Neurology Flashcards
Ascending vs descending spinal cord tracts
Ascending - sensory
Descending - motor
Ascending tracts include: dorsal columns, lateral spinothalamic tracts, ventral spinothalamic tract
Descending tracts include: lateral corticospinal tract and the ventral corticospinal tract
What do the ascending tracts do? Name each one with its function
Dorsal column-medial lemniscus - deep touch, proprioception, vibration
Lateral spinothalamic tract - pain, temperature
Ventral spinothalamic tract - crude touch
What do the descending tracts do? Name each one with its function
Lateral corticospinal tract is for voluntary motor of contra lateral limbs
Ventral/anterior corticospinal tract is for movement of trunk, neck and shoulders
conditions to inform the DVLA
- cataplexy
- first seizure no driving for 6 months
- epilepsy can’t drive unless free from seizure for 12 months or withdrawing from treatment
triptans (migrains and headaches) are contraindicated for which disease?
coronary artery disease because they cause coronary vasospasm
symptoms of cluster headache
sudden onset retro-orbital pain with excessive lacrimation and redness
+ autonomic symptoms ( ptosis, miosis, conjunctival injection and excessive lacrimation)
Mx of cluster headache
treatment: high flow oxygen + Sub cut sumatriptan
prophylaxis: verapamil
Mx TIA
Patients presenting with a suspected TIA whilst taking anticoagulants or who have a bleeding disorder should have urgent imaging to exclude haemorrhage.
Other patients should be given 300mg of aspirin immediately then assessed by a specialist within 24 hours.
First-line secondary prevention is clopidogrel 75mg once daily.
what do you give to patients that cannot tolerate clopidogrel?
aspirin + dipyridamole
conditions for aspirin immediately following TIA/ ischaemic stroke
Immediate antithrombotic therapy:
give aspirin 300 mg immediately, unless
1. the patient has a bleeding disorder or is taking an anticoagulant (needs immediate admission for imaging to exclude a haemorrhage)
2. the patient is already taking low-dose aspirin regularly: continue the current dose of aspirin until reviewed by a specialist
3. Aspirin is contraindicated: discuss management urgently with the specialist team
vertigo, hearing loss, tinnitus and an absent corneal reflex, facial weakness
vestibular schwannoma aka acoustic neuroma
absent corneal reflex - CN 5
facial palsy - CN7
vertigo, hearing loss, tinnitis - CN8
CN5 vs CN7
5 - trigeminal: sensation V1,2,3, motor muscles of mastication
7 - facial: taste, bell’s palsy stuff
which lesions spare forehead? why?
upper motor neuron lesion eg strokes ‘spares’ upper face
the forehead receives motor innervation from both hemispheres of the cerebral cortex. A stroke that compromised motor innervation of the face would therefore only result in paralysis of the lower half of the face - the forehead still receiving innervation from the unaffected hemisphere.
comprension + speech production impaired
global aphasia
aphasia (aka dysphasia) subtypes
can comprehend but speech not fluent - Broca’s (inferior frontal gyrus)
can speak fluently (+neologisms and words dont make sense) but no comprehension - Wernicke’s (superior frontal gyrus)
B before W
comprehend before speak
global - both impaired
conduction aphasia (supramarginal gyrus) = can comprehend and can speak but with neologisms and words dont make sense and can’t repeat
spasticity in multiple sclerosis
baclofen
gabapentin
intternuclear opthalmoplegia
brainstem problem
affected eye cannot adduct when asked to look in the contralateral direction
classic multiple sclerosis sign
management MS
vitamin B, steroids, IV immunoglobulin, plasmapheresis, immunosuppressants (Recombinant beta-IFN), manage symptoms with physical and cognitive therapy. spasticity (baclofen, gabapentin)
normal pressure hydrocephalus
Ataxia, urinary incontinence and dementia
bitemporal hemianopia. where is the lesion?
lesion of optic chiasm
upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour
lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma
epiepsy treatment
Generalised tonic-clonic seizures
sodium valproate
second line: lamotrigine, carbamazepine
Absence seizures* (Petit mal)
sodium valproate or ethosuximide
sodium valproate particularly effective if co-existent tonic-clonic seizures in primary generalised epilepsy
Myoclonic seizures**
sodium valproate
second line: clonazepam, lamotrigine
Focal seizures
carbamazepine or lamotrigine
second line: levetiracetam, oxcarbazepine or sodium valproate
carbmazepine contraindictions
absence and myoclonic seizures
status epilepticus treatment
Benzo: IV 4mg lorazepam/IV/PR 10mg diazepam, buccal 10mg midazolam repeat after 10mins if seizure does not terminate
if seizure still recurs after 2nd dose, IV phenytoin/ sodium valproate — consult specialists for dose
Subarachnoid haemorrhage management
ABC + OXYGEN
Isotonic/normal saline to resuscitate
arterial line (monitor BP specifically) - stop anti-hypertensives
Nimodipine - cerebral vasodilator to stop cerebral ischaemia and improve outcomes
reverse anticoagulation - we want clotting
neurosurgery: surgical clipping, endovascular coil embolization
reduce high ICP: lumbar drainage or ventriculostomy, mannitol
subdural haemorrhage management
haematoma <10mm without significant neurological dysfunction
conservative
prophylactic anti epileptics
stop and reverse anticoagulants
ICP lowering regimen: raise head, hyperventilate, sedation (lower anxiety), hyperosmolar therapy (hypertonic saline, mannitol), cooling, decompressive hemicraniectomy
haematoma >10mm or expansile or significant dysfunction
1. ventriculoperitoneal shunt
chronic haematoma — craniotomy
Cushing’s triad
Increased ICP –> Cushing’s triadofhypertension, bradycardia, irregular respiration (+ altered mental status, compression of cranial nerves)
indication for emergency intubation
A Glasgow coma scale score of 8 or less is in indication for emergency intubation
rhinorrhoea + halo sign
CSF!!!!
basilar skull fracture symptoms
Basilar skull fracture can lead to injury of any structures at the skull base
The middle meningeal vessels are particularly at risk because they run underneath the relatively thin pterion.–> extradural haematoma
raised ICP
racoon eye bruising + battle sign (behind ear) bruising
rhinorrhoea
Urthoff’s phenomenon
Multiple sclerosis
Symptoms worse in heat
Parkinson’s key symptoms
Tremor
Rigidity (cog wheeling)
Akinesia (bradykinesia)
Postural instability (falls, hypotension)
dementia, depression, insomnia, hallucinations mask like facial expression, monotonous speech, poor swallow, aspiration pneumonias,
autonomic (multiple system atrophy) — gastric reflux, constipation, postural hypotension, urinary incontinence, erectile dysfunction, cerebellar signs
Parkinsons plus syndromes
lewy body - fluctuating cognition, visual hallucinations, early dementia
progressive supranuclear palsy - limited vertical gaze, can’t look down
corticobasal syndrome - unilateral parkinsonism, non-fluent aphasia
multiple system atrophy - autonomic symptoms
vascular parkinsonism - multi-infarcts, lower body
gold standard diagnosis of parkinson’s
brain histology (death) is definitive:
staining for alpha synuclein which indicates cell death
Braak stages
in practice: 2/3 TRAP symptoms + reversibility with levodopa
Parkinson’s conservative treatment
physio - muscle stiffness
occupational health - practical solutions to things you might find hard like dressing yourself or getting around your house, shower
SALT - dysphagia, speech
diet advice: fibre, higher salt (postural instability)
parkinsons surgical option
deep brain stimulation therapy
Parkinsons medical treatments
- levodopa + carbidopa
- dopamine agonists
- MAO-B inhibitors
- COMT inhibitors
Side effects of levodopa
dizzy, lethargy
uncontrollable, jerky muscle movements (dyskinesias) and “on-off” effects, where the person rapidly switches between being able to move (on) and being immobile (off
dopamine agonists side effects
hallucinations
increased confusion
compulsive behaviour - gambling, shopping, excessive sexual interest
so they need to be used with caution, particularly in elderly patients, who are more susceptible. + family members watch out for any odd behaviours
how do the parkinsons medications work?
- levodopa + carbidopa
levodopa is turned into dopamine
carbidopa acts to reduce peripheral conversion - dopamine agonists
- MAO-B inhibitors
monoamine oxidase B inhibitors prevent dopamine breakdown - COMT inhibitors
inhibit Catechol-O-methyltransferase (COMT) prevent dopamine breakdown
which tuning fork for rinnie and webers?
512 Hz
what is rinnie’s test
512 tuning fork on mastoid process vs in front of pinna
bone vs air conduction
air conduction should be better
Think: telephone rings (ear)
what would be an abnormal rinnie’s test?
bone conduction is louder
suggests a conductive problem in the same ear
what is weber’s test?
512 tuning fork on the centre of the forehead. Patient asked if sound is heard louder on one side or not?
normal is when sound does not lateralise
conductive hearing loss findings
rinnie’s air < bone in affected air OR normal (air>bone)
weber’s localises to affected ear
sensorineural hearing loss findings
rinnie’s normal air > bone
weber’s localises to UNaffected ear
weber’s test mneumonic
Sun Caffe
sensorineural - unaffected ear
Conductive - affected ear
menier’s disease symptoms
sensorineural hearing loss
tinnitis
vertigo
minutes to hours
bilateral vestibular schwannomas are seen in which familial disease?
neurofibromatosis 2
what test to look at patients diability? following what disease?
Barthel index – used particularly after stroke
10 tasks and the patient is scored based on the amount of time and assistance needed
- presence of faecal/ urinary incontinence
- help with feeding, transfer, dressing etc
scored 0 to 100. 0 is completeld dependent, 100 is completely independent
brain tumours management
dexamethasone - oedema
surgery
post-op chemotherapy
radiotherapy
migraine prophylaxis - what do you give and when do you
topiramate (asthmatics but teratogenic, cleft palate) or propanolol (better for women of childbrearing age)
riboflavin is also effective
> 2 attacks per month
ischaemic stroke Mx time for definitive mx
thrombolysis (4.5hrs) & thrombectomy (6hrs) from symptom onset
investigations for acoustic neuroma/ vestibular schwannoma
audiogram
gadalinium-enhanced MRI head
where are most acoustic neuroma/ vestibular schwannoma in the brain
cerebellopontine angle
wrist drop - which nerve effected
radial nerve palsy
which neurology drug is highly associated with steven johnson syndrome and how do you treat it? after how long of treatment to SJS symptoms typically start to develop?
lamotrigine
<2 months of starting it
prodrome of a viral URTI for 2 weeks then rapid onset painful rash on face and limbs
Mx. stop drug, admit, ICU, fluids, IV and NG
prophylaxis of cluster headaches
verapamil
anti-nausea drug for raised ICP causes of nausea
haloperidol
anti-nausea drug for GI causes of nausea
metoclopramide
types of motor neurone disease and key points
***Amyotrophic Lateral Sclerosis: UMN legs + LMN arms
Primary Lateral Sclerosis Variant: UMN
Progressive Muscular Atrophy Variant: LMN, distal → proximal, best prognosis
progressive bulbar palsy: palsy of tongue, chewing, swallowing, facial muscles due to loss of function of brainstem motor nuclei. worst prognosis. LMN signs only
myasthenia gravis medical management
mild disease: pyridostigmine
prednisolone (titrate up as intiail worsening of symptoms)
steroid-sparing agents (azathioprine) to avoid side effects
life-threatening exacerbations: IV immunoglobulin/ plasma exchange
malignant thymomas excised
most likely dominant hemisphere
left
global aphasia, which blood supply affected
left middle cerebral artery
signs of essential tremor
tremor arises with sustained muscle tone eg. outstretching arms, improved by alcohol and rest
can also effect the vocal cords
autosomal dominant condition
Mx. of essential tremor
propanolol
explain the cushing’s triad feature of hypertension and bradycardia with raised ICP
cerebral perfusion pressure = mean arterial pressure - intracranial pressure
so if ICP rises, to maintain adequate cerebral perfusion, the MAP rises too by a sympathetic reflex
this HTN is then detected by baroreceptors to decrease HR
migrains with aura and COCP
absolute contradication due to increased stroke risk
migraine with aura type only
migraine with menstruation mx
mefanamic acid
Or
aspirin, paracetamol, caffeine
migraine and HRT
it is safe to prescribe HRT for people with history of migraines
but HRT might make the migraines worse
electomyography findings
neuropathy: increased duration and amplitude of action potentials
myopathy: decreased duration and amplitude of action potentials
mx. post lumbar puncture headache
- analgesia, rest
2. >72 hours – IV caffeine, epidural saline, blood patch
what happens if you suddenly stop parkinson’s drugs
acute akinesia or neuroleptic malignant syndrome
DVLA and seizures
first seizure - 6 month seizure seizure free + no findings on brain imaging or epileptiform EEG
epilepsy - 12 month seizure free
withdrawing drugs - no driving for 6 months until last dose
bus driver - 10 year seizure fee
secondary prevention after stroke
clopidogrel alone is first line
or aspirin and dipyridamole
at what point do you start IV phenytoin in status epilepticus
2 doses of benzos
at what point do you intubate and GA in status epilepticus?
45 mins from onset
stroke/TIA and DVLA?
don’t need to inform DVLA if no residual neurological defect (or if just 1 episode)
1 month off driving
which is single biggest risk factor for bell’s palsy?
pregnancy
signs and symptoms of neuroleptic malignant syndrome
pyrexia, muscle ragidity, hypertension, tachycardia, tachypnoea, delirium, confusion
trigeminal neuralgia signs and treatment
unilateral electric shock like pain in one/more divisions of trigerminal nerve
provoked by light touch, brushing teeth, combing hair
Mx. carbamazepine
refer to neuro if under 50y/o
how soon do you start anticoagulation following an ischaemic stroke?
14 days
earlier may exacerbate secondary haemorrhage
dysarthria vs aphasia
dysarthria = motor disorder and find difficult to pronounce and speak words
aphasia = compression, repetition or production of speech
Ix for myasthenia gravis
single fibre electromyography
CT thorax to exclude thymoma
CK normal
autoantibodies against acetylcholine receptors and anti-muscle-specific tyrosine kinase
antibodies in myasthenia gravis
autoantibodies against acetylcholine receptors and anti-muscle-specific tyrosine kinase
Mx. myasthenia gravis
- long acting acetylcholinesterase inhibitors eg. pyridostigmine
- immunosuppression prednisolone
- thymectomy
blood test to distinguish between pseudoseizure and actual seizure
serum prolactin 10-20 minutes after seizure
homonoymous quadrantopias - where is the lesion?
contralateral side
PITS
Parietal inferior
Temporal superior
craniopharyngiomas symptoms
lower bitemporal hemianopia
diabetes inspidus
why do you get oedema with brain tumours
disruprtion of the blood-brain barrier
give dexamethasone to treat oedema
most common primary brain tumour in children
pilocytic astrocytoma
Total anterior circulation stroke
3
Unilateral sensory/motor loss (face, arm and leg)
Higher cerebral function eg. Dysphasia, visuospatial
Homonymous hemianopia
Partial anterior circulation stroke
2 of:
Unilateral sensory/motor loss (face, arm and leg)
Higher cerebral function eg. Dysphasia, visuospatial
Homonymous hemianopia
Lacunar syndrome
1 of: ***of face and arm, arm and leg or all three. Pure sensory Pure motor Sensory-motor stroke Ataxic hemiparesis
Posterior circulation syndrome
1 of
Cranial nerve palsy and contra lateral motor or sensory deficit
Bilateral motor or sensory deficit
Cerebellum dysfunction: ataxia, nystagmus, vertigo
Isolated homonymous hemianopia or cortical blindness
Loss of conscious, brain stem problems
Which stroke syndrome, no loss of higher cerebral functions
Lacunar syndrome
lateral medullary syndrome
the combination of facial and contralateral body loss of pain sensation along with nystagmus and ataxia
Posterior circulation syndrome subtype
What score to assess risk of repeat TIA?
ABCD2 score
Signs of Alzheimer’s
5 As Amnesia Anomia naming Apraxia doing, calculation, dressing Agnosia recognising people Aphasia speaking
Csf analysis in dementia
Tau high as it leaks into csf
Beta amyloid low as it deposits into plaque
Neuroleptic malignant syndrome cause, key symptoms and treatment
2 weeks after new antipsychotic (Dopamine antagonist) ie. excessive dopamine blockade
FEVER
Fever
Encephalopathy confusion, restless
Vital sign dysregulation - BP up or down, high Hr, RR
Enzymes elevated creatinine kinase, myoglobin as muscle breaks down
Rigid and Hyperreflexia, dilated pupils, diaphoresis
Mx. stop cause. Benzodiazepines (lorazepam), Dantrolene (fever) and bromocriptine (d2 agonists)
signs of optic neuritis
inflammation of optic nerve
- pain on eye movents
- unilateral decrease in visual acuity
- poor discrimination of colours “red desaturaation”
- RAPD
- central scotoma
