Week 12 - Neurology Flashcards
What is internuclear ophthalmoplegia?
Disorder of conjugated gaze.
Lesion of medial longitudinal fascicles (connects CN III and VI)
What is herpes zoster ophthalmic? (shingles)
Painful skin rash with vesicles
V1 (ophthalmic) dermatomal distribution
Conjuctivitis, iritis, uvitis, keratitis
What are seizure?
A sustained or synchronised electrical discharge in the brain causing signs and symptoms
Define relapse and how would you manage it.
New neurological deficits, lasting more than 24 hours, in the absence of infection or pyrexia
IV methylprednisolone 3 days or oral for 5 days. + PPi
Define pseudo-relapse
Re-emergance of previous neurological symptoms or signs related to an old area of demyelination in the context of infection or pyrexia
Define stroke
Rapid onset cerebral deficit (usually focal) lasting more than 24 hour or leading to death, with a vascular cause.
What investigation would you perform to confirm MS?
MRI brain and cervical spine with gadolinium contrast.
Must be in at least 2 areas:
Periventricular
Infratentorial (cerebellum)
juxtacortical (Grey:white matter junction)
Spinal cord
What is a TIA?
A brief period of neurological dysfunction due to a temporary focal cerebral/retinal ischaemia without infarction e.g. weak limb, aphasia or loss of vision. It usually lasts seconds or minutes and completely resolves.
What symptoms would a person experience if the large vessel stroke was to the MCA?
Arm weakness > leg
Right MCA - neglect, apraxia, anosognosia, topographical difficulty
Left MCA - aphasia (can’t understand)
What symptoms would a person experience if the large vessel stroke was to the ACA?
Leg > arm
muteness, abulia
What symptoms would a person experience if the large vessel stroke was to the PCA?
Hemianopia
Memory loss, confusion, Alexia
Where is Broca’s area located?
Posterior, inferior frontal gyrus
Where is wernicke’s area located?
Posterior of the superior temporal gyrus
What is an ischaemic stroke?
85%
Cerebral infarction mostly due to thromboembolic disease secondary to atherosclerosis.
20% due to thrombosis from the heart (AF)
20% thrombosis in situ (intrinsic(
What is a haemorrhage stroke?
15%
Either die to a brain aneurysm burns or a weakened blood vessel leak. Blood seeps round the brain causing an increase in pressure and swelling - damaging cells and tissue of the brain
What is first line treatment for an ischaemic stroke?
Alteplase - tPA within 4.5 hours
After 4.5 hours ASPIRIN
Endovascular surgery within 6 hours is effective
What are some Symptoms that might lead you to think the patient is having a brainstem stroke?
Double vision Problems swallowing Ataxia Slurred speech Facial numbness/ weakness Vertigo Hoarseness
What is a hypertensive stroke?
Spontaneous rupture of a small artery deep in the brain
Sites: basal ganglia, pins, cerebellum
What are some clinical manifestations of a cerebellar haemorrhage?
Vomiting Small sluggish pupils Altered mental status Eyes deviate to the opposite side Ataxia
Clinical manifestations of a pontine haemorrhage
Pin point but reactive pupils
Abrupt onset of coma
Ataxic breathing pattern
Decerebrating posturing or flaccidity
What are some contraindications for tPA?
Haemorrhage Recent stroke, trauma or surgery Coagulopathy SBP > 185 or DBP > 110 Glucose < 2.2 Seziures at onset of Sx
What vessels is affected in total anterior circulation syndrome and what might it manifest as?
MCA
Haemiparesis
Haemianopia
Higher cortical dysfunction
What vessels is affected in Partial anterior circulation syndrome and what might it manifest as?
Branch of the MCA
Isolated higher cortical dysfunction
and any 2 of
haemapesis, hemianopia, higher cortical dysfunction
What symptom control medication is available in secondary progressive MS
Fatigue: amantadine, modafinil
Urinary problems: oxybutynin
Spasticity: Benzodiazepine, gabapentin
Define epilsepsy
A tendency to have recurrent unprovoked seizures
What are the immediate measures taken in seizure?
Secure airways
Oxygen administration
Assess bp, pulse, RR
What drug is used to treat seizures?
Benzodiazapine
What Anti-epileptic drug inhibits VG Na channels to reduce excitability?
Carbamezapine, lamotrigine, oxcarbazepine
What anti-epileptic increases K efflux at the pre-synpatic terminal?
Retigabine
What Anti-epileptic drug inhibits SV2A?
Levetriacetam
What Anti-epileptic drug inhibits VG Ca?
Pregabalin, gabapentin
What drug inhibits the GABA transporter?
Tiagabine
What drugs inhibit GABA metabolism?
Vigabatrin
Valporate
What drugs increase GABA receptor activity?
Benzodiazapine
Barbiturates
Felbamate
Topiramate
What symptoms might be experienced in a subarachnoid haemorrhage?
LOC, Seizures, neck stiffness, sentinel headache, speech and limb disturbances, visual disturbances
What tests might you do in subarachnoid haemorrhage?
CT
LP- cell count, Xanthochromia (CSF yellowy)
Define dementia
Chronic, progressive cognitive decline due to brain disease
What are some Sx of dementia?
Cognitive impairment (language, memory, calculation)
Psychiatric or behavioural disturbances
Affects activities of daily living - cooking, bathing, dressing
Acetylcholinesterase inhibitors are used in the treatment of dementia, to increase ACh, give e.g’s.
Galantamine, donepizil, rivastigmine
cardiac adverse effects (so need a baseline ECG before), peptic ulcers, dizzy, fatigue
What is the action of memantine?
NMDA receptor antagonist
Improves memory by restoration of homeostasis in the glutaminergic system.
How would you define BPSD (behavioural and psychological symptoms of dementia)
Sx of disturbed mood, perception and behaviour
Define parkinsons
A neurodegenerative disorder of the basal ganglia. loss of dopaminergic neutrons in the substanitia nigra
What areas are involved in the different stages of Parkinson’s?
Stage 1-2 - pons, medulla, anterior olfactory nucleus = LOSS OF SMELL
Stage 3-4 - midbrain, sunstantia nigra (pars compacts) = Parkinsonism
Stage 5-6 - neocortex involvement = Parkinson’s dementia
What investigation shows abnormality in degenerative Parkinsonism.
DAT SPECT (MRI)
What are some red flags for headaches? (SNOOP)
Systemic symptoms, seizures, secondary risk factors
neurological Sx
Rapid onset, age onset
progressive, papilloedema, precipitated by cough, exertion, sleep
Define migraine
A severe headache described as throbbing pain at the front or side of the head
What is a cluster headache?
A series of relatively short but extremely painful headaches every day for weeks to months at a time
Give some characteristics of a tension headache
Bilateral Pressing or tightening Not aggravated by physical activity no nausea or vomiting no photophobia or phonophobia at least 10 episodes at least 1 time per month
Give some characteristics of a migraine
throbbing pain last 4-72 hours unilateral pulsating aggravated by physical activity N&V, photophobia
What medication might you use in chronic migraine?
> /=15 headache days per month, 8 oh which are migraine days
Erenumab - CGRP inhibitor
Onabotulinumtoxin A
What is impaired executive function?
Impaired reasoning and handling of complex tasks, poor judgment
What is impaired visuospatial function?
Inability to recognise faces or common objects or to find objects in direct view despite good acuity
What domains does the addenbrookes cognitive exam test?
Memory, attention/concentration, visuospatial, language, executive function
What syndromes may develop into MS?
Optic neuritis, transverse myelitis, clinically isolated syndromes, radiologically isolated syndromes
What is first line for an acute relapse and in secondary progressive in MS?
Methylprednisolone IV 3 days or oral 5 days + PPi (gastro protection)
What is first line treatment in RR MS?
Interfernon (beta-interferons, glatiramer acetate)
Dimethyl fumarate
What might trigger Guillain barre syndrome (acute inflammatory demyelinating neuropathy)?
CMV, EBV, campylobacter jejuni**
Progressive symmetrical ascending muscle weakness
Steroids and IV Ig
How would you grade the results from a MMSE?
24-30 - no cognitive impairment
18-23 - mild cognitive impairment
0-17 - severe cognitive impairment
What are some complications of a SAH?
Endovascular coil or neurosurgical coiling
Hydrocephalus (shunt)
Hyponatraemia (CSWS or SIADH - Hypertonic saline or fludrocortisome)
Haemorrhage
Delayed ischaemia
A patient who just had a SAH has progressive deterioration in consciousness (delayed ischamia, a complications) how would you manage?
Colloids - fluid management
Nimodipine to prevent vasospasm
Angioplasty
When is MS diagnosed?
When there is 2 or more episodes of demyelination dissemination in time and space
How would you treat secondary progressive MS?
Methylprednisolone
Natalizumab is a monoclonal Ab that can be used 2nd line to treat RR MS, what is a risk?
JC virus - Progressive multifocal leukencephalopathy
What may indicate a previous optic neuritis?
Red desaturation, optic disc pallor and so atrophy, relative afferent pupillary defect
How might Total anterior circulatory syndrome present?
Higher cortical dysfunction (aphasia, neglect)
Homonymous Hemianopia
Hemiparesis
MCA or ICA occlusion
How might Partial anterior circulatory syndrome present?
Isolated Higher cortical dysfunction OR
Any 2 of: Homonymous Hemianopia, Hemiparesis, higher cortical dysfunction
Branch of MCA
How might Posterior circulatory syndrome present?
Isolated hemianopia OR brain stem syndrome (ipsilateral CN III palsy)
How might lacunar syndrome present?
Pure motor or Pure sensory, ataxic hemiparesis
What is Status Epilepticus?
Medical emergency
Tonic clonic seizures lasting >5 min or >2 in 1 hour
What is 1st line for focal seizures?
Lamotrigine or carbamazepine
then Levetriacetam
What is 1st line for generalised seizures?
Sodium valproate
then Lamotirgine or Carbamazepine
What Autonomic Sx may you get in Parkinson’s?
U CrEEP Urinary urgency/ nocturne Constipation Erectile dysfunction Excessive sweating/ salivation Postural instability
What Neuropsychiatric Sx may you get in Parkinsons?
DAD
Depression, anxiety, dementia
What is Parkinsons?
Functional imaging - DAT SPECT
Neurodegenerative disorder of the basal ganglia. Loss of dopaminergic neurones in the Pars compacta of the substantial nigra
What are some red flags for headaches?
SSSNOOPPP
Systemic features, Secondary risk factors, Seizures
Neurological Sx
Age onset >50, rapid onset
Papilloedema, Precipitated (cough, eversion, sleep), progression
What is 1st line in migraine?
Sumatriptan PO (or Zolmitriptan) if vomiting - Metoclopramide or prochlorperazine
