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Yr4: Neurology & Special Senses > Neurology: Other Common Conditions > Flashcards

Neurology: Other Common Conditions Flashcards

1
Q

What 3 presentations does diabetic foot disease include?

A
  • Diabetic neuropathy
  • Ischaemia e.g. absent pulses, reduced ABPI, intermittent claudication
  • Complications e.g. calluses, ulceration, Charcot’s arthropathy, osteomyelitis, gangrene

*See Yr3 medicine endocrinology FC for more

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2
Q

Describe the typical presentation of peripheral diabetic neuropathy

A
  • Typically sensory loss (motor loss to lesser extent)
  • Glove & stocking distribution affecting lower legs first
  • Neuropathic pain
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3
Q

Discuss the management of peripheral diabetic neuropathy

A
  • Improve glycaemic control (diet, medications)
  • Neuropathic pain medications:
    • First line: amitriptyline, duloxetine, gabapentin, pregabalin
    • Second line: try one of others above
    • Topical capsaicin for those who don’t want or tolerate oral treatments with localised neuropathic pain
  • Education about diabetes and diabetic neuropathy
  • Advise to check feet regularly
  • Annual screening
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4
Q

Patients with diabetes can also get autonomic neuropathy, state some symptoms associated with this (categorise based on organ system affected)

A
  • GI symptoms: metoclopramide, domperidone, erythromycin (prokinetic)
  • Gustatory sweating: antimuscarinics
  • Erectile dysfunction: phosphodiesterase-5 inhibitors
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5
Q

For Brown-Sequard syndrome, discuss:

  • What it is
  • Tracts affected
  • Presentation
A
  • Injury to half of spine (hemi section of spinal cord)
  • Tracts affected on one side:
    • Lateral corticospinal tract
    • Dorsal columns
    • Lateral spinothalamic tract
  • Presentation:
    • Ipsilateral motor loss at and below lesion
    • Ipsilateral segmental anaesthesia
    • Ipsilateral loss of DC modalities (proprioception, vibration, fine touch, two point discrimination) below lesion
    • Contralateral loss of ST modalities (crude touch, pain, temperature) below lesion
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6
Q

For subacute combined degeneration of the spinal cord, discuss:

  • What it is
  • Tracts affected
  • Presentation/clinical features
A
  • A neurological complication of vitamin B12 deficiency. It is characterized by degeneration of the posterior and lateral spinal cord due to demyelination
  • Tracts affected:
    • Dorsal columns
    • Lateral corticospinal tracts
    • Spinocerebellar tracts
  • Presentation/features:
    • Bilateral motor weakness/spastic paresis
    • Bilateral loss of DC modalities (proprioception, vibration, fine touch, two point discrimination)
    • Bilateral limb ataxia
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7
Q

For syringomyelia, discuss:

  • What it is
  • Tracts affected
  • Presentation/clinical features
A
  • Fluid filled cyst forms on spinal cord. Usually occurs in cervicothoracic cord
  • Tracts affected depend where the cyst is, but if near central canal then:
    • Lateral spinothalamic
    • Ventral horns
  • Presentation/clinical features:
    • Loss of pain & proprioception in cape like distribution
    • Flacid paresis (typically in hands)
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8
Q

For anterior spinal artery occlusion, discuss:

  • What it is
  • Tracts affected (main ones for you to be aware of)
  • Presentation/clinical features
A
  • Occlusion of anterior spinal artery which supplies anterior ⅔ of spinal cord leading to damage to parts of cord supplied by this artery
  • Tracts affected:
    • Lateral corticospinal
    • Lateral spinothalamic
  • Presentation/clinical features:
    • Muscle weakness/spastic paresis
    • Bilateral loss of ST modalities (pain, temp, crude touch)
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9
Q

Which part of spinal cord does neurosyphilis affect?

A

Dorsal columns

Loss of proprioception, vibration, fine touch & 2 point discrimination

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10
Q

Define radiculopathy

A

Conduction block in axons of spinal nerve or it its root; results in weakness (when impacts of motor neurones) and parasthesia or anaesthesia (when impacts on sensory neurones)

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11
Q

Define radicular pain

A

Radicular pain= pain deriving from damage or irritation of the spinal nerve tissue- particularly dorsal root ganglion

*NOTE: different from radiculopathy wich can be thought of as a state of neurologial loss and may or may not be associated with radicular pain

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12
Q

Define myelopathy

A

Myelopathy is neurological signs & symptoms due to pathology of the spinal cord

*NOTE: must be compressing spinal cord e.g. therefore not cauda equina

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13
Q

State some potential causes of radiculopathy

A

Most commonly a result of nerve compression which can be due to:

  • Intervertebral disc prolapse (lumbar spine most common)
  • Degenerative diseases of spine which lead to neuroforaminal or spinal canal stenosis (cervical spine most common as it is most mobile)
  • Fracture (trauma or pathological)
  • Malignancy (most commonly metastatic)
  • Infection (e.g. extradural abscesses, osteomyelitis, herpes zoster)
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14
Q

Describe clinical features of radiculopathy

A
  • Sensory features: parasthesia, numbness
  • Motor features: weakness
  • Radicular pain (deep, burning, strap like pain. Can be intermittent)
  • Red flag symptoms
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15
Q

Discuss the general principles of the management of radiculopathy

A
  • Depends on underlying cause.
  • Main one to identify quickly/rule out is CES as it requires emergency surgical treatment.
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16
Q

For cervical spondylosis, discuss:

  • What it is
  • Presentation
  • Managment
A
  • Cervical spondylosis is an age-related degeneration (‘wear and tear’) of the bones (vertebrae) and discs in the neck.
  • Presentation:
    • Neck pain
    • Neck stiffness
    • Headaches
    • Pins and needles
    • Clumsiness of hands/difficulty fine movements of hands
  • Management:
    • Analgesia (paracetamol, NSAIDs, weak opioids e.g. codeine, neuropathic pain meds)
    • Physiotherapy
    • Advise to use firm supportive pillow when sleeping
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17
Q

Remind yourself of the following for facial nerve:

  • Path
  • Function
    *
A
  • Exits brainstem at cerebellopontine angle, travels through temporal bone and parotid gland. Then divides into 5 branches: temporal, zygomatic, buccal, marginal mandibular, cervical
  • Function:
    • Motor: muscles of facial expression, stapedius, posterior digastric, stylohyoid and platysma
    • Sensory: taste anterior ⅔ tongue
    • Parasympathetic: submandibular, sublingual and lacrimal glands
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18
Q

State some potential causes of facial nerve palsy (think about UMN &LMN causes)

A

UMN

  • Stroke
  • Tumours
  • MND (would cause bilateral palsy- rare)

LMN

  • Bell’s palsy
  • Ramsey-Hunt syndrome
  • Infection:
    • Otitis media
    • Malignant otitis media
  • Systemic disease
    • MS
    • Guillian-Barre syndrome
    • Diabetes
  • Tumours
    • Acoustic neuroma
    • Parotid tumourr
    • Cholesteatoma
  • Trauma
    • Direct
    • Damage in surgery
    • Base of skull fractures
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19
Q

For Bell’s palsy, discuss:

  • What it is
  • Presentation
  • Management
  • Prognosis
A
  • Acute, unilateral, idiopathic, facial nerve paralysis
  • Presentation:
    • LMN lesion (forehead involved)
    • Altered taste
    • Dry eyes
    • Hyperacusis
  • Management:
    • If present within 72hrs of symptoms, give oral corticosteroids
      • 50mg prednisolone for 10 days
      • Or 60mg for 5 days followed by 5-day reducing regime of 10mg per day
    • Lubricating eye drops
    • Tape eye closed at bedtime
    • Advised that if they develop pain in eye need to go to eye casualty as may be exposure keratopathy
    • If the paralysis shows no sign of improvement after 3 weeks, refer urgently to ENT
  • Prognosis:
    • Majority recover within 3-4 months
    • 15-30% left with some residual weakness
20
Q

Describe the typical presentation of carpal tunnel syndrome

A
  • Pain, numbness, parasthesia in median nerve sensory distribution (NOTE: palm often spared)
  • Symptoms worse at night
  • Symptoms relieved by handing arm over side of bed or shaking
  • Weakness of thumb abduction & wasting of thenar eminence
  • Positive Tinel’s test or positive Phalen’s test
21
Q

What is carpal tunnel syndrome?

A

Symptoms due to compression of median nerve within the carpal tunnel

22
Q

State some risk factors for carpal tunnel syndrome

A
  • Female
  • Age (45-60yrs)
  • Pregnancy
  • Obesity
  • Previous injury to wrist
  • Repetitive hand or wrist movements
  • Hypothyroid
  • RA
  • Diabetes
23
Q

What investigations may be done for suspected CTS?

A
  • Diagnosis= clinical
  • May do nerve conduction studies to confirm emdaiin nerve damage (but normal NCS does not rule out CTS)
24
Q

Discuss the management of carpal tunnel syndrome

A

​Conservative

  • Wrist splint (worn at night)
  • Physiotherapy
  • Corticosteroid injections into carpal tunnel

Surgical

  • Carpal tunnel release surgery to decompress carpal tunnel (cut through flexor retinaculum to reduce pressure on median nerve)
25
Q

State some potential complications of carpal tunnel release surgery

A
  • Persistent CTS symptoms
  • Infection
  • Scar formation
  • Nerve damage
  • Trigger thumb

(90% report good outcomes post-surgery)

26
Q

Explain why the palm is often spared in carpal tunnel syndrome

A

Palmar cutenaous branch of median nerve branches proximal to flexor retinaculum and passes over carpal tunnel

27
Q

What is tuberous sclerosis?

A

Genetic condition in which hamartomas- benign neoplastic growths of the tissue that they originate from- develop in numerous body systems such as: skin, brain, lungs, heart, kidneys, eyes etc…

28
Q

What is inheritance pattern of tuberous sclerosis?

What genetic defects are present in tuberous sclerosis?

A
  • Autosomal dominant
  • Caused by mutation in 1 of 2 genes:
    • TSC1 gene (chromosome 9): codes for hamartin
    • TSC2 gene (chromosome 16): codes for tuberin

Hamartin & tuberin interact with each other to control the size & growth of cells; hence, abnormalities in either of these genes causes abnormal cell size & growth

29
Q

Outline the classical presentation of tuberous sclerosis

A

Child presenting with epilepsy found to have skin features of tuberous sclerosis (but can also present in adulthood)

Skin Signs

  • Ash leaf spots are depigmented areas of skin shaped like an ash leaf
  • Shagreen patches are thickened, dimpled, pigmented patches of skin
  • Angiofibromas are small skin coloured or pigmented papules that occur over the nose and cheeks
  • Subungual fibromata are fibromas growing from the nail bed. They are usually circular painless lumps that grow slowly and displace the nail
  • Cafe-au-lait spots are light brown “coffee and milk” coloured flat pigmented lesions on the skin
  • Poliosis is an isolated patch of white hair on the head, eyebrows, eyelashes or beard

Neurological Features

  • Epilepsy
  • Learning disability and developmental delay

Other Features

  • Rhabdomyomas in the heart
  • Gliomas (tumours of the brain and spinal cord)
  • Polycystic kidneys
  • Lymphangioleiomyomatosis (abnormal growth in smooth muscle cells, often affecting the lungs)
  • Retinal hamartomas
30
Q

Management of tuberous sclerosis is supportive primarily focused on treating complications; true or false?

A

True

31
Q

What is neurofibromatosis?

A

Genetic condition that causes benign neuromas (nerve cell tumours) to develop throughout the nervous system; although tumours are benign, they cause neurological & structural problems.

32
Q

There are two types of neurofibromatosis; type 1 and type 2. Which is more common?

A

Neurofibromatosis type 1

33
Q

For neurofibromatosis type 1, discuss:

  • Inheritance pattern
  • Gene mutation
  • Features/diagnostic criteria

**HINT: crabbing

A
  • Autosomal dominant
  • NF1 gene on chromosome 17 (codes for neurofibromin which is tumour suppressor protein)
  • Features/diagnostic criteria is at least 2 of the 7 features:
    • C- cafe-au-lait spots (6 or more, ≥5mm in children, ≥15mm adults)
    • R- relative with NF1
    • A- axillary or inguinal freckles
    • BB- bony dysplasia (e.g. bowing of long bone, sphenoid wing dysplasia)
    • I- Irish hamartomas/Lisch nodules (yellow spots on iris) (2 or more)
    • N- Neurofibromas (2 or more) or 1 plexiform neurofibroma
    • G- glioma of optic nerve
34
Q

Discuss the management of neurofibromatosis type 1

A

NOTE: no investigations are required to make diagnosis

  • No treatment to slow disease progress
  • Management is therefore based on symptom control, monitoring the disease and treating complications
35
Q

State some complications of neurofibromatosis type 1

A
  • Migraines
  • Epilepsy
  • Renal artery stenosis causing hypertension
  • Learning and behavioural problems (e.g. ADHD)
  • Scoliosis of the spine
  • Vision loss (secondary to optic nerve gliomas)
  • Malignant peripheral nerve sheath tumours
  • Gastrointestinal stromal tumour (a type of sarcoma)
  • Brain tumours
  • Spinal cord tumours with associated neurology (e.g. paraplegia)
  • Increased risk of cancer (e.g. breast cancer)
  • Leukaemia
36
Q

For neurofibromatosis type 2, discuss:

  • Inheritance pattern
  • Mutation
  • Features
A
  • Autosomal dominant
  • Mutation in NF2 gene on chromosome 22; leads to mutation in merlin (a tumour suppressor protein important in Schwann cells)
  • Features:
    • Acoustic neuromas (bilateral acoustic neuromas pretty much pathognomonic for NF2)
      • Hearing loss
      • Tinnitus
      • Balance problems
    • Can also get other tumours developing elsewhere
  • Management: surgery can be done to resect acoustic neuromas with subsequent brainstem implants
37
Q

State some types of brain tumour

A
  • Secondary metastases (e.g. lung [most common], breast, renal, melanoma)
  • Gliomas
    • Astrocytoma (least malignant)
    • Oligodendroglioma
    • Ependymoma (most malignant)
  • Meningioma
  • Pituitary tumours
  • Acoustic neuromas
38
Q

Meningiomas are usually benign; true or false?

A

True

39
Q

Broadly outline possible management options for brain tumours

A

Given brain tumours can be benign to extremely malignant management varies; options include:

  • Radiotherapy
  • Chemotherapy
  • Surgery
  • Palliative care

Pituitary tumours can be managed with:

  • Trans-sphenoidal surgery
  • Radiotherapy
  • Bromocriptine (if prolactin secreting tumour)
  • Somatostatin (if growth hormone secreting tumour)
40
Q

Remind yourself of some causes of neuropathic pain

A
  • Postherpetic neuralgia
  • Nerve damage from surgery
  • Multiple sclerosis
  • Diabetic neuralgia
  • Trigeminal neuralgia
  • Complex Regional Pain Syndrome
41
Q

Remind yourself of features of neuropathic pain

A
  • Burning
  • Tingling
  • Pins and needles
  • Electric shocks
  • Loss of sensation to touch of the affected area
42
Q

What questionnaire can be used to estimate probability of neuropathic pain?

A

DN4 questionniare

43
Q

State some potential treatment options for neuropathic pain, including:

  • First line medications recommended by NICE
  • Other options
A

First line medications recommended by NICE

  • Amitriptyline (TCA)
  • Duloxetine (SNRI)
  • Gabapentin (anticonvulsant)
  • Pregabalin (anticonvulsant)

Other options

  • Tramadol ONLY FOR RESCUE USE/short term control flares
  • Capsaicin cream
  • Physiotherapy
  • Psychological input
  • Certain conditions have NICE recommended management e.g. trigeminal neuraliga → carbamezapine
44
Q

What is complex regional pain syndrome?

A

Umbrella term for number of conditions in which abnormal nerve functioning causes neuropathic pain and other abnormal sensations; usually triggered by injury to an area

45
Q

State some features of complex regional pain syndrome

A
  • Neuropathic pain
  • Allodynia
  • Abnormal hair growth
  • Oedema
  • Sweating
  • Temperature changes
  • Skin colour changes
  • Motor dysfunction

*Symptoms of oedema, sweating, temp an colour changes can be intermittent

46
Q

Discuss the management of complex regional pain syndrome

A

Managed by specialists (pain team):

  • Neuropathic pain meds
  • Early physiotherapy
47
Q

What are the rules regarding driving for the following conditions:

  • Craniotomy
  • Pituitary tumour
  • Narcolepsy/cataplexy
  • Chronic neurological conditions e.g. MS, MND
A
  • craniotomy e.g. For meningioma: 1 year off driving*
  • pituitary tumour: craniotomy: 6 months; trans-sphenoidal surgery ‘can drive when there is no debarring residual impairment likely to affect safe driving’
  • narcolepsy/cataplexy: cease driving on diagnosis, can restart once ‘satisfactory control of symptoms’
  • chronic neurological disorders e.g. multiple sclerosis, motor neuron disease: DVLA should be informed, complete PK1 form (application for driving licence holders state of health)

Yr4: Neurology & Special Senses (28 decks)

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