Neurology - Level 1 Flashcards
Definition of stroke?
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
Definition of ischaemic stroke?
Due to ischaemia and death of tissue following vascular occlusion or stenosis
Definition of haemorrhagic stroke?
Due to collection of blood from rupture of blood vessel within the brain (intercerebral) or between brain and arachnoid tissues (subarachnoid)
Definition of TIA?
o Sudden focal deficit lasting <24 hours with complete recovery and no evidence of acute infarction
Epidemiology of stroke?
2nd commonest cause of death worldwide 7% of deaths in UK Rates higher in Asians and Africans Incidence 1 in 1000 Men > Women
Risk factors of stroke?
- Hypertension, AF, Valve disease
- DM, PCV, Syphilis
- Smoking, Obesity, Alcohol, High cholesterol, clotting factors, OCP
- Hx of TIA
Aetiology of stroke?
- 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
Symptoms of TIA - carotid artery symptoms?
- 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
Symptoms of TIA - vertebrobasilar symptoms?
o Diplopia o Vertigo o Vomiting o Choking and dysarthria o Ataxia o Hemisensory loss o Visual loss
Symptoms of stroke - cerebral infarction?
- 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
Symptoms of stroke - brainstem infarction?
o Lateral medullary syndrome – vertigo, Horner’s, facial numbness, ataxia, nystagmus
o Locked in syndrome
Symptoms of stroke - lacunar haemorrhage?
o Pure motor, sensory, ataxic hemiparesis, cognition intact
Symptoms of stroke - cerebral haemorrhage?
Sudden LOC, severe headache and meningism
Oxford Bamford Stroke Classification - Total Anterior Circulation Stroke (TACS)?
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)
Oxford Bamford Stroke Classification - Partial Anterior Circulation Stroke (PACS)?`
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)
Oxford Bamford Stroke Classification - Posterior Circulation Stroke (POCS)?
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
Oxford Bamford Stroke Classification - Lacunar Syndrome (LACS)?
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
Initial Assessment in A&E of stroke?
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)
Management of TIA - initial assessment?
- 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)
Management of TIA - initial management?
o Aspirin 300mg immediately (with PPI)
o Refer for urgent (within 24 hours of symptoms) assessment with specialist
Management of TIA - brain imaging?
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
Management of TIA - further management?
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
Management of TIA - secondary prevention?
Clopidogrel 75mg daily
Dipyridamole MR + aspirin
• Dipyridamole MR alone if aspirin contraindicated/not tolerated
Management of stroke - initial assessment?
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)
Management of stroke - initial management?
o ABCDE assessment – protect airway
o Vital signs – BP, pulse, O2 sats, HR, temp
o Oxygen (only if O2 <95%)
Management of stroke - initial investigations?
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
Management of stroke - imaging?
CT scan
Management of stroke - when to perform CT within 1 hour?
If indications for thrombolysis (<4.5 hours)
On anticoagulant or Bleeding tendency
GCS<13
Progressing or fluctuating symptoms
Papilledema, Neck stiffness, Severe headache
Management of stroke - when to perform CT within 24 hours?
If no indications for immediate brain scanning
Management of stroke - further imaging?
o If thrombectomy indicated – CT contrast angiography & add on CT perfusion imaging (or MR equivalent) if indicated beyond 6 hours of symptom onset
Management of stroke - management of confirmed ischaemic stroke?
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
Management of ischaemic stroke - thrombolysis - when is it indicated and how? Post-thrombolysis management?
<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
Management of ischaemic stroke - thrombectomy - when is it done and why?
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
Management of ischaemic stroke - cerebral sinus thrombosis?
• Full-dose LMWH and then warfarin (INR2-3)
Management of ischaemic stroke - ischaemic stroke with AF?
Aspirin 300mg for first 2 weeks before anticoagulation treatment
Management of ischaemic stroke - haemorrhagic stroke with DVT/PE?
• Treat with anticoagulation or caval filter to prevent further pulmonary emboli
Management of haemorrhagic stroke - initial management?
Refer to neurosurgery
Managing hydrocephalus
Previously fit people – consider surgical intervention
Management of haemorrhagic stroke - medical treatment initially - when?
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
Management of haemorrhagic stroke - reversing anticoagulation?
If receiving warfarin (and have elevated INR) – use IV vitamin K and prothrombin complex concentrate
Management of haemorrhagic stroke - blood pressure control?
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
Management of haemorrhagic stroke - When not to offer BP control?
- Structural cause (tumour, arteriovenous malformation, aneurysm)
- GCS<6
- Having early neurosurgery to evacuate haematoma
- Massive haematoma with poor prognosis
Management of stroke in specialist stroke unit?
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
When to perform decompressive hemicranectomy in stroke?
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
When to image carotid arteries in stroke?
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
Rehabilitation teams involved in stroke?
o Inpatient stroke rehabilitation service
o Offer training in care for family members, carers
o May need SALT, OT, orthoptics, physiotherapy, fitness training
AF stroke prevention following acute stroke?
• Aspirin 300mg for 2 weeks, then restart anticoagulation (warfarin/DOAC) and stop aspirin
Secondary prevention of ischaemic stroke or TIA?
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)
Follow up after acute stroke?
o Follow up at specialist clinic in 6 weeks
o 6-month primary care and then annually with specialist
General advice given to stoke patients?
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
Complications of stroke?
- Cerebral oedema
- Seizures
- VTE
- Mobility problems – falls, ataxia, hemiparesis
- Sensory/Communication problems
- Visual/Cognitive impairment
- Continence problems
- Pain
Definition of meningitis?
- Inflammation of the meninges
Pathogenesis of meningitis?
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 proteinscerebral oedema (hydrocephalus)
o Alteration in cerebral blood flow and metabolism
o Cerebral vasculitis
Acute bacterial of meningitis pathology?
o Pia-arachnoid gather polymorphs and layers of pus
o May form adhesions and cause cranial nerve palsies
o Chronic – brain covered in tubercles
Pathology of viral meningitis?
o Lymphocytic inflammation without pus
o Little cerebral oedema
Epidemiology of viral meningitis?
- Viral Meningitis is most common
o Enteroviruses = more common in autumn and winter
o 95% have complete recovery with no neurological complications
Epidemiology of bacterial meningitis?
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
Risk Factors of meningitis?
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
Causative organisms of viral meningitis?
Enteroviruses (80%)
EBV, CMV, VZV, HSV
Adenovirus
Mumps (pre-MMR)
Causative organisms of bacterial meningitis?
Neisseria meningitidis S. pneumoniae S. aureus Streptococcus Group B TB
Causative organisms of fungal meningitis?
Cryptococcus neoformans
Candida Albicans
Symptoms of meningitis?
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
Signs of meningitis?
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
Signs of raised ICP?
Papilledema (rare)
↓ level of consciousness
Focal neurology
• VI nerve palsy
• Cushing reflex (High BP, Low HR, Cheyne-Stokes breathing (irregular and apnoeas))
Investigations of meningitis?
- 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
Management of meningitis - if meningococcal disease?
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
Management of meningitis - if no non-blanching rash?
o Admit to hospital with 999
o Do not give antibiotics unless urgent transfer not possible
Management of meningitis - initial management and investigations?
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
Management of meningitis - imaging?
If reduced consciousness (GCS<9 or drop of 3 or more) or focal neurological signs, perform CT scan
Management of meningitis - lumbar puncture?
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
Management of meningitis - if septic signs predominate?
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
What antibiotics to give in meningitis - if 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
What antibiotics to give in meningitis - over 50?
o IV cefotaxime/ceftriaxone + amoxicillin/ampicillin for 10 days
What antibiotics to give in meningitis - neonate and <3 months?
o IV Amoxicillin + Cefotaxime for 14 days
Management of meningitis - if meningitic signs predominate?
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
Management of meningitis - subsequent management?
o Discuss antibiotic therapy with microbiology
o IV fluids if needed
o Isolate for 1st 24 hours
Management of meningitis -antibiotics depending on cause?
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)
Management of meningitis -prophylaxis?
o Rifampicin or ciprofloxacin to all household contacts
Management of meningitis - discharge advice?
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
Complications of meningitis?
- During Illness:
o Convulsions, cerebral oedema, circulatory shock, DIC - Neurological
o Hearing loss (10%), visual impairment, cerebral palsy, vasculitis
o Hydrocephalus, cerebral abscess
Complications of meningitis?
- During Illness:
o Convulsions, cerebral oedema, circulatory shock, DIC - Neurological
o Hearing loss (10%), visual impairment, cerebral palsy, vasculitis
o Hydrocephalus, cerebral abscess
Pathology of subarachnoid haemorrhage?
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
Epidemiology of subarachnoid haemorrhage?
- Accounts for 5% of strokes
- Typical age between 30-60
Risk factors of subarachnoid haemorrhage?
o Smoking o Alcohol o Family history o Post-menopause o Increased BP o Bleeding disorder
Aetiology of subarachnoid haemorrhage?
o Rupture of Berry aneurysm in circle of Willis (mostly)
o Arteriovenous malformations
o Tumours
o Connective tissue disorders
Symptoms of subarachnoid haemorrhage?
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
Signs of subarachnoid haemorrhage?
o Meningism
o Retinal, vitreous bleeds
o Focal neurology may indicate site
Investigations of subarachnoid haemorrhage?
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
Severity assessment of subarachnoid haemorrhage?
- Hunt and Hess Scale
o Grade 1-5 to assess severity
Management of subarachnoid haemorrhage - initial management?
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
Management of subarachnoid haemorrhage - further management - general measures?
o Refer to neurosurgery
Bed rest
Control BP (<140mmHg)
Management of subarachnoid haemorrhage - further management - neurosurgery?
Endovascular coiling (after CT angiography)
Stenting/Clipping
Management of subarachnoid haemorrhage - further management - medical management?
Nimodipine (60mg PO every 4 hours) – reduces vasospasm
Mannitol IV (if raised ICP)
Complications of subarachnoid haemorrhage?
o Rebleeding – 20% in 1st few days
o Cerebral ischaemia
o Hydrocephalus
o Hyponatraemia
Describe normal gait cycle?
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
Description of hemiplegic gait?
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
Clinical features of hemiplegic gait?
Increased tone with clasp-knife Hyperreflexia Upgoing plantars (positive Babinski) Reduced power Sensory deficit
DDx of hemiplegic gait?
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
Description of diplegic (scissoring) gait?
Similar to hemiplegic but bilateral
Limbs stiff and held in extension, feet inverted, hips drawn together
Circuduction of both legs during swing phase
Clinical findings of diplegic (scissoring) gait?
Increased tone with clasp-knife Hyperreflexia Upgoing plantars (positive Babinski) Reduced power Sensory deficit
DDx of diplegic gait?
Spinal cord lesion - prolasped disc, spinal spondylosis/tumour/infarct, transverse myelitis, syringomelia
Bilateral brain lesion - cerebral palsy, MS, bilateral brain infarcts, paraspinal meningioma
MND
Description of Parkinsonian (festinant) gait?
- Short-stepping, shuffling gait
- Minimal arm swing
- Hesitancy when asked to start, turn around and stop
- Stooped posture
- Hypomimia (expressionless)
- Hypokinetic gait
Clinical features of Parkinsonian (festinant) gait?
Tremor (pin-rolling)
Rigidity (cog-wheel)
Bradykinesia
DDx of Parkinsonian (festinant) gait?
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)
Description of ataxic gait?
Broad-based Unsteady Foot stamping Veer towards side of lesion Heel-toe may elicit ataxia
Clinical features of ataxic gait?
Cerebellar - nystagmus, dysarthria, past-pointing, dysdiadokinesia, intension tremor
Sensory - impaired proprioception and vibration, positive Romberg’s sign
Vestibular - vertigo, nausea and vomiting
DDX of ataxic gait?
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
Description of high-stepping gait (neuropathic)?
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
Clinical features of high-stepping gait (neuropathic)?
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
DDx of high-stepping gait?
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)
Description of sensory gait (stomping)?
Caused by peripheral sensory nerve impairment
Cannot sense where foot is so slams foot on ground
Clinical features of sensory gait (stomping)?
Romberg’s positive
Stomping exacerbated by dark
Impaired sensation of feet
DDx of sensory gait (stomping)?
B12 deficiency Tabes Dorsalis (syphilis) Diabetes Vasculitis Charcot-Marie Tooth GBS
Description of myopathic gait? (Waddling or Trendelenburg)
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
Clincial features of myopathic gait? (Waddling or Trendelenburg)
Trendelenberg’s sign positive
Signs of proximal myopathy
DDx of myopathic gait? (Waddling or Trendelenburg)
Hyperthyroidism Hypothyroidism Cushing's syndrome Acromegaly PMR Polymyositis Dermatomyositis Duchenne's muscular dystrophy Becker's muscular dystrophy Myotonic dystrophy
Description of choreiform (hyperkinetic) gait?
Normal gait with involuntary movements through body (grimacing, lip smacking, writhing, dance-like)
DDx of choreiform (hyperkinetic) gait?
Huntington’s disease
Cerebral palsy
Wilson’s disease
Dopaminergic medications
Description of antalgic (painful) gait?
Gait painful, shortened length of time in stance phase on affected leg
DDx of antalgic (painful) gait?
Osteoarthritis
Inflammatory joint disease
Lower limb fracture
Nerve entrapment
LP findings in bacterial meningitis?
Opening Pressure - elevated WBC Count - >1000 WBC - polymorphs (neutrophils) Protein - Increased CSF-to-serum glucose - Decreased
LP findings in viral meningitis?
Opening Pressure - Normal WBC Count - <100 WBC - Lymphocytes Protein - Normal CSF-to-serum glucose - normal
LP findings in fungal meningitis?
Opening Pressure - Normal/Elevated WBC Count - Normal/Elevated WBC - Lymphocytes Protein - Elevated CSF-to-serum glucose - Low
LP findings in TB meningitis?
Opening Pressure - Normal/Elevated WBC Count - Normal/Elevated WBC - Lymphocytes Protein - Elevated CSF-to-serum glucose - Low
