Neurology + ACH Flashcards
What is multiple sclerosis?
A chronic disease characterised by acute episodes of inflammatory demyelination of neurons in the CNS, leaving characteristic plaques.
What are the types of MS?
Relapsing remitting - 85%
Primary progressive - 15%
Around 65% of relapsing remitting will convert to secondary progressive after 15 years.
What are some common deficits in MS?
Loss of sight - optic neuritis
DANISH - cerebellum
Spastic paraparesis, urinary symptoms and LL sensory loss due to cord lesion
Conjugate gaze palsy - MLF
How is MS diagnosed?
Need to evidence demyelinating lesions disseminated in time and space. This can be based on clinical evidence, but additional evidence is desirable. MRI head and/or spine can demonstrate demyelinating plaques, and LP will show oligoclonal bands in most patients (LP can be substitute for DIT in patients at first presentation). McDonald criteria
How are acute MS relapses managed?
IV (1g OD) or oral (500mg OD) methylprednisolone for 3 days
What disease modifying drugs are available for MS?
Alemtuzumab, natalizumab, interferon-b)
What specific things should be considered in a headache history?
HPC - SOCRATES (attempt to rule in or out ICP, migraine, cluster headache, tension headache, subarachnoid temporal arteritis, glaucoma) meningism signs, associated N+V
PMHx - any strokes, bleeds, eye problems, previous episodes like this, previous malignancy?
DHx - overuse of medication may cause headaches. COCP can cause venous sinus thrombosis
What should be included in a neuro systems review?
General - fits/feints, falls, funny turns, neck stiffness, malaise, vision, hearing, memory
Motor - weakness, incontinence
Sensory - numbness, tingling, pain
What is Bell’s palsy?
Bell’s palsy is the syndrome of: acute unilateral facial palsy (affecting all branches of facial nerve); ipsilateral auricular pain, hyperacuisis; change in taste, chewing difficulties etc. It is caused by compression of the facial nerve 2ndary to swelling.
What are the differentials for Bell’s palsy and how are they distinguished?
Stroke - usually will involve upper limb, and forehead is spared in unilateral UMN lesions.
Infection - herpes zoster can cause facial pain and weakness with vesicular rash. Also, HIV, otitits media
Neuro - GBS, mononeuropathy
Lyme disease
Facial nerve schwannoma
Parotid tumour
How is Bell’s palsy managed?
Give high dose prednisolone within 72 hours (60mg OD for 5 days, then reduce by 10mg per day, or 25mg BD for 10 days)
Tape eye shut at night + eye drops
What is the timeline of recovery for Bell’s palsy?
Sx should improve after 2-3 weeks, but can take 3-6 months for complete resolution.
What is myaesthenia gravis?
Antibodies bind to receptors at neuromuscular junction, disrupting signal transmission. Patients typically present with muscle weakness.
What are the three different forms of myaesthenia gravis?
Ocular
Oropharyngeal
Generalised
What is myaesthenic crisis?
Respiratory failure requiring mechanical ventilation. It is experienced by 15-20% of patients.
How should suspected myaesthenia gravis be investigated?
Serum analysis for auto-antibodies for ACh receptor
Muscle specific tyrosine kinase antibodies (MuSK) will also be positive. LRP4 is another receptor which can be targeted.
Chest XRAY important to exclude Lambert-Eaton myaesthenic syndrome
Pulmonary function tests indicated if respiratory involvement suspected.
How is myaesthenia gravis treated?
Cholinesterase inhibitor such as pyridostigmine for mild disease with frequent symptoms.
Corticosteroids for maintenance in ocular MG and treatment of moderate-sever symptoms (high dose acute)
Thymectomy
Immunosuppressants
Plasma exchange or IVIG
What are some types of Guillain-Barre syndrome?
AIDP - most common in West
AMAN (Japan and China)
AMSAN
Miller-Fisher syndrome
What is Miller-Fisher syndrome characterised by?
Ophthalmoplegia, ataxia and areflexia
What are the main risk factors for MS?
Female sex
Northern latitude
Also, Vit D, smoking, genetic factors
What investigations can be performed to confirm diagnosis of Guillain-Barre?
Nerve conduction studies
Lumbar puncture will show albuminocytological dissociation (high protein and normal WBC)
Spirometry to detect impending respiratory involvement
Antiganglioside antibodies can be useful in distinguishing types if diagnosis unclear
What drugs can be used for fatigue in MS?
Amantadine and modafinil
What drugs can be used for tremor in MS?
Propranolol, clonazepam
What drugs are useful for neuropathic pain and dysaesthesia in MS?
Gabapentin, pregabalin, carbamazepine, amitryptaline
What drug is useful for spasticity in MS?
Baclofen activates GABA receptors, decreasing tone
In a headache history, what are the key red flags to rule out?
Meningism - stiff neck, photophobia, unwell
SAH - sudden onset, blurry/double vision, speech problems, recent trauma
ICP - incontinence, worse in morning, straining
Temporal arteritis - scalp tenderness, jaw claudication, vision changes
Glaucoma - vision changes, halos, blurring
Remember: SIGMA = subarach, ICP, glaucoma, meningism, arteritis
What are the causes of cerebellar syndrome?
PASTRIES
P = Paraneoplastic (bronchial Ca) A = Alcohol (B12 + thiamine deficiency) S = Sclerosis (as in MS) T = Tumour (e.g. CPA tumour) R = Rare (Friedrich's ataxia, MSA, telangectasia) I = Iatrogenic (e.g. phenytoin OD) E = Endocrine (e.g. hypothyroidism) S = Stroke (vertebrobasilar)
What are the differentials for a blackout?
CRASH
C = Cardiogenic (arrhythmias, CCF, PE, tamponade) R = Reflexes (vasovagal or post. hypotension) A = Arterial (subclavian steal, insufficiency, TIA) S = Systemic (hypoglycaemia, hypoxia, anaemia etc) H = Head (epilepsy)
What are the causes of delirium?
PINCH ME
P = Pain I = Infection/inflammation/neoplasm N = Nutrition C = Constipation/retention H = Hydration
M = Medicines E = Environment
What are the differentials for acute headache?
VICIOUS
V = Vascular (haemorrhage, VST) I = Infection (meningitis, encephalitis, abscess) C = Compression (obstructive hydrocephalus, pituitary apoplexy) I = ICP O = Ophthalmic U = Unknown S = Systemic (HTN, phaeo, sinusitis, tonsillitis, toxins like CO)
What are the differentials for chronic headache?
MCD TINGS
M = Migraine C = Cluster headaches D = Drugs (analgesics, caffeine, vasodilators)
T = Tension I = ICP (up or down) N = Neuralgia G = GCA S = Systemic (HTN, organ failure, endocrine like Cushings, Addison's, thyroxine changes
What is the rule of 60s with temporal arteritis?
> 60 years old
ESR >60
60mg prednisolone
What is first line in acute management of migraine?
Tryptan + either paracetamol or NSAID
NICE Guidance
What is first line in prophylaxis of migraine?
Topiramate or propanolol
NICE guidance
What is the definition of a stroke?
Rapid onset focal neuro deficit of presumed vascular origin lasting >24 hours
What are the criteria for TACS?
All three of:
1) hemiparesis and/or sensory deficit (2 or more of face, arm and leg)
2) homonymous hemianopia
3) higher cortical dysfunction (dysphasia or neglect)
What are the criteria for PACS?
Any 2 of:
1) hemiparesis and/or sensory deficit (2 or more of face, arm and leg)
2) homonymous hemianopia
3) higher cortical dysfunction (dysphasia or neglect)
What are the criteria for POCS?
Any of:
1) cerebellar syndrome
2) homonymous hemianopia
3) brainstem syndrome
What symptoms and signs are by definition not seen in a LACS?
1) Higher cortical dysfunction
2) Homonymous hemianopia
3) Drowsiness
4) Brainstem signs
What are the key symptoms of complex partial seizures?
The 5 As
Aura Autonomic (skin colour, temp, palpitations) Awareness lost Automatisms (lip smacking) Amnesia
How is status epilepticus managed?
Secure the airway, get ECG on, 100% oxygen
IV lorazepam 2-4mg slow bolus into large vein. Repeat after 10-20 mins if no response (can use buccal midazolam or rectal diazepam for first doseif access is difficult)
IV phenytoin infusion is next
ICU and anaesthetics if still no response
What signs point towards a diagnosis of MND?
Fasciculations, absence of sensory signs, mixture of upper and lower motor neuron signs, wasting of the small muscles of the hand/tibialis anterior, doesn’t affect external ocular muscles
What are the typical features of ALS?
LMN signs in arms, UMN signs in legs (typically)
What are the 5 key symptoms to ask about in an ear history?
1) Otalgia
2) Discharge
3) Hearing loss
4) Tinnitus
5) Dizziness
What are the 5 key symptoms to ask about in a nose history?
1) Obstruction
2) Runny nose
3) Loss of sense of smell
4) Nose bleeds
5) Facial pain
What are some relevant medical conditions to ask about in a patient with epistaxis?
HTN, rhinitis, bleeding disorders, GPA + sarcoidosis
What are 5 key symptoms to ask about when asking about the throat?
1) Sore throat
2) Dysphagia
3) Odynophagia
4) Dysphonia
5) Regurgitation
What are the 9 descriptive domains when assessing a lump?
3 Ss, 3 Cs, 3 Ts, 3 Fs = 12 domains
Site, Size, Surface (overlying skin)
Colour, Contour (well-defined vs irregular), Consistency
Temperature, Tenderness, Transillumination
Fluid (a.k.a fluctuance), Fixity, Field (are there any lymph nodes in surrounding field?)
Also: is it pulsatile, expansile
List the indications for urgent referral for head and neck cancer.
Hoarseness >6 weeks
Oral swellings >3 weeks
Dysphagia >3 weeks
Unilateral nasal obstruction, esp. with purulent discharge
Unresolving neck masses for more than 3 weeks
Cranial neuropathies
Orbital masses
What are the risk factors for ischaemic stroke?
Vascular RFs: DM, HTN, hyperlipidaemia, smoking, obesity
Age
AF
Family Hx
What are the risk factors for haemorrhagic stroke?
HTN, age, anticoagulation, alcohol abuse, PKD, smoking, stress
What is the tetrad of Parkinson’s disease?
Rigidity - lead pipe or cogwheel
Tremor - 4-6 Hz, resting, pill-rolling
Bradykinesia - stooped shuffling gait, hypomimia, micrographia
Postural instability - falls
What is the differential diagnosis for suspected Parkinson’s disease?
IPD Vascular Parkinsonism Parkinson's plus - MSA, PSP, Lewy-body, corticobulbar degeneration Iatrogenic - anti-dopaminergic drugs Wilson's disease
Bonus: communicating hydrocephalus and supratentorial tumours
What are the options for management of the motor symptoms of Parkinson’s Disease?
Levo-dopa is most effective, but carries risk of dyskinesia and on-off phenomena
Dopamine agonists (e.g. ropinirole, pramipexole) are next most effectivereduce motor complications and levo-dopa needs
MAO-B inhibitors are least effective but reduce off time
Other adjuncts to L-Dopa: COMT inhibitors (entacapone) reduces off time, apomorphine can be used subcut as a rescue therapy in off time, amantadine can be used for l-dopa induced dyskinesia
What management options are available for symptomatic control of urinary incontinence in MS?
Intermittent self catheterisation for overflow, anticholinergics (oxybutinin, tolteradone, soliferacin) for urge.
What are the DVLA guidelines relating to TIAs and stroke?
No driving for 4 weeks
Must inform DVLA if residual symptoms after 4 weeks, or if there are complications
Outline the management of stroke.
CT head within 1 hour
Thrombolysis if <4.5 hours and no contraindications
or aspirin 300mg for 2 weeks or clopidogrel 300mg stat then 75mg OD
Transfer to stroke ward and consider endovascular clot retrieval
In who should fragility fracture risk be assessed?
All women over 65 and men over 75
All men and women over 50 with any of the broad risk factors (previous frag frax, steroid use, falls hx, fam hx, smoker, EtOH, or any secondary cause of oseoporosis like IBD, DM, Cushing’s, COPD, CKD etc)
All men and women under 50 with high dose steroid use, untreated prem menopause, or prev frag frax.
In who should a DEXA be offered?
FRAX score >10%, or younger patients with major risk factors
Broadly, what are the causes of delirium?
PINCH ME
Pain Infection/inflammation/injury (think brain and hip)/infarction Nutrition/neoplasm Constipation (and retention) Hydration
Medicines/metabolic
Environmental (including deafness and blindness)
How is delirium diagnosed?
Acute onset and fluctuating course + inattention + either disorganised thinking or altered level of consciousness.
How is the AMTS performed?
What is your age? What is the time to the nearest hour? Give the patient an address (42 West St) What is the name of the hospital we are in? Can patient recognise two people? What is your date of birth? What year did WW1 begin? Name the present monarch/prime minister Count backwards from 20 to 1 Recall address
Score 6 or less indicates possible delirium or dementia
How is the 4AT performed?
Alertness - normal = 0, abnormal = 4
AMT4 - ask age, DoB, location and current year: all correct = 0, 1 wrong = 1, 2 or more wrong = 2.
Attention - ask patient to name months backwards starting at December: 7 or more correct = 0, less than 7 = 1, untestable = 2.
Acute and fluctuating course: no = 0, yes = 4
Score of 1-3 indicated possible cog impairment, 4 or above indicated possible delirium +/- cog impairment
What are the four aspects that should be considered as causes for falls?
DAME
Drugs (polypharmacy, antihypertensives, sedatives, opioids, psychotropics)
Age related (vision, cog decline, gait, sarcopenia, osteoporosis, oa)
Medical causes (cardiac, neuro, cognitive problems, cataracts, glaucoma and mac degen)
Environmental (footwear, walking aids, home hazards)
What investigations should be done in any elderly patient presenting with a fall?
12 lead ECG
Urine dip (interpret with caution)
U+E, glucose, CRP, FBC
