Neurology and Neurosurgery Flashcards
1
Q
What would you be worried about in a patient with breathing difficulties following head trauma?
A
Patients with raised ICP may exhibit Cushing’s triad:
- widening pulse pressure (hypertension)
- bradycardia
- irregular breathing (Cheyne–Stokes respirations)
2
Q
What dementia is associated with MND?
A
Frontotemporal dementia is associated with motor neurone disease
3
Q
LEMS - features
A
Lambert Eaton syndrome (LES) is a rare autoimmune disorder in which antibodies are formed against pre-synaptic voltage-gated calcium channels in the neuromuscular junction. A significant proportion of those affected have an underlying malignancy, most commonly small cell lung cancer. It is therefore regarded as a paraneoplastic syndrome.
The weakness from LES typically involves the muscles of the proximal arms and legs. In contrast to myasthenia gravis, the weakness affects the legs more than the arms. This leads to difficulties climbing stairs and rising from a sitting position. Weakness is often relieved temporarily after exertion or physical exercise, in contrast to myasthenia gravis.
4
Q
Diagnosis of Guillain Barre
A
Nerve conduction studies
5
Q
Features of Syringomyelia
A
The classical presentation of a syrinx is a patient who has a ‘cape-like’ (neck and arms) loss of sensation to temperature but preservation of light touch, proprioception and vibration.
Syringomyelia - spinothalamic sensory loss (pain and temperature)
6
Q
Triad of symptoms in LB dementia
A
resting tremor, visual hallucinations and cognitive decline
7
Q
Lateral Medullary Syndrome
A
A combination of ipsilateral ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy with contralateral hemisensory loss indicates this diagnosis.
8
Q
Normal CSF pressure
A
12-20mmHg
9
Q
Describe the headache that occurs with increased ICP
A
Morning headache - wakes them up
Worse on valsalva
Associated with N+V
10
Q
Which genetic syndrome is acoustic neuromas associated with?
A
NF2 - Neurofibromatosis
11
Q
Symptoms of acoustic neuroma
A
hearing loss
tinitus
dysequilibrium
12
Q
Management of acoustic neuroma
A
If hearing is affected then either surgery or conservative management with hearing aids
If hearing preserved then try and avoid surgery
Stereotactic Radiosurgery is tumour is less than 3 cm
Main aim of surgery is to preserve hearing
13
Q
Which tests are offered to children with midline brain tumours?
A
AFP
BHCG
LDH
14
Q
Surgical management of childhood hydrocephalus?
A
VP shunt - 50% require 10 yr revision
Endoscopic Third Ventriculostomy - permanent solution
15
Q
Medical management of PRLoma
A
Cabergoline first- line followed by surgery
16
Q
Why does GHoma require excision?
A
Risk of HOCM
17
Q
What is the most common metastatic brain tumour?
A
Lung
18
Q
Most common primary brain tumour
A
Glioblastoma multiforme
19
Q
Brain tumour. solid tumours with central necrosis and a rim that enhances with contrast
A
Glioblastoma multiforme
20
Q
Brain Histology: Pleomorphic tumour cells border necrotic areas
A
Glioblastoma multiforme
21
Q
Second most common primary brain tumour
A
Meningioma
22
Q
Where are meningiomas typically located?
A
They typically are located at the falx cerebri, superior sagittal sinus, convexity or skull base.
23
Q
Brain Histology: Spindle cells in concentric whirls and calcified psammoma bodies
A
Meningioma
24
Q
Where do vestibular schwannomas typically occur?
A
Cerebellopontine angle
25
Bilateral vestibular schwannomas
NF2
26
Brain Histology: Rosenthal fibres (corkscrew eosinophilic bundle)
Pilocystic astrocytoma
27
Most common brain tumour in children
Pilocystic astrocytoma
28
Brain Histology: Small, blue cells. Rosette pattern of cells with many mitotic figures
Medulloblastoma
29
Brain Histology: perivascular pseudorosettes
Ependymoma
30
Brain Histology: Calcifications with 'fried-egg' appearance
Oligodendroma
31
Brain Histology: foam cells and high vascularity
Haemangioblastoma
32
Brain Histology: Derived from remnants of Rathke pouch
Craniopharyngioma
33
Most common supratentorial brain tumour in children
Craniopharyngioma
34
Brain tumour with dural tail seen on CT
Meningioma
35
Percentage of self-limiting vertebral disc prolapses
80% - only refer for MRI after 6 weeks of physiotherapy
unless foot drop - refer in 2 weeks as you risk permanent change
36
Sciatica. Nerve root. radiates to bottom of the foot and the little toe
S1
37
Which action tests L5 spinal nerve alone?
extensor hallicus longus
38
Spinal nerve. dorsiflex ankle
L4 (a little L5)
39
Spinal nerve. hip flexion
L1/2
40
Spinal nerve. knee extension
L3/4
41
Spinal nerve. ankle plantarflexion
S1 (a little L5)
42
Features of cauda equina
saddle anaethesia
bladder incontinence
bilateral sciatica
impotence
refer for urgent MRI and neurosurgery within 48 hours
43
Night sweats and back pain
Vertebral TB
44
Features of lumbar claudication
bilateral tingling
decreased walking distance
relieved when leaning over (shopping troller +ve)
not worse walking uphill
45
What causes lumbar claudication?
Ligamentum flavum thickening and buckling forwards to compress spinal cord (whereas disc prolapse slips posteriorly to compress nerve root)
46
Management of lumbar claudication
surgical removal of ligamentum flavum
47
Features of cervical myelopathy
banana fingers
legs jump at night (hyperreflexia)
poor balance when closing eyes (e.g. when shampooing hair)
48
Cerebellar symptoms
```
Dysdiadokinesia
Ataxia
Nystagmus
Intention tremor
Slurred speech
Hypotonia
```
49
Spastic gait
scissoring foot movements e.g. in cerebral palsy
50
High stepping gait
foot drop due to L3/4 disc prolapse or common peroneal nerve injury
51
Broad based gait
cerebellar
52
Hemiplegic gait
circumducting foot movement as lower limb extensors are stronger (UL flexors are stronger) e.g. due to stroke
53
Festinant gait
looks like centre of gravity is in front of them e.g. Parkinsonism
54
Shuffling gait
Normal Pressure Hydrocephalus
55
Trendelenburg gait
weak hip abductors e.g. OA
56
Myotome. deltoid
C4/5
57
Myotome. biceps
C5/6 (mostly 6)
58
Myotome. wrist flexion
C7
59
Myotome. finger flextion
C8
60
Myotome. interossei (finger abduction)
T1
61
Management of trigeminal neuralgia
1 - Carbamazepine
2 - Gabapentin or Pregablin
3 - Topiramate or Phenytoin
4 - Surgery
62
Signs of a base of skull fracture
Periorbital bruising (Racoon eyes)
Bruising over mastoid process (Battlesign)
Blood or CSF leak from eyes or nose
Head bump
Note: Nasopharyngeal airway is contraindicated
63
GCS: eyes
4 - opens spontaneously
3 - opens to verbal command
2 - opens to pain
1 - none
64
GCS: verbal
```
5 - orientated
4 - confused
3 - inappropriate words
2 - groans (incomprehensible sounds)
1 - none
```
65
GCS: motor
```
6 - obeys commands
5 - localises to pain (flexes towards the pain)
4 - withdraws from pain
3 - abnormal flexion
2 - extension
1 - none
```
66
GCS: coma
≤8
67
Head CT following trauma. Crescent shaped hyper dense accumulation that crosses suture lines
Acute subdural
68
Head CT following trauma. Convex shaped hyper dense accumulation occurring after pteriod trauma
MMA damage causing extradural haematoma
69
Calculate cerebral perfusion pressure
CPP = Mean arterial pressure - ICP
Normal CPP is 70-100
Cerebral ischaemia if <50
70
Auto-immune Disorder. Anti-MOG and Anti-Aquaporin-4
Neuromyelitis Optica Spectrum (N.O.S) Disorder
71
Neuromyelitis Optica Spectrum Disorder features.
Sub acute visual loss in 1 eye with painful movement and a poor prognosis for visual recovery
72
Visual loss associated with B12/Folate deficiency
bilateral and painless
73
Features of demyelinating optic neuropathy
Unilateral painful loss of vision over 2-3 days occurring in individuals aged 20-50
Blurring of vision lasts about 2 weeks and 80% improves
74
Difference between binocular and monocular diplopia
Binocular - diplopia always there
| Monocular - diplopia goes if an eye is covered
75
Diplopia going down stairs
CNIV palsy
76
Inability to look up
Hydrocephalus -> pressure on tectal plate
77
Diplopia. How to tell which eye is pathological?
The eye which when covered causes the outer image to disappear
78
Hepatic enzyme inducers
Carbamazepine
Topiramate
Phenytoin
Rifampicin
reduces COCP and morning after pill efficacy, so increase dose
79
Use of EEG in epilepsy
To classify epilepsy
Confirm non-epileptic attacks
To evaluate surgical options
80
Treatment of focal seizures
1 - Carbmazepine
| 2 - Lamotrigine (safe in pregnancy)
81
Treatment of generalised seizures
1 - Sodium Valproate
| 2 - Lamotrigine
82
Treatment of absence seizures
Ethosuximide
83
In which type of seizure is carbmazepine contraindicated
Myoclonic and absence
84
Side effects. Sodium Valproate
Weight gain, teratogenic, hair loss, fatigue
85
Side effects. Topiramate
Sedation, dysphasia, weight loss
86
What is epilepsia partialis continua?
Continuous focal seizure - consciousness is preserved
87
What is status epilepticus?
a single seizure lasting >5 minutes, or
| >= 2 seizures within a 5-minute period without the person returning to normal between them
88
Management of prolonged seizure (more than 5-10 mins)
Community: Rectal diazepam (10-20mg) and buccal midazolam (10-20mg)
Hospital: IV Lorazepam (4mg) if venous access; otherwise Rectal diazepam (10-20mg) and IM Midazolam (5-10mg)
89
Seizures and Driving
generally patients cannot drive for 6 months following a seizure
for patients with established epilepsy they must be fit free for 12 months before being able to drive
withdrawal of epilepsy medication: should not drive whilst anti-epilepsy medication is being withdrawn and for 6 months after the last dose
90
Adverse effect of Lamotigine
SJ syndrome
91
Difference in the CSF of viral and bacterial meningitis
Bacteria - elevated opening pressure, cloudy, neutrophilia, high protein, low glucose
Virus - normal opening pressure, clear, lymphocytosis, high protein and normal glucose
92
CSF with oligoclonal bands
MS
93
CSF with high phosphorylated TAU-protein and low B-amyloid
Alzheimer's
94
CSF with high I 4-3-3 protein
Creutzdeldt-Jakob disease
95
CSF with low orexin/hypocretin
Narcolepsy
96
CSF with elevated opening pressure, fibrin webs, lymphocytes, high protein, low glucose
TB meningitis
97
Most common cause of encephalitis
HSV
98
Management of community acquired meningitis
If in GP then give IM benzylpenicillin whilst waiting for transer
Hospital: IV Ceftriaxone and Dexamethasone
99
Management. Meningitis in <3 months
Intravenous cefotaxime + amoxicillin (or ampicillin)
100
Meningitis management. Initial empirical therapy aged 3 months - 50 years
Intravenous cefotaxime (or ceftriaxone)
101
Management of Meningitis caused by Listeria
Intravenous amoxicillin (or ampicillin) + gentamicin
102
Meningitis prophylaxis if in contact with someone in previous 7 days
oral ciprofloxacin or rifampicin
103
Management of idiopathic intracranial hypertension
Weight loss
Acetazolamide
LP shunt
104
MRI brain. Slit like ventricles
Increased ICP
105
Features of SUNCT headaches
```
Short-lived (15-120s)
Unilateral
Neuralgiaform headache (stabbing)
Conjunctival injections
Tearing
```
106
Management of CUNCT headaches
Lamotrigine or Gabapentin
107
Management of Paroxysmal Hemicrania
Absolute response to indomethacin
108
Features of paroxysmal hemicrania
Only last 10-30 mins (rather that a couple hours like cluster headaches), and occur much more frequently upto 40x per day
109
Management of cluster headaches
Acute: O2 and SC sumitriptan
Prophylaxis: Verapamil
110
Features of Cluster headaches
Unilateral, ipsilateral autonomic features, usually occurs at night, lasts 10 mins- 3 hours, occurs 1-8 times daily
111
Management of Migraine
Acute - PO Sumatriptan, NSAID and Antiemetic
| Prophylaxis - Propanolol, Topiramate
112
First line in primary progressive MS
Ocrelizumab
113
First line in relapsing remitting MS
Tecfedira
114
Management of MS acutely
Oral Prednisolone if moderate
| IV methylprednisolone if severe
115
Sign caused by demyelination of medial longitudinal fasciculus
INO - right sided -> cannot adduct right eye
| + Left eye nystagmus
116
Which condition is both Lhermitte's sign and Uhthoff's phenomenon associated with? What are they?
MS
Lhermitte's sign - electric shock pain on neck flexion
Uhthoff's phenomenon - exacerbation of current symptoms in hot environments (hot bath)
117
Two variants of FT dementia
- Behavioural (most common)
- Primary progressive aphasia
> Sematic dementia (impaired object naming and loss of recognition of faces or objects)
> Progressive non-fluent aphasia (word-finding deficits with slow and hesitant speech)
118
Management of alzheimers
mild/mod -> ACHE - donepezil, galantamine, rivastigmine
| severe -> Memantine (NMDA receptor antagonist)
119
Most common cause of Guillain Barre
Campylobacter
120
Is Myasthenia Gravis pre or post -synaptic ?
Post
121
Features of Myasthenia Gravis
Myalgia - worse at the end of the day or on exercise
Ocular features - diplopia and ptosis
Proximal > Distal Myalgia
Associated with Thymoma
122
Which conditions are associated with Myasthenia Gravis?
Thymoma, hyperthyroidism, SLE
123
Auto-antibodies. Myasthenia Gravis
Anti-AChR
| Anti-MUSK
124
Management of Myasthenia Gravis
Pyridostigmine
125
Is LEMS pre or post -synaptic ?
Pre
126
Features of LEMS
```
Anti-VGCC
Associated with SCLC
Distal myalgia - better on movement
Waddling gait
Autonomic features - constipation, postural hypotension, impotence
Diminished tendon reflexes
```
127
Auto-antibodies. LEMS
Anti-VGCC
128
Which condition is associated with LEMS?
SCLC
129
Management. LEMS
3,4-Diaminopyridine
130
Features of myotonic dystrophy
```
Autosomal Dominant
Foot drop
Grip myotonia
Facial weakness ("haggard" appearance)
Ptosis, ophthalmoplegia and bilateral "christmas tree" cataracts
Wasting of the temporalis muscle
Frontal balding
```
131
Which antiemetic is used in Parkinson's?
Domperidome
132
Meningitis. CSF LP reveals yeast and a capsule in the CSF stained with India ink
Cryptococcal Meningitis - common in immunodeficient patients e.g. HIV
133
Features of Lateral Medullary Syndrome (posterior inferior cerebellar artery stroke) AKA Wallenberg's syndrome
Remember Dysphagia-Ataxia-Nystagmus-Vertigo-Anaesthetic-Horner's
Ipsilateral - ataxia, nystagmus, hoarseness, dysphagia, facial numbness, CN palsy (E.g, Horner's)
Contralateral - limb sensory loss and loss of pain and temperature
Depressed Consciousness
134
Features of Weber's Syndrome
Ipsilateral CN3 palsy
| Contralateral weakness
135
Most common brainstem stroke
Wallenberg's syndrome (Lateral Medullary Syndrome)
136
Describe a diet that may be beneficial in childhood seizure syndromes
Ketogenic
- High fat
- Low Carbs
- Controlled protein
137
Prophylaxis of meningococcal meningitis for close contacts
Oral Ciprofloxacin or Rifampicin - 1 dose
138
Acute management of suspected meningitis in community setting
IM Benzylpenicillin
139
Meningitis Management. Initial empirical therapy aged < 3 months
Intravenous cefotaxime + amoxicillin (or ampicillin)
140
Meningitis Management. Initial empirical therapy aged 3 months - 50 years
Intravenous cefotaxime (or ceftriaxone)
141
Meningitis Management. Initial empirical therapy aged > 50 years
Intravenous cefotaxime (or ceftriaxone) + amoxicillin (or ampicillin)
142
Management of meningococcal meningitis
Intravenous benzylpenicillin or cefotaxime (or ceftriaxone)
143
Management of pneumococcal meningitis
Intravenous cefotaxime (or ceftriaxone)
144
When is meningitis prophylaxis justified?
people who have been exposed to a patient with confirmed bacterial meningitis should be given prophylactic antibiotics if they have close contact within the 7 days before onset
145
Diagnosing TB Meningitis from CSF
Ziehl-Neelsen stain is only 20% sensitive in the detection of tuberculous meningitis and therefore PCR is sometimes used (sensitivity = 75%)
146
Most common complication following meningitis
SN hearing loss
147
Contraindications to Lumbar Puncture
Signs of increased ICP e.g.
```
focal neurological signs
papilloedema
significant bulging of the fontanelle
disseminated intravascular coagulation
signs of cerebral herniation
```
148
What is contraindicated in patients with meningococcal septicaemia?
Lumbar Puncture
149
What should be done for patients with meningococcal septicaemia?
Lumbar Puncture is Contraindicated
blood cultures and PCR for meningococcus should be obtained
150
What other than antibiotics should be given in meningitis management?
Dexamethasone - except in <3months
151
Management of Viral Meningitis
Self-limiting 7-14 days
| If suspicion of bacterial cause or encephalitis then commence on ceftriaxone and aciclovir intravenously
152
Precipitating factors of Migraine
CHOCOLATE
```
Chocolate
Hangovers
Orgasms
Cheese, Caffeine
Oral contraceptive pill
Lie-ins
Alcohol
Travel
Exercise
```
153
Features of Bell's Palsy + Management
lower motor neuron facial nerve palsy - forehead affected*
patients may also notice post-auricular pain (may precede paralysis), altered taste, dry eyes, hyperacusis
All patients should receive oral prednisolone within 72 hours of onset + Antivirals if severe
