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3B > Neurology 2 > Flashcards

Neurology 2 Flashcards

1
Q

Shingles aetiology

A

VZV reactivation

Immunosuppression

  • Elderly
  • HIV
  • Steroids
  • Chemotherapy
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2
Q

Shingles presentation

A

Pre-eruptive

  • Itching and burning
  • Paraesthesia
  • B-symptoms

Painful rash - Dermatomal!
- Clusters of small vesicles

Herpes zoster ophthalmicus - Ophthalmic branch of trigeminal

  • Visual loss
  • Needs urgent referral
  • Hutchinson sign - Rash on nose
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3
Q

Shingles management

A

Acyclovir - Within 72 hours

Pain relief

  • Paracetamol
  • Ibuprofen
  • Gabapentin
  • Pregabalin
  • Amitriptyline

Housekeeping

  • Contagious - Chickenpox
  • Vaccine offered 70-79
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4
Q

Bell’s palsy aetiology

A

Facial nerve paralysis - Acute, unilateral
Ipsilateral LMNL

Infection - EBV / HSV 
SOL - Parotid tumour
GBS
Forceps delivery
Increased risk in pregnancy and DM

VZV - Ramsay Hunt syndrome

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5
Q

Bell’s palsy presentation

A

CN7 palsy

  • Speech disturbance
  • Eating disturbance
  • Dry eyes
  • Taste - Loss of anterior 2/3 tongue
  • Post-auricular pain/numbness
  • Hearing - Hyperacusis
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6
Q

Bell’s palsy investigations and management

A

Serology - VZV
CT/MRI

Management - Prednisolone + protect the eye
- Consider antivirals

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7
Q

GBS pathophysiology

A

Immune-mediated
Demyelination of PNS

Triggered by infection
Campylobacter jejuni

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8
Q

GBS presentation

A

AAAAA - Symmetrical

Ascending weakness - Proximal muscles
Absent reflexes 
Autonomic dysfunction 
- Urinary retention
- Tachycardia 
- Arrhythmias
Abnormal eyes - Diplopia
Ataxia

Paraesthesia
Respiratory depression

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9
Q

GBS investigations

A

Nerve conduction studies

Anti-ganglioside antibodies
Spirometry
LP - Protein ^
ECG - Arrhythmias

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10
Q

GBS management and complications

A

IV IG
ECG - Monitor arrhythmias
VTE prophylaxis

Severe - Plasmapheresis

Complications

  • Respiratory depression
  • Death
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11
Q

MS aetiology

+ Twins?

A

Cell-mediated AI disorder
Demyelination in CNS

3x more common in women
Aged 20-40

Monozygotic twin with MS = 30% risk
Dizygotic twin with MS = 2% risk

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12
Q

MS types

A

Relapsing-remitting - Most common

  • Acute attacks followed by periods of remission
  • 65% develop secondary progressive after 15 years

Secondary progressive

  • Relapsing-remitting patients who have deteriorated
  • Signs/symptoms present between relapses
  • Gait and bladder disorders

Primary progressive - 10%

  • Progressive deterioration from onset
  • More common in elderly
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13
Q

MS presentation

A

Visual
- Optic atrophy
- Uhthoff’s phenomenon - “Worse after a bath”
Internuclear ophthalmoplegia

Sensory

  • Numbness / paraesthesia
  • Trigeminal neuralgia
  • Lhermitte’s - Limb paraesthesia with neck flexion

Motor - Spastic weakness - Most common in legs
Cerebellar - Ataxia - Usually in acute relapse

Urinary incontinence
Sexual dysfunction
Intellectual deterioration

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14
Q

MS investigations

A

MRI - 2 lesions disseminated in time and space

LP - Oligoclonal bands

Anti-MOG antibodies

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15
Q

MS management

A

Acute - Methylprednisolone - 5 days

Chronic

  • Beta-interferon
  • Glatiramer acetate
  • Natalizumab
  • Fingolimod

Symptom control

  • Muscle relaxant - Baclofen
  • Tremor - BB
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16
Q

MG aetiology

A

AI disorder
Antibodies to acetylcholine receptors
More common in women

Exacerbations caused by…

  • Drugs - BB, opioids, gent, Li
  • Pregnancy
  • Infection
  • Change in environment
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17
Q

MG presentation

A

Weakness and fatigability!

Eyes

  • Diplopia
  • Ptosis
  • Peek sign - Gentle sustained lid closure, then separate

Bulbar - D

  • Dysphagia
  • Dysphasia
  • Difficulty chewing

Proximal weakness
Normal reflexes

“Can’t walk upstairs”
“Difficulty watching TV - Eyes get tired”

Ask them to count to 50 - Voice trails off!

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18
Q

MG investigations

A

Electromyography - Decreased evoked potentials

Anti-MuSK antibodies
Anti-AchR antibodies

CT - Thymoma
Spirometry

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19
Q

MG management and complications

A

Pyridostigmine
Prednisolone
Azathioprine

Complications - Respiratory

Lambert-Eaton syndrome - Associated with SCLC

  • Repeated muscle contraction
  • Increased strength
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20
Q

Myasthenic crisis

A

Known MG
Increasing generalised or bulbar weakness
Respiratory depression

Management

  • Intubation / ventilation
  • Plasma exchange - 2-3 sessions
  • IVIG - 4-5 days
  • Prednisolone
  • Eculizumab
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21
Q

MND aetiology

A

Apoptosis of motor neurons - SOD1 mutation

ALS - Most common - Mixed

  • UMN + LMN
  • Loss of neurons in motor cortex

Progressive muscular atrophy - LMN - Distal to proximal

Primary lateral sclerosis - UMN

Progressive bulbar palsy

  • Facial muscles, tongue, muscles of chewing/swallowing
  • Loss of function of brainstem motor nuclei
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22
Q

MND presentation

UMN + LMN

A

UMN

  • Upgoing plantars
  • Increased reflexes
  • Clonus
  • Spasticity

LMN

  • Fasciculations
  • Decreased reflexes
  • Wasting
  • Atrophy

Asymmetrical + Purely motor = ?MND

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23
Q

MND presentation

Bulbar + Limb

A

Bulbar - D

  • Dysphagia
  • Dysphasia
  • Dysarthria
  • Drooling
  • Emotionally labile

Limb

  • Foot drop
  • Asymmetrical weakness
  • Wasting - Thenar + Ant. tibialis

Asymmetrical + Purely motor = ?MND

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24
Q

MND complications

A

Speech difficulties
Aspiratory pneumonia
Respiratory failure

UTI
Constipation

Immobility complications - Skin ulcers

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25
Q

MND investigations

A

Clinical diagnosis

El Escorial diagnostic criteria

EMG

  • Decreased action potential
  • Increased amplitude
26
Q

MND management and prognosis

A

Symptom control

Spasticity - Baclofen
Feeding - NG/PEG
NIV - BiPAP
Respiratory failure - Opioids

MDT

  • PT
  • OT
  • SALT

Riluloze prolongs life by 3 months

Prognosis - 2-4 years

  • 50% die within 3 years
  • Respiratory failure
27
Q

Meningitis aetiology

A

Neonates - GBS / E.Coli

Children / adults - NM / Strep P

Viral

  • HSV
  • EBV
  • Mumps
  • Adenovirus
28
Q

Meningitis presentation

A
  1. Neck stiffness
  2. Fever
  3. Headache

Photophobia
Non-blanching purpuric rash
Kernig’s sign
Brudzinski’s sign

Late presentation…

  • Seizures
  • FND
  • Coma
29
Q

Meningitis investigations

A

Sepsis 6

LP - CI if ICP ^ 
Blood cultures
PCR virus
FBC
U&E
CRP/ESR
Glucose
ABG
30
Q

Meningitis CSF findings

A

Bacterial

  • Cloudy
  • PMNs ^
  • Protein ^^^
  • Glucose - LOW

Viral

  • Clear
  • Lymphocytes
  • Protein ^
  • Glucose - Normal / Low

TB

  • Cloudy / Fibrin web
  • Monocytes
  • Protein ^^^
  • Glucose - Very LOW
31
Q

Meningitis management

A

Community - IM BENPEN
IV Cef

Listeria - Amox

Household contact - Rifampicin

Paediatrics
< 3 months - IV Amox + Cef
> 3 months - IV Cef
- Fluids
- Cerebral monitoring

Notify PHE!

32
Q

Meningitis complications

A

Sensorineural deafness
Abscess
Septicaemia

33
Q

Encephalitis aetiology

A

Inflammation of cerebral cortex

HSV
Enterovirus
HIV
Mumps
Measles - Spontaneous sclerosing panencephalitis 
Lyme disease
TB
34
Q

Encephalitis presentation

A
  1. Personality changes
  2. Fever
  3. Headache

FND
ICP ^
Seizures
Coma

FND + Personality changes = Encephalitis (vs Meningitis)

35
Q

Encephalitis investigations and management

A

LP - Viral picture

  • Clear
  • Lymphocytes
  • Protein ^
  • Glucose - Normal or LOW

Bloods - Culture, PCR, clotting, ESR

EEG
MRI - Temporal lobe involvement?

Management - IV acyclovir

36
Q

Horner’s syndrome aetiology

A

STC!

Central - S

  • Stroke
  • MS

Preganglionic - T

  • Tumour
  • Thyroidectomy
  • Trauma

Post-ganglionic - C

  • Cluster headache
  • Cavernous sinus thrombosis
  • Carotid dissection
37
Q

Horner’s syndrome presentation

A

Ptosis
Miosis - Small pupil
Anhidrosis - Unilateral loss of sweating
Enophthalmus - Sunken eye

38
Q

Horner’s syndrome investigations and management

A

Apraclonidine - Affected eye does not dilate
CT - Suspected tumour
CXR - Pancoast tumour

Management - Treat cause

39
Q

Anterior cord syndrome aetiology

A

Ischaemia of the anterior spinal artery

  • Branch of vertebral artery
  • Comes from aorta

Most commonly due to aortic compromise

  • Dissection
  • Aneurysm
  • Vasculitis
40
Q

Anterior cord syndrome presentation / investigations / management

A

Paralysis
Loss of pain and temperature sensation
Fine touch preserved - Dorsal column intact
Areflexia

Autonomic failure

  • Urinary/bowel
  • Sexual dysfunction

Investigations - CT angiography

Management - Treat cause

41
Q

Cerebellar disorders aetiology

A

Vitamin D

Vascular - Stroke
Infection - Meningitis, encephalitis, VZV, mumps
Trauma 
AI 
Metabolic - B12, thiamine, hypothyroid, hypoPTH
Idiopathic
Neoplasm
Degnerative
Drugs - Li, phenytoin, isoniazid, Met.
42
Q

Cerebellar disorders presentation

A

DANISHH - P

Dysdiadochokinesis 
Ataxia - Cerebellar vermis
Nystagmus
Intention tremor
Slurred speech 
Heel-shin test
Hypotonia

Pendular reflexes

43
Q

Peripheral neuropathy aetiology

A

Motor

  • Infection
  • GBS

Sensory

  • DM
  • B12 deficiency
  • Uraemia

Alcohol
SLE
Thyroid disease
Chemo/radio

44
Q

Peripheral neuropathy investigations

A

Bloods

  • FBC
  • U&E
  • LFT
  • Toxicology
  • Cultures - Infection?
  • Anti-Ro / Anti-La - SLE?

Nerve conduction studies - GBS?

45
Q

Neurofibromatosis

A

Type 1 - Ch17 - AD

  • SKIN LESIONS
  • CAFE AU LAIT SPOTS
  • Axillary freckles
  • Optic lesions
  • Scoliosis
  • Phaemochromocytoma

Type 2 - Ch20 - AD

  • TUMOURS
  • B/L ACOUSTIC NEUROMAS
  • Ependymomas
  • Schwannomas
  • Meningiomas
46
Q

Brain tumours aetiology

A

Metastatic - Most common - Non-surgical

  • Lung - Most common
  • Breast
  • Bowel
  • Skin - Melanoma
  • Kidney
47
Q

Glioblastoma multiforme

A

Most common primary tumour

Imaging

  • Solid tumour
  • Central necrosis
  • Rim enhances contrast
  • BBB disruption - Vasogenic oedema

Histology - Pleomorphic with necrotic areas

Management

  • Surgical excision
  • Chemo/Radio
  • Dex - Reduce oedema

Prognosis - Poor - 1 year

48
Q

Meningioma

A

Second most common primary tumour
Benign extrinsic
Arise from dura mater

Cause symptoms by compression rather than invasion

Typical locations

  • Falx cerebri
  • Superior sagittal sinus
  • Convexity
  • Skull base

Histology

  • Spindle cells in concentric whorls
  • Calcified psammoma bodies

Investigations - CT/MRI
Management - Surgery ± Chemo/Radio

49
Q

Vestibular schwannoma

A

Benign
Arises from CN8 - Vestibulocochlear
Associated with NF2

Clinical features

  • Hearing loss
  • Facial nerve palsy (compression)
  • Tinnitus

Histology

  • Antoni A or B patterns
  • Verocay bodies - Acellular areas surrounded by nuclear palisades

Management - Surgery ± Chemo/Radio

50
Q

Pliocytic astrocytoma

A

Most common primary brain tumour in children

Histology - Rosenthal fibres
Corkscrew eosinophilic bundle

51
Q

Pituitary adenoma

A

Benign tumour of pituitary gland
Secretory or non-secretory

Microadenomas < 1cm
Macroadenomas > 1cm

Clinical features

  • ACTH - Cushing’s
  • GH - Acromegaly
  • Bitemporal hemianopia

Investigations

  • CT/MRI
  • Pituitary blood profile

Management - Hormonal / surgical

52
Q

Brain abscess aetiology

A

VITAMIN DC

V - CHD - R-L shunting
Infection - OM, dental, meningitis, endocarditis, mastoiditis, HIV, IVDU
Trauma/surgery
AI - DM, chronic granulomatous disease
M 
Iatrogenic - Haemodialysis
N

D
C - Prematurity

53
Q

Brain abscess clinical features

A

Depends on site

Headache - Dull and persistent
Meningism
CN palsy - 3 or 6
Kernig / Brudzinski +ve
Fever

Neonates - Increasing head circumference / bulging fontanelle

54
Q

Brain abscess investigations

A

Sepsis 6
FBC - WCC ^
ESR / CRP ^
Blood cultures

Leucocytosis!

CT / MRI - Halo around lesion

Neonates - USS head

55
Q

Brain abscess management

A

Surgery - Craniotomy + Debridement
IV abx - Cef + Met
ICP management - Dex

56
Q

Myopathies aetiology

A

Inflammatory - Polymyositis

Inherited

  • Duchenne’s / Becker’s
  • Myotonic dystrophy

Endocrine

  • Cushing’s
  • Thyrotoxicosis

Alcohol

57
Q

Myopathies clinical features

A

Symmetrical weakness - Proximal to distal
Difficulty standing from sitting
Difficulty getting out of bath

Normal sensation
Normal reflexes
No fasciculations

58
Q

Duchenne’s aetiology

A

Progressive generalised muscle disease
X-linked

Becker muscular dystrophy is a milder form!

59
Q

Duchenne’s clinical features

A

Lower limbs - Flexion > Extension
Delayed motor milestones - Ambulation > 18 months
Gower’s sign - Use of arms to stand from squatting

Contractures
Decreased tone/reflexes
Toe walking

Normal sensation
Urinary and bowel incontinence

Intellectual impairment
Associated with dilated cardiomyopathy

60
Q

Duchenne’s investigations

A

Serum CK - 50-100x normal level

Genetic testing - Xp21 mutation

61
Q

Duchenne’s management and prognosis

A

Prednisolone
PT

Surgery for contractures

LVEF < 40-50% - Cardioprotective drugs

  • Carvedilol
  • Perindopril
  • Lisinopril
  • LVAD

Prognosis - 40 year survival - 10-40%
- Progressive respiratory weakness - Treated with NIV

3B (23 decks)

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