Neurology - Movement disorders Flashcards
What is Parkinson’s
Loss of dopaminergic neurons in substantia nigra in basal ganglia
More common in males
What causes Parkinson’s
Age
Repeated head trauma - Boxing
Metoclopramide
Neuroleptics - EPSE
Parkinson’s DDx
Other causes of tremor
- SSRI
- Amphetamines
- Salbutamol
- Lithium
- Alcohol
- Hyperthyroidism
Wilson's disease Cerebellar tumour EPSE Normal pressure hydrocephalus Lewy body dementia
Parkinson’s TRIAD
Bradykinesia
Resting tremor - Pill rolling
Rigidity - COG WHEEL
Additional Parkinson’s symptoms
REM sleep disorders Shuffling gait Anosmia Monotone voice Micrographia Loss of facial expressions Dementia - Visual hallucinations Depression Urinary incontinence Sexual dysfunction
Parkinson’s investigations
Clinical diagnosis - TRIAD
Histology
- Lewy bodies
- Eosinophilic cytoplasmic inclusions consisting of alpha synuclein
SCREEN FOR DEPRESSION
Exclude differential
- Drugs
- Cerebellar disorder - Imaging
- Wilson’s - Cu bloods
Parkinson’s dopamine management
Increase dopamine
- Levodopa
- Dopamine agonist - Ropinirole
- Delay as much as possible, body stops responding after 5-10 years
Stop dopamine breakdown
- MOA-B inhibitor - Rasagiline, selegiline
- COMT inhibitor - Entacapone
Parkinson’s tremor management
Amantadine
Anticholinergics - FALL RISK
Parkinson’s non-pharmacological management
Physio S/L therapy Occupational therapy Deep brain stimulation Surgery - Interrupt overactive BG circuits SSRI for depression
Side effects of ropinirole
Drowsiness Impulsivity/inhibition disorder N/V Dizziness Visual hallucinations
Parkinson’s plus
VIVID
Vertical gaze palsy - Supranuclear gaze palsy
Impotence/incontinence - Multiple system atrophy
Visual hallucinations - LBD
Interfering limb - Cortico-basal degeneration
Diabetes/HTN - Vascular Parkinson’s
Causes of tremor
Cerebellar disease - DANISH
Parkinson’s
Essential tremor
Orthostatic - Legs
Multiple system atrophy - Autonomic symptoms
Drugs causing tremor
Salbutamol Lithium Caffeine Valproate SSRI Amphetamines
Causes of normal pressure hydrocephalus
Reduced CSF resorption at arachnoid villi
Idiopathic Meningitis Head injury CNS tumour SAH
NPH presentation
WET - Urinary incontinence
WACKY - Dementia
WOBBLY - Falls
NPH investigations
RULE OUT PARKINSON’S
CT - Enlarged 4th ventricle
LP - CSF pressure normal
NPH management
Ventriculoperitoneal shunt
Acetazolamide
Hydrocephalus causes
Obstructive
- Tumour
- Haemorrhage
Non-obstructive
- NPH
- Increased production - Choroid plexus tumour
Hydrocephalus presentation
Raised ICP
- Headache
- N/V
- Papilloedema
- Confusion
- HTN
Hydrocephalus investigations
CT - Dilatation of ventricles above lesion
LP - Diagnostic and therapeutic - Do not perform in obstructive
Hydrocephalus management
Eternal ventricular drain
Ventriculoperitoneal shunt
What causes Huntington’s
Autosomal dominant Mutation of Huntingtin gene 4p16.3 Trinucleotide CAG repeat Degeneration of cholinergic and GABA neurons in basal ganglia
Early symptoms of Huntington’s
Self neglect / apathy Personality changes Clumsiness Chorea Tics Myoclonus
Late symptoms of Huntington’s
Seizures
Spasticity
Clonus
Supranuclear gaze palsy
Psychiatric symptoms of Huntington’s
Apathy
Dementia
Depression
Huntington’s investigations
Genetic testing
MRI
- Loss of corpus striatum volume
- Large frontal horns of lateral ventricles
Huntington’s management
Chorea - Benzodiazepines, valproate
Dopamine depleting agents - Tetrabenzene
Deep brain stimulation
SSRI
Antipsychotics
Reflex syncope
Most common
Vasovagal - Emotion, stress, standing
Situational - Cough, micturition, GI, exercise
Carotid sinus hypersensitivity
Cardiogenic syncope
ARRHYTHMIAS Structural - MI, valve disease, aortic stenosis, tamponade, dissection BBB Brugada syndrome Heart block WPWS
Orthostatic hypertension
Dehydration - Infection, haemorrhage
Drugs - Diuretics, alcohol, vasodilators
AI failure - Parkinson’s, LBD, uraemia, diabetic neuropathy
Syncope presentation
Transient global cerebral hypoperfusion
LOC
Clonic jerking
Rapid post-octal recovery
Syncope investigations
Orthostatic BP - Change > 20/10 is abnormal ECG - 24 hours Full cardio exam Tilt table test FBC - Anaemia ESR - Infection EEG - Epilepsy
Essential tremor characteristics
Can affect vocal cords
Worse with arms outstretched
Improved by alcohol and rest
May be caused by BB
GBS pathophysiology
Immune mediated
Demyelination
Polyneuropathy
GBS aetiology
Post-viral
Campylobacter jejuni
CMV
EBV
GBS presentation
AAAAA - Hours to days
Symmetrical
Ascending weakness - Proximal muscles
Absent reflexes
Autonomic dysfunction - Urinary retention / tachy
- Arrhythmias
Paraesthesia
Respiratory depression
Miller Fisher syndrome - Ataxia and paraesthesia
GBS investigations
Nerve conduction studies
Anti ganglioside antibodies
Spirometry
LP - Protein ^
ECG - Arrhythmias
GBS management
IV IG
ECG - Monitor for arrhythmias
VTE prophylaxis
Plasmapheresis if severe
GBS complications
Respiratory depression
Death
MS aetiology
Females Away from the equator 20-40 Smoking Previous mono infection
MS pathophysiology
Autoimmune destruction of myelin sheath by autoantibodies
MS presentation
Eyes
- Optic neuritis
- Internuclear ophthalmoplegia
- Optic atrophy
Motor - Spastic weakness
Sensory
- Lhermitte’s sign
- Trigeminal neuralgia
- Numbness
Urogen
- Sexual dysfunction
- Incontinence
Cerebellar
- Ataxia
- Tremor
Cognitive impairment
UHTOFF’S PHENOMENON
MS types
Relapsing and remitting - Most common
Primary progressive
Secondary progressive
MS investigations
MRI - 2 lesions disseminated in time and space
LP - Oligoclonal bands
Anti-MOG
MS management
Acute - Methylprednisolone
Chronic
- Interferon
- Galantamir
- Natalizumab
Other
- Muscle relaxant - Baclofen
- Reduce tremor - BB
Myasthenia gravis pathophysiology
Antibodies to Ach receptors
Myasthenia gravis aetiology
Associated with
- Thyroid
- Parkinson’s
- Thymoma
Myasthenia gravis presentation
Proximal weakness and fatiguability
Normal reflexes - Synapses aren’t fatigued on brief contraction
Eyes
- Diplopia
- Ptosis - Better after ice
Bulbar
- Dysphagia
- Dysphasia
- Difficulty chewing
Myasthenia gravis common complaints
Peek sign - Gentle sustained lid closure - Then lids separate
Difficulty watching TV - Eyes get tired
Can’t count to 50 - Voice fades
Myasthenia gravis exacerbation triggers
Drugs
- BB
- Opioids
- Gentamicin
- Lithium
Pregnancy
Infection
Change in environment
Myasthenia gravis investigations
Electromyography - Decreased evoked potentials
AntiMuSK antibodies
AntiAchR antibodies
CT - Thymoma
Spirometry
Myasthenia gravis management
Pyridostigmine
Steroids
Azathioprine
Myasthenia gravis complications
Respiratory collapse
Lambert Eaton syndrome
Associated with small cell lung cancer
Similar to myasthenia gravis
Repated muscle contraction - Increased muscle strength
Cerebellar disorders cause
VITAMIN DD
Vascular - Stroke
Infection - Meningitis, encephalitis, VZV, mumps
Trauma
Autoimmune
Metabolic - B12, thiamine, hypothyroid, hypoparathyroid
Iatrogenic - Lithium, phenytoin, isoniazid, metronidazole
Neoplasm
Degenerative
Cerebellar disorders presentation
DANISH P
Dysdiadochokinesis Ataxia - Vermis Nystagmus Intention tremor Slurred speech Heel shin test / hypotonia
Pendular reflexes
