Neurology Lectures Flashcards
What artery is the most common site of a stroke?
Middle cerebral artery.
Define a lacunar stroke.
Stroke of deep branches of the middle cerebral artery that supply the basal ganglia.
Define watershed infarct.
Ischaemic stroke due to hypoperfusion, sudden BP drop >40mmHg.
Define ischaemic core.
Tissue likely to die due to ischaemia.
Define ischaemic penumbra.
Tissue preserved for a short period of time due to collateral circulation, potentially able to survive.
What symptom is found in a stroke of Broca’s area?
Expressive aphasia —> inability to produce written and spoken language, although comprehension remains intact.
What symptom is found in a stroke of Wernicke’s area.
Reactive aphasia —> inability to comprehend written and spoken language, although language production remains intact.
Define dysphasia.
Difficulty to comprehend or produce speech.
List 3 general causes/types of stroke.
1) ischaemic (80%)
2) haemorrhagic (17%)
3) other (3%)
What percentage of strokes occur secondary to a subarachnoid haemorrhage?
5%.
List the 5 possible syndromes in a lacunar stroke.
1) pure motor syndrome
2) pure sensory syndrome
3) sensorimotor syndrome
4) ataxic hemiparesis
5) dysarthria/clumsy hand
Define hemiplegia.
Paralysis of one side of the body.
Define quadriplegia.
Paralysis of all four limbs.
Define locked in syndrome.
Inability to respond despite understanding.
List 3 features that point to a haemorrhagic stroke.
1) meningism (neck stiffness, photophobia, headache)
2) severe headache
3) coma
List 4 features that point to an ischaemic stroke.
1) carotid bruit
2) past TIA
3) AF
4) IHD
When should hypertension be treated in a stroke?
Only in a hypertensive emergency (e..g encelopathy or aortic dissection).
When should thrombolysis be carried out for the best result?
Within 90 minutes.
What test should be carried out post thrombolysis of an ischaemic stroke?
Head CT 24 hours post thrombolysis.
What percentage of deaths does stroke account for in the UK?
11%.
What is the leading cause of adult disability in the world?
Strokes.
How does a large artery stenosis lead to an ischaemic stroke?
Embolism not occlusion.
What should stroke patients with oral anticoagulants always be assumed to have until proven otherwise?
Haemorrhagic stroke.
What should always be excluded when diagnosing stroke?
Hypoglycaemia.
What should be ruled out before starting thrombolysis for strokes?
Haemorrhagic stroke.
List 8 contraindications of thrombolysis.
1) recent surgery - last 3 months
2) recent arterial puncture
3) history of active malignancy
4) evidence brain aneurysm
5) anticoagulant
6) severe liver disease
7) acute pancreatitis
8) clotting disorder
List 6 anterior cerebral artery territory ischaemia/infarct symptoms.
1) contralateral numbness (esp. leg)
2) contralateral weakness (esp. leg)
3) truncal ataxia
4) gait ataxia
5) incontinence
6) drowsiness
List 4 middle cerebral artery territory ischaemia/infarct symptoms.
1) contralateral numbness (arms + legs)
2) contralateral weakness (arms + legs)
3) dysphasia —> aphasia
4) visuo-spatial disturbances
List 5 posterior cerebral artery territory ischaemia/infarct symptoms.
1) contralateral homonymous hemianopia
2) cortical blindness
3) visual agnosia
4) prosopagnosia
5) unilateral headache (esp. haemorrhagic)
List 5 vertebrobasilar artery territory ischaemia/infarct symptoms.
1) quadriplegia
2) dysarthria
3) dysphasia
4) visual disturbances
5) locked in syndrome
Define dysarthria.
Difficulty to articulate speech.
Define truncal ataxia.
Inability to sit or stand unsupported, tend to fall backwards.
Define gait ataxia.
Inability to coordinate walking.
Define aphasia.
Inability to comprehend or produce speech.
Define visual agnosia.
Inability to interpret visual information.
Define prosopagnosia.
Inability to interpret faces.
Define amaurosis fugax.
Sudden loss of vision in one eye.
How might a patient describe amaurosis fugax.
Curtain coming down vertically into field of vision.
Define transient global amnesia.
Episode of amnesia/confusion that resolves within 24 hours.
What score is used to assess the risk of a stroke post TIA?
ABCD2.
What is the most common cause of a TIA?
Carotid artery atherothromboembolism.
What is a TIA impossible to differentiate from, and until when?
Ischaemic stroke, until a full recovery is made.
How is TIA generally diagnosed?
Via history.
List 4 factors that indicate that a TIA patient is high risk for stroke.
1) ABCD2>4
2) AF
3) >1 TIA in a week
4) anticoagulation
List 4 factors that indicate a TIA patient should be seen by a specialist within 24 hours.
1) ABCD2>4
2) AF
3) >1 TIA in a week
4) anticoagulant
When does amaurosis fugax occur?
Retinal artery occlusion in TIA.
What percentage of TIA are due to thromboemboli?
80%.
Why is there a star shaped lesions in subarachnoid haemorrhage head CTs?
Blood fills gyral patterns around brain and ventricles.
Why is a subarachnoid haemorrhage lumbar puncture xanthochromic and what colour is this?
Yellow, break down of RBC haemoglobin to bilirubin.
How is the severity of a subarachnoid haemorrhage graded?
GCS score.
What percentage of subarachnoid haemorrhages are diagnosed by head CT?
95%.
What is the preferred management for subarachnoid haemorrhages endovascular coiling or surgical clipping, and why?
Endovascular coiling, less risk, better outcomes.
What is an important differential to rule out for subarachnoid haemorrhages?
Migraine.
What is the target blood pressure for subarachnoid haemorrhage patients?
SBP>160.
Where are berry aneurysms found?
Branching points in the circle of Willis (esp. anterior cerebral and anterior communicating arteries).
Elderly patient with progressive personality change and decreased GCS, what is the diagnosis?
Subdural haematoma.
Why does cerebral atrophy lead to subdural haematoma? (3)
1) brain size decreases
2) bridging veins are stretched away from dura
3) bridging veins are more susceptible to burst
Define febrile seizure.
Generalised epileptic seizure lasting <15 minutes in a neurologically intact child aged between 6 months and 6 years.
How long do epileptic seizures generally last for?
30-120 seconds.
How many types of epilepsy are there?
> 40.
What age group do absence seizures present in?
Children.
Child stops talking for 10 seconds mid-sentence, pales and stares, then continues sentence, what type of epilepsy is this?
Absence epilepsy (generalised).
Patient falls to the floor then experiences generalised bilateral rhythmical muscle jerking, what type of epilepsy is this?
Tonic-clonic epilepsy (generalised).
List 3 features of simple focal epileptic seizures.
1) no loss of consciousness
2) no loss of memory
3) no post-ictal symptoms
List 3 features of complex focal epileptic seizures.
1) loss of consciousness
2) loss of memory
3) post-ictal symptoms (esp. confusion)
What is the difference between focal and partial epilepsy?
Nothing, focal is the updated term for partial (2017).
What type of epilepsy has a characteristic guttural cry/grunt?
Tonic epilepsy.
List 5 potential post-ictal symptoms of epileptic seizures.
1) headache
2) confusion
3) myalgia
4) temporary weakness (focal seizure of motor cortex —> Todd’s palsy)
5) dysphasia (focal seizure of temporal lobe)
What is the aura phase of an epileptic seizure?
Patient is aware of upcoming seizure and experiences deja vu, epigastric sensation or sensory hallucinations.
What type of seizure is an aura phase often seen in?
Partial focal temporal seizure.
What is the prodrome phase of an epileptic seizure?
Mood/behaviour change, rarely precedes seizure.
What imaging is preferred for epilepsy?
MRI.
How should long term anti-epileptics be prescribed?
One drug prescribed by one specialist slowly build up dose until seizures are controlled or maximal dose (at which point change drug and repeat).
What percentage of epileptic patients require anti-epileptic dual therapy?
<10%.
How is Parkinson’s disease diagnosed?
Clinically.
What is the Parkinson’s disease triad?
1) tremor
2) rigidity
3) bradykinesia
What habit decreases risk of Parkinson’s disease?
Smoking.
Which part of the substantia nigra are dopaminergic neurones found?
Pars compacta.
Where do substantia nigra dopaminergic neurones project to?
Striatum (caudate nucleus and putamen).
Define Lewy bodies.
Aggregates of α-synuclein and ubiquitin in neurones that contribute to Parkinson’s disease.
What histological feature is characteristic of Parkinson’s disease?
Lewy bodies.
What can worsen Parkinsonian tremors?
Anxiety.
What can improve Parkinsonian tremors?
Voluntary movement.
What is the frequency of a Parkinsonian tremor?
4-6Hz (slower than a cerebellar tremor).
Define passive movements.
Clinician moving patient limbs without voluntary movement.
Define leadpipe rigidity.
Sustained resistance to passive movements, found in Parkinson’s disease.
Define cogwheel rigidity.
Jerky resistance to passive movements, found in Parkinson’s disease.
List 5 features of a Parkinsonian gait.
1) stooped posture
2) small shuffling steps
3) narrow base
4) reduced arm swing
5) difficulty turning
What percentage of Parkinsonism is caused by vascular pathology?
2.5-5% (e.g. diabetes mellitus or hypertension)
List 4 Parkinson’s plus syndromes.
1) progressive supranuclear palsy
2) multiple system atrophy
3) cortico-basal degeneration
4) Lewy body dementia
List 4 features that would rule out early Parkinson’s disease.
1) dementia
2) incontinence
3) symmetry
4) early falls
What is a tell tale sign of Parkinson’s disease?
Asymmetrical motor symptoms.
List 4 reasons why prescription of levodopa for Parkinson’s disease is delayed.
1) decreasing efficacy
2) decreasing duration (end of dose deterioration)
3) worsening side effects
4) response fluctuations (50% at 5 years, 100% at 10 years)
What are MAO-B inhibitors?
Drugs that inhibit dopamine break down by monoamine oxidase B enzymes, used in Parkinson’s disease.
What are COMT inhibitors?
Drugs that inhibit dopamine break down by catechol-o-methyl transferase, used in Parkinson’s disease.
List 3 drugs that are prescribed before levodopa.
1) dopamine agonists
2) monoamine oxidase B inhibitors
3) catechol-o-methyl transferase inhibitors
What drugs is always prescribed with levodopa?
Decarboxylase inhibitors.
How do decarboxylase inhibitors work in treating Parkinson’s disease? (3)
1) inhibit peripheral conversion of levodopa to dopamine
2) decreases peripheral side effects
3) increases levodopa efficacy (more crosses BBB)
List 5 side effects of levodopa.
1) nausea
2) vomiting
3) arrhythmia
4) psychosis
5) visual hallucinations
List 4 side effects of dopamine agonists.
1) nausea
2) visual hallucinations
3) drowsiness
4) compulsive behaviour
List 2 side effects of MAO-B inhibitors.
1) atrial fibrillation
2) postural hypotension
What is a side effect of COMT inhibitors?
Liver damage.
List 2 components of the striatum.
1) caudate nucleus
2) putamen
List 2 components of the corpus striatum.
1) basal ganglia
2) internal capsule
Define chorea.
Relentlessly progressive jerky, explosive, fidgety movements.
How is Huntington’s disease diagnosed?
Clinically.
Define saccade.
Rapid eye movements in between fixation points.
Define motor impersistence.
Inability to sustain voluntary acts (e.g. closed eyelids).
How many CAG repeats do children who present with Huntington’s generally have?
> 60.
Is Huntington’s disease curable?
No.
What percentage of migraine patients experience auras?
15-30%.
How long do migraine auras last for?
5-60 minutes.
How long between migraine auras and migraines?
<60 minutes.
How are migraines diagnosed?
Clinically.
List 6 migraine red flags that indicate a brain MRI.
1) thunderclap headache
2) posteriorly located headache
3) migraine pattern change
4) abnormal neurological exam
5) onset >50 years old
6) epilepsy
List 2 medications to avoid in migraines and why.
1) paracetamol
2) ibuprofen
Medication overuse headaches.
How long can tension headaches last for?
30 minutes to 7 days.
List 3 features that exclude tension headaches.
1) vomiting
2) motion sensitivity
3) aura
Why should analgesia use be limited when treating tension headaches?
Prevent medication overuse headaches.
How is analgesia for tension headaches limited to prevent drug overuse headaches?
<6 days/month.
How long do cluster headache attacks last for?
15-160 minutes.
During a cluster how many attacks are there per day?
Once or twice, usually at the same time.
When do cluster headache attacks often occur?
Night/early morning.
What drugs are not useful for cluster headaches?
Analgesics (e.g. paracetamol).
What is associated with giant cell arteritis?
Polymyalgia rheumatica (50%).
What is the prognosis of giant cell arteritis?
2 year course, then complete remission (typically).
What is the main cause of death in giant cell arteritis?
Long term steroid use side effects.
When do you reduce prednisolone dose in giant cell arteritis? (2)
1) symptoms resolution
2) low ESR
When should you suspect encephalitis? (4)
1) odd behaviour
2) decrease in consciousness
3) focal neurology or seizure
4) preceding infection symptoms
What percentage of encephalitis is the cause unknown?
50%.
What is the triad of encephalitis? (3)
1) fever
2) headache
3) altered mental status
What lobes are mostly likely to be affected by encephalitis?
Frontal or temporal.
List 4 investigations carried out in CSF studies for encephalitis.
1) analysis
2) culture
3) PCR
4) serology
List 5 things tested for in CSF analysis for encephalitis.
1) opening pressure
2) protein
3) glucose
4) RBC
5) WBC
List 3 positive findings of encephalitis in a CSF analysis.
1) high protein
2) low glucose
3) high lymphocytes
What is the mortality of untreated viral encephalitis?
70%.
How long does empirical antiviral (aciclovir) treatment for encephalitis last?
14 days in normal patients, 21 days in immunocompromised patients.
Why has meningitis caused by Haemophilus influenzae type B decreased?
Hib vaccine.
What is the triad of meningism?
1) headache
2) neck stiffness
3) photophobia
List 3 instances when a lumbar puncture is not performed on a suspected meningitis patient.
1) shock
2) petechia
3) high ICP (cerebral oedema)
What is meningeal septicaemia? (2)
Neisseria meningitides enters bloodstream causing:
1) non-blanching petechiae
2) sepsis signs
Who should be identified in meningococcal diseases?
Public Health England.
Describe viral meningitis.
Benign self limiting condition (4-10 days).
Why pregnant women told to avoid eating cheese. (2)q
1) cheese contains Listeria monocytogenes
2) Listeria monocytogenes causes meningitis
What differentiates subarachnoid haemorrhage from meningitis?
Headache more sudden in SAH.
What differentiates encephalitis from meningitis?
Altered mental state is the main symptom in encephalitis.
How do you test is a rash is blanching or non-blanching? (3)
1) press clear glass against rash
2) rash disappears —> blanching
3) rash doesn’t disappear —> non-blanching
What percentage of under 16s have been exposed to varicella zoster?
90% (chickenpox).
What increases incidence and severity of shingles?
Age.
Can shingles be contracted from someone with chickenpox?
No.
When do shingles rash lesions stop being infectious?
Crust formation.
What causes herpes zoster ophthalmicus?
Zaricella zoster reactivation in ophthalmic branch of trigeminal nerve.
List 6 conditions associated with herpes zoster ophthalmicus.
1) conjunctivitis
2) keratitis
3) corneal ulceration
4) iridocyclitis
5) glaucoma
6) blindness
Why is aciclovir administered within 72 hours of rash appearance in shingles?
Decrease risk of post heretic neuralgia.
What is post herpetic neuralgia?
Burning pain that responds poorly to analgesia 4 months after developing shingles.
List 5 common multiple sclerosis perivenular demyelination plaque sites.
1) optic nerves
2) ventricles
3) corpus callosum
4) brainstem (inc. cerebellar peduncles)
5) cervical spinal tract (esp. corticospinal tract, dorsal column)
When do perivenular demyelination plaques form?
During MS relapses.
What criteria is used to diagnose multiple sclerosis?
McDonald criteria.
What is often the cause of death in multiple sclerosis?
Aspiration pneumonia.
How many years does multiple sclerosis take off life expectancy?
5-10 years.
List 5 poor prognostic signs of multiple sclerosis.
1) older age
2) female
3) onset motor symptoms
4) many early relapses
5) many MRI plaques
Why is early diagnosis crucial in multiple sclerosis? (2)
1) reduces relapse rates
2) reduces disability
List 2 unusual migrant incidence facts.
1) adult migrants maintain risk of origin country
2) child migrants gain risk of settle country
What percentage of relapsing remitting multiple sclerosis develop secondary multiple sclerosis?
75% (within 35 years).
Describe the 3 types of multiple sclerosis in terms of disability, relapses and remissions.
1) primary - worsening disability without relapses or remissions
2) relapsing remitting - worsening disability with relapses and remissions
3) secondary - worsening disability with fewer relapses and remissions
What cells are lost in primary lateral sclerosis?
Motor cortex Betz cells.
List 4 upper motor neurone disease symptoms.
1) weakness
2) spasticity
3) brisk reflexes
4) clonus
List 4 lower motor neurone disease symptoms.
1) weakness
2) hypotonia
3) absent/depressed reflexes
4) fasciculation
Define bulbar palsy.
CN IX-XII lower motor neurone lesion of speech and swallowing muscles (inc. tongue).
Define corticobulbar palsy.
CN IX-XII upper motor neurone lesion of speech and swallowing muscles (inc. tongue).
List 3 muscle groups spared by motor neurone disease.
1) occulomotor
2) bladder sphincter
3) rectal sphincter
What is the prognosis of motor neurone disease?
50% death in 3 years.
Define spasticity.
Hypertonia, continuous muscle contraction.
Define brisk reflexes.
Above average reflex tests, e.g. patellar reflex.
Define clonus.
Series of involuntary rhythmic muscular contractions and relaxations.
Define split hand sign.
Thumb sided hand muscle wasting.
Define Babinski’s sign.
Dorsiflexion (upward) of big toe when sole of for is stimulated by a blunt instrument.
Define tongue fasciculation.
Tongue twitching, like a sack of worms.
List 4 types of motor neurone disease.
1) amyotrophic lateral sclerosis —> UMN + LMN
2) progressive bulbar palsy —> CN IX-XII LMN
3) progressive muscular atrophy —> LMN
4) primary lateral sclerosis —> UMN
Olfactory nerve palsy symptoms. (2)
1) hyposmia
2) anosmia
Optic nerve palsy symptoms. (1)
Vision loss.
Occulomotor nerve palsy symptoms. (3)
1) ptosis
2) fixed dilated pupil
3) eyes down and out
Trochlear nerve palsy symptoms. (1)
Vertical diplopia.
Trigeminal nerve palsy symptoms. (2)
1) ipsilateral jaw deviation
2) corneal reflex loss
Abducens nerve palsy symptoms. (1)
Eyes in.
Facial nerve palsy symptoms. (2)
1) facial droop
2) facial weakness
Vestibulocochlear nerve palsy symptoms. (3)
1) hearing loss
2) balance loss
3) vertigo
Why do CN IX-XII nerve lesions occur together?
Close proximity to each other.
What causes CN IX-XII nerve lesions?
Jugular foremen lesion.
Define disc herniation.
Nucleus pulposus goes through annulus (inner through outer).
Define disc prolapse.
Nucleus pulposus pushes against annulus (inner against outer).
Why is spinal cord compression relieved of high pressure as soon as possible?
Prevent irreversible paraplegia.
What differentiates cauda equina syndrome from lesions higher up the spinal cord?
Leg weakness is flaccid and areflexic not spastic and hyperreflexic.
What percentage of Guillain-Barré syndrome is there infectious cause found?
40%.
What is the prognosis of Guillain-Barré syndrome? (3)
1) 85% complete recovery (inc. near complete)
2) 10% unable to walk unassisted in 1st year
3) 10% mortality
When does full recovery from Guillain-Barré syndrome generally occur?
After 4 weeks.
When does Guillain-Barré syndrome develop post infection?
1-3 weeks post infection.
