Neurology and Geriatrics Flashcards
1
Q
list 3 things that may cause disruption of blood supply
A
- thrombus formation/embolus
- AF
- atherosclerosis
- shock
- vasculitits
2
Q
sudden onset of what symptoms (4) indicate a stroke?
A
asymmetrical
- weakness of limbs
- facial weakness
- dysphasia
- visual or sensory loss
3
Q
4 RF for stroke
A
- previous stroke TIA
- CVD - angina/MI/PVD
- AF
- carotid artery disease
-HTN - DM
- smoking
0 vasculitis - combined oral contraceptive pill
4
Q
scoring tool for stroke in community?
A
FAST
5
Q
scoring tool for recognition of stroke in emergency room
A
ROSIER (>0 = likely)
6
Q
immediate imaging and medication for stroke management
A
immediate ct (exclude primary intracerebral haemorrhage) aspirin 300mg stat - 2wks
7
Q
2 main surgical managements for stroke?
A
- thrombolysis
- thrombectomy
8
Q
2 medications given for secondary prevention of stroke
A
- clopidogrel 75mg 1x day
- atorvastatin 80mg
9
Q
classification system for ischaemic stroke?
A
bamford classification
based on presenting s/s
10
Q
what three signs must all be present to diagnose a total anterior circulation stroke
A
- unilateral weakness (and or sensory deficit) of face, arms, leg
- homonymous hemianopia
- higher cerebral dysfunction (dysphasia )
11
Q
what are the 5 s/s you may see in posterior circulation syndrome
A
-Cranial nerve palsy and a contralateral motor/sensory deficit
Bilateral motor/sensory deficit
Conjugate eye movement disorder (e.g. horizontal gaze palsy)
Cerebellar dysfunction (e.g. vertigo, nystagmus, ataxia)
Isolated homonymous hemianopia
12
Q
list the 4 s/s used to diagnose a lacunar stroke
A
- pure sensory stroke
- pure motor stroke
- sensori-motor stroke
- ataxic hemiparesis
13
Q
3 investigations for epilepsy
A
EEG, MRI brain, ECG (exclude heart probs)
14
Q
associated features of tonic-clonic seizures (3)
A
- tongue biting
- incontinence
- groaning
- irregular breathing
15
Q
first and second line treatment for tonic-clonic seizures
A
1st = sodium valproate 2nd = carbamazepine or lamotrigine
16
Q
in what lobe of the brain do focal seizures start?
A
temporal lobe
17
Q
what can a focal seizure effect (4)
A
hearing
speech
memory
emotions
18
Q
1st and 2nd line treatment for focal seizures?
A
1st - carbamazepine or lamotrigine
2nd - sodium valproate or levetiracetam
19
Q
what type of seizure is typically seen in children?
A
absence seizure
20
Q
first line absence seizure treatment
A
- sodium valproate
21
Q
what type of seizure is also known as a “drop attack”
A
atonic seizure
22
Q
first line treatment for atonic seizure
A
sodium valproate
23
Q
1st line treatment for myoclonic seizure
A
sodium valproate
24
Q
SE of sodium valproate (4)
A
- teratogenic
- liver damage and hep
- hair loss
- tremor
25
how does sodium valproate work?
increases activivity of gaba which relaxes the brain
26
why is sodium valproate avoided in women or girls unless no suitable alternative is available?
teratogenic
27
SE of carbamazepine (3)
agranulocytosis
aplastic anaemia
induce p450 -\> many drug interactions
28
3 phenytoin SE
- folate and vit d deficiency
- megoblastic anaemia
- osteomalacia
29
what is a myasthenic crisis
severe, life threatening complication of myasthenia gravis (acute worsening of symptoms)
30
usual cause of myasthenic crisis
triggered by another illness - respiratory tract infection
31
what organ failure can occur due to myasthenic crisis
respiratory failure as weakness in resp muscles
32
what management may be needed for a myasthenic crisis
bipap or full intubation/ventilation
33
medical treatment for myasthenic crisis?
IV immunoglobulins and plasma exchange
34
pathophysiology of guillian-barre
b cells create antibodies against antigen on pathogen
these antibodies also match proteins on nerve cell
- these may target myelin sheath of motor cell or nerve axon
35
presentation of gullian-baree syndrome (4)
1. symmetrical ascending weakness
2. reduced reflexes
3. peripheral loss of sensation or neuropathic pain
4. progress to cranial nerves -\> facial nerve weakness
36
how long after infection do guillian-barre symptoms typically occur?
within 4 weeks of the preceding infection
37
what is the criteria used for guillian-barre diagnosis
the brighton criteria
38
what two investigations can be used to support diagnosis of guillian-barre syndrome and what is seen?
1. nerve conduction studies (reduced signal through nerves)
2. lumbar puncture for CSF (raised protein, normal cell count and glucose)
39
management options for guillian-barre syndrome (4)
1. IV immunoglobulins
2. plasma exchange (alternative to iv ig)
3. supportive care
4. VTE prophylaxis (PE is leading cause of death)
40
leading cause of death in guillian-barre syndrome
PE
41
what is the most common type of spinal stenosis
lumbar spinal stenosis
42
what type of spinal stenosis causes narrowing of the nerve root canals?
lateral stenosis
43
list 2 causes of spinal stenosis
Congenital spinal stenosis
Degenerative changes, including facet joint changes, disc disease and bone spurs
Herniated discs
Thickening of the ligamenta flava or posterior longitudinal ligament
Spinal fractures
Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)
Tumours
44
3 s/s of cauda equina syndrome
- saddle anaesthesia
- sexual dysfunction
- incontinence of the bladder and bowel
45
3 typical symptoms of pseudoclaudication
- lower back pain
- buttock and leg pain
- leg weakness
46
define radiculopathy
compression of the nerve root as they exit spinal cord/column -\> motor/sensory probs
47
how to spot difference between spinal stenosis and peripheral arterial disease? (2)
- AKBI normal -\> think spinal stenosis
- struggling with back pain -\> think spinal stenosis
48
primary imaging investigation for diagnosing spinal stenosis
MRI
49
management for spinal stenosis
- exercise and weight loss
- analgesia
- physio
- decompression surgery if conservative treatment fails
50
at what level does the spinal cord terminate?
L2/L3
51
what do the nerves of the cauda equina supply? (3)
Sensation to the lower limbs, perineum, bladder and rectum
Motor innervation to the lower limbs and the anal and urethral sphincters
Parasympathetic innervation of the bladder and rectum
52
3 causes of spinal compression
1. herniated disc (most common)
2. tumour, metastasis
3. spondylolisthesis
4. abscess
5. trauma
53
4 red flags for cauda equina syndrome
1. saddle anaesthesia
2. loss of sensation in bladder/rectum (not knowing when theyre full)
3. urinary incontinence or retention
4. faecal incontinence
5. bilateral sciatica
6. bilateral or severe motor weakness in legs
7. reduced anal tone on PR exam
54
emergency management of cauda equina (3)
- immediate hospital admission
- emergency MRI
- neurosurgical input to consider lumbar decompression surgery
55
key differentiating feature between cauda equina and metastatic spinal cord compression
back pain worse on cough or strain in MSSC
56
what are the three domains on the GCS used to measure a coma?
- eye opening
- motor respone
- verbal response
57
what number on the GCS suggests a coma?
coma \<8
| (usually E2,M4,V2 or less)
58
what is meant by the term "AVPU"
scoring system of a persons consciousness
Alert
responsive to Voice
responsive only to Pain
Unresponsive
59
4 common causes of coma
- drugs/toxins (opiates, EtOH)
- anoxia (post arrest)
- mass lesions (bleeds)
- head injury
- infections (bact meningitis)
- brainstem infarct
- metabolic
- SAH
- seizures
60
microbiology of neisseria meningitidis
gram negative diplococcus
61
what does a non-blanching rash represent in meningococcal septicaemia?
disseminated intravascular coagulopathy (DIC) and sc haemorrhages
62
most common cause of bacterial meningitis in:
1. children and adults (2)
2. neonates (1)
1. neisseria meningitidis (meningococcus)
2. strep pneumoniae
63
presentation of meningitis (6)
1. fever
2. neck stiffness
3. vomiting
4. headache
5. photophobia
6. altered consciousness and seizures
64
what should be part of your investigation for meningitis for all children
lumbar puncture as can be non-specific signs
65
what 2 tests can you do for meningeal irritation? define them
kernigs test: patient lies on back and flexes one hip and knee 90 degrees -\> spinal pain or resistance to movement
Brudzinski's test: pt lies flat on back as dr lifts head/neck off bed and flex chin 2 chest -? involuntary flexion of hips and knees
66
usual choice of post mengititis exposure prophylaxis
single dose ciprofloxacin within 24hr inital diagnosis
67
most common cause of viral meningitis (3)
1. herpes simplex virus
2. enterovirus
3. varicella zoster virus
68
what is the standard difference in appearance of CSF for bacterial vs viral meningitis
bacterial is cloudy, viral is clear
bacterial (high protein, low glucose, high neutrophils + bacteria)
viral ( high white cell count, negative for bacteria)
69
3 complications of meningitis
1. hearing loss is a key one
2. seizures and epilepsy
3. cognitive impairment and learning disability
4. memory loss
5. focal neuro deficit e.g limb weakness or spasticity
70
3 possible symptoms of a brain abscess
1. headache
2. lethargy
3. fever
4. focal neurological deficit
71
investigations for diagnosis of brain abscess
contrast-enhanced MRI or CT
72
2 causes of a brain abscess
- cranial infection (osteomyelitis, sinusitis)
- penetrating head wounds
- haematogenous spread (bacterial endocarditis)
- unknown
73
treatment of brain abscess
1. abx - cefotaxime or ceftriaxone + metronidazole or vancomycin for staph. aureus
74
a pt presents with an unusual change in personality and behaviour, what type of tumour may be present?
frontal lobe tumour
(frontal lobe responsible for personality and higher-level decision making)
75
what is the key finding on fundoscopy in a pt with raised intracranial pressure which suggests a diagnosis of a brain tumour
papilloedema
76
3 causes of raised intracranial pressure
1. brain tumours
2. intracranial haemorrhage
3. idiopathic intracranial hypertension
4. abscesses or infection
77
5 headache red flags
1. constant
2. nocturnal
3. worse on waking
4. worse on cough, straining or bending forward
5. vomiting
78
define papiloedema
swelling of the optic disc due to raised intracranial pressure
79
2 fundoscopic changes seen with raised intra-cranial pressure
1. blurring of optic disc margin
2. elevated optic disc
3. loss of venous pulsation
4. engorged retinal veins
5. haemorrhages around optic disc
6. patons lines
80
the four common cancers which metastasise to the brain
1. lung
2. breast
3. renal cell carcinoma
4. melanoma
81
the three types of gliomas
1. astrocytoma (gliobastoma multiform is most common)
2. oligodendroglioma
3. ependymoma
82
optic field defect seen when a pituitary tumour grows large enough
bitemporal hemianopia (presses on optic chiasm)
83
4 hormone deficiences caused by pituitary tumour
acromegaly
hyperprolactinaemia
cushings disease
thyrotoxicosis
84
define an acoustic neruoma
tumours of the schwann cells surrounding the auditory nerve that innervates the inner ear
85
triad of symptoms for acoustic neuroma
1. hearing loss
2. tinnitus
3. balance problems
86
treatment for pit tumours (4)
1. trans-sphenoidal surgery
2. radiotherapy
3. bromocriptine (block prolactin secreting tumours)
4. somatostatin analogues
87
3 RF for an intracranial bleed
- head injury
- HTN
- aneurysm
- ischaemic stroke -\> haemorrhage
- brain tumour
- anticoag e.g. warfarin
88
main presentation of an intracranial bleed
sudden onset headache
think also:
Seizures
Weakness
Vomiting
Reduced consciousness
Other sudden onset neurological symptoms
89
GCS score signalling you may need to secure the airway as theres a riskt they may not maintain on their own
= 8
90
what will be seen on a CT scan of a subdural haemorrhage
crescent shape
91
patients most at risk of subdural haemorrhage?
elderly and alcoholics as increased atrophy = more likely to rupture
92
what fracture can cause an extradural haemorrhage and how do they present on CT?
fracture of the temporal bone
CT: bi-convex shape and limited by cranial structures
93
what type of haemorrhage is seen here
intracerebral
94
what type of haemorrhage is seen below
SAH
95
what is the usual cause of a SAH
ruptured cerebral aneurysm
96
what headache is associated with SAH
what else is associated with SAH
thunderclap headache
cocaine and sickle cell anaemia also associated
97
4 features of a SAH
1. thunderclap headache
2. neck stiffness
3. photophobia
4. vision changes
5. neuro symptoms e.g. speech changes, weakness, seizures and LOC
98
3 RF for SAH
1. HTN
2. smoking
3. excessive alcohol consumption
4. cocaine use
5. family history
99
first line investigation for SAH
CT head
100
CSF results in a SAH?
- red cell count RAISED
- xanthochromia (yellow coloured csf caused by bilirubin)
101
surgical management of a SAH
medication option for SAH
surgery - coiling or clipping
meds - nimodipine (CCB prevent vasospasm)
102
common complication which can result in brain ischaemia following a SAH
vasospasm
103
what cells produce myelin
schwann cells in peripheral nervous system
oligodendrocytes in CNS
104
what part of the nervous system is affected in MS
CNS (oligodendrocytes)
105
3 causes of MS
1. multiple genes
2. Epstein-barr virus
3. low vit D
4. smoking
5. obestiy
106
what is the most common presentation of MS
optic neuritis
involves demyelination of the optic nerve and loss od vision in one eye
107
what two key phrases are used to describe a sixth nerve palsy (seen in MS)
- intranuclear opthalmoplegia
- conjugate lateral gaze disorder
108
2 focal sensory symptoms seen in MS
1. trigeminal neuralgia
2. numbness
3. paraesthesia
- lhermittes sign
109
what is Lhermitte's sign and what condition is it associated with?
electric shock down spine into limbs when flexing the neck = disease in cervical spinal cord dorsal column
seen in MS
110
what is the most common pattern of MS
relapsing-remitting
111
describe secondary progressive MS
Secondary progressive MS is where there was relapsing-remitting disease at first, but now there is a progressive worsening of symptoms with incomplete remissions. Symptoms become more and more permanent.
112
main cause of optic neuritis
MS
113
how long to symptoms have to be progressive to diagnose primary progressive MS
1 year
114
4 key features of optic neuritis
1. central scotoma (enlarged blind spot)
2. pain on eye movement
3. impaired colour vision
4. relative afferent pupillary defect
115
list 2 causes of optic neuritis aside from MS
- sarcoidosis
- SLE
- DM
- syphilis
\_ measles
- mumps
- lyme disease
116
treatment of optic neuritis
steroids (recovery 2-6wks)
117
NICE recommendation for treatment of relapsed MS
steroids = Methylprednisolone 500mg oral 5 days,
(1g IV daily 3-5 days if oral treatment failed previous or severe)
118
what is the most common specific motor neurone disease
amyotrophic lateral sclerosis (ALS)
119
what muscles are affected by progressive bulbar palsy?
affects primarily muscles of talking and swallowing
120
why is family history important when taking a hx for MND
5-10% of cases of MND are inherited
121
where is weakness first noticed in MND
upper limbs noted first (progressive weakness affecting limbs, trunk, face, speech)
122
4 presentation symptoms of MND
1. progressive upper limb weaknes
2. increased fatigue when exercising
3. clumsiness
4. slurred speech (dysarthia)
123
4 signs of MND
1. muscle wasting
2. reduced tone
3. fasciculations (muscle twitch)
4. reduced reflexes
124
what are three signs of upper MND
1. increased tone and spasticity
2. brisk reflexes
3. upgoing plantar responses
125
what medication can slow progession of MND and increase survival for few months
Riluzole
126
usual cause of death in pts with MND
respiratory failure or pneumonia
127
what are the five branches of the facial nerve?
1. temporal
2. zygomatic
3. buccal
4. marginal mandibular
5. cervical
128
what type of neurone facial nerve palsy should be referred urgently as a stroke risk?
upper motor neurone facial nerve palsy
129
in what type of motor neurone lesion is the forehead spared?
UMN lesion = forehead sparing
130
unilateral motor lesions occur in ____ and \_\_\_\_
bilateral upper motor neurone lesions occur in _____ and \_\_\_\_\_\_
1. cerebrovascular accidents (stroke) and tumours
2. peudobulbar palsies and MND
131
what type of palsy presents as a unilateral LMN facial nerve palsy?
bells palsy
132
pt presents with bells palsy within 72 hrs of symptom development - what is the treatment as per NICE guidlines
- prednisolone:
- 50mg 10 days
- 60mg for 5 days followed by 5 day reducing regime of 10mg a day
133
what is the concern regarding pain in the eye following a bells palsy
exposure keratopathy
134
what is the cause of Ramsey-hunt syndrome?
varicella zoster virus
135
how does ramsay-hunt syndrome present (2)
- unilateral lower motor neurone facial nerve palsy
- painful/tender vesicular rash in the ear canal, pinna and around ear on affected side (check tongue and hard palate too)
136
what treatments are administered within 72hr onset of ramsay-hunt syndrome
- prednisolone
- acicilovir
137
list 2 infection causes of LMN facial nerve palsy
- otitis media
- malignant otitis externa
- HIV
- lymes disease
138
list 2 systemic diseases which may cause LMN facial nerve palsy
- diabetes
- sarcoidosis
- leukaemia
- MS
- guillain-barre syndrome
139
list 1 antenatal, perinatal and postnatal cause of cerebral palsy
antenatal: maternal inf. trauma in pregnancy
perinatal: birth asphyxia, pre-term birth
postnatal: meningitis, severe neonatal jaundice, head injury
140
what are the four types of cerebral palsy
1. spastic hypertonia ( from damage of UMN)
2. dyskinetic (from damage to basal ganglia)
3. ataxic (damage to cerebellum)
4. mixed
141
what is the difference between monoplegia and hemiplegia
mono - one limb affected
hemiplegia - one side of body affected
diplegia - four limbs, mainly legs
quadriplegia - four limbs more severe (seizures, speech distrubed, other imapirments)
142
3 s/s of cerebral palsy
1. failure to meet milestone
2. increased/decreased tone (general or specific)
3. hand preference UNDER 18 MONTHS (key sign)
4. feeding/swallow issues
5. learning difficulties
143
what type of gait suggests foot drop or LMN lesion
high stepping gate
144
what gait suggests pelvic muscle weakness due to myopathy
waddling gait
145
what are the findings of a LMN lesion on examination
1. inspection = reduced muscle bulk with fasciculations
2. tone - hypotonia
3. power - dramatically reduced
4. reflex = reduced
146
reflex findings with an UMN lesion
brisk reflexes
147
2 differentials of UMN lesion
brain injury or tumour
148
4 complications and associated conditions with cerebral palsy
1. learning disability
2. epilepsy
3. kyphoscoliosis
4. muscle contractures
5. hearing/visual impairement
6. gastro-oesophageal reflux
149
why may baclofen be prescribed in cerebral palsy?
muscle relaxant for muscle spasticity and contractures
150
on what chromosome is the neurofibromatosis type 1 gene found
chromosome 17
151
what type of protein is neurofibromin
tumour suppressor protein
152
name 5 features that indicate a diagnosis of neurofibromatosis (hint: CRABBING)
c- cafe-au-lait spots (\>6)
r - relative with NF1
A - axillary or inguinal freckles
BB - bony dysplasia such as Bowing of a long bone or sphenoid wing dysplasia
i - iris hamartomas (yellow/brown spots on iris)
N - neurofibromas (2+)
g - glioma of optic nerve
153
what imaging techniques are used for neurofibromatosis and what is seen?
xray = bone pain and lesion investigation
ct/mri = lesions in brain, spinal cord or elsewhere in body
154
2 complications of neurofibromatosis
1. Renal artery stenosis -\> HTN
2. malignant peripheral nerve sheath tumours
3. GI stromal tumour
4. migraines
5. epilepsy
6. vision loss (2ndary to optic nerve gliomas)
155
what chromosiome is neurofibromatosis type 2 gene found and what does it code for\>
found on chromosome 22 and codes for merlin protein (tumour supressor protein in schwann cells)
156
what neuroma is commonly found in neurofibromatosis type 2
acoustic neuroma -\> hearing loss, tinnitus and balance problems
157
what does a pt presenting with BILATERAL acoustic neuroma certainly indicate?
neurofibromatosis type 2
158
what type of bacteria is neisseria meningitidis?
gram negative diplococcus (meningococcus)
159
what type of meningitis causes the non-blanching rash and what does it suggest?
meningococcal septicaemia causes a non-blanching rash and indicates inf. has -\> disseminated intravascular coagulopathy (DIC) and SC haemorrhages
160
what is the most common cause of bacterial meningitis in children and adults? in neonates?
children and adults - neisseria meningitidis and strep pneumonia
neonates - group B strep
161
5 symptoms of meningitis
1. fever
2. neck stiffness
3. vomiting
4. headache
5. photophobia
6. altered consciousness and seizures
162
what investigation must be utilised in all children \<1m with fever, 1-3m with fever and unwell and \<1yr with unexplained fever and other serious illness features
lumbar puncture
163
what two tests can be performed to look for meningeal irritation
- kernigs sign
- brudzinski's sign
164
treatment of children seen in primary care with suspected meningitis AND a non-blanching rash ?
urgent stat injection (IM or IV) of benzylpenicillin prior to hospital transfer
165
treatment for meningitis \<3m ? \>3m?
\<3m = cefotaxime + amoxicillin
\>3m = ceftriaxone
166
what is given as post-exposure prophylaxis for meningococcal infection of close contact
single dose ciprofloxacin ideally within 24hr initial diagnosis
167
what are the most common causes of viral meningitis
- herpes simplex virus
- enterovirus
- varicella zoster virus
168
what is used to treat suspected of confirmed HSV meningitis
aciclovir
169
at what level is a lumbar puncture inserted?
L3-L4 intervertebral space
170
difference in CSF appearance between viral and bacterial meningitis
bacterial CSF - cloudy
viral CSF - clear
171
4 complications of meningitis
1. memory loss
2. HEARING LOSS
3. seizures and epilepsy
4. cognitive impairment and learning difficulty
5. focal neuro deficity such as limb weakness or spasticity
172
squint is also known as ....
strabismus
173
what is the cause of a concomitant squint
difference in control of the extra-ocular muscles
174
define amblyopia
affected eye becomes passive and has reduced function compared to other dominant eye
175
name some non-idiopathic causes of squint (3)
1. hydrocephalus
2. cerebral palsy
3. space occupying lesions (e.g retinoblastoma)
4. trauma
176
what 2 tests can be used to examine a squint?
- hirschbergs test
- cover test
177
what management options may be considered in a squint of a child ?
occlusive patch (covers good eye helps weaker eye to develop)
atropine drops - good eye is blurry allows weaker eye to develop
178
define myasthenia gravis
autoimmune condition that causes muscle weakness that gets worse with activity sand improves with rest
179
what links the thymus and myasthenia gravis?
strong link between thyoma and myasthenia gravis (10-20% will have)
180
what antibodies are produced in pts with myasthenia gravis?
85% = acetylcholine receptor antibodies
181
what are the three antibodies with cause myasthenia gravis
1. acetylcholine receptor antibodies
2. muscle-specific kinase ab (MuSK)
3. lipoprotein receptor-related protein 4 (LRP4)
182
4 facial symptoms of myasthenia gravis
1. extraocular muscle weakness -\> double vision (diplopia)
2. eyelid weakness -\> ptosis
3. weak facial movement
4. difficulty swallowing
5. fatigue in jaw when chew
6. slurred speech
7. progressive weakness with competitive movement
183
how is myasthenia gravis diagnosed?
testing directly for relevant antibodies
- 85% ACh-R
- 10% MuSK
- \<5% LRP4
ct or mri of thymus to look for thyoma
184
if in doubt about diagnosis of myasthenia gravis what test can be done which will show a brief and temporary relief of weakness?
edrophonium test (IV dose of edrophonium hydrochloride)
185
what are the treatment options for myasthenia gravis (4)
- reversible acetylcholinesterase inhibitors (pyridostigmine or neostigmine)
- immosuppression (prednisolone or azathioprine)
- thymectomy
- MONOCLONAL ANTIBODIES (rituximab, eculizumab)
186
what is a myasthenic crisis
severe complication of myasthenia gravis -\> acute worsening of symptoms and often triggered by another illness (resp inf) 0-\> resp fail
187
what is the medical treatment of myasthenic crisis
immunomodulatory therapies (IV immunoglobulins and plasma exchange)
188
define parkinsons disease
progressive reduction of dopammine in the basal ganglia -\> disorders of movement
189
what is the triad of parkinsons disease
1. resting tremor
2. rigidity
3. bradykinesia
190
4 features of parkinsons disease
1. shuffling gait
2. unilateral tremor "pill-roll tremor"
3. cogwheel rigidity
4. bradykinesia
191
if a tremor presents symmetrical, improving at rest and alcohol what type of tremor is most likely?
benign essential tremor
192
what type of tremor is asymmetrical, worse at rest and improves with intentional movement?
parkinsons tremor
193
whar types of dysfunction are caused by multiple system atrophy (2)
1. autonomic dysfunction (postural hypotension, constipation, abnormal sweat)
2. cerebellar dysfunction (causing ataxia)
194
what type of associated symptoms are seen with dementia with lewy bodies (3)
1. visual hallucinations
2. delusions
3. disorders of REM sleep
4. fluctuating consciousness
195
combined medication options for parkinsons
co-benyldopa (levodopa and benserazide)
co-careldopa (levodopa and carbidopa)
196
three examples of side effects of dopamine
1. dystonia (excessibe muscle contraction -\> abnormal postures)
2. chorea (involuntary jerking and random)
3. athetosis (involuntary twisting or writhing)
197
what is the action of COMTi entacapone?
taken with levodopa to slow breakdown of levodopa in the brain -\> extends effective duration of the levodopa
198
name a notable side effect of prolonged use of dopamine agonists
pulmonary fibrosis
199
list 5 differentials of headache
1. tension headache
2. migraine
3. cluster headache
4. raised intracranial pressure
5. GCA
6. SAH
7. meningitis
200
list 4 key red flags to note on a "headache" presentation
1. fever, photophobia or neck stiffness (meningitis or encephalitis)
2. new neuro symptoms (haemorrhage, malignancy, stroke)
3. dizziness (stroke)
4. visual disturbance (temporal arteritis or glaucoma)
5. sudden onset occipital headache (SAH)
6. postural, worse on standing, lying, bending over (raised ICP)
201
what important assessment is done for a headache presentation via fundoscopy and why is it done?
look for papilloedema - indicates raised ICP -\> brain tumour, benign IC HTN, intracrania bleed
202
describe the sensation of a tension headache
mild ache around forehead in a band like pattern around the head
203
list 3 causes of a secondary headache
1. underlying medical condition (inf. obstructive sleep apnoea, pre-eclampsia)
2. alcohol
3. head injury
4. carbon monoxide poisoning
204
how may an analgesic headache present?
similar non-specific features to a tension headache
205
what is the general cause of a hormonal headache and what treatment may improve them
related to low level oestrogen
oral contraceptive pill can improve headaches
206
what condition is caused by degenerative changes in cervical spine and often presents with a headache
cervical spondylosis
207
how is the pain of trigeminal neuralgia typically described as
electricity-like shooting pain, attacks worsen over time and come on spontaneously, lasting few seconds -\> hours
208
first line treatment for trigeminal neuralgia?
carbamazepine
(surgery can be used to decompress or damage trigeminal nerve)
209
list the 4 types of migraine
- migraine without aura
- migraine with aura
- silent migraine
- hemiplegic migraine
210
how long will a migraine last?
describe 4 features of a migraine
4-72hrs
- pounding or throbbing
- unilateral (can be bi)
- photophobia
- phonophobia
- with/without aura
- nausea and vomiting
211
3 signs of a hemiplegic migraine and what condition do they typically mimic?
1. migraine symptoms
2. sudden or gradual onset
3. hemiplegia
4. ataxia
5. changes in consciousness
212
list the 5 stages of migraine
1. premonitory or prodromal
2. aura
3. headache
4. resolution stage (headache fades or relieved by vomiting or sleep\_
5. postdromal or recovery phase
213
4 acute management options for migraine
1. paracetamol
2. triptans (e.g sumitriptan)
3. NSAIDs (e.g. ibruprofen or naproxen)
4. anti-emetics
214
3 ways triptans work
1. smooth muscle in arterties -\> vasoconstriction
2. peripheral pain receptors to inhibit activation of pain receptors
3. reduce neuronal activity in CNS
215
3 medications used in migraine prophylaxis
- propranolol
- topiramate
- amitriptyline
216
define the sensation of a cluster headache
severe and unbearable unilateral headache, usually around the eye
217
define the typical patient presenting with cluster headache
30-50yr old male smoker, attacks triggered by alcohol/strong smells/exercise
218
4 symptoms of cluster headache
1. red, swollen and watering eye
2. pupil constriction (miosis)
3. eyelid drooping (ptosis)
4. nasal discharge
5. facial sweating
219
what are the two acute managements for a cluster headache
1. triptans (e.g. sumitriptan 6mg SC)
2. 100% high flow o2 for 15-20 min (can be given at home)
220
3 prophylaxis options for a cluster headache
- verapamil
- lithium
- prednisolone (2-3wks to break the cycle during cluster)
221
what is temporal arteritis (GCA) strongly linked with?
polymyalgia rheumatica
pts at higher risk are white female \>50
222
key complication of GCA
vision loss (irreversible) - high dose steroids given as soon as diagnosis is SUSPECTED
223
4 features of GCA
1. severe unilateral headache around forehead/ temple
2. scalp tenderness (think hair brushing)
3. jaw claudication
4. blurred or doublev vision
5. irreversible painless complete sight loss can occur rapidly
224
a definitive diagnosis of GCA is made via that 3 investigations
1. clinical presentation
2. raised ESR
3. temporal artery biopsy findings
225
what are found on the temporal artery biopsy in GCA
multinucleated giant cells
226
what anaemia may be seen with GCA and what may be seen on duplex ultrasound
FBC = normocytic anaemia
duplex uss = hypoechoic halo sign
227
aside from steroids what 2 other medications may be given in GCA
- aspirin
- ppi
228
list 2 late complications of GCA
- relapses
- steroid related SE/comps
- cerebrovascular accident (stroke)
- aortitis -\> aortic anaeurysm and aortic dissection
229
what type of genetic condition is huntingtons chorea
autosomal dominant
230
what gene is mutated in huntingtons and on what chromosome
HTT gene on chromosome 4
231
define what is meant by anticipation in the case of huntingtons chorea
successive generations have more repeats in gene -\>
- earlier age of onset
- increased severity of diease
232
what 4 movement disorders may be seen in huntingtons
- chorea (involuntary abnormal movement)
- eye movement disorders
- speech difficulty (dysarthia)
- swallow difficulty (dysphagia)
233
what is the medical treatment for huntingtons
- based on symptomatic relief, no treatment for stopping or slowing progression
234
3 medications which may be given in huntingtons to suppress the disordered movement
- antipsychotics (olanzapine)
- benzodiazepines (diazepam)
- dopamine-depleting agents (tetrabenazine)
235
life expectancy for huntingtons and leading cause of death in these pts
15-20yrs after onset of symptoms
death often due to respiratory disease (pneumonia)
suicide risk higher
236
where does charcot-marie-tooth disease cause dysfunction?
myelin or the axons
237
typical age pts present with charcot-marie-tooth disease symptoms
\<10yrs, can be delayed to \>40yrs
238
3 features to look for in assessing charcot-marie-tooth disease
- high arched foot (pes cavus)
- distal muscle wasting "inverted champagne bottle legs"
- weakness in lower legs (loss of ankle dorsiflexion)
- weakness in hands
- reduced tendon reflexes
- reduced muscle tone
- peripheral sensory loss
239
causes of peripheral neuropathy (hint: ABCDE)
- alcohol
- B12 deficiency
- Cancer and CKD
- Diabetes and Drugs (isonazid, amiodarone, cisplatin)
- Every vasculitis
TOM TIP: This is a common OSCE scenario. You will have to perform a neurological examination on a patient that has a peripheral neuropathy. Charcot-Marie-Tooth is a relatively common (1 in 2,500 people) condition with good signs that has a high chance of appearing in your exams. Look for the other features, suggest the diagnosis, then run through the ABCDE mnemonic to suggest the possible other causes.
240
the spinal nerves _______ come together to form the sciatic nerve
L4-S3
241
what does the sciatic nerve divide in to?
tibial nerve and the common peroneal nerve
242
what does the sciatic nerve supply for?
sensation to lateral lower leg and foot
motor function to posterior thigh, lower leg and foot
243
3 symptoms of sciatica
- unilateral pain from buttock down back of thigh -\> below knee/feet
- paraesthesia
- numbness and motor weakness
- reflexes may be effected
244
3 main causes of sciatica are lumbosacral nerve root compression by? (3)
- herniated disc
- spondylolisthesis
- spinal stenosis
245
what type of sciatica is a red flag for cauda equina syndrome
bilateral sciatica
246
what 5 main cancers metastasise to the bone
PoRTaBLe
prostate
renal
thyroid
breast
lung
247
test to help diagnose sciatice?
sciatica stretch test
248
3 types of muscular dystrophy
1. duchennes muscular dystrophy (worth knowing)
2. beckers muscular dystrophy
3. myotonic dystrophy
249
what sign is seen in children with proximal muscle weakness (may be seen in muscular dystrophy)
Gowers sign
x-linked recessive inheritance
250
what is the cause of duchennes muscular dystrophy
defective gene for dystrophin on the x-chromosome
251
where is weakness first noticed in a child with DMD?
3-5 yrs old with weakness in muscles around the PELVIS
wheelchair bound by a teen
25-35yrs life expectancy with good management
252
what medication has been shown to slow progression of muscle weakness in DMD?
steroids
253
4 typical features of myotonic dystrophy
1. progressive muscle weakness
2. PROLONGED MUSCLE CONTRACTIONS
3. cataracts
4. cardiac arrhythmia
TOM TIP: The key feature of myotonic dystrophy to remember is the prolonged muscle contraction. This may present in exams with a patient that is unable to let go after shaking someones hand, or unable to release their grip on a doorknob after opening a door. When doing an upper limb neurological examination always shake the patients hand and observe for difficulty releasing their grip.
254
what type of muscular dystrophy typically presents with childhood facial weakness -\> shoulders and arms (e.g. sleep with eyes slightly open)
facioscapulohumeral muscular dystrophy
255
define how oculopharyngeal muscular dystrophy typically presents
weakness of the ocular muscles and pharynx
bilateral ptosis, restriced eye movement and swallowing problems
256
what age does limb-girdle muscular dystrophy typically present?
teenage years
257
how does emery-dreifuss muscular dystrophy typically present
childhood with contractures, commonly elbows and ankles
258
how does blood enter the brain?
internal carotid arteries and the vertebral arteries in the neck
259
4 causes of dementia
1. increasing age
2. alzheimers
3. vascular dementia
4. lewy body dementia
5. frontotemporal dementia
260
common causes of dementia (hint: DEMENTIA)
Diabetes
Ethanol
Medication
Environmental (CO poisoning)
Nutritional
Trauma
Infection
Alzheimers
261
5 S/S of dementia
1. memory loss, difficulty retaining new info
2. language impairement
3. executive dysfunction (handling complex tasks etc)
4. visiospatial ability impairment
5. behavioural disturbance
6. personality change
262
what is seen on CT for vascular dementia
microinfarcts
263
diagnostic tests for dementia (3)
1. mental state examination
2. montreal cognitive assessment (MoCA)
3. mini-mental state examination (MMSE)
264
why are acetlycholinesterase inhibitors used in alzheimers
increase acetylcholine (brains primary neurotransmitter) levels
265
what medication is given in advanced dementia
N-methyl-D-asperate (NMDA) receptor antagonist
266
most common form of dementia?
alzheimers
267
how does amyloid precursor protein -\> alzheimers disease
- abnormal APP degredation via b-secretase
- APP cut into insoluble fragments
- -\> beta amyloid plaque
268
3 RF for alzheimers disease
- age\>60
- family history
- trisomy 21 (downs syndrome)
- gene mutations affecting APP
- hx of HTN, dyslipidemia, cerebrovascular disease, altered glucose metabolism, brain trauma
269
how many years after symptom onset is life expectancy for alzheimers
5-10yrs
270
diagnostic imaging for alzheimers and results?
CT/MRI
- excludes other dementias
- brain scans show DIFFFUSE CORTICAL ATROPHY, GYRI NARROWING, SULCI WIDENING, VENTRICLE ENLARGEMENT
271
there is no cure for alzheimers, what medications may be given to pt? (3)
1. acetylcholinesterase inhibitors
2. vitamin E supplementation may provide benefit
3. memantine (advanced)
272
cause of lewy body dementia
alpha-synuclein protein aggregation in the neurons (particularly cortex, substantia nigra) forming lewy bodies -\> apoptosis
273
3 complications of lewy body dementia
1. persistent psychotic symptoms (especially visual hallucinations)
2. depression
3. complete debilitation, dependence on others
4. debilitation -\> death, decreased life expectancy
5. neuroleptic-agent sensitivity (adverse effects, parkinsonism)
274
what type of dementia motor symptoms mimic parkinsons disease
lewy-body dementia (resting tremor, stiffness, slow movement, reduced facial expressions)
275
3 medications used to alleviate symptoms of lewy-body dementia
- acetylcholinesterase inhibitors
- dopamine analogue
- atypical neuroleptic agents
276
diagnostic imaging for lewy body dementia
single-photon emission computerized tomography (SPECT) scanning
277
define frontotemporal dementia
heterogenous degenerative frontal/temporal lobe disease
278
what specific protein cellular inclusions are seen in frontotemporal dementia (2)
- TAU proteins (Pick disease)
- TAR DNA-binding protein 43 (TDP43)
279
diagnostic imaging for frontotemporal dementia?
MRI
SPECT/perfusion-MRI/PET
280
how do pick cells in frontotemporal dementia affect the neurons
swollen (ballooned) neurons
281
features of pick disease (hint:PICK)
Progressive degeneration of neurons
Intracytoplasmic degeneration of neurons
Cortical atrophy
Knife edge gyri
282
what is the second most common dementia in the elderly
vascular dementia
283
4 causes of vascular dementia
1. cerebral artery atherosclerosis
2. carotid artery/heart embolization
3. chronic HTN
4. vasculitis
284
3 RF for vascular dementia
1. smoking
2. HTN
3. DM
4. insulin resistance
5. hyperlipidaemia
285
vaguely define the S/S of vascular dementia
progressive, stepwise cognitive function impairment
286
what is seen on MRI/CT in vascular dementia
multiple cortical, subcortical infarcts
287
what is the cause of shingles
varicella zoster virus
288
when and how does shingles occur
- dominant VSZ reactivates
reactivation in dorsal root -\> cranial nerve ganglia -\> down axons -\> local skin inflammation innervated by ganglion
- prodromal 2-4 day tingle/localized pain b4 rash onset
289
3 RF for shingles
1. primary varicella infection history
2. more common in adults \>50
3. immunocomprimised
4. stress
290
3 complications of shingles
1. ramsay hunt syndrome
2. postherpetic neuralgia
3. herpes zoster opthalmicus (sight-threatening)
291
appearance of shingles
erythematous, maculopapular lesions evolve into a painful vesicular rash
292
4 medication options for shingles
- oral/IV antiviral therapy
- analgesia (paracetamol/ibuprofen etc)
- calamine lotion
- varicella-zoster immune globulin
293
pathophysiology of normal pressure hydrocephalus
CSF accumulation -\> progressive lateral ventricle enlargement
294
main RF for normal pressure hydrocephalus
prevelance largest among elderly
295
3 main s/s of normal pressure hydrocephalus
- unsteady gait (glue-footed)
- urinary incontinence
- cognitive impairment
296
what is seen on CT/MRI in normal pressure hydrocephalus (3)
- ventriculomegaly
- enlarged sylvian fissure
- enlarged sulci with no cortical atrophy
297
2 treatment options in normal pressure hydrocephalus
surgery in some situations
ventriculoperitoneal shunt (increase ICP relief)
298
cause of wenicke-kosakoff syndrome
vitamin B1 or thiamine deficiency
299
name the acute-reversible stage of wenicke-korsakoff syndrome?
wernickes encephalopathy -\> korsakoff syndrome (chronic, irreversible)
300
where is thiamine stored and absorbed
stored in liver
absorbed in duodenum
301
major cause of thiamine deficiency
alcohol abuse
302
how does thiamine deficiency affect the cerebellum
movement and balance affected
303
2 later findings in thiamine deficiency
- haemorrhage
- necrosis of mamillary bodies -\> affect memory/emotion/behaviour
304
define the triad of wernickes encephalopathy
1. opthalmoplegia (weakness or paralysis of eye muscles)
2. ataxia or unsteady gait
3. changes in mental state (confusion, apathy, difficulty concentrating)
305
what is the main impairment caused by korsakoff syndrome
mainly targets limbic system = severe memory impairment (anterograde/retrograde amnesia)
confabulation
306
what is the most common cause of encephalitis
viral - HSV-1 (herpes simplex virus)
307
one bacterial cause of encephalitis
- listeria monocytogenes
- mycobacteria
- spirochetes (syphilis)
308
3 RF for encephalitis
1. immunosuppression
2. travel to low-income nations
3. exposure to disease vectors in endemic areas
309
3 complications of encephalitis
1. seizures
2. SIADH
3. increased ICP
4. coma
310
how is meningism seen in encephalitis
nuchal rigidity (cant flex neck forward passively due to increased tone/stiffness)
311
what is seen in a brain MRI for viral (HSV) encephalitis
increased T2 signal intensity in fronto-temporal region
312
what is seen in the CSF chemistry in viral encephalitis
lymphocytosis (\>5 WBC/ml) with normal glucose
313
how can a definitive diagnosis be made for viral encephalitis
brain biopsy
- cowdry type A inclusions
- haemorrhagic necrosis in temporal, orbitofrontal lobes (HSV)
314
what is seen in this CT scan
HSV encephalitis
315
what medication is given for HSV encephalitis
acylcovir
316
what medication is given for CMV encephalitis
ganciclovir/foscarnet
317
medication for bacterial encephalitis
targeted abx
318
1 cause of a first order lesion horners syndrome:
1 cause of 2nd order lesion horners syndrome
1 cause of 3rd order lesion horners syndrome
1st - arnold-chiari malformation, cerebrovascular insult, basal skull tumor
2nd - trauma, cervical rib, pancoast tumour, neuroblastoma, aortic dissection
3rd - herpes zoster, internal carotid artery dissection, cluster headache
319
triad of horners syndrome
ptosis, miosis and anhidrosis
320
2 diagnostic imagings used for horners syndrome investigation
x-ray - detect pancoast tumour/shoulder trauma
mri - detects aneurysm/dissection
321
define narcolepsy
recurrent sleep phenomena during wakefulness
322
what neuropeptide is narcolepsy associated with and what is the action of this peptide
associated with lack of orexin
orexin (A&B): increase state of wakefulness when binding to polysnynaptic neurons
323
cause of narcolepsy
damage to orexin-transporting neurons (by autoimmune process/injury)
324
2 RF for narcolepsy
- genetics
- low levels of histamine
- infections
- autoimmune diseases
325
3s/s of narcolepsy
1. daytime sleepiness
2. cataplexy
3. hallucinations
4. sleep paralysis
326
how to diagnose narcolepsy
recurrent feeling of sleepiness in daytime \>3x week \>3m
+ at least 1:
- cataplexy
- hypocretin deficiency
- short rapid eye movements (REM)
327
treatment for narcolepsy (2)
SSRI's
stimulants (modafinil)
328
define cataplexy
muscles go weak or limp with no warning - typically experienced during a strong emotion or emotional sensation
329
what is cataplexy often associated with
narcolepsy
330
3 symptoms of cataplexy
drooping eyelids
jaw dropping
head falling to the side due to neck muscle weakness
whole body falling to the ground
various muscles around your body twitching without an obvious cause
331
define NEAD
non-epileptic attack disorder
look like epileptic seizures but not caused by electrical activity in the brain
332
what is the current understanded cause of NEAD (2)
brains response to overwhelming stress
traumatic events
333
what cranial nerves are typically affected in bulbar palsy
nerves that arise from brainstem
9,10,11,12
334
name two affects of a damaged CN9
dysphagia (difficulty swallowing)
reduced gag reflex
335
what type of palsy may you see a nasal speech that lacks in modulation (e.g. controlling or adjusting of one’s speech)
bulbar palsy
336
how is pseudobulbar palsy characterised
atypical expression of emotion displayed by unusual outbursts of laughing/crying (emotional lability)
337
2 most common causes of bulbar palsy
brainstem strokes and tumours
338
briefly define radiculopathy
pain/numbness/tingling/weakness in arms or legs caused by compression of a nerve root in the spinal column
339
what is the most common type of lumbar radiculopathy
sciatica
340
where is cervical radiculopathy commonly seen
c5-c7
341
two forms of cervical radiculopathy
disc degeneration and spondylosis
342
define radiculopathy pain
sharp and spreads from specific locations to other parts of the body
343
typical treatment for radiculopathy (3)
- nsaids
- physical therapy
- surgical procedures to relieve nerve compression if necessary
344
define mononeuropathy
damage or dysfunction of a single peripheral nerve that connects the CNS to the body
345
what are the two most common mononeuropathies and briefly define them
cubital tunnel syndrome = neuropathy of the ulnar nerve (sensation to 4th/5th finger, part of palm and underside forearm)
carpel tunnel syndrome = neuropathy of median nerve (sensation to 1st/2nd/3rd/4th fingers)
346
3 non-compression related causes of mononeuropathy
infection
radiation
cold
347
what is the main cause of a fixed mononeuropathy
nerve compression against a hard surface (i.e. tumour/cast/cramped posture for long time)
348
3 RF for entrapment of a nerve in a restricted anatomical structure
pregnancy
hypothyroidism
RA
349
define delerium
fast decline in attention/consciousness thinking
350
3 categories that are a RF for delirium and 1 example of each
disease (dementia, pneumonia, UTI)
post-surgical complication (meds like anticholinergics)or chronic fatigue
increase falls risk (head injuries etc)
351
3 S/S of delirium
- difficulties with attention span, concentration, remaining conscious
- disorganised and delayed thinking
- hyperactive symptoms
- hypoactive symptoms
352
treatment option for severe symptoms of delerium
haloperidol/second gen antipsychotics
353
what medication must be avoided in delirium
opiates (increased risk delirium)
354
list 3 medication types that can increase the risk of osteoporosis
- long term corticosteroids
- SSRI's
- PPI
- anti-epileptics
355
why are post-menopausal women at higher risk of osteoporosis than pre-menopausal women?
post-menopause have reduced oestrogen
(oestrogen is a protective factor against osteoporosis)
356
assessment tool for identify osteoporisis risk over 10yrs?
FRAX tool
357
investigation for bone mineral density
DEXA scan
358
what is the bone mineral density result for a patient with a T score of -2
osteopenia
T-score of -1 to -2.5 is osteopenia
359
what is the bone mineral density result for a patient with a T score of -2.7
osteoporosis
(less than -2.5 is osteoprosis
less than-2.5 + # is severe osteoporosis)
360
supplementation for patients at risk of fragility #
vitamin D and calcium
361
first line treatment for osteoporosis
bisphosponates
362
3 notible SE of osteoporosis
- reflux and oesophageal erosions
- atypical #
- necrosis of the jaw
- osteonecrosis of external auditory canal
363
3 examples of bisphonates
- alendronate
- risedronate
- zolendronic acid
364
what areas of the body are mainly affected by pressure ulcers
bony prominences
- sacrum/heels/hips/elbows
365
3 RF for pressure ulcers
- reduced mobility (e.g. parkinsons, hip #, stroke)
- reduced perfusion (atherosclerosis, smoking,)
- factors affecting skin structure (malnutrition, skin moisture)
366
what type of medication has an increase risk of mortality in dementia patients
anti-psychotics
367
What type of drug is memantine
NMDA agonist
