Passmed neuro/neurosurg Flashcards
First line investigation for suspected stroke?
Non-contrast CT
Long term antiplatelet for TIA/ischaemic stroke?
Clopidogrel
What is indicative of Guillian Barre on an LP?
Isolated result of high protein
Which anti-epileptics should be started after a first seizure?
Only started after specialist review
Features of viral encephalitis?
Fever, headache, psychiatric symptoms, seizures and focal features
Most common cause of viral encephalitis?
HSV
What is a Jacksonian March and what does it signify?
Clonic movements moving proximally - indicates frontal lobe epilepsy
When is carotid endarterectomy considered?
Patients who’ve had a TIA and carotid artery stenosis exceeds 50% on side contralateral to symptoms
How to differentiate syncope and seizures?
Post-ictal period: syncope has a short post-ictal time and fast recovery
Which drugs should be avoided in myasthenia gravis?
Beta-blockers - they interfere with acetylcholine receptors and exacerbate MG symptoms
Features of multiple system atrophy?
Parkinsonism with autonomic features (atonic bladder, postural hypotension)
What symptoms suggest Guillain-Barré syndrome?
Progressive peripheral polyneuropathy with hyporeflexia
(usually ascending)
What should be given in a stroke once haemorrhagic stroke is ruled out on CT?
Aspirin 300mg
If a patient on anticoagulation has a suspected TIA what is done?
Urgent imaging to exclude haemorrhage
What is the Barthel index?
A scale that measures disability or dependence in ADLs in stroke patients
What are Chiari malformations associated with and why?
Syringomyelia due to disturbed CSF flow at foramen magnum
What symptoms does anterior cerebral artery stroke cause and not cause?
Leg weakness but not face weakness or speech impairment
What is used to treat idiopathic cranial hypertension?
Acetazolamide (carbonic anhydrase inhibitor)
Features of subacute degeneration of the cord?
Distal sensory loss, tingling, absent knee jerks/extensor planters, gait abnormalities and Romberg’s positive
What suggests Korsakoff’s syndrome over Wernicke’s encephalopathy?
An inability to acquire new memories and confabulation
How does subacute degeneration of the cord occur and how is it avoided?
Giving folate before b12 can precipitate it so correct B12 before folate
Features of ALS?
Mixed UMN and LMN signs with usually no sensory deficit
How is Creutzfeld-Jakob disease characterised?
Rapid onset dementia and myoclonus
Which cranial nerves are affected by acoustic neuromas?
V, VII, VIII
2nd line management of status epilepticus?
If not responding to benzodiazepines then:
-IV phenytoin
-IV levetiracetam
-IV sodium valproate
How does lateral medullary syndrome present?
PICA lesion:
Cerebellar signs, contralateral sensory loss and ipsilateral Horner’s
What is conduction dysphasia?
Speech is fluent, repetition is poor but comprehension is intact
What is spared in MND?
Sensory and eye movements
What is a common trigger for cluster headaches?
Alcohol
What is controlled hyperventilation used for?
Raised ICP
What is a rare but serious side effect of Lamotrigine?
Steven-Johnson syndrome
How does an MCA stroke present?
Contralateral hemiparesis and sensory loss - upper extremity more affected than lower
Contralateral homonymous hemianopia and aphasia
What’s used for spasticity in MS?
Baclofen and gabapentin
Typical patient with idiopathic intracranial hypertension?
Obese, young female with headaches and blurred vision
If there is fluid loss from nose/ear after trauma, how do you tell if it is CSF?
Test for glucose
What must be ruled out before diagnosing a TIA?
Hypoglycaemia
What is a very common early symptom of MS?
Lethargy
What is an important consideration when assessing GCS?
Take the best response from both sides
What does a loss of corneal reflex suggest?
Acoustic neuroma
How does an AICA stroke present?
Sudden onset vertigo and vomiting with ipsilateral facial paralysis and deafness
Features of intracranial venous thrombosis?
Risk factors for thrombosis, headache, vomiting and reduced consciousness
What does a painful third nerve palsy suggest?
Posterior communicating artery aneurysm
Causes of cerebellar syndrome?
PASTRIES:
Posterior fossa tumours, alcohol, stroke, trauma, paRaneoplastic syndromes, inherited (Freidereich’s), epilepsy drugs (phenytoin), sclerosis (multiple)
What are common precipitants of myasthenia crises?
Beta blockers
Headache linked to Valsalva manoeuvres?
Rated ICP until proven otherwise
Treatment of essential tremor?
Propranolol
Which GCS number do you intubate at?
8 or below
What reduces relapse the most in MS?
Monoclonal antibodies such as natalizumb
What features points to a pseudo seizure?
Widespread convulsions without conscious impairment
What is the most likely operation for symptomatic subdural haematomas?
Burr hole evacuation
What is paroxysmal hemicranial and how is it treated?
Rare headache with severe throbbing pain around eye and back of neck
Treated with indomethacin
What features suggest a brain abscess?
Headache, fever and focal neurology
What is Weber’s syndrome?
Midbrain stroke characterised by an ipsilateral CNIII palsy and contralateral hemiparesis
What are common symptoms in children with migraine?
Nausea, vomiting and abdominal pain
What causes superior homonymous quadrantopias?
Lesions of inferior optic radiations in the temporal lobe
How to differentiate drug induced and idiopathic Parkinson’s disease?
Drug induced - may be symmetrical
Idiopathic - rarely symmetrical
How does syringomyelia present?
Cape-like loss of pain and temperature sensation due to compression of spinothalamic tract fibres decussating in the anterior white commissure of the spinal cord
What is Hoover’s sign used for?
To differentiate organic and non-organic lower leg weakness
How does a PCA stroke present?
Contralateral homonymous hemianopia with macular sparing and visual agnosia
What is done in patients under 55 with no obvious cause of their stroke?
Bloods - thrombophilia and autoimmune screening
Which spinal tracts are affected in subacute degeneration of the spinal cord?
Dorsal columns and lateral corticospinal tracts
What is amaurosis fugax?
Form of stroke that affects the retinal/ophthalmic artery
Where is Broca’s area?
Left inferior frontal gyrus
What is the most common complication of meningitis?
Sensorineural hearing loss
How long does a cluster headache last?
15m to 2h
Which stroke causes aphasia?
Dominant MCA
Why are carbonic anhydrase inhibitors used for raised ICP?
They’re thought to exert their effect on ICP by reducing CSF production in the choroid plexus
What isa feature of lacunar stroke?
Isolated hemisensory loss
What are axillary freckles indicative of?
Neurofibromatosis type I
Where is Wernicke’s area?
Superior temporal gyrus
Which artery stroke can cause locked-in syndrome?
Basilar artery
What is observed in patients taking levodopa?
Wearing off phenomenon - symptomatic when they’re ready for their next dose
What is pituitary apoplexy?
Rare, life threatening complication of pituitary adenoma - bleeding/infarction within a pituitary macro adenoma
How is pituitary apoplexy treated?
Urgent steroids due to loss of ACTH
What is the first-line drug in ocular myasthenia gravis?
Pyridostigmine
What is a common contraindication of triptan use and why?
Cardiovascular disease due to coronary artery vasospasm (also why people may experience throat/chest tightness on triptans)
Which cranial nerve is most commonly affected by raised ICP?
Third nerve palsy - ptosis, mydriasis, down and out eye
What is used to treat neuroleptic malignant syndrome?
Dantrolene and bromocriptine
Pathophysiology of neuroleptic malignant syndrome?
Isn’t understood, one theory suggests the dopamine blockade by antipsychotics triggers massive glutamate release and subsequent neurotoxicity and muscle damage
What are found in the CSF of patients with MS?
Oligoclonal bands (up to 95%)
What is hemispatial neglect?
After damage to one hemisphere of the brain, inability of a person to process and perceivestimulitowards the contralesional side of the body or environment
What has to be ruled out in status epileptics first?
Hypoglycaemia (A-E assessment)
Features of normal pressure hydrocephalus?
Wet, wacky, wobbly:
Incontinence, dementia, gait abnormality
What is a lifestyle modification for children with hard-to-control epilepsy?
Ketogenic diet - low carbs, high fat, controlled protein
In patients with suspected TIA who require brain imaging, which method is preferred?
Diffusion-weighted MRI
First line treatment for females with myoclonic seizures?
Levetiracetam
How does neuroleptic malignant syndrome present on bloods?
Leukocytosis and raised CK
Which nerves does Charcot-Marie-Tooth syndrome affect?
Motor and sensory peripheral nerves
What is the Cushing reflex?
Physiological response to raised ICP:
Hypertension, bradycardia
Neuroimaging findings of normal pressure hydrocephalus?
Ventriculomegaly in the absence of, or out of proportion to sulcal enlargement
Features of progressive supranuclear palsy?
Postural instability, impairment of vertical gaze, parkinsonism, frontal lobe dysfunction
Which drugs increase the risk of idiopathic intracranial hypertension?
Tetracyclines
What is neurofibromatosis type II associated with?
Bilateral acoustic neuromas
Types of bilateral hemianopia and their causes?
Upper quadrant more than lower = inferior chiasm compression - pituitary tumour
Lower quadrant more than upper = superior chiasm compression - craniopharyngioma
Which imaging method is best for viewing demyelinating lesions?
MRI with contrast
Which type of seizures do you see plucking of clothes in?
Temporal lobe seizures
What is an ataxic gait?
Wide based gait with loss of heel-toe walking
What is required when starting phenytoin infusion?
Cardiac monitoring due to pro-arrhythmogenic effects
Treatment of brain abscess?
Metronidazole and 3rd gen cephalosporin
What is the best way to nutritionally support patients with MND?
Percutaneous gastrostomy tube (PEG)
(NG tube not recommended for long term)
What is an important lifestyle modification with patients with idiopthaic intracranial hypertension?
Weight loss
What should be considered if falls occur soon after a diagnosis of Parkinson’s?
Alternative diagnosis such as Parkinson-plus syndrome -
Acute management of cluster headaches?
100% oxygen
Subcut triptans (faster than oral)
How do patients present with a pontine haemorrhage?
Reduced GCS, quadriplegia, miosis, horizontal eye movements
Which Parkinson’s drug is associated with greatest improvement in symptoms and ADLs?
Levodopa
How may a frontal lobe lesion present?
Disinhibition
What is a common side effect of sodium valproate?
Weight gain
What is Lhermitte’s sign?
Tingling in hands when the neck is flexed
Do you get pain more in Ramsay-Hunt syndrome or Bell’s palsy?
Ramsay-Hunt but up to 50% of patients get pain with Bell’s palsu
Which type of dementia is associated with MND?
Frontotemporal dementia
Difference between Weber’s and Wallenberg’s?
Weber’s - weakness in eyes/body
Wallenberg’s - ataxia (no weakness)
Describe the tremor in Parkinson’s disease?
Unilateral, improves with movement
First-imaging investigation for acoustic neuroma?
Audiogram and gadolinium-enhanced MRI
What is seen on venography is sagittal sinus thrombosis?
Empty delta sign
What is juvenile myoclonic epilepsy associated with?
Seizures in the morning following sleep deprivation
-Typcially affects teenage girl
-Absence, myoclonic and tonic-clonic
Common complication of intraventricular haemorrhages?
Hydrocephalus
Most common neurosurgical cause of sudden collapse and LOC?
Subarachnoid haemorrhage
Management of patients with intracranial bleeds who become unresponsive?
Urgent CT to check for hydrocephalus
If SAH is suspected, they present within 6h and the CT scan is normal, what is done?
Nothing - consider alternative diagnosis
If SAH is suspected, they present after 6h and CT is normal, what is done?
LP 12 hours after symptom onset
What is a common neurosurgical condition in premature neonates?
Intraventricular haemorrhages
What is a basal skull fracture characterised by?
Battle’s sign (mastoid bruising) and periorbital bruising (raccoon eyes)
Which drug is used in SAH and why?
Nimodipine - to prevent cerebral artery vasospasm
Difference on CT between extradural and subdural bleeds?
Extradural - biconvex shape
Subdural - crescent shape
What is seen on LP of SAH?
Xanthochromia (RBC breakdown products - bilirubin)
May also have normal/raised opening pressure
LP done 12h after onset to allow xanthochromia to develop
Which brain bleed has fluctuating consciousness/cognition?
Subdural
Which brain bleed is initially fine then a reduced GCS/consciousness after?
Extradural
What is a common complication of SAH?
SIADH and hyponatraemia
What requires a CT head within an hour? (mnemnonic)
Skilled fighters never get violent:
Seizures
Fractures - battle’s sign, fluid leakage
Neurological deficit
GCS score <13 at injury, <15 2h after
Vomiting
What requires a CT head within 8 hours?
LATE:
Legendary story (dangerous mechanism)
Amnesia (30m+ retrograde)
Thrombin (bleeding/clotting disorders, anticoagulants)
Elderly (>65)
What is the primary pathology in subdural bleeds?
Rupture of bridging veins
What is the primary pathology in extradural bleeds?
Rupture of middle meningeal artery
What is the best imaging to diagnose diffuse axonal injury?
MRI
How are intracranial aneurysms treated after SAH?
Coiling by interventional neuroradiologist
What is a risk factor for SAH?
ADPKD due to their association with cerebral berry aneurysms
Which tests used to confirm death?
Pupillary reflex, corneal reflex, oculo-vestibular reflex, cough reflex, absent response to supraorbital pressure, no spontaneous respiratory effort
