Neurology and Geriatrics Flashcards
list 3 things that may cause disruption of blood supply
- thrombus formation/embolus
- AF
- atherosclerosis
- shock
- vasculitits
sudden onset of what symptoms (4) indicate a stroke?
asymmetrical
- weakness of limbs
- facial weakness
- dysphasia
- visual or sensory loss
4 RF for stroke
- previous stroke TIA
- CVD - angina/MI/PVD
- AF
- carotid artery disease
-HTN - DM
- smoking
0 vasculitis - combined oral contraceptive pill
scoring tool for stroke in community?
FAST
scoring tool for recognition of stroke in emergency room
ROSIER (>0 = likely)
immediate imaging and medication for stroke management
immediate ct (exclude primary intracerebral haemorrhage) aspirin 300mg stat - 2wks
2 main surgical managements for stroke?
- thrombolysis
- thrombectomy
2 medications given for secondary prevention of stroke
- clopidogrel 75mg 1x day
- atorvastatin 80mg
classification system for ischaemic stroke?
bamford classification
based on presenting s/s
what three signs must all be present to diagnose a total anterior circulation stroke
- unilateral weakness (and or sensory deficit) of face, arms, leg
- homonymous hemianopia
- higher cerebral dysfunction (dysphasia )
what are the 5 s/s you may see in posterior circulation syndrome
-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
list the 4 s/s used to diagnose a lacunar stroke
- pure sensory stroke
- pure motor stroke
- sensori-motor stroke
- ataxic hemiparesis
3 investigations for epilepsy
EEG, MRI brain, ECG (exclude heart probs)
associated features of tonic-clonic seizures (3)
- tongue biting
- incontinence
- groaning
- irregular breathing
first and second line treatment for tonic-clonic seizures
1st = sodium valproate 2nd = carbamazepine or lamotrigine
in what lobe of the brain do focal seizures start?
temporal lobe
what can a focal seizure effect (4)
hearing
speech
memory
emotions
1st and 2nd line treatment for focal seizures?
1st - carbamazepine or lamotrigine
2nd - sodium valproate or levetiracetam
what type of seizure is typically seen in children?
absence seizure
first line absence seizure treatment
- sodium valproate
what type of seizure is also known as a “drop attack”
atonic seizure
first line treatment for atonic seizure
sodium valproate
1st line treatment for myoclonic seizure
sodium valproate
SE of sodium valproate (4)
- teratogenic
- liver damage and hep
- hair loss
- tremor
how does sodium valproate work?
increases activivity of gaba which relaxes the brain
why is sodium valproate avoided in women or girls unless no suitable alternative is available?
teratogenic
SE of carbamazepine (3)
agranulocytosis
aplastic anaemia
induce p450 -> many drug interactions
3 phenytoin SE
- folate and vit d deficiency
- megoblastic anaemia
- osteomalacia
what is a myasthenic crisis
severe, life threatening complication of myasthenia gravis (acute worsening of symptoms)
usual cause of myasthenic crisis
triggered by another illness - respiratory tract infection
what organ failure can occur due to myasthenic crisis
respiratory failure as weakness in resp muscles
what management may be needed for a myasthenic crisis
bipap or full intubation/ventilation
medical treatment for myasthenic crisis?
IV immunoglobulins and plasma exchange
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
presentation of gullian-baree syndrome (4)
- symmetrical ascending weakness
- reduced reflexes
- peripheral loss of sensation or neuropathic pain
- progress to cranial nerves -> facial nerve weakness
how long after infection do guillian-barre symptoms typically occur?
within 4 weeks of the preceding infection
what is the criteria used for guillian-barre diagnosis
the brighton criteria
what two investigations can be used to support diagnosis of guillian-barre syndrome and what is seen?
- nerve conduction studies (reduced signal through nerves)
- lumbar puncture for CSF (raised protein, normal cell count and glucose)
management options for guillian-barre syndrome (4)
- IV immunoglobulins
- plasma exchange (alternative to iv ig)
- supportive care
- VTE prophylaxis (PE is leading cause of death)
leading cause of death in guillian-barre syndrome
PE
what is the most common type of spinal stenosis
lumbar spinal stenosis
what type of spinal stenosis causes narrowing of the nerve root canals?
lateral stenosis
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
3 s/s of cauda equina syndrome
- saddle anaesthesia
- sexual dysfunction
- incontinence of the bladder and bowel
3 typical symptoms of pseudoclaudication
- lower back pain
- buttock and leg pain
- leg weakness
define radiculopathy
compression of the nerve root as they exit spinal cord/column -> motor/sensory probs
how to spot difference between spinal stenosis and peripheral arterial disease? (2)
- AKBI normal -> think spinal stenosis
- struggling with back pain -> think spinal stenosis
primary imaging investigation for diagnosing spinal stenosis
MRI
management for spinal stenosis
- exercise and weight loss
- analgesia
- physio
- decompression surgery if conservative treatment fails
at what level does the spinal cord terminate?
L2/L3
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
3 causes of spinal compression
- herniated disc (most common)
- tumour, metastasis
- spondylolisthesis
- abscess
- trauma
4 red flags for cauda equina syndrome
- saddle anaesthesia
- loss of sensation in bladder/rectum (not knowing when theyre full)
- urinary incontinence or retention
- faecal incontinence
- bilateral sciatica
- bilateral or severe motor weakness in legs
- reduced anal tone on PR exam
emergency management of cauda equina (3)
- immediate hospital admission
- emergency MRI
- neurosurgical input to consider lumbar decompression surgery
key differentiating feature between cauda equina and metastatic spinal cord compression
back pain worse on cough or strain in MSSC
what are the three domains on the GCS used to measure a coma?
- eye opening
- motor respone
- verbal response
what number on the GCS suggests a coma?
coma <8
(usually E2,M4,V2 or less)
what is meant by the term “AVPU”
scoring system of a persons consciousness
Alert
responsive to Voice
responsive only to Pain
Unresponsive
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
microbiology of neisseria meningitidis
gram negative diplococcus
what does a non-blanching rash represent in meningococcal septicaemia?
disseminated intravascular coagulopathy (DIC) and sc haemorrhages
most common cause of bacterial meningitis in:
- children and adults (2)
- neonates (1)
- neisseria meningitidis (meningococcus)
- strep pneumoniae
presentation of meningitis (6)
- fever
- neck stiffness
- vomiting
- headache
- photophobia
- altered consciousness and seizures
what should be part of your investigation for meningitis for all children
lumbar puncture as can be non-specific signs
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
usual choice of post mengititis exposure prophylaxis
single dose ciprofloxacin within 24hr inital diagnosis
most common cause of viral meningitis (3)
- herpes simplex virus
- enterovirus
- varicella zoster virus
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)
3 complications of meningitis
- hearing loss is a key one
- seizures and epilepsy
- cognitive impairment and learning disability
- memory loss
- focal neuro deficit e.g limb weakness or spasticity
3 possible symptoms of a brain abscess
- headache
- lethargy
- fever
- focal neurological deficit
investigations for diagnosis of brain abscess
contrast-enhanced MRI or CT
2 causes of a brain abscess
- cranial infection (osteomyelitis, sinusitis)
- penetrating head wounds
- haematogenous spread (bacterial endocarditis)
- unknown
treatment of brain abscess
- abx - cefotaxime or ceftriaxone + metronidazole or vancomycin for staph. aureus
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)
what is the key finding on fundoscopy in a pt with raised intracranial pressure which suggests a diagnosis of a brain tumour
papilloedema
3 causes of raised intracranial pressure
- brain tumours
- intracranial haemorrhage
- idiopathic intracranial hypertension
- abscesses or infection
5 headache red flags
- constant
- nocturnal
- worse on waking
- worse on cough, straining or bending forward
- vomiting
define papiloedema
swelling of the optic disc due to raised intracranial pressure
2 fundoscopic changes seen with raised intra-cranial pressure
- blurring of optic disc margin
- elevated optic disc
- loss of venous pulsation
- engorged retinal veins
- haemorrhages around optic disc
- patons lines
the four common cancers which metastasise to the brain
- lung
- breast
- renal cell carcinoma
- melanoma
the three types of gliomas
- astrocytoma (gliobastoma multiform is most common)
- oligodendroglioma
- ependymoma
optic field defect seen when a pituitary tumour grows large enough
bitemporal hemianopia (presses on optic chiasm)
4 hormone deficiences caused by pituitary tumour
acromegaly
hyperprolactinaemia
cushings disease
thyrotoxicosis
define an acoustic neruoma
tumours of the schwann cells surrounding the auditory nerve that innervates the inner ear
triad of symptoms for acoustic neuroma
- hearing loss
- tinnitus
- balance problems
treatment for pit tumours (4)
- trans-sphenoidal surgery
- radiotherapy
- bromocriptine (block prolactin secreting tumours)
- somatostatin analogues
3 RF for an intracranial bleed
- head injury
- HTN
- aneurysm
- ischaemic stroke -> haemorrhage
- brain tumour
- anticoag e.g. warfarin
main presentation of an intracranial bleed
sudden onset headache
think also:
Seizures
Weakness
Vomiting
Reduced consciousness
Other sudden onset neurological symptoms
GCS score signalling you may need to secure the airway as theres a riskt they may not maintain on their own
= 8
what will be seen on a CT scan of a subdural haemorrhage
crescent shape
patients most at risk of subdural haemorrhage?
elderly and alcoholics as increased atrophy = more likely to rupture
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
what type of haemorrhage is seen here
intracerebral
what type of haemorrhage is seen below
SAH
what is the usual cause of a SAH
ruptured cerebral aneurysm
what headache is associated with SAH
what else is associated with SAH
thunderclap headache
cocaine and sickle cell anaemia also associated
4 features of a SAH
- thunderclap headache
- neck stiffness
- photophobia
- vision changes
- neuro symptoms e.g. speech changes, weakness, seizures and LOC
3 RF for SAH
- HTN
- smoking
- excessive alcohol consumption
- cocaine use
- family history
first line investigation for SAH
CT head
CSF results in a SAH?
- red cell count RAISED
- xanthochromia (yellow coloured csf caused by bilirubin)
surgical management of a SAH
medication option for SAH
surgery - coiling or clipping
meds - nimodipine (CCB prevent vasospasm)
common complication which can result in brain ischaemia following a SAH
vasospasm
what cells produce myelin
schwann cells in peripheral nervous system
oligodendrocytes in CNS
what part of the nervous system is affected in MS
CNS (oligodendrocytes)
3 causes of MS
- multiple genes
- Epstein-barr virus
- low vit D
- smoking
- obestiy
what is the most common presentation of MS
optic neuritis
involves demyelination of the optic nerve and loss od vision in one eye
what two key phrases are used to describe a sixth nerve palsy (seen in MS)
- intranuclear opthalmoplegia
- conjugate lateral gaze disorder
2 focal sensory symptoms seen in MS
- trigeminal neuralgia
- numbness
- paraesthesia
- lhermittes sign
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
what is the most common pattern of MS
relapsing-remitting
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.
main cause of optic neuritis
MS
how long to symptoms have to be progressive to diagnose primary progressive MS
1 year
4 key features of optic neuritis
- central scotoma (enlarged blind spot)
- pain on eye movement
- impaired colour vision
- relative afferent pupillary defect
list 2 causes of optic neuritis aside from MS
- sarcoidosis
- SLE
- DM
- syphilis
_ measles
- mumps
- lyme disease
treatment of optic neuritis
steroids (recovery 2-6wks)
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)
what is the most common specific motor neurone disease
amyotrophic lateral sclerosis (ALS)
what muscles are affected by progressive bulbar palsy?
affects primarily muscles of talking and swallowing
why is family history important when taking a hx for MND
5-10% of cases of MND are inherited
where is weakness first noticed in MND
upper limbs noted first (progressive weakness affecting limbs, trunk, face, speech)
4 presentation symptoms of MND
- progressive upper limb weaknes
- increased fatigue when exercising
- clumsiness
- slurred speech (dysarthia)
4 signs of MND
- muscle wasting
- reduced tone
- fasciculations (muscle twitch)
- reduced reflexes
what are three signs of upper MND
- increased tone and spasticity
- brisk reflexes
- upgoing plantar responses
what medication can slow progession of MND and increase survival for few months
Riluzole
usual cause of death in pts with MND
respiratory failure or pneumonia
what are the five branches of the facial nerve?
- temporal
- zygomatic
- buccal
- marginal mandibular
- cervical
what type of neurone facial nerve palsy should be referred urgently as a stroke risk?
upper motor neurone facial nerve palsy
in what type of motor neurone lesion is the forehead spared?
UMN lesion = forehead sparing
unilateral motor lesions occur in ____ and ____
bilateral upper motor neurone lesions occur in _____ and ______
- cerebrovascular accidents (stroke) and tumours
- peudobulbar palsies and MND
what type of palsy presents as a unilateral LMN facial nerve palsy?
bells palsy
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
what is the concern regarding pain in the eye following a bells palsy
exposure keratopathy
what is the cause of Ramsey-hunt syndrome?
varicella zoster virus
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)
what treatments are administered within 72hr onset of ramsay-hunt syndrome
- prednisolone
- acicilovir
list 2 infection causes of LMN facial nerve palsy
- otitis media
- malignant otitis externa
- HIV
- lymes disease
list 2 systemic diseases which may cause LMN facial nerve palsy
- diabetes
- sarcoidosis
- leukaemia
- MS
- guillain-barre syndrome
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
what are the four types of cerebral palsy
- spastic hypertonia ( from damage of UMN)
- dyskinetic (from damage to basal ganglia)
- ataxic (damage to cerebellum)
- mixed
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)
3 s/s of cerebral palsy
- failure to meet milestone
- increased/decreased tone (general or specific)
- hand preference UNDER 18 MONTHS (key sign)
- feeding/swallow issues
- learning difficulties
what type of gait suggests foot drop or LMN lesion
high stepping gate
what gait suggests pelvic muscle weakness due to myopathy
waddling gait
what are the findings of a LMN lesion on examination
- inspection = reduced muscle bulk with fasciculations
- tone - hypotonia
- power - dramatically reduced
- reflex = reduced
reflex findings with an UMN lesion
brisk reflexes
2 differentials of UMN lesion
brain injury or tumour
4 complications and associated conditions with cerebral palsy
- learning disability
- epilepsy
- kyphoscoliosis
- muscle contractures
- hearing/visual impairement
- gastro-oesophageal reflux
why may baclofen be prescribed in cerebral palsy?
muscle relaxant for muscle spasticity and contractures
on what chromosome is the neurofibromatosis type 1 gene found
chromosome 17
what type of protein is neurofibromin
tumour suppressor protein
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
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
2 complications of neurofibromatosis
- Renal artery stenosis -> HTN
- malignant peripheral nerve sheath tumours
- GI stromal tumour
- migraines
- epilepsy
- vision loss (2ndary to optic nerve gliomas)
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)
what neuroma is commonly found in neurofibromatosis type 2
acoustic neuroma -> hearing loss, tinnitus and balance problems
what does a pt presenting with BILATERAL acoustic neuroma certainly indicate?
neurofibromatosis type 2
what type of bacteria is neisseria meningitidis?
gram negative diplococcus (meningococcus)
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
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
5 symptoms of meningitis
- fever
- neck stiffness
- vomiting
- headache
- photophobia
- altered consciousness and seizures
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
what two tests can be performed to look for meningeal irritation
- kernigs sign
- brudzinski’s sign
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
treatment for meningitis <3m ? >3m?
<3m = cefotaxime + amoxicillin
>3m = ceftriaxone
what is given as post-exposure prophylaxis for meningococcal infection of close contact
single dose ciprofloxacin ideally within 24hr initial diagnosis
what are the most common causes of viral meningitis
- herpes simplex virus
- enterovirus
- varicella zoster virus
what is used to treat suspected of confirmed HSV meningitis
aciclovir
at what level is a lumbar puncture inserted?
L3-L4 intervertebral space
difference in CSF appearance between viral and bacterial meningitis
bacterial CSF - cloudy
viral CSF - clear
4 complications of meningitis
- memory loss
- HEARING LOSS
- seizures and epilepsy
- cognitive impairment and learning difficulty
- focal neuro deficity such as limb weakness or spasticity
squint is also known as ….
strabismus
what is the cause of a concomitant squint
difference in control of the extra-ocular muscles
define amblyopia
affected eye becomes passive and has reduced function compared to other dominant eye
name some non-idiopathic causes of squint (3)
- hydrocephalus
- cerebral palsy
- space occupying lesions (e.g retinoblastoma)
- trauma
what 2 tests can be used to examine a squint?
- hirschbergs test
- cover test
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
define myasthenia gravis
autoimmune condition that causes muscle weakness that gets worse with activity sand improves with rest
what links the thymus and myasthenia gravis?
strong link between thyoma and myasthenia gravis (10-20% will have)
what antibodies are produced in pts with myasthenia gravis?
85% = acetylcholine receptor antibodies
what are the three antibodies with cause myasthenia gravis
- acetylcholine receptor antibodies
- muscle-specific kinase ab (MuSK)
- lipoprotein receptor-related protein 4 (LRP4)
4 facial symptoms of myasthenia gravis
- extraocular muscle weakness -> double vision (diplopia)
- eyelid weakness -> ptosis
- weak facial movement
- difficulty swallowing
- fatigue in jaw when chew
- slurred speech
- progressive weakness with competitive movement
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
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)
what are the treatment options for myasthenia gravis (4)
- reversible acetylcholinesterase inhibitors (pyridostigmine or neostigmine)
- immosuppression (prednisolone or azathioprine)
- thymectomy
- MONOCLONAL ANTIBODIES (rituximab, eculizumab)
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
what is the medical treatment of myasthenic crisis
immunomodulatory therapies (IV immunoglobulins and plasma exchange)
define parkinsons disease
progressive reduction of dopammine in the basal ganglia -> disorders of movement
what is the triad of parkinsons disease
- resting tremor
- rigidity
- bradykinesia
4 features of parkinsons disease
- shuffling gait
- unilateral tremor “pill-roll tremor”
- cogwheel rigidity
- bradykinesia
if a tremor presents symmetrical, improving at rest and alcohol what type of tremor is most likely?
benign essential tremor
what type of tremor is asymmetrical, worse at rest and improves with intentional movement?
parkinsons tremor
whar types of dysfunction are caused by multiple system atrophy (2)
- autonomic dysfunction (postural hypotension, constipation, abnormal sweat)
- cerebellar dysfunction (causing ataxia)
what type of associated symptoms are seen with dementia with lewy bodies (3)
- visual hallucinations
- delusions
- disorders of REM sleep
- fluctuating consciousness
combined medication options for parkinsons
co-benyldopa (levodopa and benserazide)
co-careldopa (levodopa and carbidopa)
three examples of side effects of dopamine
- dystonia (excessibe muscle contraction -> abnormal postures)
- chorea (involuntary jerking and random)
- athetosis (involuntary twisting or writhing)
what is the action of COMTi entacapone?
taken with levodopa to slow breakdown of levodopa in the brain -> extends effective duration of the levodopa
name a notable side effect of prolonged use of dopamine agonists
pulmonary fibrosis
list 5 differentials of headache
- tension headache
- migraine
- cluster headache
- raised intracranial pressure
- GCA
- SAH
- meningitis
list 4 key red flags to note on a “headache” presentation
- fever, photophobia or neck stiffness (meningitis or encephalitis)
- new neuro symptoms (haemorrhage, malignancy, stroke)
- dizziness (stroke)
- visual disturbance (temporal arteritis or glaucoma)
- sudden onset occipital headache (SAH)
- postural, worse on standing, lying, bending over (raised ICP)
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
describe the sensation of a tension headache
mild ache around forehead in a band like pattern around the head
list 3 causes of a secondary headache
- underlying medical condition (inf. obstructive sleep apnoea, pre-eclampsia)
- alcohol
- head injury
- carbon monoxide poisoning
how may an analgesic headache present?
similar non-specific features to a tension headache
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
what condition is caused by degenerative changes in cervical spine and often presents with a headache
cervical spondylosis
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
first line treatment for trigeminal neuralgia?
carbamazepine
(surgery can be used to decompress or damage trigeminal nerve)
list the 4 types of migraine
- migraine without aura
- migraine with aura
- silent migraine
- hemiplegic migraine
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
3 signs of a hemiplegic migraine and what condition do they typically mimic?
- migraine symptoms
- sudden or gradual onset
- hemiplegia
- ataxia
- changes in consciousness
list the 5 stages of migraine
- premonitory or prodromal
- aura
- headache
- resolution stage (headache fades or relieved by vomiting or sleep_
- postdromal or recovery phase
4 acute management options for migraine
- paracetamol
- triptans (e.g sumitriptan)
- NSAIDs (e.g. ibruprofen or naproxen)
- anti-emetics
3 ways triptans work
- smooth muscle in arterties -> vasoconstriction
- peripheral pain receptors to inhibit activation of pain receptors
- reduce neuronal activity in CNS
3 medications used in migraine prophylaxis
- propranolol
- topiramate
- amitriptyline
define the sensation of a cluster headache
severe and unbearable unilateral headache, usually around the eye
define the typical patient presenting with cluster headache
30-50yr old male smoker, attacks triggered by alcohol/strong smells/exercise
4 symptoms of cluster headache
- red, swollen and watering eye
- pupil constriction (miosis)
- eyelid drooping (ptosis)
- nasal discharge
- facial sweating
what are the two acute managements for a cluster headache
- triptans (e.g. sumitriptan 6mg SC)
- 100% high flow o2 for 15-20 min (can be given at home)
3 prophylaxis options for a cluster headache
- verapamil
- lithium
- prednisolone (2-3wks to break the cycle during cluster)
what is temporal arteritis (GCA) strongly linked with?
polymyalgia rheumatica
pts at higher risk are white female >50
key complication of GCA
vision loss (irreversible) - high dose steroids given as soon as diagnosis is SUSPECTED
4 features of GCA
- severe unilateral headache around forehead/ temple
- scalp tenderness (think hair brushing)
- jaw claudication
- blurred or doublev vision
- irreversible painless complete sight loss can occur rapidly
a definitive diagnosis of GCA is made via that 3 investigations
- clinical presentation
- raised ESR
- temporal artery biopsy findings
what are found on the temporal artery biopsy in GCA
multinucleated giant cells
what anaemia may be seen with GCA and what may be seen on duplex ultrasound
FBC = normocytic anaemia
duplex uss = hypoechoic halo sign
aside from steroids what 2 other medications may be given in GCA
- aspirin
- ppi
list 2 late complications of GCA
- relapses
- steroid related SE/comps
- cerebrovascular accident (stroke)
- aortitis -> aortic anaeurysm and aortic dissection
what type of genetic condition is huntingtons chorea
autosomal dominant
what gene is mutated in huntingtons and on what chromosome
HTT gene on chromosome 4
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
what 4 movement disorders may be seen in huntingtons
- chorea (involuntary abnormal movement)
- eye movement disorders
- speech difficulty (dysarthia)
- swallow difficulty (dysphagia)
what is the medical treatment for huntingtons
- based on symptomatic relief, no treatment for stopping or slowing progression
3 medications which may be given in huntingtons to suppress the disordered movement
- antipsychotics (olanzapine)
- benzodiazepines (diazepam)
- dopamine-depleting agents (tetrabenazine)
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
where does charcot-marie-tooth disease cause dysfunction?
myelin or the axons
typical age pts present with charcot-marie-tooth disease symptoms
<10yrs, can be delayed to >40yrs
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
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.
the spinal nerves _______ come together to form the sciatic nerve
L4-S3
what does the sciatic nerve divide in to?
tibial nerve and the common peroneal nerve
what does the sciatic nerve supply for?
sensation to lateral lower leg and foot
motor function to posterior thigh, lower leg and foot
3 symptoms of sciatica
- unilateral pain from buttock down back of thigh -> below knee/feet
- paraesthesia
- numbness and motor weakness
- reflexes may be effected
3 main causes of sciatica are lumbosacral nerve root compression by? (3)
- herniated disc
- spondylolisthesis
- spinal stenosis
what type of sciatica is a red flag for cauda equina syndrome
bilateral sciatica
what 5 main cancers metastasise to the bone
PoRTaBLe
prostate
renal
thyroid
breast
lung
test to help diagnose sciatice?
sciatica stretch test
3 types of muscular dystrophy
- duchennes muscular dystrophy (worth knowing)
- beckers muscular dystrophy
- myotonic dystrophy
what sign is seen in children with proximal muscle weakness (may be seen in muscular dystrophy)
Gowers sign
x-linked recessive inheritance
what is the cause of duchennes muscular dystrophy
defective gene for dystrophin on the x-chromosome
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
what medication has been shown to slow progression of muscle weakness in DMD?
steroids
4 typical features of myotonic dystrophy
- progressive muscle weakness
- PROLONGED MUSCLE CONTRACTIONS
- cataracts
- 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.
what type of muscular dystrophy typically presents with childhood facial weakness -> shoulders and arms (e.g. sleep with eyes slightly open)
facioscapulohumeral muscular dystrophy
define how oculopharyngeal muscular dystrophy typically presents
weakness of the ocular muscles and pharynx
bilateral ptosis, restriced eye movement and swallowing problems
what age does limb-girdle muscular dystrophy typically present?
teenage years
how does emery-dreifuss muscular dystrophy typically present
childhood with contractures, commonly elbows and ankles
how does blood enter the brain?
internal carotid arteries and the vertebral arteries in the neck
4 causes of dementia
- increasing age
- alzheimers
- vascular dementia
- lewy body dementia
- frontotemporal dementia
common causes of dementia (hint: DEMENTIA)
Diabetes
Ethanol
Medication
Environmental (CO poisoning)
Nutritional
Trauma
Infection
Alzheimers
5 S/S of dementia
- memory loss, difficulty retaining new info
- language impairement
- executive dysfunction (handling complex tasks etc)
- visiospatial ability impairment
- behavioural disturbance
- personality change
what is seen on CT for vascular dementia
microinfarcts
diagnostic tests for dementia (3)
- mental state examination
- montreal cognitive assessment (MoCA)
- mini-mental state examination (MMSE)
why are acetlycholinesterase inhibitors used in alzheimers
increase acetylcholine (brains primary neurotransmitter) levels
what medication is given in advanced dementia
N-methyl-D-asperate (NMDA) receptor antagonist
most common form of dementia?
alzheimers
how does amyloid precursor protein -> alzheimers disease
- abnormal APP degredation via b-secretase
- APP cut into insoluble fragments
- -> beta amyloid plaque
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
how many years after symptom onset is life expectancy for alzheimers
5-10yrs
diagnostic imaging for alzheimers and results?
CT/MRI
- excludes other dementias
- brain scans show DIFFFUSE CORTICAL ATROPHY, GYRI NARROWING, SULCI WIDENING, VENTRICLE ENLARGEMENT
there is no cure for alzheimers, what medications may be given to pt? (3)
- acetylcholinesterase inhibitors
- vitamin E supplementation may provide benefit
- memantine (advanced)
cause of lewy body dementia
alpha-synuclein protein aggregation in the neurons (particularly cortex, substantia nigra) forming lewy bodies -> apoptosis
3 complications of lewy body dementia
- persistent psychotic symptoms (especially visual hallucinations)
- depression
- complete debilitation, dependence on others
- debilitation -> death, decreased life expectancy
- neuroleptic-agent sensitivity (adverse effects, parkinsonism)
what type of dementia motor symptoms mimic parkinsons disease
lewy-body dementia (resting tremor, stiffness, slow movement, reduced facial expressions)
3 medications used to alleviate symptoms of lewy-body dementia
- acetylcholinesterase inhibitors
- dopamine analogue
- atypical neuroleptic agents
diagnostic imaging for lewy body dementia
single-photon emission computerized tomography (SPECT) scanning
define frontotemporal dementia
heterogenous degenerative frontal/temporal lobe disease
what specific protein cellular inclusions are seen in frontotemporal dementia (2)
- TAU proteins (Pick disease)
- TAR DNA-binding protein 43 (TDP43)
diagnostic imaging for frontotemporal dementia?
MRI
SPECT/perfusion-MRI/PET
how do pick cells in frontotemporal dementia affect the neurons
swollen (ballooned) neurons
features of pick disease (hint:PICK)
Progressive degeneration of neurons
Intracytoplasmic degeneration of neurons
Cortical atrophy
Knife edge gyri
what is the second most common dementia in the elderly
vascular dementia
4 causes of vascular dementia
- cerebral artery atherosclerosis
- carotid artery/heart embolization
- chronic HTN
- vasculitis
3 RF for vascular dementia
- smoking
- HTN
- DM
- insulin resistance
- hyperlipidaemia
vaguely define the S/S of vascular dementia
progressive, stepwise cognitive function impairment
what is seen on MRI/CT in vascular dementia
multiple cortical, subcortical infarcts
what is the cause of shingles
varicella zoster virus
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
3 RF for shingles
- primary varicella infection history
- more common in adults >50
- immunocomprimised
- stress
3 complications of shingles
- ramsay hunt syndrome
- postherpetic neuralgia
- herpes zoster opthalmicus (sight-threatening)
appearance of shingles
erythematous, maculopapular lesions evolve into a painful vesicular rash
4 medication options for shingles
- oral/IV antiviral therapy
- analgesia (paracetamol/ibuprofen etc)
- calamine lotion
- varicella-zoster immune globulin
pathophysiology of normal pressure hydrocephalus
CSF accumulation -> progressive lateral ventricle enlargement
main RF for normal pressure hydrocephalus
prevelance largest among elderly
3 main s/s of normal pressure hydrocephalus
- unsteady gait (glue-footed)
- urinary incontinence
- cognitive impairment
what is seen on CT/MRI in normal pressure hydrocephalus (3)
- ventriculomegaly
- enlarged sylvian fissure
- enlarged sulci with no cortical atrophy
2 treatment options in normal pressure hydrocephalus
surgery in some situations
ventriculoperitoneal shunt (increase ICP relief)
cause of wenicke-kosakoff syndrome
vitamin B1 or thiamine deficiency
name the acute-reversible stage of wenicke-korsakoff syndrome?
wernickes encephalopathy -> korsakoff syndrome (chronic, irreversible)
where is thiamine stored and absorbed
stored in liver
absorbed in duodenum
major cause of thiamine deficiency
alcohol abuse
how does thiamine deficiency affect the cerebellum
movement and balance affected
2 later findings in thiamine deficiency
- haemorrhage
- necrosis of mamillary bodies -> affect memory/emotion/behaviour
define the triad of wernickes encephalopathy
- opthalmoplegia (weakness or paralysis of eye muscles)
- ataxia or unsteady gait
- changes in mental state (confusion, apathy, difficulty concentrating)
what is the main impairment caused by korsakoff syndrome
mainly targets limbic system = severe memory impairment (anterograde/retrograde amnesia)
confabulation
what is the most common cause of encephalitis
viral - HSV-1 (herpes simplex virus)
one bacterial cause of encephalitis
- listeria monocytogenes
- mycobacteria
- spirochetes (syphilis)
3 RF for encephalitis
- immunosuppression
- travel to low-income nations
- exposure to disease vectors in endemic areas
3 complications of encephalitis
- seizures
- SIADH
- increased ICP
- coma
how is meningism seen in encephalitis
nuchal rigidity (cant flex neck forward passively due to increased tone/stiffness)
what is seen in a brain MRI for viral (HSV) encephalitis
increased T2 signal intensity in fronto-temporal region
what is seen in the CSF chemistry in viral encephalitis
lymphocytosis (>5 WBC/ml) with normal glucose
how can a definitive diagnosis be made for viral encephalitis
brain biopsy
- cowdry type A inclusions
- haemorrhagic necrosis in temporal, orbitofrontal lobes (HSV)
what is seen in this CT scan
HSV encephalitis
what medication is given for HSV encephalitis
acylcovir
what medication is given for CMV encephalitis
ganciclovir/foscarnet
medication for bacterial encephalitis
targeted abx
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
triad of horners syndrome
ptosis, miosis and anhidrosis
2 diagnostic imagings used for horners syndrome investigation
x-ray - detect pancoast tumour/shoulder trauma
mri - detects aneurysm/dissection
define narcolepsy
recurrent sleep phenomena during wakefulness
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
cause of narcolepsy
damage to orexin-transporting neurons (by autoimmune process/injury)
2 RF for narcolepsy
- genetics
- low levels of histamine
- infections
- autoimmune diseases
3s/s of narcolepsy
- daytime sleepiness
- cataplexy
- hallucinations
- sleep paralysis
how to diagnose narcolepsy
recurrent feeling of sleepiness in daytime >3x week >3m
+ at least 1:
- cataplexy
- hypocretin deficiency
- short rapid eye movements (REM)
treatment for narcolepsy (2)
SSRI’s
stimulants (modafinil)
define cataplexy
muscles go weak or limp with no warning - typically experienced during a strong emotion or emotional sensation
what is cataplexy often associated with
narcolepsy
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
define NEAD
non-epileptic attack disorder
look like epileptic seizures but not caused by electrical activity in the brain
what is the current understanded cause of NEAD (2)
brains response to overwhelming stress
traumatic events
what cranial nerves are typically affected in bulbar palsy
nerves that arise from brainstem
9,10,11,12
name two affects of a damaged CN9
dysphagia (difficulty swallowing)
reduced gag reflex
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
how is pseudobulbar palsy characterised
atypical expression of emotion displayed by unusual outbursts of laughing/crying (emotional lability)
2 most common causes of bulbar palsy
brainstem strokes and tumours
briefly define radiculopathy
pain/numbness/tingling/weakness in arms or legs caused by compression of a nerve root in the spinal column
what is the most common type of lumbar radiculopathy
sciatica
where is cervical radiculopathy commonly seen
c5-c7
two forms of cervical radiculopathy
disc degeneration and spondylosis
define radiculopathy pain
sharp and spreads from specific locations to other parts of the body
typical treatment for radiculopathy (3)
- nsaids
- physical therapy
- surgical procedures to relieve nerve compression if necessary
define mononeuropathy
damage or dysfunction of a single peripheral nerve that connects the CNS to the body
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)
3 non-compression related causes of mononeuropathy
infection
radiation
cold
what is the main cause of a fixed mononeuropathy
nerve compression against a hard surface (i.e. tumour/cast/cramped posture for long time)
3 RF for entrapment of a nerve in a restricted anatomical structure
pregnancy
hypothyroidism
RA
define delerium
fast decline in attention/consciousness thinking
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)
3 S/S of delirium
- difficulties with attention span, concentration, remaining conscious
- disorganised and delayed thinking
- hyperactive symptoms
- hypoactive symptoms
treatment option for severe symptoms of delerium
haloperidol/second gen antipsychotics
what medication must be avoided in delirium
opiates (increased risk delirium)
list 3 medication types that can increase the risk of osteoporosis
- long term corticosteroids
- SSRI’s
- PPI
- anti-epileptics
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)
assessment tool for identify osteoporisis risk over 10yrs?
FRAX tool
investigation for bone mineral density
DEXA scan
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
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)
supplementation for patients at risk of fragility #
vitamin D and calcium
first line treatment for osteoporosis
bisphosponates
3 notible SE of osteoporosis
- reflux and oesophageal erosions
- atypical #
- necrosis of the jaw
- osteonecrosis of external auditory canal
3 examples of bisphonates
- alendronate
- risedronate
- zolendronic acid
what areas of the body are mainly affected by pressure ulcers
bony prominences
- sacrum/heels/hips/elbows
3 RF for pressure ulcers
- reduced mobility (e.g. parkinsons, hip #, stroke)
- reduced perfusion (atherosclerosis, smoking,)
- factors affecting skin structure (malnutrition, skin moisture)
what type of medication has an increase risk of mortality in dementia patients
anti-psychotics
What type of drug is memantine
NMDA agonist
