Rest of acute neuro Flashcards
A 62-year-old woman presents back pain and difficulty walking. On examination there is increased tone and hyper-reflexia in both legs. She has not opened her bowels or passed urine for the previous day. She has a past medical history of breast cancer, diagnosed two years earlier. Which is the most likely diagnosis?
Spinal cord compression
A 20-year-old woman presents with pins and needles in both legs. Her symptoms rapidly progress over 4 days to include lower extremity weakness to the point that she is unable to mobilise her lower extremities. She reports gastrointestinal symptoms 2 weeks ago. Lumbar puncture reveals mildly elevated protein with no cells and normal glucose.Given the most likely neurological diagnosis which organism is most likely to have caused the gastroenteritis?
Salmonella Campylobacter Jejuni E. Coli 0517 Rotavirus Entamoeba histolytica
Campylobacter jejuni
Define GBS
Acute autoimmune demyelinating polyneuropathy
affecting the PNS
What is the pathophysiology of GBS
AI process attacking myelin sheath or Schwann cells in sensory and motor peripheral nerves
Cause of GBS?
Unknown but 2/3rds preceded by an URTI or gastroenteritis 2-3 weeks previously
Which type of cell produces myelin
Schwann cells
What are the viral causes of GBS (5)
CMV, EBV, HepB/C, HIV
What are the bacterial causes of GBS (2)
campylobacter jejuni, mycoplasma
What is the triad in Miller-Fischer syndrome and the one thing it is without
ophthalmoplegia, areflexia & ataxia but NO muscle weakness. In Miller-Fisher syndrome there are antibodies against a specific ganglioside (GQ1b)
What is the triad of: ophthalmoplegia, areflexia & ataxia but NO muscle weakness known as
Miller-Fischer syndrome
Signs of GBS (4)
Hypotonia
Flaccid paralysis ( = weakness/paralysis & ↓ muscle tone)
Altered sensation/numbness
Fasciculations
Symptoms of GBS (6)
Peripheral neuropathy
Progresses acutely
Ascending paraesthesia & pain
Symmetrical limb weakness
Can also cause facial nerve palsy
Can also have autonomic symptoms (urinary retention, ileus)
If this progresses to resp. paralysis, patients might need ventilatory support
Ix for GBS (4)
Nerve conduction studies
Lumbar puncture
Spirometry
Bloods
How often should you perform spirometry in a GBS patient
Every 6 hours
What do you see in the nerve conduction study of a GBS patient
Decreased nerve conduction
What do you see in the lumbar puncture of a GBS patient (3)
Albuminocytological dissociation (a hallmark of demyelinating polyneuropathies)
↑ protein (reflects CNS inflammation)
normal glucose & cell count (due to no infection)
What are you looking for in the bloods of a GBS suspected patient
Anti-ganglioside AB’s (Miller-Fischer variant)
Which AB is present in Miller-Fischer variant GBS
anti-ganglioside
Define hydrocephalus
Excessive accumulation of CSF in the ventricular
system in the brain.
Epidemiology of hydrocephalus
Bimodal distribution (affects the young & elderly)
Pathophysiology of hydrocephalus
Bc you have excess CSF, the ICP increases. CSF also permeates through the ependymal lining into the periventricular white matter. This results in white matter damage and gliotic scarring.
What is the difference between a communicating and non-communicating hydrocephalus
Non-communicating
/Obstructive - Caused by CSF flow obstruction
Communicating
↓ absorption, ↑production of CSF
What is a normal pressure hydrocephalus
Idiopathic chronic ventricular enlargement but without significantly elevated CSF pressure measured via lumbar puncture
What is a hydrocephalus ex vacuo
ventricular expansion 2ary to to compensate for brain atrophy (eg in AD)
What are the four types of hydrocephalus
Communicating
non-communicating
normal pressure
ex vacuo
Causes of non-communicating hydrocephalus (5)
Stenosis of the cerebral aqueduct
Stenosis of the interventricular foramina
Lesions in 3rd, 4th ventricle
Posterior fossa lesions (tumour, blood) compressing the 4th ventricle
These cause an obstruction in the flow of the CSF flow
Causes of communicating hydrocephalus (3)
Tumours
Meningitis (typically TB)
Normal pressure hydrocephalus
What is a communicating hydrocephalus
: the problem is outside the ventricular system – for example, it can be due to reduced absorption or blockage of the venous drainage system or due to increased CSF production
Acute onset presentation of hydrocephalus (4)
Nausea & vomiting
Headache
Papillooedema
Chronic onset presentation of hydrocephalus (4)
Cognitive impairment
Unsteady gait
Double vision
CN palsies
Normal pressure hydrocephalus presentation (3)
Cognitive impairment
Gait apraxia
Hyperreflexia
Hydrocephalus Ix (2)
CT/MRI Head – 1st line Ventricular enlargement Might show the cause (eg tumour) CSF analysis From ventricular drain May show infection
What must you assess before a LP
ICP
What is a radiculopathy
Compression of a nerve root as it exits the spinal cord
Causes of spinal cord compression (7)
Trauma Tumours Osteoporosis, Corticosteroid Tx Osteomalacia, Osteomyelitis Intervertebral disc disease (disc herniation)
Presentation of spinal cord compression (motor 3, sensory 2, autonomic 3)
Motor
Limb weakness (hemiplegia/paraplegia)
UMN symptoms below the level of the lesion
LMN symptoms at the level of the lesion
Sensory
Sensory loss below a specific level
Back pain
Autonomic
Constipation
Urinary retention
Erectile dysfunction
Ix for cord compression (8)
MRI or CT (MRI is Definitive)
Bloods - FBC, U&Es, calcium, ESR, immunoglobulin
electrophoresis (multiple myeloma)
Urine - look for Bence Jones proteins (multiple myeloma)
What do you look for in the urine in multiple myeloma
Bence Joyce proteins
What is a Bence Joyce protein
Protein found in urine in MM
What do you do to investigate MM (2)
Urine Bence Joyce protein and Ig electrophoresis
Define cauda equina syndrome
Lumbosacral nerve roots that form the cauda
equina in the spinal canal become compressed
Causes of cauda equina (3)
Lumbar disc herniation
Tumours
Epidural abscess
Presentation of cauda equina (4)
LMN symptoms
Perianal anaesthesia
Bladder retention
Leg weakness
What is sciatica
Lumbosacral nerve root impingement
Presentation of sciatica (motor and sensory)
Motor: LMN symptoms for the muscles innervated by this spinal root
Sensory: DERMATOMAL pattern
Pain, numbness
Causes of radiculopathy (5)
Degenerative disc disease, osteoarthritis, spondylolisthesis, tumours, infection
Define spondylolisthesis
forward displacement of a vertebra on the one below producing pain by compression of the nerve roots
What is forward displacement of a vertebra on the one below producing pain by compression of the nerve roots known as
Spondylolisthesis
How to diagnose sciatica
straight leg raise test: If pain in the distribution of the sciatic nerve is reproduced on passive flexion of the straight leg at the hip between 30-70 degrees then it is considered a positive sign (Lasegue’s sign)
This test is sensitive but not very specific
A 21-year-old woman presents to A & E with acute onset of left-sided body twitching, lasting for 5 minutes, after a minor accident in which she hit her head. She reports 3 similar episodes in the past month, after her boyfriend broke up with her. Past-medical history includes IBS for which she takes laxatives. Physical examination, laboratory investigations and imaging studies are normal.
What is the most likely diagnosis?
Dissociative seizure Simple partial seizure Vasovagal episode Todd’s palsy Myoclonic seizure
Dissociative seizure
What is a dissociative seizure
can resemble epileptic seizures
but have NO biological correlate.
When should you suspect dissociative seizure (4)
Suspect Dissociative seizures if:
Prolonged duration
Hx of abuse, psychological or emotional precipitants
Explain GCS scoring
Eyes 4 spontaneous 3 to speech 2 to pain 1 no response
Verbal response 5 oriented to time, person and place 4 confused 3 inappropriate words 2 incomprehensible sounds 1 no response
6 obeys command 5 moves to localised pain 4 flex to withdraw from pain 3 abnormal flexion 2 abnormal extension 1 no response
