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Neurology > Neurology: Clinical - CNS infection, muscle/nerve diseases, spinal cord disease, CSF > Flashcards

Neurology: Clinical - CNS infection, muscle/nerve diseases, spinal cord disease, CSF Flashcards

1
Q

What is meningitis?

A

Inflammation/infection of the meninges

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2
Q

What is encephalitis?

A

Inflammation/infection of the brain substance

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3
Q

What is myelitis?

A

Inflammation/infection of the spinal cord

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4
Q

What is the classical triad of meningitis symptoms?

A

Fever
Neck stiffness
Altered mental status

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5
Q

What is meningism?

A

Neck stiffness, photophobia, nausea and vomiting

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6
Q

What are the clinical features of meningitis?

A

Classical triad - fever, neck stiffness, altered mental state
Progressive headache
Meningism
Cerebral dysfunction - confusion, delirium, declining conscious level (GCS <14)
Sometimes: cranial nerve palsy, seizures, focal neurological deficits
Petechial skin rash (Tumbler test)

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7
Q

What is the hallmark of meningococcal meningitis?

A

Petechial skin rash

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8
Q

What are some differential diagnoses for meningitis?

A

Infective - bacterial, fungal, viral
Inflammatory - sarcoidosis
Drug induced
Malignant - metastatic, haematological e.g. leukaemia, lymphoma

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9
Q

Which bacteria can cause meningitis?

A 
Neisseria meningitidis (meningococcus)
Streptococcus pneumonias (pneumococcus)
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10
Q

What is an example of a viral cause of meningitis?

A

Enteroviruses

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11
Q

Which has the slower onset: viral encephalitis or bacterial meningitis?

A

Viral encephalitis

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12
Q

For which is cerebral dysfunction a more prominent feature: viral encephalitis or bacterial meningitis?

A

Viral encephalitis

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13
Q

What are the clinical features of encephalitis?

A

Flu-like prodrome (4-10 days)
Progressive headache associated with fever
+/- meningism
Progression cerebral dysfunction: confusion, abnormal behaviour, memory disturbance, depressed conscious level
Seizures
Focal symptoms/signs

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14
Q

What are differential diagnoses of encephalitis?

A 
Infection: viral (HSV)
Inflammatory: limbic encephalitis
Metabolic: hepatic, uraemia, hyperglycaemic
Malignant: metastatic, paraneoplastic
Migraine
Post-ictal
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15
Q

What are the investigations for meningitis?

A 
Blood cultures
Lumbar puncture (CSF culture/microscopy)
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16
Q

What are the investigations encephalitis?

A

Blood cultures
Imaging: CT and MRI
Lumbar puncture
EEG

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17
Q

When would you do a CT scan before a LP?

A 
Focal neurological deficit
New-onset seizures
Papilloedema
Abnormal level of consciousness (GCS <10)
Severe immunocompromised state
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18
Q

What are the CSF findings in bacterial meningitis?

A

Opening pressure = increased
Cell count = high (mainly neutrophils)
Glucose = reduced
Protein = high

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19
Q

What are the CSF findings in viral meningitis or encephalitis?

A

Opening pressure = normal/increased
Cell count = high (mainly lymphocytes)
Glucose = normal (60% of blood glucose)
Protein = slightly increased

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20
Q

In what condition would the CSF cell count be high and mainly neutrophils?

A

Bacterial meningitis

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21
Q

In what condition would CSF cell count be high and mainly lymphocytes?

A

Viral meningitis (or encephalitis)

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22
Q

In what condition would CSF glucose be reduced?

A

Bacterial meningitis?

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23
Q

In what condition would CSF protein be elevated?

A

Both bacterial meningitis and viral meningitis

Bacterial meningitis higher

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24
Q

What is the commonest cause of encephalitis?

A

Herpes simplex (HSV) encephalitis

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25
Q

Which type of HSV is more likely to cause coldsores?

A

Type 1

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26
Q

Where does HSV remain latent after primary infection?

A

Trigeminal or sacral ganglion

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27
Q

How are enteroviruses spread?

A

Faecal-oral route

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28
Q

What do enteroviruses include?

A

Polioviruses, coxsackieviruses and echoviruses

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29
Q

What are examples of arbovirus encephalitis?

A

West Nile virus
Japanese B encephalitis
Tick Borne encephalitis

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30
Q

How are arboviruses spread?

A

Arthropod vectors

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31
Q

What is a brain abscess?

A

Localised area of pus in brain

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32
Q

What is a subdural empyema?

A

Thin layer of pus between dura and arachnoid membranes over surface of the brain

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33
Q

What are the clinical features of a brain abscess or subdural empyema?

A

Fever, headache, focal symptoms/signs (seizures, dysphagia, hemiparesis), signs of raised ICP (papilloedema, false localising signs, depressed conscious level), meningism may be present (empyema esp.), features of underlying source (e.g. dental, sinus, ear infection)

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34
Q

What are some causes of brain abscess or empyema?

A

Penetrating head injury
Spread from adjacent infection (dental, sinus, ear)
Blood borne infection (bacterial endocarditis)
Neurosurgical procedure

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35
Q

What are the investigations for brain abscess/empyema?

A 
CT
MRI
Investigate source
Blood cultures
Biopsy (drainage of pus)
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36
Q

What are the organisms usually causing brain abscess?

A

Streptococci - anginosus, intermedius, constellatus

Anaerobes

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37
Q

What is the management of brain abscesses?

A

Surgical drainage is possible
Penicillin or ceftriaxone to cover streps
Metronidazole for anaerobes
Culture and sensitivity tests on aspirate

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38
Q

What are HIV indicator illnesses of the brain?

A 
Cerebral toxoplasmosis
Aseptic meningitis/encephalitis
Primary cerebral lymphoma
Cerebral abscess
Cryptococcal meningitis
SOP of unknown cause
Dementia
Leucoencephalopathy
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39
Q

What are likely brain infections in HIV patients with low CD4 counts?

A

HIV-encephalopathy (HIV-associated dementia)
Cryptococcus neoformans
Toxoplasma gondii
Progressive multifocal leukoencephalopathy (PML)
Cytomegalovirus (CMV)

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40
Q

What is the main likely brain infection in HIV patients with low CD4 counts?

A

HIV-encephalopathy

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41
Q

What species causes cryptococcal meningitis?

A

Cryptococcal neoformans and cryptococcal gatti

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42
Q

Who is at an increased risk of getting a cryptococcal infection?

A

Immunocompromised e.g. AIDS

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43
Q

How does exposure and infection of cryptococcal infection occur?

A

Inhalation of airborne organisms into the lungs

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44
Q

How do most clinical cases of cryptococcal infection present?

A

Meningoencephalitis

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45
Q

What are examples of diseases of spirochetes in the CNS?

A 
Lyme disease (Borrelia burgoferi)
Syphilis (Trepomena pallidum)
Leptospirosis (Leptospira interrogens)
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46
Q

What is the organism causing Lyme disease?

A

Borrelia (burgoferi)

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47
Q

What is the organism causing syphilis?

A

Trepomena pallidum

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48
Q

What is the organism causing leptospirosis?

A

Leptospira

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49
Q

How many stages of Lyme disease are there?

A

3

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50
Q

What happens during the stage 1 of Lyme disease?

A

Early localised infection (1-30d)
Characteristic expanding rash at site of tick bite = erythema migrans
50% flu-like symptoms e.g. fatigue, myalgia, arthralgia, headache, fever, chills, neck stiffness

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51
Q

What happens during the stage 2 of Lyme disease?

A

Early disseminated infection (wks-mnths)
1+ organ systems involved (haematology/lymphatic spread)
Musculoskeletal and neurological most common
PNS>CNS e.g. mononeuropathy, mononeuritis multiplex, painful radiculoneuropathy, cranial neuropathy, myelitis, meningo-encephalitis

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52
Q

What happens during the stage 3 of Lyme disease?

A

Chronic infection (mnths-yrs)
Musculoskeletal and neurological involvement most common
As stage 2 but subacute encephalopathy, encephalomyelitis

53
Q

What are the investigations for Lyme disease?

A 
Serological tests
CSF lymphocytosis
PCR of CSF
MRI brain/spine
Nerve conduction studies/EMG
54
Q

What is the treatment for Lyme disease?

A

Prolonged antibiotic treatment:
IV ceftriaxone
Oral doxycycline

55
Q

What is poliomyelitis caused by?

A

Poliovirus types 1, 2 or 3 (enteroviruses)

56
Q

What are the symptoms of most polio infections?

A

Asymptomatic

57
Q

What are the features of polio if there are symptoms?

A

Muscle weakness, flaccid paralysis

58
Q

What is rabies?

A

Acute infectious disease of the CNS

59
Q

How is rabies transmitted?

A

Bite or salivary contamination of open lesion

60
Q

What is the causative agent of tetanus?

A

Claustridium tetani

61
Q

What is claustridium tetani?

A

Anaerobic gram positive bacillus

62
Q

What is botulism caused by?

A

Clostridium botulinum

63
Q

What is clostridium botulinum?

A

Anaerobic gram positive bacillus

64
Q

What are the three modes of infection of botulism?

A

Infantile - intestinal colonization
Food-borne - outbreaks
Wound - almost exclusively injecting

65
Q

What is an example of a post infective inflammatory syndrome of the CNS?

A

Acute disseminated encephalomyelitis (ADEM)

66
Q

What is an example of post infective inflammatory syndrome of the PNS?

A

Guillain Barre Syndrome (GBS)

67
Q

What are general symptoms of muscle disease?

A 
Weakness of skeletal muscles
Short of breath (respiratory muscles)
Poor swallow (aspiration)
Cardiomyopathy
Cramp, pain, stiffness, myoglobinuria
68
Q

What are the general signs of muscle disease?

A

Wasting/hypertrophy
Normal or reduced tone and reflexes
Motor weakness (NOT SENSORY)

69
Q

What investigations would you do for muscle disease?

A 
History and examination
Creatine kinase (CK)
EMG
Muscle biopsy
Genetic testing
70
Q

What are the different classifications of muscle disease?

A

Congenital/genetic: structural, contractile, coupling, energy
Acquired: metabolic, endocrine, inflammatory muscle disease, iatrogenic

71
Q

What are the symptoms of myasthenia gravis?

A

Fatiguable weakness in: limbs, eyelids (ptosis), muscles of mastication (chewing/swallowing), talking, SOB, diplopia

72
Q

What are the investigations for myasthenia gravis?

A

Serology:
AChR antibodies
Anti-MuSK antibodies
Neurophysiology: repetitive stimulation, jitter
CT chest (to check for widening of mediastinum due to tumour = thymoma, found in many MG patients)

73
Q

What are the treatment options for myasthenia gravis?

A

Symptomatic:
Acetylcholinesterase inhibitor (pyridostigmine)
Immunosuppresion: prednisolone, steroid saving agent (azathioprine)
Immunoglobulin/plasma exchange
Thymectomy

74
Q

What would a disorder of the spinal cord be called?

A

Myelopathy

75
Q

What would a disorder of the spinal root be called?

A

Radiculopathy

76
Q

What would be the expected signs if there was a cord pathology?

A 
UMN motor signs:
No wasting
Increased tone
Increased reflexes, extensor plantar
Pyramidal pattern of weakness
77
Q

What is Brown-Sequard syndrome?

A

Damage to one half of the spinal cord resulting in weakness, decreased vibration sense and decreased joint position sense on the ipsilateral side and decreased pain and temperature sense on the contralateral side

78
Q

What is syringomyelia?

A

Cyst or cavity develops in spinal cord and destroys spinal cord

79
Q

What would be the signs of a C5 cord lesion?

A

Wasting of C5 innervated muscles
Increased tone in legs > arms
Increased all lower reflexes
Power decreased in C5 innervated muscles, pyramidal pattern below

80
Q

What can cause ischaemic myelopathy?

A

Spinal stroke/infarction

81
Q

What are some causes of spinal cord ischaemia?

A

Atheromatous disease (aortic aneurysm)
Thromboembolic disease (endocarditis, AF)
Arterial dissection
Systemic hypotension

82
Q

What is the clinical presentation of a spinal cord stroke?

A

Onset may be sudden or over several hours
Pain: back pain/radicular, visceral referred pain
Weakness: usually paraparesis
Numbness and paraethesia
Urinary symptoms: retention and then incontinence

83
Q

Where is spinal cord stroke usually located?

A

Anterior spinal artery (mid-thoracic)

84
Q

What is the treatment for a spinal cord stroke?

A

Reduce risk of reoccurrence - BP, reverse hypovolaemia/arrhythmia, anti platelet therapy
OT and physio
Manage vascular risk factors

85
Q

What is autoimmune condition which prevents B12 absorption?

A

Pernicious anaemia

86
Q

How is B12 absorption prevented in pernicious anaemia?

A

Antibodies to intrinsic factor prevent B12 absorption

87
Q

How would B12 deficient myelopathy present?

A 
Paraesthesia hands and feet, areflexia
First UMN sign extensor plantars
Paraplegia
Secondary ataxia
Painless retention of urine
88
Q

What is the treatment for B12 deficient myelopathy?

A

IM B12

89
Q

What is hydrocephalus?

A

Excess CSF within intracranial space and intraventricular spaces within the brain

90
Q

What does hydrocephalus do to the ventricles?

A

Causes dilation of the ventricles

91
Q

Where is CSF produced?

A

Choroid plexus

92
Q

Where is choroid plexus mainly located?

A

In the lateral ventricles, posterior 3rd ventricle roof, caudal 4th ventricle roof

93
Q

How much CSF is there at any given moment in the average adult?

A

150cc’s

94
Q

How much CSF does the average adult brain produce per day?

A

450-600cc’s

95
Q

What is the route of CSF?

A

From lateral ventricle -> Foramen of Munro -> 3rd ventricle -> cerebral aqueduct -> 4th ventricle -> Formaina of Luschka/Foramen of Magendie -> through subarachnoid space to surround the brain and spine -> arachnoid granulations along dural venous sinuses and into venous system

96
Q

What are the two types of hydrocephalus?

A 
Communicating hydrocephalus (CoH) (non-obstructive)
Non-communicating hydrocephalus (NCH) (obstructive)
97
Q

Which type of hydrocephalus is it if CSF can flow freely from choroid plexus to arachnoid granulations?

A

Communicating hydrocephalus

98
Q

Which type of hydrocephalus is it if CSF can’t travel freely from start to finish?

A

Non-communicating hydrocephalus

99
Q

What is usually the cause of communicating hydrocephalus?

A

CSF production > resorption

100
Q

What happens when CSF production > resorption?

A

Ventricular system dilates uniformly and ICP rises

101
Q

What are the signs/symptoms of communicating hydrocephalus?

A

If cranial sutures not fused, can see disproportional increase in head circumference, ‘sunset’ eyes
If cranial sutures fused, symptoms of increased ICP = headaches, nausea/vomiting, papilloedema, gait disturbance, CNVI palsy, upgaze difficulty

102
Q

Why is there CNVI palsy in someone with communicating hydrocephalus?

A

Abducens nerve has longest course through brain, can get damaged

103
Q

What are some of the causes of communicating hydrocephalus?

A

Infection
SAH
Post-operative
Head trauma

104
Q

How can SAH cause communicating hydrocephalus?

A

Blood and blood breakdown products cause scarring of arachnoid granulations

105
Q

When does non-communicating hydrocephalus occur?

A

When there is ANY physical obstruction to normal flow of CSF before it leaves the ventricles

106
Q

What are some causes of non-communicating hydrocephalus?

A 
Aqueductal stenosis
Tumours/cancers/masses
Cysts
Infection
Haemorrhage/hematoma
Congenital malformations/conditions
107
Q

What is the earliest radiographic finding indicative of development of hydrocephalus?

A

Dilation of the temporal horns of the lateral ventricles

108
Q

What are findings on imaging of hydrocephalus?

A

3rd ventricle becomes ballooned
Lateral ventricle size increase
Peripheral sulk effaced
Look at Evans ratio

109
Q

What does the Evans ratio have to be for a diagnosis of hydrocephalus?

A

An Evans ratio of at least 0.3 may be consistent with a diagnosis of hydrocephalus

110
Q

What is the treatment for communicating hydrocephalus?

A

External ventricular drain (EVD)

Permanent shunt

111
Q

What are the treatment options for non-communicating hydrocephalus?

A

Removal of obstructing lesion
Shunt placement
EVD
Third ventriculostomy

112
Q

What is third ventriculostomy?

A

Hole surgically opened in floor of 3rd ventricle so CSF flows out into the interpeduncular cistern and pre-ponitine space (bypasses cerebral aqueduct)

113
Q

What is normal pressure hydrocephalus often misdiagnosed as?

A

Dementia

114
Q

What is the classic triad of normal pressure hydrocephalus?

A

Wet, wobbly and wacky

115
Q

What is a contraindication for LP?

A

Unstable patient with cardiovascular or respiratory instability
Localised skin/soft tissue infection over puncture site
Evidence of unstable bleeding disorder
Increased ICP (focal neurological findings)
Chiari malformations

116
Q

What is the spinal needle gauge used for LP usually?

A

22 gauge

117
Q

What is the position called for LP?

A

Lateral decubitus position

118
Q

Where are the sites for LP?

A

L3-4 or L4-5

119
Q

What records opening pressure of CSF during an LP?

A

Manometer

120
Q

What 3 lab tests does the CSF go to?

A

Culture and gram stain
Glucose, protein
Cell count and differential

121
Q

When do you use the paramedic (lateral) approach for LPs?

A

In patients who have calcifications from repeated LPs or anatomic abnormalities

122
Q

What are some of the complications of LP?

A 
Headache
Apnea
Back pain
Bleeding or fluid leak around spinal cord
Infection, pain, hematoma
Subarachnoid epidermal cyst
Ocular muscle palsy
Nerve trauma
Brainstem herniation
123
Q

What is the most common complication of LP?

A

Spinal headache

124
Q

What are the risk factors for a spinal headache post-LP?

A

Female, age 18-30, low BMI, Hx of headache, prior spinal HA

125
Q

What are the treatments for a spinal headache post-LP?

A

Hydration, caffeine either PO or IV, epidural blood patch

126
Q

How does herniation post-LP present?

A

Altered mental status, cranial nerve abnormalities, Cushing triad

127
Q

What treatment would you use for brain herniation?

A

Mannitol

128
Q

What would you do if LP fails?

A

Someone else: anesthesia/neurology
Bedside ultrasound for difficult LPs
Radiographic guided procedure
Cisterna magna tap

129
Q

What are the normal CSF ranges?

A 
Appears clear and colourless
Opening pressure 6-16mm/H20
Protein level - 35mg%
Glucose level - 60mg%
(60% of serum glucose)
WCC <5 (Ratio WCC:RCC = 1/750)

Neurology (9 decks)

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