, zidovudine, vincristine, cocaine
clinical features of facioscapulohumeral muscular dystrophy?
- onset 12-14
- inabiltiy to puff out cheeks
- cant raise arms over head
- foot drop
- scapular winging
what is dermatomyositis?
insidious onset of progressive symmetrical proximal muscle weakness plus ‘skin signs’ macular rash, purple eyelids
how are polymyositis and dermatomyositis investigated?
- ALT, AST, LDH, CK all raised
- muscle biopsy confirms diagnosis
- MRI shows some muscle oedema
how are polymyositis and dermatomyositis managed?
prednisolone
use hydroxychloroquine in dermatomyositis
what is status epilepticus?
a seizure lasting more than 30 minutes or repeated seizures without regaining consciousness
how is a diagnosis of status epilepticus confirmed?
EEG