Passmed: Neuro Flashcards
What are 5-HT3 anatagonists used for and give a example
chemotherapy related nausea - medulla oblongata
e.g. ondansetron
Adverse effects of 5-HT3 antagonist
Prolonged QT interval
constipation
What is Aphasia?
Language / speech difficulties
What is Wernicke’s aphasia
Superior temporal gyrus lesion - left inferior MCA
sentences making no sense - word salad, comprehension is impaired
Brocas Aphasia
Inferior frontal gyrus - left superior MCA
speech non-fluent and halted
normal comprehension
Conduction aphasia
arcuate fasiculus - wernicke to broca
speech fluent but repetition is poor
comprehension normal
Global aphasia
all 3 of cond, broca & wernicke
severe expressive and receptive aphasia
gesture communication
Lesions causing gait ataxia
cerebellar vermis lesions
hemisphere = finger nose ataxia
What is Autonomic dysreflexia
spinal cord injury above T6
trigger: faecal impaction / urinary retention - sympathetic spinal reflex (PS response inhibited by lesion)
unbalanced physio response - extreme hypertension, flushing and sweating above the lesion - haemorrhagic stroke
Mx of Autonomic dysreflexia
removal of stimulus and treatment of LT hypertension / bradycardia
Features of Bells Palsy
Acute unilateral, idiopathic, facial nerve paralysis
Lower motor neuron facial nerve palsy - forehead spared
Post - auricular pain
Altered taste
dry eyes
hyperacusis - reduced tolerance to sound
Mx of Bells Palsy
oral pred within 72 hrs
eye care - prevent keratopathy
eye lubricants, tape eye if cannot close
Follow up and prognosis of Bells Palsy
no improvement of paralysis after 3 weeks - refer to ENT
plastic if many months
3-4 month recovery, untreated 15% keep moderate weakness
Nerve that supplies extensor muscle group
radial
Abbduction of fingers
rock paper scissors
ulner nerve
Features of Carbamazepine
Epilepsy - partial seizures & Trigeminal neuralgia, bipolar
binds to sodium channels increase refractory period
Adverse effects of carbmazepine
P450 enzyme inducer
dizziness and ataxia
drowsiness
headache
visual disturbances (especially diplopia)
Steven-Johnson syndrome
leucopenia and agranulocytosis
hyponatraemia secondary to syndrome of inappropriate ADH secretion
What is cerebral perfusion pressure
net gradient blood flow to brain
sharp rise in CPP - rising ICP
fall in CPP - cerebral ischaemia
arterial - intra cranial pressure
Features of Cluster headache
men 3:1
smoker
alcohol
nocturnal sleep
intense sharp stabbing pain one eye,15-2 hrs
restless
4-12 weeks
lacrimation
nasal stuffiness
Mx of Cluster headache
acute 0 oxygen and sc triptain
prophylaxis - verpamil
Ocuomotor palsy
ptosis
down and out eye
dilated, fixed pupil
Trochlear palsay
downward gaze - vertical diplopia
Trigeminal palsy
trig neuralgia, loss of corneal reflex, loss of facial sensataion, paralysis of mastication muscles and deviation of jaw to weak side
abducens palsy
hroizontal diplopia
facial palsy
flaccid paralysis upper and lower face
loss of corneal relfex
loss of taste
hyperacusis
vestibulo palsy
hearing loss
vertigo
nystagmus
acoustic neuroma
Glosspharyngeal palsy
hypersensitive carotid sinus relfex
loss of gag
vagus palsy
uvula deviates away from site
loss of gag
hypoglossal - tongue towards
accessory palsy
weakness turing head to other side
Features of degenerative cervical myelopathy
RF smoking - intervertbral disk
pain on neck, loss of motor function e.g. digital dexterity
loss of sensroy function
loss of autonomic function
Hoffmans
MRI cervical spine - disc degeneration and ligament hypertrophy
specialist, treatment within 6 months - decompressive surgery
Dermatomes
c6 - make 6 with hand - index finger and thumb
c7 - middle finger and palm
c8 - ring + little finger
t4 - nipples
t10 - umbilicus
l1 - inguinal ligament
l5 - big toe and dorsum of foot
DVLA: Neuro specifics
Epilepsy
- first - 6 months off if no abnormalities, if are then 12
- multiple - 12 months, 5 yrs then fully restore
- not drive 6 months after last dose if withdrawing
syncope
- single episode and explained - 4 weeks
- unexplained - 6 months
- two or more - 12 months
Other
– stroke - 1 month
- multiple tia - 3 months and inform
- craniotomy - 1 year
- pit tumour - 6 months
- nacrolepsy - control
- chronic e.g. ms - inform dvla
Encephalitis
fever, focal features and peripheral lesions
HSV1 - temporal and inferior frontal lobes
CSF - lymphocytosis, elevated protein, PCR for organism
neuroimaging shows - petechial haemorrhages in areas
eeg - lateralised periodic discharges at 2 hz
IV aciclovir
Areas of focal seizures
temporal - aure, rising epigastric sensation - one minute, lipsmacking, grabbing, plucking
frontal - head and leg movements, posturing, post-ictal weakness, jacksonian march ( movement of tingling)
parietal - paraesthesia
occiptal - floaters
Indications to start anti-epileptic
neurological deficit
brain imaging - structural abnormality
eeg
risk
generalised tonic - clonic seizure
M: sodium valproate
F: lamotrigine
focal seizure
first: lamotrigine
second: carbamazepine
absence
first: ethosuzimide
second: M: valproate, F: Lamotrigine
Myoclonic
M; valproate
F: Levetiracetam
Tonic
M: valproate
F: Lamotrigine
GCS
Motor - 6 (4 = withdraw from pain, 3 = flexion to pain, 2 extending to pain)
verbal - 5 ( 3 = words)
eye - 4 (2 = to pain)
Huntingdon
chorea, personality changes, dystonia, saccadic eye movements
Features of idiopathic intracranial hypertension
young overweight females
pregnany, drugs (COCP, steroids, tetracycline, reintoids, lithium)
headache, blurred vision, papilloedema, enlarged blind spot, sixth nerve palsy
weight loss
carbonic anhydrase inhibitor - acetazolamide
optic nerve sheath decompression
Lamotrigine
sodium channel blocker
steven johnson syndrome
Lateral medullary syndrome
posterior inferior cerebellar artery
ataxia + nystagmus
ipsilateral: dysphagia, facial numbness, cranial nerve palsy e.g. horners
contralateral: limb sensory loss
Med overuse headache
chronic daily
15 days
opioid use
withdraw triptan and anlgesics abruptly
opioid - gradual withdrawn
e.g. woule get vomiting, hypotension, tachycardia, restlessess, sleep distrubance and anxiety
Migraine A to E criteria
A - 5 attacks fulfilling below
B - 4-72 hrs headache
C - unilateral, pulsating, moderate pain, aggravation (2)
D - N&V, photophobia (1)
E - not another disorder
Gi distrubance in children
Atypical aura symptoms
motor weakness
double vision
visual symptoms one eye
poor balance
decreased level of consciousness
Acute migraine
oral triptan + NSAID/Paracetamol
nasal ifyoung
if not work - oral metoclopramide - caution due to acute dystonic reactions
Prophylaxis for migraine
quality of life and daily function
propranolol
topiramate - avoid in child bearing age
amitriptyline
10 sessions of acupuncture over 5-8 weeks
Migraine and women
Preg - paracettamol 1g
COCP - no COCP if have migraine due to risk of stroke
Menstruation - mefanamic acid or combo of aspirin / paracetoml / caffeine
HRT - normal
Main features of motor neuron disease
UMN + LMN - ALS, PMA, BP
Asymmetirc limb weakness - ALS
wasting of hand muscles
fasciulations
absence of sensory signs
not external ocular muscles
no cerebellar signs
abdominal reflexes preserved
normal motor conduction - MRI to exclude CC compress & myelopathy
MS features
75% lethargy
two or more relapses
Visual: optic neuritis, atrophy, uhthoff phenomenon (worse vision rise in body temp), internuclear opthalmoplegia
Sensory: Pins, numbness, tri neuralgia, lhermittes parathesai in limbs on neck flexion
Motor: spastic weakness - legs
Cerebellar: Ataxia - acute relapse, tremor
Other: UI, SD, Intellectual deterioration
MS Mx
Acute: high dose steorid - 5 days
DMARD - natalizumab relapsing
Fatigue - amantadine
Spast - baclofen & gabapentin + physio
Bladder - USS, significant residual - intermittent self cather, no residual volume - anticholinergic
Oscillopsia (oscillating visual fields) - gabapentin
Multiple system atrophy
predominant parkinsonian MSA-P
predominant cerebellar MSA-C
parkinsonism
autonomic distrubance - ED, postural hypo, atonic bladder,
cerebellar signs
Key feature of Myasthenia gravis
women and fatigability of muscles
diplopia, proximal muscle weakness, ptosis, dysphaiga
Associations of MG
thymomas 15%
Autoimmune disorder
thmic hyperplasia 50-70%
Ix & Mx of Mysathenia gravis
single fibre EMG
antibodies to ACH receptor
- if fail - anti-muscle specific tyorsine kinase
tensilon test - iv edrophonium reduces muscle weakness - (no if cardiac)
long acting ach inhib 0 pyridostigmine
thymectomy
crisis - plasmpheresis & immunoglobulins
Neurofibromatosis
NF1: cafe au lait, axillary freckles, peripheral neurofibromas, scoliosis, phaeo
NF2: bilateral vestibular schwannomas, intracrianl schwannoms, mengiomas, epdnymomas
Neuropathic pain
pain damage to nervous system
e.g diabetic neuropathy, post-herpectic neuraliga, trigeminal, prolapsed discs
amitriptyline, duloxetine, gabapentin - try another if not work - switch do not add
tramadol - exacerbatin
capsaicin - localised
carbamazepin e- specific for trigeminal neuralgia
Normal pressure hydrocephalus
wet, wacky and wobbly
reversible dementia, reduced csf absroption at archnoid villi
ventriculomegaly in absence or sulcal enlargment
shunting is the treatment - can cause seizures, infection and intracerebral haemorrhages
Featrues of parkinson disease
progressive neurodegenerativve condition of dopaminerigc neurons insubstantia nigra
bradykinesia - short shufflinf steps, reduced arm swiniing
, tremor - rest, worse on stress, better with voluntary movement, pill rolling
and ridigity - lead pipe, cogwheel
- asymmetrical
men
flexed postures, pyschiatric e.g. depression, rem sleep behavour, postural hypotension - autonomic dysfunction
Drug induced parkinsonism
motor symptoms rapid onset and bilateral
rigidity and res tremor uncommon
Parkinson Mx
Specialist
motor - levodopa - improvement in motor symptoms
not affecting motor - dopamina agonist - can cause sleepiness, hallucinations, impulse control disorder
features of levodopa
combineed with decarboxylase inhibitor - carbidopa
- prevents peripheral metabolism
dry mouth, anorexia, palpitations, postural hypotension, psychosis
end dose wearing off - symptoms worse near end
on-off phenomenon - large variation in motor peroformance
dyskinesias at peak doseL dystonia, horea and athetosis (involuntary writhing movements)
do not stop acutely - give as patch to prevent acute dystonia
Other parkinson medication features
Dopamine rec agonist - bromocriptine, impulse control and daytime somnolence, hallucinations, nasal congestion and postural hypotension
Mao-B - selgiline 0 inhibit breakdown
Amantadine
COMT inh - entacapone
Antimuscarinic - drug induced - tremor and rigidity - procyclidine
Peripheral neuropathy
motor - GBS, porphyria, lead poisoning, charcot marie tooth, diphtheria
sensory - diabetes, uraemia, leprosy, alcoholism, vit b12, amyloidoisis
alcohol more sensory - decrease absorption of B vitamins
vit b12 0 subacute deg of spinal cord - doral column - distal paraesthesia
Adverse affects of phenytoin
bind to sodium increase refractory period
inducer of p450 system
acute: dizziens, ataxia - later confusion and seizures
chronic - gingival hyperplasia (exposure of pdgf, hirsutism, megaloblastic anaemia, peripheral neuropathy
fever, rashes toxic epidermal necrolysis, hepatiis, aplsatic anaemia,
tetraogenic - cleft palate and congentical heart disease
trough levels before dose check - adjustment dose, suspect toxicity, detect non adherence
Progressive supranuclear palsy
parkinson plus
postural instability
impairment of vertical gaze
parkinsonism - bradykinesia
cognitive impair ment - frontal lobe dysfunction
no L-DOPA
Pyschogenic non-epileptic seizure
pseudo
pelvic thrusting, crying after, gradual
no tongue biting or rasied prolactin
Rasied intracranial pressure
CPP - arterial - icp
IIH, trauma, infection, tumour, hydrocephalus
headache, vomiting, papulloedmea, cushing tria (wide pulse pressure, bradycardia, ireegular breathing)
neuroimagin,
elevate to 30 degrees, mannitol osmotic diurectic, controlled hyperventilation reduce pCO2, vaso constrict, decrease pressure
removal of csf
Roots of reflexes
Ankel - s1/s2
knee - l3/l4
bicep - c5/c6
tricep - c7/c8
Restless leg syndrome
akathisia - night
family history - IDA, diabetes, pregnancy
ferritin exclude IDA
stretching, dopamine agonists - rpinirole, benzo, gabapentin
Middle cerebral artery
aphasia
contralateral homonymous hemianopia
+ the usual hemiparesis
webers
posterior cerebral artery that supply midbrain
ipsilateral CN III palsy
contralateral weakness
Posterior inferior cerebellar artery
wallenburg
Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus
Anterior inferior cerebellar artery
lateral pontine
ipsilateral facial parlysis and deafness
retinal and basilar artery
ret - amurosis fugax
basilar - locked in
Lacunar stroke
isolated hemiparesis, hemisensory, with limb ataxia
hypertension
basal ganglia, thalamus and internal capsule
Criteria assessed for stroke
unilateral hemiparesis
homonymous hemianopia
higher cognitic dysfunction
Subdural haematoma
dural layer
head trauma, lucid interval, gradual decline in consciousness
cresenteric collection not limited by suture lines- hyperdense in comparision- midline shift
small birdging veins - chronic = hypodense and dark in contrast to acute
burr hole decompression
Causes of third nerve palsy
diabetes
vasculitis
false localising sign
posterior communicaitg artery aneurysm - pupil dilated, often associated with pain, cavernous sinus thrombsis, webers, amyloid
Triptans adverse effects
tingling, heat, tightness
avoid in IHD and CVD
Tuberous sclerosis
AD
ash leaf spot under uv light, rough skin over lumbar spine, butterfly rase, fibromate beneath nails, cafe au lait spots,
developmental delay, epilepsy,
kidney issues, heart issues etc
Features of vestibular schwannoma
vertigo, hearing loss, tinnitus and abset corneal reflex
VIII, V, VII (facial palsy)
MRI cerebellopontine angle
PITS
Parietal - inferior homonymous quadrantonpoia
temporal = superior
Homonymous hemianopia
incongruous defects: lesion of optic tract
congruous defects: lesion of optic radiation or occipital cortex
macula sparing: lesion of occipital cortex
Homonymous quadrantanopias*
superior: lesion of the inferior optic radiations in the temporal lobe (Meyer’s loop)
inferior: lesion of the superior optic radiations in the parietal lobe
mnemonic = PITS (Parietal-Inferior, Temporal-Superior)
Bitemporal hemianopia
lesion of optic chiasm
upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour
lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma
