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Stage 3 > Neurology: Nerve palsies and neuropathies > Flashcards

Neurology: Nerve palsies and neuropathies Flashcards

1
Q

What is the most common cause of facial nerve palsy?

A

Bell’s palsy (idiopathic syndrome)

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2
Q

What are the four groups of differential diagnoses for facial nerve palsy?

A

1) Central nerve
2) Peripheral
3) Neuromuscular
4) Muscular

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3
Q

How would central nerve (UMN) facial nerve palsy present and why?

A

Forehead sparing weakness - the upper part of the face is bilaterally represented cortically

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4
Q

What are other causes of peripheral facial nerve palsy/disease besides Bell’s palsy?

A

1) Acoustic neuroma (physical lesions of the cerebellopontine angle)
2) Basal meningitis
3) Ramsay hunt syndrome
4) Trauma
5) Diseases of the middle/inner eat
6) Mononeuritis multiplex

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5
Q

Which tumour can cause facial nerve palsy?

A

Acoustic neuroma (any physical lesions of the cerebellopontine angle)

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6
Q

What can cause bilateral facial nerve palsy?

A

Basal meningitis - infective or inflammatory causes including Lyme disease and sarcoidosis

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7
Q

What is Ramsay Hunt syndrome?

A

Herpes zoster of the facial nerve causing facial nerve palsy and skin/ear lesions and pain

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8
Q

Diseases of which organ can cause facial nerve palsy?

A

Middle/inner ear

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9
Q

How would neuromuscular and muscular mimics of facial nerve palsy be different from true nerve weakness?

A

Often bilateral and associated with weakness elsewhere

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10
Q

Which cranial nerves are located in the midbrain?

A

CN 1, 2, 3, 4

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11
Q

Which cranial nerves are located in the pons?

A

CN 5, 6, 7, 8

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12
Q

Which cranial nerves are located in the medulla?

A

CN 9, 10, 11, 12

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13
Q

What are the key features of Horner’s syndrome?

A

Ptosis, meiosis ± anhidrosis

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14
Q

What causes Horner’s syndrome?

A

Interruption of the sympathetic nerve supply to the eye

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15
Q

What are the types of causes of Horner’s syndrome?

A

1) Pre-ganglion causes
2) Post ganglionic causes
3) Central causes

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16
Q

What are three causes of Horner’s syndrome?

A

1) Pancoast tumour - affecting sympathetic nerve supply
2) Stroke
3) Carotid artery dissection

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17
Q

What is a red flag for carotid artery dissection?

A

Neck pain ± Horner’s syndrome

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18
Q

How does a surgical CN III palsy present?

A

1) Ipsilateral fixed dilated pupil (responds poorly to light)
2) Ipsilateral ophthalmoplegia with the classic down and out appearance (pupil in inferotemporal position) + ptosis
3) Pain - bc of underlying cause

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19
Q

What is a most common cause of a surgical CN III palsy?

A

Posterior communicating artery aneurysm

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20
Q

What is an Argyll-Robertson pupil and what condition is it associated with?

A

Small and irregular pupils bilaterally that do not respond to light but accommodation reflexes are intact - neurosyphilis (could also have poor balance due to tabes dorsalis)

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21
Q

How would opiate overdose present?

A

1) Bilateral miosis
2) Respiratory depression
3) Altered mental status

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22
Q

What is internuclear ophthalmoplegia?

A

Ocular movement disorder caused by a lesion of the medial longitudinal fasciculus blocking the connection between the contralateral sixth nerve nucleus and the ipsilateral third nerve nucleus

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23
Q

What does internuclear ophthalmoplegia cause?

A

Impaired horizontal gaze/double vision:
1) Ipsilateral impaired adduction in the eye
2) Contralateral nystagmus in the abducting eye
- Some patients may converge to a near target

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24
Q

What are the two most common causes of internuclear ophthalmoplegia?

A

1) Vascular e.g. stroke
2) Demyelination e.g. multiple sclerosis (more commonly bilateral)

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25
What would an abducens nerve palsy cause?
Failure to abduct ipsilateral eye
26
How does an oculomotor nerve palsy present?
Ipsilateral down and out eye (unopposed activation of SO and LR) with ptosis ± pupillary dilation
27
Which muscles have their motor supply by the oculomotor nerve?
Levator palpebrae superioris and extraocular muscles (except superior oblique and lateral rectus)
28
What is the pupillary action of the oculomotor nerve?
Parasympathetic supply to the sphincter pupillae muscles to mediate pupil constriction
29
What is different about a surgical third nerve palsy?
Pupil involvement (dilated) - bc the parasympathetic (constrictive) fibres run on the outside of the nerve so external compression will impair function of these fibres, causing pupil dilation
30
What is different about a surgical third nerve palsy?
Pupil involvement (dilated) - bc the parasympathetic (constrictive) fibres run on the outside of the nerve so external compression will impair function of these fibres, causing pupil dilation
31
What are other causes of a surgical third nerve palsy?
Cavernous sinus lesions - infection, thrombosis, tumour infiltration
32
What would be the investigation for a surgical third nerve palsy and why?
MRI - looking for aneurysm
33
What investigation should be done in all cases of cranial nerve neuropathies and why?
Fundoscopy - to exclude papilloedema
34
What investigation would you do in cases of pupil-sparing (non surgical) oculomotor nerve palsy and why?
HbA1c - to look for diabetes (major cause)
35
How does giant cell arteritis present?
Unilateral temporal headache and amaurosis fugax
36
What investigation should be done in suspected GCA?
ESR
37
What is Guillain-Barré syndrome (GBS)?
Ascending inflammatory demyelinating polyneuropathy
38
What causes GBS?
1) Post-infection 2) Idiopathic (60%)
39
How soon after infection does GBS present?
Typically 1-3 weeks
40
Give 3 examples of infections that can lead to GBS?
Campylobacter, mycoplasma, EBV
41
How does GBS present?
1) Progressive ascending symmetrical limb weakness/paralysis (affecting lower limbs first) 2) Paraesthesia may precede motor symptoms 3) LMN signs in lower limbs - hypotonia, flaccid paralysis, areflexia 4) Cranial nerve signs e.g. ophthalmoplegia, LMN facial nerve palsy (bilateral), bulbar palsy 5) Type 2 respiratory failure due to resp muscle weakness e.g. CO2 flap, bounding pulse 6) Autonomic dysfunction e.g, arrhythmia, labile BP
42
What investigations are done in GBS?
1) Spirometry - to check for reduced FVC 2) Bloods - ABG (to check for type 2 resp failure) and anti-ganglioside antibodies 3) Lumbar puncture
43
Which antibodies are present in GBS bloods?
Anti-ganglioside antibodies
44
What does lumbar puncture show in GBS?
Albuminocytological dissociation 1) Raised protein 2) Normal cell counts + glucose
45
What are conservative measures in GBS management?
1) Monitoring of ventilation - serial spirometry and ABG ± ventilation (intubation and admission to ICU) if FVC dangerous reduced 2) VTE prophylaxis - TEDs, LMWH 3) Protection of pressure areas
46
What is medical management of GBS?
1) Intravenous immunoglobulin (IVIG) 2) If ineffective - plasmapheresis
47
What is Miller Fisher syndrome?
A variant of GBS
48
How does Miller Fisher syndrome present and which antibodies are positive?
Ataxia, ophthalmoplegia, areflexia - anti-GQ1b antibodies
49
Which measure is used to monitor respiratory involvement in GBS?
Forced vital capacity (the volume of air exhaled following maximum inhalation)
50
What is sensory peripheral neuropathy?
Damage to the peripheral sensory nerves responsible for causing symptoms of weakness, numbness and pain - large differential diagnosis
51
What are the most common causes of sensory peripheral neuropathies?
ABCDE: 1) Alcohol toxicity 2) B12/folate deficiency 3) Chronic renal failure 4) Diabetes 5) Everything else - vasculitis and paraneoplastic
52
How do sensory peripheral neuropathies present?
1) Gradually developing sensory disturbance and pain in a glove-and-stocking distribution with foot involvement preceding hand involvement - length dependent 2) If large fibres affected - paraesthesia and proprioceptive ataxia 3) If small unmyelinated fibres affected - burning, allodynia and hyperalgesia
53
What are potential consequences of vitamin B12 deficiency?
1) Peripheral neuropathy 2) Subacute combined degeneration of the cord 3) Optic neuropathy 4) Dementia/encephalopathy
54
What is diabetic amyotrophy?
1) Uncommon variant neuropathy seen in patients with poorly controlled diabetes 2) More common in older males with type 2 3) May be precipitated by sudden improvement in diabetic control 4) The response to medication is often poor, though most cases are self limiting (though often with some residual disability)
55
How does diabetic amyotrophy present?
1) Prominent pain in the back, hips and proximal thigh muscles 2) May develop with progressive weakness and wasting
56
How does diabetic polyneuropathy present?
1) Affects all sensory modalities with numbness and tingling 2) Followed by proprioceptive balance issues 3) Later followed by motor features
57
What is the most common cause of foot drop?
Disease or trauma affecting the common peroneal nerve (often as it loops over the head of the fibula on the lateral aspect of the knee joint)
58
Injury to which nerve most commonly causes foot drop?
Common peroneal nerve
59
What is the key clinical feature of foot drop?
Weakness or paralysis of dorsiflexion and eversion (motor findings)
60
What are other causes of foot drop?
1) L5 root lesion 2) Distal motor neuropathy 3) Small cortical lesions - other UMN features may be present 4) Uncommonly - intrinsic cord disease, partial sciatic nerve disease and myopathy may also mimic foot drop
61
How would distal motor neuropathy present?
1) Foot drop 2) Loss of all movements of the foot 3) Glove and stocking sensory disturbance
62
Lesion at which spinal root would cause foot drop?
L5
63
How would an L5 root lesion (radiculopathy) present?
1) Foot drop + loss of inversion (as well as dorsiflexion and eversion) - bc inversion is a tibial nerve function and not lost in patients with a common peroneal nerve lesion 2) Sensory loss over L5 dermatome 3) Sciatica-type shooting leg pain may be present + acute onset back pain (compression of L5 nerve root on MRI)
64
What is the most common cause of L5 radiculopathy?
Lumbosacral disc herniation
65
How do you test for impairment of motor function in muscles served by the L5 nerve root?
Power of dorsiflexion of the big toe

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