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MSRA Content > Neurology - Level 1 > Flashcards

Neurology - Level 1 Flashcards

1
Q

Definition of stroke?

A

o Syndrome of rapid onset of cerebral deficit lasting >24 hours with no apparent cause except vascular
o Complete – deficit becomes maximal <6 hours
o Stroke in evolution – progression during first 24 hours

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2
Q

Definition of ischaemic stroke?

A

 Due to ischaemia and death of tissue following vascular occlusion or stenosis

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3
Q

Definition of haemorrhagic stroke?

A

 Due to collection of blood from rupture of blood vessel within the brain (intercerebral) or between brain and arachnoid tissues (subarachnoid)

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4
Q

Definition of TIA?

A

o Sudden focal deficit lasting <24 hours with complete recovery and no evidence of acute infarction

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5
Q

Epidemiology of stroke?

A 
2nd commonest cause of death worldwide
7% of deaths in UK
Rates higher in Asians and Africans
Incidence 1 in 1000
Men > Women
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6
Q

Risk factors of stroke?

A
  • Hypertension, AF, Valve disease
  • DM, PCV, Syphilis
  • Smoking, Obesity, Alcohol, High cholesterol, clotting factors, OCP
  • Hx of TIA
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7
Q

Aetiology of stroke?

A
  • Ischaemic (85%) – embolism/thrombosis/artherosclerosis
  • Haemorrhagic (15%) – intracranial, SAH
  • Rare – Venous thrombosis, sudden BP drop, lesion, carotid artery dissection
  • TIA – microembolism from atherosclerotic plaques or mural thrombi
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8
Q

Symptoms of TIA - carotid artery symptoms?

A
  • Sudden onset of focal deficit usually lasting 5-15 minutes

o Hemiparesis – unilateral weakness to one side of body
o Hemiplagia – flaccid and then spastic
o Aphasia – speech problems
o Ataxia, vertigo, syncope
o Amaurosis Fugax – sudden transient loss of vision in one eye
o Hemianopia

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9
Q

Symptoms of TIA - vertebrobasilar symptoms?

A 
o	Diplopia
o	Vertigo
o	Vomiting
o	Choking and dysarthria
o	Ataxia
o	Hemisensory loss
o	Visual loss
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10
Q

Symptoms of stroke - cerebral infarction?

A
  • Sudden onset focal deficit ongoing or persisted for >24 hours and cannot be explained by another condition

o Symptoms of TIA, Sensory loss, hemiplegia (flaccid and then spastic), dysphagia, hemianopia

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11
Q

Symptoms of stroke - brainstem infarction?

A

o Lateral medullary syndrome – vertigo, Horner’s, facial numbness, ataxia, nystagmus
o Locked in syndrome

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12
Q

Symptoms of stroke - lacunar haemorrhage?

A

o Pure motor, sensory, ataxic hemiparesis, cognition intact

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13
Q

Symptoms of stroke - cerebral haemorrhage?

A

Sudden LOC, severe headache and meningism

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14
Q

Oxford Bamford Stroke Classification - Total Anterior Circulation Stroke (TACS)?

A

o Large stroke – both the middle and anterior cerebral arteries

o All 3 of following:

 Unilateral weakness (and/or sensory deficit) of face, arm and leg
 Homonymous hemianopia
 Higher cerebral dysfunction (dysphasia, visuospatial disorder)

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15
Q

Oxford Bamford Stroke Classification - Partial Anterior Circulation Stroke (PACS)?`

A

o Less severe than TACS, part of anterior circulation compromised

o 2 of the following:

 Unilateral weakness (and/or sensory deficit) of face, arm and leg
 Homonymous hemianopia
 Higher cerebral dysfunction (dysphasia, visuospatial disorder)

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16
Q

Oxford Bamford Stroke Classification - Posterior Circulation Stroke (POCS)?

A

o Damage to area supplied by posterior circulation (cerebellum and brainstem)

o 1 of the following:

 Cranial nerve palsy and contralateral motor/sensory deficit
 Bilateral motor/sensory deficit
 Conjugate eye movement disorder (horizontal gaze palsy)
 Cerebellar dysfunction (vertigo, nystagmus, ataxia)
 Isolated homonymous hemianopia

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17
Q

Oxford Bamford Stroke Classification - Lacunar Syndrome (LACS)?

A

o Subcortical stroke secondary to small vessel disease (no loss of higher cerebral function)

o	1 of the following:
	Pure sensory stroke
	Pure motor stroke
	Sensori-motor stroke
	Ataxic hemiparesis
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18
Q

Initial Assessment in A&E of stroke?

A 
FAST tool/Rossier Tool --- Stroke unlikely if score 0 or less
	Facial Weakness (asymmetrical) (1)
	Arm Weakness (asymmetrical) (1)
	Leg weakness (asymmetrical) (1)
	Speech disturbance (1)
	Visual field defect (1)
	Loss of consciousness or syncope (-1)
	Seizure (-1)
ABCDE assessment – protect airway
Vital signs – BP, pulse, O2 sats, HR, temp
Blood glucose
ECG
Neurological assessment (fundoscopy)
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19
Q

Management of TIA - initial assessment?

A 
-	ABCD2 (not used anymore)
o	Age >60
o	BP >140/90
o	Clinical weakness (2)/speech problem (1)
o	Duration >1hr (2)/<1hr (1)
o	Diabetes (1)
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20
Q

Management of TIA - initial management?

A

o Aspirin 300mg immediately (with PPI)

o Refer for urgent (within 24 hours of symptoms) assessment with specialist

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21
Q

Management of TIA - brain imaging?

A

CT
 Do not offer CT scan unless suspicion of alternative diagnosis that CT could detect

MRI
 After specialist assessment in TIA clinic, consider to determine territory of ischaemia or haemorrhage – perform on same day

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22
Q

Management of TIA - further management?

A

Carotid imaging and carotid endarterectomy
 Extent measured using NASCET or ECST
 Surgery when symptomatic & NASCET >50% or ECST >70% stenosed
 Stenting alternative if patient unable to have endarterectomy

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23
Q

Management of TIA - secondary prevention?

A

 Clopidogrel 75mg daily
 Dipyridamole MR + aspirin
• Dipyridamole MR alone if aspirin contraindicated/not tolerated

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24
Q

Management of stroke - initial assessment?

A 
o	FAST tool/Rossier Tool
	Stroke unlikely if score 0 or less
•	Facial Weakness (asymmetrical) (1)
•	Arm Weakness (asymmetrical) (1)
•	Leg weakness (asymmetrical) (1)
•	Speech disturbance (1)
•	Visual field defect (1)
•	Loss of consciousness or syncope (-1)
•	Seizure (-1)
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25
Q

Management of stroke - initial management?

A

o ABCDE assessment – protect airway
o Vital signs – BP, pulse, O2 sats, HR, temp
o Oxygen (only if O2 <95%)

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26
Q

Management of stroke - initial investigations?

A

o Blood glucose —- Maintain at 4-11mmol/l with IV glucose and insulin in T1DM
o ECG
o Neurological assessment (fundoscopy)
o NBM if choking risk – NG tube within 24 hours, gastrostomy if needed
o Blood tests —- ESR, FBC, glucose, U&Es

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27
Q

Management of stroke - imaging?

A

CT scan

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28
Q

Management of stroke - when to perform CT within 1 hour?

A

If indications for thrombolysis (<4.5 hours)

On anticoagulant or Bleeding tendency

GCS<13

Progressing or fluctuating symptoms

Papilledema, Neck stiffness, Severe headache

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29
Q

Management of stroke - when to perform CT within 24 hours?

A

 If no indications for immediate brain scanning

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30
Q

Management of stroke - further imaging?

A

o If thrombectomy indicated – CT contrast angiography & add on CT perfusion imaging (or MR equivalent) if indicated beyond 6 hours of symptom onset

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31
Q

Management of stroke - management of confirmed ischaemic stroke?

A

o Aspirin 300mg (orally or rectal/enteral if dysphagia) once haemorrhagic excluded
 Add PPI if previous dyspepsia
 Continue aspirin 300mg daily until 2 weeks after stroke
 Then start definitive long-term antithrombotic treatment

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32
Q

Management of ischaemic stroke - thrombolysis - when is it indicated and how? Post-thrombolysis management?

A

 <4.5 hours onset and haemorrhage been excluded on CT
 IV recombinant tissue plasminogen activator (alteplase 0.9mg/kg over 1h)
 CT 24-hour post lysis to identify bleeds

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33
Q

Management of ischaemic stroke - thrombectomy - when is it done and why?

A

ASAP and within 6 hours of symptoms, with IV thrombolysis if:
• Acute ischaemia stroke and confirmed occlusion of proximal anterior circulation on CTA or MRA

ASAP in people who were well 6-24 hours previously
• Acute ischaemia stroke and confirmed occlusion of proximal anterior circulation on CTA or MRA
• AND salvagable on CT/MRI with limited core infarct

Pre Stroke mRS <3 and NIHSS >5

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34
Q

Management of ischaemic stroke - cerebral sinus thrombosis?

A

• Full-dose LMWH and then warfarin (INR2-3)

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35
Q

Management of ischaemic stroke - ischaemic stroke with AF?

A

Aspirin 300mg for first 2 weeks before anticoagulation treatment

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36
Q

Management of ischaemic stroke - haemorrhagic stroke with DVT/PE?

A

• Treat with anticoagulation or caval filter to prevent further pulmonary emboli

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37
Q

Management of haemorrhagic stroke - initial management?

A

Refer to neurosurgery

Managing hydrocephalus
 Previously fit people – consider surgical intervention

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38
Q

Management of haemorrhagic stroke - medical treatment initially - when?

A

 Small deep haemorrhages
 Lobar haemorrhage without either hydrocephalus or rapid neurological deterioration
 Large haemorrhage and significant comorbidities
 GCS <8, unless due to hydrocephalus
 Posterior fossa haemorrrhage

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39
Q

Management of haemorrhagic stroke - reversing anticoagulation?

A

 If receiving warfarin (and have elevated INR) – use IV vitamin K and prothrombin complex concentrate

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40
Q

Management of haemorrhagic stroke - blood pressure control?

A

 Offer to all, without exclusions, if present within 6 hours of symptoms and systolic blood pressure between 150-220:
• Aim for 130-140 within 1 hour of starting treatment and maintain for at least 7 days
• Use IV labetalol 5mg bolus for rapid control, GTN infusion used for long-term hospital control until titrated onto oral medications

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41
Q

Management of haemorrhagic stroke - When not to offer BP control?

A
  • Structural cause (tumour, arteriovenous malformation, aneurysm)
  • GCS<6
  • Having early neurosurgery to evacuate haematoma
  • Massive haematoma with poor prognosis
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42
Q

Management of stroke in specialist stroke unit?

A

Admit everyone with stroke directly to specialist acute stroke unit after initial assessment

Swallow Function (specialist assessment within 24 hours and not >72 hours)
 NG tube and fed within 24 hours unless had thrombolysis
 Nasal bridle tube or gastrostomy if unable to tolerate NG tube
 Refer to dietician
 Amend oral medications

Early Mobilisation
 Help patients sit out of bed, walk as soon as able

Statin Treatment
 Do not start in acute stroke but continue if already on statin

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43
Q

When to perform decompressive hemicranectomy in stroke?

A

 If middle cerebral infarction within 48 hours who:
• >15 on NIHSS
• Decreased level of consciousness, score of 1 or more on item 1a of NIHSS
• Signs on CT of infarct in >50% MCA territory

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44
Q

When to image carotid arteries in stroke?

A

 Carotid imaging and carotid endarterectomy
• Extent measured using NASCET or ECST
• Surgery when symptomatic & NASCET >50% or ECST >70% stenosed
• Stenting alternative if patient unable to have endarterectomy

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45
Q

Rehabilitation teams involved in stroke?

A

o Inpatient stroke rehabilitation service
o Offer training in care for family members, carers
o May need SALT, OT, orthoptics, physiotherapy, fitness training

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46
Q

AF stroke prevention following acute stroke?

A

• Aspirin 300mg for 2 weeks, then restart anticoagulation (warfarin/DOAC) and stop aspirin

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47
Q

Secondary prevention of ischaemic stroke or TIA?

A

Control risk factors – HTN, DM, HF, BP (<130/80)

Atorvastatin 80mg daily (started 48h after ischaemic stroke)

Clopidogrel 75mg daily (dipyridamole 200mg + aspirin 75mg if clopidogrel contraindicated or not tolerated)

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48
Q

Follow up after acute stroke?

A

o Follow up at specialist clinic in 6 weeks

o 6-month primary care and then annually with specialist

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49
Q

General advice given to stoke patients?

A 
o	No LMWH for 2 months
o	Inform DVLA – no driving for 1 month
o	Assessment to return to work and may need support
o	Encourage physical activity
o	Stop smoking
o	Keep low salt intake
o	Reduce alcohol
o	Physio/OT assessments
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50
Q

Complications of stroke?

A
  • Cerebral oedema
  • Seizures
  • VTE
  • Mobility problems – falls, ataxia, hemiparesis
  • Sensory/Communication problems
  • Visual/Cognitive impairment
  • Continence problems
  • Pain
51
Q

Definition of meningitis?

A
  • Inflammation of the meninges
52
Q

Pathogenesis of meningitis?

A

o Micro-organisms reach meninges by direct extension from ears, nasopharynx, head injury or blood
o Invasion of the blood stream
o Attachment to and invasion of the meninges
o Induction of inflammation with leak of proteinscerebral oedema (hydrocephalus)
o Alteration in cerebral blood flow and metabolism
o Cerebral vasculitis

53
Q

Acute bacterial of meningitis pathology?

A

o Pia-arachnoid gather polymorphs and layers of pus
o May form adhesions and cause cranial nerve palsies
o Chronic – brain covered in tubercles

54
Q

Pathology of viral meningitis?

A

o Lymphocytic inflammation without pus

o Little cerebral oedema

55
Q

Epidemiology of viral meningitis?

A
  • Viral Meningitis is most common
    o Enteroviruses = more common in autumn and winter
    o 95% have complete recovery with no neurological complications
56
Q

Epidemiology of bacterial meningitis?

A

o 80% of cases of bacterial meningitis occur in <16yr olds in UK
o 5-10% mortality
o Meningococcus:
 causes majority of bacterial infections in >2m.
 This has ↓ since intro of MenB/MenC vaccine

57
Q

Risk Factors of meningitis?

A

o Impaired Immunity
 Young age, complement defects, splenic defects from sickle-cell disease or asplenia (Strep pneumonia and Hib susceptibility)
o Factors associated with low socio-economic status

58
Q

Causative organisms of viral meningitis?

A

 Enteroviruses (80%)
 EBV, CMV, VZV, HSV
 Adenovirus
 Mumps (pre-MMR)

59
Q

Causative organisms of bacterial meningitis?

A 
	Neisseria meningitidis
	S. pneumoniae
	S. aureus
	Streptococcus Group B
	TB
60
Q

Causative organisms of fungal meningitis?

A

 Cryptococcus neoformans

 Candida Albicans

61
Q

Symptoms of meningitis?

A

o Fever
o Headache, neck stiffness, photophobia - meningism
o Altered Consciousness, seizures
o Nausea & Vomiting, anorexia
o Rash – petechial non-blanching rash in meningococcal septicaemia
o Focal cranial nerve signs common in tuberculous or cryptococcal meningitis

62
Q

Signs of meningitis?

A

Neck Stiffness – meningeal irritation prevents neck flexion
 Not always present in infants

Brudzinski’s Sign
 Flexion of the neck with the child supine causes flexion of the knees and hips

Kernig’s Sign
 In supine position, when knee and hip are flexed, extension of knee leads to pain

Rash – Purpuric or petechial:
 Usually non-blanching (but may initially be blanching)
 Characteristic of meningococcal infection

63
Q

Signs of raised ICP?

A

Papilledema (rare)

↓ level of consciousness

Focal neurology
• VI nerve palsy
• Cushing reflex (High BP, Low HR, Cheyne-Stokes breathing (irregular and apnoeas))

64
Q

Investigations of meningitis?

A
  • Bloods – FBC, LFTs, U&E, glucose, coagulation screen, CRP
  • Blood cultures, throat swabs, rectal swabs, serology
  • Head CT scan if suspicion of raised ICP
  • Lumbar puncture usually done after CT unless GCS 15 and no raised ICP
    o Send CSF for M, C&S
65
Q

Management of meningitis - if meningococcal disease?

A

o Admit to hospital with 999
o If in community/GP then give IM/IV 1.2g Benzylpenicillin (single dose) before admission
 Children 1-9 – 600mg
 Children <1 – 300mg

66
Q

Management of meningitis - if no non-blanching rash?

A

o Admit to hospital with 999

o Do not give antibiotics unless urgent transfer not possible

67
Q

Management of meningitis - initial management and investigations?

A

 15L/min O2 if needed
 IV fluids, pressure area care and monitor conscious level
 In child <16 years
• Bloods (FBC, CRP, coagulation, glucose, VBG, PCR for N.meningitides)
• Blood culture
 Adults
• FBC, U&E, coagulation
• CXR
• Urine culture, nasopharyngeal swabs, stool virology

68
Q

Management of meningitis - imaging?

A

 If reduced consciousness (GCS<9 or drop of 3 or more) or focal neurological signs, perform CT scan

69
Q

Management of meningitis - lumbar puncture?

A

 Contraindicated if:
• Signs of raised ICP (reduced consciousness, bad headache, papilloedema)
• Focal neurology
• Severse shock
• Sepsis
 WBC count, examination, Gram stain, total protein and glucose concentations, culture and PCR

70
Q

Management of meningitis - if septic signs predominate?

A 
	Do not LP
	Antibiotics
Adults and child 3 months -50 years
o	IV Cefotaxime (2g, OD) for 10 days 
o	Add vancomycin if prolonged or multiple use of other antibacterials in last 3 months/travelled outside UK with highly resistant pneumococci

Adults over 50
o IV cefotaxime + amoxicillin for 10 days
o If over 55 or immunocompromised, add ampicillin

Neonates and child <3 months
o IV Amoxicillin + Cefotaxime for 14 days
 Critical care team input
 If shocked, ICU for fluids, intubation, inotropes

71
Q

What antibiotics to give in meningitis - if 3 months - 50 years?

A

o IV Cefotaxime (2g, OD) for 10 days
o Add vancomycin if prolonged or multiple use of other antibacterials in last 3 months/travelled outside UK with highly resistant pneumococci

72
Q

What antibiotics to give in meningitis - over 50?

A

o IV cefotaxime/ceftriaxone + amoxicillin/ampicillin for 10 days

73
Q

What antibiotics to give in meningitis - neonate and <3 months?

A

o IV Amoxicillin + Cefotaxime for 14 days

74
Q

Management of meningitis - if meningitic signs predominate?

A

Assess ICP signs
• If raised ICP – ICU and no LP
• If no raised ICP – do LP

Antibiotics
• Adults and child 3 months -50 years - IV Cefotaxime (2g, OD) for 10 days - Add vancomycin if prolonged or multiple use of other antibacterials in last 3 months/travelled outside UK with highly resistant pneumococci
• Adults over 50 - IV cefotaxime + amoxicillin for 10 days - If over 55 or immunocompromised, add ampicillin
• Neonates and child <3 months - IV Amoxicillin + Cefotaxime for 14 days

Dexamethasone 0.15mg/kg, up to 10mg QDS if LP reveals:
• Purulent CSF, WBC >1000, protein >1g/l, bacteria on Gram stain
• Give within 4 hours of antibiotics but not after 12 hours

75
Q

Management of meningitis - subsequent management?

A

o Discuss antibiotic therapy with microbiology
o IV fluids if needed
o Isolate for 1st 24 hours

76
Q

Management of meningitis -antibiotics depending on cause?

A

o Meningococci – Benzylpenicillin or cefotaxime for 7 days

o Pneumococci – Cefotaxime +/- dexamethasone for 14 days

o H.influenzae – Cefotaxime +/- dexamethasone for 10 days

o Listeria – Amoxicillin + gentamicin for 21 days (stop gentamicin after 7 days)

77
Q

Management of meningitis -prophylaxis?

A

o Rifampicin or ciprofloxacin to all household contacts

78
Q

Management of meningitis - discharge advice?

A

o Notify relevant Health Authorities
o Hospital Follow Up with paediatrician 4-6 weeks after discharge
o Audiological Assessment in children within 4 weeks of being fit to test, preferably before discharge

79
Q

Complications of meningitis?

A
  • During Illness:
    o Convulsions, cerebral oedema, circulatory shock, DIC
  • Neurological
    o Hearing loss (10%), visual impairment, cerebral palsy, vasculitis
    o Hydrocephalus, cerebral abscess
80
Q

Complications of meningitis?

A
  • During Illness:
    o Convulsions, cerebral oedema, circulatory shock, DIC
  • Neurological
    o Hearing loss (10%), visual impairment, cerebral palsy, vasculitis
    o Hydrocephalus, cerebral abscess
81
Q

Pathology of subarachnoid haemorrhage?

A

Rupture of blood vessel into subarachnoid space

o Berry aneurysm at junction of posterior communicating with internal carotid or anterior communicating with anterior cerebral or bifurcation of middle cerebral
o Associated with polycystic kidneys, coarctation, Ehlers-Danlos syndrome

82
Q

Epidemiology of subarachnoid haemorrhage?

A
  • Accounts for 5% of strokes

- Typical age between 30-60

83
Q

Risk factors of subarachnoid haemorrhage?

A 
o	Smoking
o	Alcohol
o	Family history
o	Post-menopause
o	Increased BP
o	Bleeding disorder
84
Q

Aetiology of subarachnoid haemorrhage?

A

o Rupture of Berry aneurysm in circle of Willis (mostly)
o Arteriovenous malformations
o Tumours
o Connective tissue disorders

85
Q

Symptoms of subarachnoid haemorrhage?

A

o Sudden onset, severe headache – often occipital
o “Worst pain ever”, “kicked in back of head”
o Nausea and vomiting
o Neck pain
o Photophobia
o Collapse and coma
o May be preceded by sentinel headache

86
Q

Signs of subarachnoid haemorrhage?

A

o Meningism
o Retinal, vitreous bleeds
o Focal neurology may indicate site

87
Q

Investigations of subarachnoid haemorrhage?

A

Assess airway and breathing, if unconscious open airway and contact ICU - May need RSI, tracheal intubation and ventilation

IV access – check BMG, FBC, clotting, U&Es

Emergency CT scan (<12 hours) - 90% detected

Lumbar puncture (if CT negative, no CI and >12 hours)
o	Blood early on and yellow after hours – bilirubin from Hb – xanthochromia

CT angiogram – localise source of bleed

88
Q

Severity assessment of subarachnoid haemorrhage?

A
  • Hunt and Hess Scale

o Grade 1-5 to assess severity

89
Q

Management of subarachnoid haemorrhage - initial management?

A

o O2 if saturations low
o IV fluids resuscitation
o Analgesia (codeine PO or morphine IV) and antiemetic
o If GCS <8, agitated – may need tracheal intubation

90
Q

Management of subarachnoid haemorrhage - further management - general measures?

A

o Refer to neurosurgery

 Bed rest
 Control BP (<140mmHg)

91
Q

Management of subarachnoid haemorrhage - further management - neurosurgery?

A

 Endovascular coiling (after CT angiography)

 Stenting/Clipping

92
Q

Management of subarachnoid haemorrhage - further management - medical management?

A

 Nimodipine (60mg PO every 4 hours) – reduces vasospasm

 Mannitol IV (if raised ICP)

93
Q

Complications of subarachnoid haemorrhage?

A

o Rebleeding – 20% in 1st few days
o Cerebral ischaemia
o Hydrocephalus
o Hyponatraemia

94
Q

Describe normal gait cycle?

A

Stance phase - limb with foot on ground, heel strike-toe off, hip abductors contract to prevent pelvis dropping on contralateral side

Swing phase - foot off ground, toe-off, foot plantar flexes to push foot off ground, knee and hip flex and foot dorsiflexes after toe off so to not drag

95
Q

Description of hemiplegic gait?

A

Asymmetrical gait, one limb normal while other stiff (spastic)

Affected limb held in extension, toes may drag on floor

Affected leg swings around (circumducts) during swing phase

96
Q

Clinical features of hemiplegic gait?

A 
Increased tone with clasp-knife
Hyperreflexia
Upgoing plantars (positive Babinski)
Reduced power
Sensory deficit
97
Q

DDx of hemiplegic gait?

A

Unilateral upper motor neuron lesion

CONTRALATERAL SIDE TO AFFECTED LIMB - Ischaemic stroke, brain tumour, trauma, MS, space-occupying lesion

HEMISECTION OF SPINAL CORD (BROWN-SEQUARD SYNDROME) OF IPSILATERAL SIDE - prolapsed disc, spinal spondylosis, spinal tumour, spinal infarct

98
Q

Description of diplegic (scissoring) gait?

A

Similar to hemiplegic but bilateral

Limbs stiff and held in extension, feet inverted, hips drawn together

Circuduction of both legs during swing phase

99
Q

Clinical findings of diplegic (scissoring) gait?

A 
Increased tone with clasp-knife
Hyperreflexia
Upgoing plantars (positive Babinski)
Reduced power
Sensory deficit
100
Q

DDx of diplegic gait?

A

Spinal cord lesion - prolasped disc, spinal spondylosis/tumour/infarct, transverse myelitis, syringomelia

Bilateral brain lesion - cerebral palsy, MS, bilateral brain infarcts, paraspinal meningioma

MND

101
Q

Description of Parkinsonian (festinant) gait?

A
  • Short-stepping, shuffling gait
  • Minimal arm swing
  • Hesitancy when asked to start, turn around and stop
  • Stooped posture
  • Hypomimia (expressionless)
  • Hypokinetic gait
102
Q

Clinical features of Parkinsonian (festinant) gait?

A

Tremor (pin-rolling)
Rigidity (cog-wheel)
Bradykinesia

103
Q

DDx of Parkinsonian (festinant) gait?

A

Parkinson’s Disease
Parkinsonian disorders
- Vascular Parkinson’s disorder
- Dementia with Lewy Body
- Parkinson’s plus syndrome (multisystem atophy with cerebellar signs, progressive supranuclear palsy with vertical gaze palsy)
- drug induced (antipsychotics, domperidone)

104
Q

Description of ataxic gait?

A 
Broad-based
Unsteady
Foot stamping
Veer towards side of lesion
Heel-toe may elicit ataxia
105
Q

Clinical features of ataxic gait?

A

Cerebellar - nystagmus, dysarthria, past-pointing, dysdiadokinesia, intension tremor

Sensory - impaired proprioception and vibration, positive Romberg’s sign

Vestibular - vertigo, nausea and vomiting

106
Q

DDX of ataxic gait?

A

Unilateral cerebellar disease - Ischaemia (PCA infarct), haemorrhagic stroke, space occupying lesion

Bilateral cerebellar disease - MS, alcoholism, B12 deficiency, Drugs (phenytoin, carbamazepine, lithium, barbituates), Frederich’s ataxia, Spinocerebellar ataxia, Ataxic telangiectasia, Multisystem atrophy

107
Q

Description of high-stepping gait (neuropathic)?

A

Caused by motor weakness of nerves supplying ankle dorsiflexor muscles (tibialis anterior)

Foot drop - weakness of dorsiflexion, so foot drops and toes drag

To prevent toes from dragging, knee and hips flex creating high stepping gait

Foot stamps on floor

108
Q

Clinical features of high-stepping gait (neuropathic)?

A

Ankle-foot orthoses - aid to keep ankle fixed in dorsiflexion

Unilateral foot drop with sensory impairment - common peroneal nerve disease

Bilateral distal muscle weakness with foot drop - MND, peripheral neuropathies

Reflexes - reduced in peripheral neuropathies, brisk with ungoing plantars and fasciculations in MND

109
Q

DDx of high-stepping gait?

A

Weakness of tibialis anterior supplied by common peroneal nerve (L4-S1)

Due to

  • Isolated palsy due to trauma or compression around fibula head
  • MND
  • L5 radiculopathy
  • Polyneuropathy (diabetic neuropathy, Charcot Marie Tooth, vasculitis, GBS)
110
Q

Description of sensory gait (stomping)?

A

Caused by peripheral sensory nerve impairment

Cannot sense where foot is so slams foot on ground

111
Q

Clinical features of sensory gait (stomping)?

A

Romberg’s positive
Stomping exacerbated by dark
Impaired sensation of feet

112
Q

DDx of sensory gait (stomping)?

A 
B12 deficiency
Tabes Dorsalis (syphilis)
Diabetes
Vasculitis
Charcot-Marie Tooth
GBS
113
Q

Description of myopathic gait? (Waddling or Trendelenburg)

A

Hip abductors weak so cannot contract and stabilise pelvis during stance phase

Pelvis tilts down on contralateral side

Conpensation - lateral flexing of torso away from leg

114
Q

Clincial features of myopathic gait? (Waddling or Trendelenburg)

A

Trendelenberg’s sign positive

Signs of proximal myopathy

115
Q

DDx of myopathic gait? (Waddling or Trendelenburg)

A 
Hyperthyroidism
Hypothyroidism
Cushing's syndrome
Acromegaly
PMR
Polymyositis
Dermatomyositis
Duchenne's muscular dystrophy
Becker's muscular dystrophy
Myotonic dystrophy
116
Q

Description of choreiform (hyperkinetic) gait?

A

Normal gait with involuntary movements through body (grimacing, lip smacking, writhing, dance-like)

117
Q

DDx of choreiform (hyperkinetic) gait?

A

Huntington’s disease
Cerebral palsy
Wilson’s disease
Dopaminergic medications

118
Q

Description of antalgic (painful) gait?

A

Gait painful, shortened length of time in stance phase on affected leg

119
Q

DDx of antalgic (painful) gait?

A

Osteoarthritis
Inflammatory joint disease
Lower limb fracture
Nerve entrapment

120
Q

LP findings in bacterial meningitis?

A 
Opening Pressure - elevated
WBC Count - >1000
WBC - polymorphs (neutrophils)
Protein - Increased
CSF-to-serum glucose - Decreased
121
Q

LP findings in viral meningitis?

A 
Opening Pressure - Normal
WBC Count - <100
WBC - Lymphocytes
Protein - Normal
CSF-to-serum glucose - normal
122
Q

LP findings in fungal meningitis?

A 
Opening Pressure - Normal/Elevated
WBC Count - Normal/Elevated
WBC - Lymphocytes
Protein - Elevated
CSF-to-serum glucose - Low
123
Q

LP findings in TB meningitis?

A 
Opening Pressure - Normal/Elevated
WBC Count - Normal/Elevated
WBC - Lymphocytes
Protein - Elevated
CSF-to-serum glucose - Low

MSRA Content (87 decks)

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