Neurology MSRA passmed Flashcards
Jacksonian movement (clonic movements travelling proximally
Frontal lobe seizures
seizures with sensory abnormalities?
PArietal lobe
seziures with aura - lip smacking/ clothes plucking, rising epigastric sensation?
Temporal lobe seizures
Absolute CI to thrombolysis in stroke?
ICH, seizures, cancer sus, SAH, stroke/ injury in 3 months before, LP 7 days before, GI bleed 3 weeks before, Oesophageal varices, HTN>200/120mmHg
Relative CI to thrombolysis?
- Pregnancy
- Concurrent anticoagulation (INR >1.7)
- Haemorrhagic diathesis
- Active diabetic haemorrhagic retinopathy
- Suspected intracardiac thrombus
- Major surgery / trauma in the preceding 2 weeks
Lacunar stroke features?
purely motor/
purely sensory
ataxic hemiparesis
ipsilateral weakness and limb ataxia that is out of proportion to the motor deficit
dysarthria-clumsy hand syndrome
affect: internal capsule, thalamus and basal ganglia.
Bilateral median N Dysfunction and twitches in elderly “fibrillation” think?/ hx of carpal tunne/ new imbalance/ sensnory/motor dysfunction
Degenerative cervical myelopathy.
MRI: gold standardL
fever, headache, malaise focal neurology, seizures, immunocompromised. what does CT show? dx?
CT: temporal lobe/ frontal changes (hypodensities). CSF: lymphocytosis and raised protein.
HSV encephalitis
asymmetric limb weakness, fasciculations, tibialis anterior wasting, small hand muscle wasting
ALS MND. risk frontotemporal dementia
Features of tuberus sclerosis?
AD, epilepsy, retinal haematoma, ash leaf spots, shagreen patches, sublingual fibromata, adenoma sebaceum, angiofibromas, poliosis
Neurofibromatosis features?
CRABBing?
Risks?
lisch nodules, AD, cafe au lait spots, phaechromocytomas, axillary/ groinfreckles,
CRABBING: cafe au lait, renal A stensosi (HTN/ relative), axillary nodules/ inguinal, Bone dysplasia/ bowing scapula, iris nodules, neurpfibroma, glioma eyes
NF2: acoustic neuroma, cns tumours
pyramidal tract lesions?
Upper limb - flexors>extensors
lower: extensores >flexors
pronator drift
acute;y flaccid paralysis then becoming spastic and increased tone over weeks with clonus/ brisk reflexes
Variation of gbs with descending demyelination?
miller fischer syndrome
ophthalmoplegia, areflexia and ataxia. The eye muscles are typically affected first
Anti GQ1B antibodies present
32 year-old female 3 day history of altered sensation of her left foot and right forearm. She had an episode of visual loss/ nystagmus?
Multiple sclerosos. ON with female <50 YO.
60 YO male with clumsy hand, dropping cups, struggles to use phone, worse over months?
degenerative cervical meylopathy (UMN signs with loss of dexterity, hoffman’s)
trigeminal neuralgia tx?
carbemazepine. if fail to respond and atypical features eg <50 - refer to neuro. preceded by pain in ear
red flag features of trigeminal neuralgia?
Sensory changes
Deafness or other ear problems
History of skin or oral lesions that could spread perineurally
Pain only in the ophthalmic division of the trigeminal nerve (eye socket, forehead, and nose), or bilaterally
Optic neuritis
A family history of multiple sclerosis
Age of onset before 40 years
Migraine tx?
menstrual migraine tx?
acute: triptan + nsaid/ paracetamol
child@ nasal triptan,
Others: non oral metoclopramide, domperidone
proph: propanolol/ topiramatee (teratogenic)/ amitryptiline/ riboflavin (for some),
predictable menstrual migraine: frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) as a type of ‘mini-prophylaxis’
differentiate between PD and essential tremour?
SPECT
features: essential: improves with alcohol, worse with intention, symmetrical
Parkinson’s symptoms?
tx?
features: resting tremour, bradykinesia, rigidity, shuffling gait, arm swinging, stooped,
tx: levodopa with peripheral decarboxylase inhibitors Co-beneldopa (levodopa and benserazide), with the trade name Madopa
Co-careldopa (levodopa and carbidopa), with the trade name Sinemet
parkinson plus syndome?
Multiple system atrophy: autonomic dysfunction (sweating, ED, postural hypotension), ataxia
Normal pressure hydrocephalus (wet, wobbly, wacky - incontinence, falls, dementia)
Lewy body dementia
progressive supranuclear palsy (virtical gaze palsy, speech/ swallowing issues)
levodopa SE?
dyskinesia :excessive motor activity, chorea, dystonia, athetosis.
MX: amantadine
PD drugs:
COMT inhibitors?
dop agonists?
MOBI?monoamine oxidase-B enzymes
when might PD sx worsen?
COMT - entacapone, slows breakdown to levodopa in brain
dopamine agonist: bromocriptine/ cabergoline/ pergolide. SE: pulmonary fibrosis. less effective but delays need for levodopa and then combined to reduce necessary dose. more risk of hallucinations
MOBi: selegiline, rasagiline
(slow breakdown)
drug holiday Ge/ missed doses
cx of brain abscess?
extension of sepsis from middle ear or sinuses, trauma or surgery to the scalp, penetrating head injuries and embolic events from endocarditis
15 min headache 5 weeks men, smoker, alcohol, crying around eye. tx?
cluster headache. get advice from specialist, imaging and acute: 02, sc triptan, prophylaxis: verapamil
features favouring epileptic seziure?
tongue biting, raised serum prolactin
wernicke’s encephalopathy triad?
Confusion, gait ataxia, nystagmus + opthalmoplegia. thiamine deficinecy
32 YO, F, altered sensation left foot and right forearm. B/L clonus in legs, and hyperreflexia in all limbs.
Multiple sclerosis
carbemazepine se?
dizziness, ataxia, and diplopiap
phenytoin se?
peripheral neuropathy, (numbness and reduced sensation in a glove-and-stocking distribution). gingival hyperplasia, bleeding gums, osteomalacia, p450 inducer, megaloblastic anaemia, Lymphadenopathy. check trough level (before dose) if dose change/ tox suspicion/ compliance doubt
lumbar spondylosis and chronic back pain presents with gradually worsening bilateral upper limb paraesthesias and leg stiffness
degenerative cervical myelopathy. do MRI c spine
Huntington’s disease features?
35 +, chromosome 4 (H, 4 arms), chorea
personality changes (e.g. irritability, apathy, depression) and intellectual impairment
dystonia
saccadic eye movements
stroke of: Posterior inferior cerebellar artery (lateral medullary syndrome, Wallenberg syndrome)
Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus
stroke: ipsilateral facial paralysis and deafness?
anterior inferior cerebellar artery
stroke: Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity
Weber’s syndrome (branches of the posterior cerebral artery that supply the midbrain)
site of lacunar stroke?
isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
AF: hypertension
common sites: basal ganglia, thalamus and internal capsule
Cushing triad?
bradycardia, irregular breathing, wide pulse pressure, systolic HTN (response to raised ICP). also dilated poorly reactive pupils, gcs low, CN6 palsy, pappiloedema
Tx of ischaemic stroke?
TIA presenting within 24 hrs. tx? DAPT? and non DAPT?
TIA - when to discuss with specialist same day? 7 days? 24 hrs?
stroke: when to do thrombectomy and thrombolysis?
When do you do thrombolysis?
when do you do thrombectomy for wake up strokes?
when do you do carotid enterectomy?
secondary tx like statin/ anticoagulation for AF?
clopidogrel not tolerated?
Aspirin 300mg 2/52 then lifelong chlopi
TIA: Clopidogrel 300mg then 75mg od lifelong. Aspirin 300mg+ 75mg od 21 days). _ppi
Not appropriate for DAPT: clopidogrel 300mg+ 75mg od
-TIA: in 24 hrs
Aspirin 300mg and stroke r/v within 24 hrs
Within 7 day - see stroke before imaging. corotid duplex uss.
TIA - discuss asap if cresencod TIA. if within 7 days - r/v within 24 hrs. if 7days + - refer within 7 days
Thrombolysis: alteplase. Tenecteplase
4.5-9hrs
BP needs to be <185/110
thrombectomy:
<6 hrs
6-12 hrs if confirmed salvageable brain tissue confirmed
within 24 hrs if proximal posterior circulation (basilar. PCA) salvageable brain tissues
Both:
Proximal AntCS and <4.5hrs do both thrombolysis and thrombectomy (within 6 hrs of symptoms) (ensure BP 185/110)
- carotid enterectomy within 7 days if 50% + stenosis
-statin if cholesterol 3.5+ (usually delayed 48 hrs due to risk of haemorrhagic transformation)
Af anticoagulation - normally 14 days after
dipyramidole
(CN8)vertigo, hearing loss, tinnitus and an absent corneal reflex (CN5)? and facial nerve palsy (CN7)
acoustic neuroma/ vestibular schwannoma
serotonin syndrome?
NMS?
presents hours rather than days, sweating, myoclonus, diarrhoea and hyperreflexia. TX: chlorpromazine, cryptoheptadine
NMS: pyrexia
muscle rigidity, reduced reflexes, HTN, hgih HR/ RR, delerium, raised CK/ WCC. over days. TX: dantrolene
Weber lateralises to?
contralasteral SN HL
ipsilateral conductive HL
valporate SE?
Teratogenic (harmful in pregnancy)
Liver damage and hepatitis
Hair loss
Tremor
Reduce fertility
now not recced in men or women <55YO, unless no alternative
1st line for focal seizures?
lamotrigine/ keppra
abscent seizures tx first line ?
ethoxusimide. made worse by carbemazepine
Myoclonic seizures first line?
valporate/ then keppra
starting IV phenytoin, what to monitor?
cardiac monitoring
Amantidine SE?
ataxia, slurred speech, confusion, dizziness and livedo reticularis
SE dopamine agonists?
cabergoline/ bromocriptine: pulmonary fibrosis, retroperitoneal/ cardaic. do CXR, echo, ESR, raised hallucinations, postural hypotension, nasal congestion
tx of drug induced parkinsonions?
procyclidine (antimuscarinics),
TIa and informing DVLA?
1 month no neuro deficit, 3 months if multiple TIA and inform DVLA,
craniotomy for meningioma : 1 yr, for pit adenoma craniotomy - 6 months (if vision clear)
laughter/ fear triggering loss of msucle tone?
cataplexy
Stokes-adams attack?
LOC/ collapse without warning, 10-30 secs with pallor, flushing on recovery. AF: complete heartblock/ eCG changes, IHD
MS ix?
MRI with contrast
PAtient on DOAC/ anticoagulant and has sx of TIA even if resolved. tx?
admit to ED to exclude haemorrhagic stroke
Raised protein/ lymphocytes CSF with swelling on CT, fever,
HSV enceph
Seizures like a ‘‘dream’’, lip smacking without remembering?
focal impaired awareness
most common initial sx of posterior circulation stroke?
dizziness
70 year-old man has pain and weakness in both legs on walking. It settles with rest
Lumbar spinal stenosis (PVD)
Types of aphasia? Speech is fluent but repetition is poor. Aware of the errors they are making. normal comprehension
conduction aphasia (connection between broca’s and wernicke’s)
Speech is non-fluent, laboured, and halting. Repetition is impaired
Comprehension is normal, type of aphasia?
broca’s aphasia - superior left MCA, inferior frontal gyrus (frontal lobe)
type of aphasia - speech fluent but comprehension is impaired?
expressive. superior temporal gyrus supplies by inferior left CMA
impairement of all 3 areas of aphasia: broca’s, wernicke’s and conductive?
global aphasia. can communicate with signs
CI of triptans?
cardiovascular disease,
the delusion that a friend or partner has been replaced by an identical-looking impostor
capgras syndrome
Fregoli’s syndrome?
delusional idea that the various people that the patient meets are in fact the same person.
cotard’s syndrome?
belief they are dead
Types of MS that have deteriorated sx between relapses?
secondary progressive. gait and baldder disorders also seen
bell’s nerve is also seen with?
hyperacusis (CN7 palsy, supplies stapes), post auricular pain, dry eyes, altered taste
double vision, right eye fails to adduct, left eye has nystagmus on abduction
Right sided intranuclear opthalmoplegia (can be feature in MS)
visual symptoms preceding the headache. B/L ‘wavy’ and ‘shimmering’ lines in his vision (scintillating scotoma)
migraine with aura
LEft inferior homonymous hemianopia. where is lesion?
right parietal lobe
Exacerbate myasthenic crisis?
penicillamine
quinidine, procainamide
beta-blockers
lithium
phenytoin
antibiotics: gentamicin, macrolides, quinolones, tetracyclines
causes of flapping tremour?
encephalopathies
phenytoin
CO2 retention
Wilson’s disease
pit adenoma visual field defect?
Bitemporal hemianopia, upper quadrant defect
Visual field defect with primary open angle glaucoma?
unilateral peripheral VL
bitemporal hemianopia - with worse VL in lower quadrants?
craniopharyngioma
headache with greying out vision worse in morning and at night. better when standing, double vision,
Raised ICP
Tx for TV - with and wihtout cns
RIPE - 2months
without CNS - RI for 4 months, wiht CNS - RI for 10 furthe rmonths
reduced visual acuity, eye pain worse with exercise, swollen optic disc?
optic neuritis (uhtoff’s phenomenon - worse with exercise/ heat), lines appear striaght o wavey
Bacterial Meng CSF?
TB CSF?
high protein, glucose <50% of serum glucose, low
TB: protein ++, glucose low
CTH within 1 hr?
GCS<15 initially, or GCS <13 within 2 hrs, suspected basal skull #, post traumatic seizure, 1 vomit, neurology
CTH within 2 hrs?
LOC/ amnesia with 65+/bleeding disorder, mechanism dangerous, retrograde amnesia 30 mins+
CTH within 8 hrs?
any patient on warfarin
CTH for children within 1 hr?
non accidental injury, post truamatic seizure (not known epileptic), intial GCS <14/ 15 paeds, GCS<15 2 hrs after, tense fontanelle, basal skull #, neuro sx, <1YO with laceration/swelling/bruise 5cm+
or 2 factors of: LOC 5mins, 3+vomit, dangerous mechanism, amnesia 5 mins+. if only 1, then observe and CTH if GCS<15, vomiting, drowsiness
When to tx if first T-C seizure?
EEG chasnges, unacceptable risk of reoccurance, known cerebral structual issue, previous myoclonic/ abscence/ focal seziures
8YO boy staring into space/ daydreaming?
Abscent seizure
60YO F, derranged LFTs, acutely confused, ataxic gait, B/Lhorizontal nystagmus. CTH petechial haemorrhages
Glucose infusion with chronic thiamine deficiency precipitating wernickes
10YO east asian, gait issues, slurred speech, scoliosis, diabetes weak arms and legs?
freidrich’s ataxia. autosomal recessive.
risk: cardiomyopathies and DM
PD sx, urine dysfunction, postural hypotension, cerebellar ataxia?
multiple system atrophy
Diagnosis of normal pressure hydrocephalus?
LP and evaluation post CSF removal. cT - enlarged ventricles without convolusional atrophy)
when to tx tension headaches prophylactically?
if more than 2 days a week, trial amitryptiline first line
13 YO girl progressive difficulty whistling/ sucking through straw?
facioscapulohumeral muscular dystrophy:
76 YO man with dementia, painful resteless legs, cant turn in bed, presents with sleep difficulty?
parkinsons
13YO boy, pulls legs up to walk upstairs, milestones delayed by 18 months, big calves?
duchenne muscular dystrophy
extrapyramidal SE present 1 yr then cognitive decline?
parkinsons disease with dementia
dementia with Lewy bodies - in cortical neurones. the motor SX and cognitive decline present within a year
45YO M, BL cataracts, worsening stiffness muscles of shoulders and hips 3 months
myotonic dystrophy - Autosomal dom. facila weakness, ptosis, frotnal balding, weakness in grip and shoulder, hallowed temples, hypernasal speech,
PMR - 50YO+
headache associated with sexual activity? type 1/ type2? mx?
coital cephalgia
t1 - B/L occipital, increases with sexual excitement
type 2- thunderclap like at point of orgasm
acute: BB (pre-emptive)/triptan,
proph:Indomethacin, propanolol/metoprolol,CCB diltiazem
charcot’s neurological triad?
AF MS but not pathognomonic.
nystagmus, intention tremour, staccato speech
When is mirtazipine/ trazadone/ reboxetine best to start in depression with chronic illness?
if patient is on NSAID/ warfarin/ aspirin, triptans, selegiline/ rasagiline (MAO-B)
best antidepressant for patient on anti-epileptics?
sertraline
T2DM with distal limb weakness, tonic muscle spasm, bald in front, eye problemsa dn small testicles. FH positive?
Myotonic dystrophy. autosomal dominant. AF: TM, testicular atrophy, dysphagia, B/L ptosis, cataracts, long myotonic face with bald front
1-5 YO with red spots, cerebella ataxia, recurrent chest infections. low platelets?
10YO with t1dm, cerebellar ataxia, visual problems?
Ataxic telangectasia - autosomal recessive, IGA deficiency, increased risk of lymphoma and leukaemia
Freidrich’s ataxia. autosomal recessive, AF: optic atrophy, hyphoscoliosis
most common hereditary polyneuropathy?
frequent sprained ankles, hammer toes stork leg with distal leg wasting??
charcot marie tooth
distal muscle weakness, atrophy, hyporeflexia, foot drop,, high arched feet
