Neurology Flashcards
Sudden onset headache and neck pain on left side. Left side ptosis and small pupil. What is the most likely diagnosis?
What is the best investigation to confirm this diagnosis?
Carotid artery dissection
CT/MR angiogram of intra and extra-cranial vessels
What are the 3 possible diagnostic criterias for Neurofibromatosis type 2?
Bilateral acoustic neuroma - pathognomic
First degree relative with NF2 and either a unilateral acoustic neuroma or 2 of meningioma, schwannoma, glioma, cerebreal calcifications, posterior subcapsular lens opacity.
What are the 6 diagnostic features of neurofibromatosis type 1?
6+ cafe au lait spots
2+ dermal neurofibromas and 1+ plexiform neurofibromas
Axillary or inguinal freckling
Optic Nerve Glioma
Sphenoid wing dysplasia or thinning/bending of long bones
Confirmed first degree relative with NF1
What is the common presentation of trigeminal neuralgia?
Sudden onset severe pain in V3 > V2 > V1. Electric shock in nature lasting a few seconds per episode
What are the aggravating factors of trigeminal neuralgia?
Light touch, talking, eating, cold wind
What is the first line treatment of trigeminal neuralgia?
A anti-convulsant such as carbamazepine
What are the common side effects of carbamazepine?
Aplastic anaemia, steven johnson syndrome, erythema multiforme, arrhythmias and hepatitis
A patient presents with ptosis, diplopia, fatigable weakness, weakness of jaw = hanging jaw sign. What is the most likely diagnosis?
Myasthenia gravis
What hormone does the pineal gland produce?
Melatonin
A patient presents with a severe headache and say it really hurts when they are brushing their hair. They also have mentioned that they are having aches in the their body as well as specifically in their jaw after eating. As well as their vision seeming to be getting some double vision. O/E there is some redness in the temporal area which is tender. They have a slight temperature
What would be the next step in the diagnosis of this patient based on the most likely diagnosis? (and what would be the gold standard diagnosis test)
Bloods - CRP and ESR
- elevated CRP and normal ESR or normal CRP and elevated ESR is indicative.
Gold standard
- temporal biopsy
!GCA!
What is the treatment for Giant cell arteritis?
Glucocorticoid such as prednisolone for several years (dose being lowered as treatment progresses)
What is a complication of GCA if it is not diagnosed or acted on quickly?
Permanent vision loss
Where is the likely lesion to be in a patient with inferior homonymous quadrantanopia?
Superior optic chiasm
Whats is Hemibalism? - and what is the cause?
Rare hyperkinetic disorder of the proximal limbs. Lesion in the subthalamic nucleus of the basal ganglia.
In what time period of a stroke onset can a patient have thrombolysis?
4.5 hours
Where in the brain is most affected by the deposition of huntingtin protein in early huntington’s disease? - what in particular does this cause?
Striatum - resulting in excess movement.
What parkinson’s medication is has side effects including gambling and sex addictions as well as reduced inhibitions (manic symptoms)
Ropinirole
A patient known to have alcohol dependence comes into A&E shaking and confused then has a seizure what would be the best treatment?
Rectal Diazepam
What is the first line treatment for a patient when they are having a status epilepticus if IV access is available?
IV Lorazepam
What is the first line treatment for a patient when they are having a status epilepticus if IV access isn’t available?
And if that doesn’t work what is the next option?
Oral Midazolam
oral Phenytoin
What is the gold standard test for acute stroke?
CT scan - as most readily available
There is a aneurysm of the superior cerebellar arteries and posterior cerebral arteries what is the most likely sign?
Right eye looking down and out. Due to involvement of the oculomotor nerve.
What is Brown-Sequard syndrome and what are the symptoms?
Hemisection to half of the spinal cord. Loss of sensations and motor. - Pain, temperature and touch
What are the 4 causes of a ischaemic stroke?
Thrombus
Embolism
Cerebral Venous sinus thrombosis
systemic hypoperfusion
What are the 3 layers of meninges from outer to inner?
Dura
Arachnoid
Pia
What supplies blood supply to the lateral aspect of the cerebrum?
Middle cerebral artery
What does the anterior cerebral artery supply blood to?
Anteromedial aspect of brain
What does the posterior cerebral artery supply?
medial and lateral posterior cerebrum
A patient presents with left sided weakness of leg, arm and face. They also admit to not being able to see much on the left side of their vision. They also appear to be struggling to recognise people’s faces. WHat is the most likely diagnosis?
Total anterior circulation stroke
Of the right side
A patient presents with right sided weakness in their arm face and leg and are not making sense when they speak as their words appear jumbled. What is the most likely diagnosis?
Partial anterior circulation stroke
Left sided.
Wernicke’s involvement
A patient has lost sensation to the left side of their body completely suddenly. What is the most likely diagnosis?
Lacunar syndrome - right sided
A patient comes in with sudden onset of weakness of the face including the forehead on the left side as well as loss of sensation to the right side of their body. WHat is the most likely diagnosis?
Posterior circulation syndrome
What is a TIA? and what is the acute treatment?
Begins like a stroke however blood flow is returned on its own.
Aspirin and PPI (if required)
What is done acutely for a patient having a ischaemic stroke?
Alteplase (within 4.5 hrs) and aspirin within 24 hours
What is the long term management for a patient after having a ischaemic stroke?
Clopidogrel long term
BP medication if needed (aim for 130/80) - not beta blockers
statin after 48 hrs
lifestyle advice
What is the acute management of a intracerebral haemorrhage?
Within 6 hours and high BP want to get their BP down to 130/140 within an hour and keep it there for 7 days.
Can have surgery to remove a haematoma.
What shouldnt be given to a normal patient after having a haemorrhagic stroke?
Statin
Aspirin
anti-platelet - aspirin
anti-coagulant
What are the symptoms of raised ICP?
Headache - worse on lying down (waking in the morning) Nausea and Vomiting Blurred vision Weakness - movement or speech reduced consciousness Altered behaviour
What are the signs of raised ICP?
Papilloedema Reduced GCS Possible 3rd, 4th or 6th nerve palsy Dilated pupil Projectile vomiting = very high ICP
A patient presents with a stroke. They have dysphasia, dysarthria and right sided weakness. What type of stroke are they having?
Left partial anterior circulation infarct
A patient is having a stroke and presents with left sided weakness, right sided homnymous hemaniopia and dysphasia. What type of stroke are they having?
Right sided total anterior circulation stroke
A patient comes in having a stroke they are have lost all sensation on their left side. What type of stroke are they having?
Right sided lacunar syndrome stroke
What are the 4 possible criteria for a lacunar stroke (only 1 of the following present at one time)?
Sensory
Motor
sensori-motor
ataxic hemiparesis
A patient is having a stroke and presents with cerebellar dysfunction only. What type of stroke are they having and what symptoms may they be experiencing?
Posterior circulation syndrome stroke
Ataxia, nystagmus or vertigo
What arteries are usually blocked in TACS?
Middle cerebral artery
or
anterior communicating artery
Up to what time from presentation can thrombolysis be offered to someone having a stroke?
4 hours
A patient presents with a stroke after 5 hours of onset of symptoms what should be done?
Urgent CT head to exclude bleed
aspirin 300mg (once bleed excluded)
Admission to stroke unit
When should a endarterectomy be considered?
Carotid stenosis >70%
What are measures for secondary prevention after an ischaemic stroke?
Anti platelet (aspirin or clopidogrel)
Treat hypertension
Statin
Investigate if AF or cardioembolic source - if so treat with DOAC
Check HbA1c
Address lifestyle factors
Vascular imaging - possible carotid endarterectomy (>70%)
What are the 4 most common causes for intracerebral haemorrhage?
Arteriosclerosis (hypertensive vasculopathy) - MOST COMMON
Cerebral amyloid angiopathy
Structural vascular lesion (AVM/Aneurysm)
Brain tumour
What is the most important investigation to do on someone who comes to hospital having a seizure (may be their first) ?
ECG
What finding on a ECG may present for someone who comes into hospital having had their first seizure?
Long QT syndrome
Which two drug options are first line for focal epilepsy?
Lamotrigine
Carbamazepine
What 2 drug options are availble first line for generalised seizures?
Sodium Valproate
Lamotrigine
What is the mechanism of action for lamotrigine?
what are some potential side effects
Inhibits voltage gated sodium channels
Vision problems
headaches and drowsiness
difficulty thinking, concentrating and speaking
What is the mechanism of action of carbamazepine?
What are some potential side effects?
Sodium channel blocker (preference to voltage gated) Gi discomfort Hyponatremia thrombocytopenia weight gain
A patient comes in with status epilepticus. What is the management? (including first and second line drugs)
ABCD
Lorazepam
Loading dose of IV phenytoin
DDx for loss of or altered consciousness. (6)
Epileptic seizure non-epileptic seizure simple syncope cardiac syncope postural hypotension hyperventilation
Someone presents with a UMN problem. Where could this problem be?
Brain or spinal cord
Positive babinski sign, hypereflexia, hypertonia, spastic paresis
A patient has a lower motor neuron condition. Where could the problem be and what symptoms may there be?
Anterior horn cell, nerve roots, nerves
NMJ
Muscle
Hypotonia, hyporeflexia, muscle atrophy and fasciculations, flaccid paresis
What are 2 serious potential complications of Guillain Barre Syndrome. And why do they occur?
Bulbar disturbance causes:
Aspiration risk
Type 2 respiratory failure risk
A 65 year old man presents with a 6 month history of worsening weakless in his arms and legs with a combination of upper and lower motor neuron signs. He has no sensory or eye signs.
What is the most likely diagnosis?
Motor neuron disease
A 70 year old women presents with proximal fatiguability signs and no definite UMN/LMN signs with primarily weakness. What is the most likely diagnosis?
Myasthenia Gravis
What is myasthenia gravis?
Autoimmune disease
acetylcholine receptor antibodies that block the binding at the NMJ
Fatiguable weakness without UMN/LMN signs, sensory signs or reflex changes
What are the causes of myopathy?
ICED
Inflammation/infectious
Congenital
Endocrinopathy
Drugs - statins and steroids
1 week insidious onset worse overnight and first thing in the morning. Bilateral papilloedema otherwise examination and CT are normal. What tests are required?
What is the most likely cause?
Blood pressure measurement
Pregnancy test
Visual acuity and formal visual assessment
CT/MR venogram
Venous sinus thrombosis
What are 10 potential important causes of a acute headache?
Intracranial infection - meningitis/encephalitis Venous sinus thrombosis Tumour Temporal arteritis pituitary apoplexy haemorrhage - subarachnoid, subdural, parenchymal Intracranial hypertension hypotension - relieved by laying down acute glaucoma CO poisoning
What is the treatment for trigeminal neuralgia?
Carbamazepine
What are the 2 potential causes of a tremor on action?
Cerebellar
Essential
What are the 7 potential causes of postural tremor (tremor against gravity)?
Physiological Benign essential anxiety hyperthyroidism beta agonists alcohol HIV
How is essential tremor treated?
Beta blockers
Primidone
A patient has chorea (dance like movement) what is the most likely cause?
Huntington’s
How long after last dose should lithium levels be checked?
12 hours after last dose
