Clinical Neurology Flashcards
(432 cards)
1
Q
what immune cells are abundant in the subarachnoid space in pyogenic meningitis?
A
neutrophils
2
Q
what is encephalitis?
A
inflammation of the brain
3
Q
what is meningitis?
A
inflammation of the meninges
4
Q
what is meningoencephalitis?
A
inflammation of the brain and meninges
5
Q
what is myelitis?
A
inflammation of the spinal cord
6
Q
what time of year is viral meningitis most common?
A
late summer/autumn
7
Q
how could you diagnose suspected viral meningitis?
A
viral stool culture
throat swab
CSF PCR
8
Q
what is the treatment for viral meningitis?
A
generally self limiting
9
Q
what is the most common type of virus to cause viral meningitis?
A
enteroviruses
10
Q
what is the treatment for viral encephalitis caused by herpex simplex?
A
IV high dose aciclovir
within 6 hours of admission
11
Q
what is the treatment for viral encephalitis?
A
IV high dose aciclovir
12
Q
what is meningismus?
A
a triad of photophobia, headache and neck stiffness
13
Q
why does meningismus occur?
A
caused by irritation of the meninges
14
Q
what are the 3 main investigations you would do for suspected viral encephalitis?
A
lumbar puncture
electroencephalogram
MRI
15
Q
what pre-emptive treatment should you start for suspected viral encephalitis? (even before investigations)
A
IV aciclovir
16
Q
what are the 3 most common bacterial causes of meningitis in neonates?
A
listeria
group B strep
E. coli
17
Q
what is the most common bacterial cause of meningitis in children?
A
Haemophilus influena
18
Q
what is the most common bacterial cause of meningitis in 10-21 year olds?
A
meningococcal
19
Q
what are the most common bacterial causes of meningitis in the 21+ age group?
A
pneumococcal (top)
meningococcal
20
Q
what are the most common bacterial causes of meningitis in the the elderly?
A
pneumococcal (top)
listeria
21
Q
what are the most common causes of bacterial meningitis in immunocompromised patients?
A
listeria
pneumococcal
meningococcal
gram negative rods
22
Q
what are the most common causes of bacterial meningitis in patients with neurosurgery or opened head trauma?
A
staph
gram negative rods
23
Q
what is the most common cause of bacterial meningitis in patients with a fracture of the cribriform plate?
A
pneumococcal
24
Q
what are the most common causes of bacterial meningitis in patients with a basilar skull fracutre?
A
pneumococcal
haemophilus influenza
group A strep
25
what are the most common causes of bacterial meningitis in patients with a CSF shunt?
staph
gram negative rods
P. acnes
26
what are the 3 main potential origins of the bacteria causing meningitis?
1. nasopharyngeal colonisation
2. direct spread (ie parameningeal foci or skull fracture)
3. remote foci of infection
27
what cause of meningitis occurs specifically in patients with AIDS?
cryptococcus neoformans (fungal)
28
how does bacteria from the nasopharynx gain access to the brain?
via bloodstream
29
what bacteria causes meningococcal meningitis?
neisseria meningitis
30
what causes the symptoms of meningococcal meningitis?
endotoxin from the bacteria
31
what is the most common cause of meningitis in children under 4 years old?
H. influenzae B
32
how many types of haemophilus influenza are there?
6
| A-F
33
what type of vaccine is available against haemophilus influenza B?
conjugated vaccine
34
what bacterial causes pneumococcal pneumonia?
Strep. pneumoniae
35
what kind of bacteria is listeria?
gram positive bacilli
36
what is the antibiotic of choice for listeria meningitis?
IV ampicillin/amoxicillin
37
what are the 3 main clinical signs of bacterial meningitis?
fever
stiff neck
alteration on consciousness
38
what is CSF pleocytosis?
increased cell count in the CSF
39
what is CSF leukocytosis?
increased white blood cell count in the CSF
40
what are the 4 investigations you should do for suspected bacterial meningitis?
blood cultures
throat swab
blood EDTA for PCR
lumbar puncture
41
what cells are found in the CSF in viral, bacterial and TB causes of meningitis?
viral and TB- lymphocytes
| bacterial- polymorphs
42
will you be able to find a gram stain in the CSF in viral, bacterial and TB causes of meningitis?
viral- no
bacterial- yes
TB- yes or no
43
will you be able to find a bacterial antigen in the CSF in viral, bacterial and TB meningitis?
viral- no
bacterial- yes
TB- yes or no
44
what is the protein within the CSF like in viral, bacterial and TB meningitis?
viral- normal or slightly high
bacterial- high
TB- high or very high
45
what is the glucose within the CSF like in viral, bacterial and TB meningitis?
viral- normal
bacterial- less than 70% of blood glucose
TB- less than 60% of blood glucose
46
describe the CSF of 'aseptic meningitis'?
low number of WBC
minimally elevated protein
normal glucose
47
what imaging should be performed on all patients with suspected bacterial meningitis with papilloedema or focal neurological signs?
CT scan
48
what are the 6 criteria to undergo a CT prior to lumbar puncture?
- immunocompromised
- history of CNS disease
- new onset seizure
- papilloedema
- abnormal level of consciousness
- focal neurological deficit
49
when is a lumbar puncture not indicated for a patient with suspected bacterial meningitis?
- clear contraindication
| - confident clinical diagnosis of meningococcal infection with a typical meningococcal rash
50
what is the empiric antibiotic therapy for suspected bacterial meningitis?
- IV ceftriaxone
| - add IV ampicillin/amoxicillin if listeria suspected
51
what is the empiric antibiotic therapy for suspected bacterial meningitis in a patient with a penicillin allergy?
- IV chloamphenicol and IV vancomycin
| - IV co-trimoxazole alone if listeria suspected
52
in addition to antibiotics, what other medication should you give to all patients with suspected bacterial meningitis?
IV corticosteroids
53
what are the contraindications to giving steroids in suspected bacterial meningitis?
post-surgical meningitis
severe immunocompromise
meningococcal or septic shock
patients who are hypersensitive to steroids
54
what are the 3 options for contact prophylaxis for bacterial meningitis?
rifampicin
or ciprofloxacin (not in children)
or ceftraixone
55
what is the pathological hallmark of parkinsons disease?
dopaminergic neuron loss in the substantia nigra of the basal ganglia and Lewy body pathology
56
what are the 4 main classes of movement disorders?
pyramidal/UMN features
hyperkinetic
hypokinetic
ataxia
57
where within the brain is the injury if there are pyramidal/UMN features?
corticospinal/pyramidal tract
58
where within the brain is the injury if there are hyperkinetic features?
basal ganglia (extrapyramidal)
59
where within the brain is the injury if there are hypokinetic features?
basal ganglia (extrapyramidal)
60
where within the brain is the injury if there is ataxia?
cerebellum
61
what are the 3 main features of parkinsonian syndrome?
- rigidity
- bradykinesia/akinesia
- resting tremor
62
what is dystonia?
prolonged muscle spasms and abnormal postures
63
what is chorea?
movements flowing irregularly fro one body segment to another- looks like dancing
64
what is ballismus?
chorea but the movements have a larger amplitude
65
what are the broad 2 subtypes of parkinsons disease?
tremor dominant PD
| non-tremor dominant PD
66
compare tremor dominant and non-tremor dominant PD in terms of motor symptoms?
tremor dominant PD has a relative absence of other motor symptoms
non-tremor dominant has other motor symptoms
67
compare tremor dominant and non-tremor dominant PD in terms of rate of progression and functional disability?
tremor dominant PD has a slower rate of progression and less functional disability
68
what special sense can be affected in parkinsons disease?
smell
| -hyposmia or anosmia
69
what sleep disorder can occur in parkinsons disease?
rapid eye movement sleep behaviour
70
what investigation is needed to diagnose rapid eye movement sleep behaviour?
overnight polysomnography with electromyogram
71
what is the requirement for the diagnosis of parkinsonian syndrome?
muscular rigidity
4-6Hz resting tremor
postural instability (not caused by primary visual, vestibular, cerebellar or proprioceptive dysfunction)
72
what are lewy bodies?
misfolded alpha-synuclein, which aggregate
73
what is the greatest risk factor for parkinsons disease?
age
74
what is the classic type of rigidity seen in parkinsons?
cogwheel rigidity
75
what can happen to the voice of a patient with parkinsons?
hypophonia
76
what can happen to the handwriting of a patient with parkinsons?
progressively smaller handwriting
77
during active movement what happens to a parkinsons tremor?
goes away
78
what is the difference between rigidity and spasticity?
spasticity is velocity dependent
79
describe the gait of a patient with parkinsons?
slow, short shuffling steps
| slow turns
80
what is asthenia?
abnormal weakness or lack of energy
81
what are the 3 investigations for parkinsons disease?
- structural brain imaging
- possibly dopamine functional imaging
- levodopa challenge
82
compare an essential tremor to a parkinsons tremor?
essential tremor is symmetrical, postural or kinetic with a higher frequency
83
how does an essential tremor respond to alcohol?
goes away
84
what is the core triad of features which make up multi system atrophy?
dysautonomia
cerebellar features
parkinsonism
85
what is the most common cause of degenerative parkinsonism?
multi-system atrophy
86
when is the onset of fragile X-tremor ataxia syndrome?
late onset, above 50 y/o
87
how do you calculate the cerebral perfusion pressure?
mean arterial pressure - intracranial pressure
88
after head injury what should you aim to keep the cerebral perfusion pressure?
above 60mmHg
| ie MAP needs to be above 80mHg and ICP needs to be below 20mmHg
89
what is the normal adult intracranial pressure?
9-11 mmHg
90
what physical finding can be seen in an anterior cranial fossa fracture?
panda eyes
91
what physical finding can be seen in a middle cranial fossa fracture?
battle sign over mastoid area
92
what is the name for the cerebellum herniating through the foramen magnum?
tonsillar herniation
93
what can happen to the pupil when the ICP increases enough to compress the third cranial nerve?
dilated pupil
94
what is the lowest GCS you can get?
3
95
what is the highest GCS you can get?
15
96
how do you elicit pain to calculate the GCS?
press on medial eyebrow or supraorbital nerve
97
when calculating the GCS, if the patient flexes to pain, what can you assume is working?
basal ganglia
98
when calculating the GCS if the patient extends to pain, where is the damage?
midbrain
99
what 3 things must be true for the definition of a coma?
patient does not open eyes
patient does not obey comands
patient does not speak
100
what is the GCS of a patient in a coma?
8 or less
101
in trauma, when should you request a CT scan?
1) skull fracture
| 2) not orientated (GCS
102
what is the normal pO2?
13-15kPa
103
what is the normal pCO2?
4-4.5kPa
104
what osmotic drug can be given to reduce ICP?
mannitol or hypertonic saline
105
what are the 3 main late effects of head injury?
epilepsy
CSF leak (nose, middle ear)
cognitive problems
106
if there is CSF leak into the middle ear, what type of hearing loss might occur?
conductive hearing loss
107
what are the 4 primary brain tumours which commonly metastasise to the brain?
breast
lung
melanoma
kidney
108
what grade of astrocytoma is a glioblastoma?
glioblastoma equal astrocytoma grade IV
109
what is another name for tonsillar herniation through the foramen magnum onto the brain stem?
coning
110
what causes tonsillar herniation or coning?
increased intracranial pressure
111
why must you avoid taking a lumbar puncture in patients with increased intracranial pressure?
reduces the pressure below the brainstem -might cause herniation
112
the loss of what particular nerves causes failure of breathing after a tonsillar herniation/coning?
loss of C3,4,5 - diaphragm
113
what is the most common tumour in the cerebellum of a child?
medulloblastoma
114
why might hydrocephalus occur due to reduces CSF absorption?
scarring of arachnoid granulations secondary to inflammation (meningitis etc)
115
what is hydrocephalus?
increased intracranial pressure due to build up of CSF
116
what is the difference between missile and non-missile head injury?
missile- penetrating foreign object
| non-missile- non-penetrating
117
why is it important to determine whether the missile head injury was low or high velocity?
with high velocity injuries there is also a pressure wave which radiates out causing damage in a further radius
118
what causes injury in a non-missile head injury?
sudden acceleration or deceleration of the head causing brain to move within the cranial cavity
119
what is a coup injury and what is a contracoup injury?
coup injury- at point of impact
| contracoup injury- diametrically opposite point of impact
120
which is more serious- coup or contracoup injury?
contracup injury
121
in the timeline of a head injury, when does diffuse axonal injury occur?
at moment of injury
122
what scale represents the extent of diffuse axonal injury?
glasgow coma scale
123
what protein accumulates in diffuse axonal injury?
amyloid precursor protein
124
what are the 5 main causes for diffuse axonal injury?
```
trauma
raised ICP
hypoxia
progression of dementia
progression of inflammatory disease
```
125
what can you do to prevent extensive diffuse axonal injury following traumatic head injury?
medically induce a coma
126
what artery is usually involved in a traumatic extradural haematoma?
middle meningeal artery
127
what is a traumatic extradural haematoma usually associated with?
fracture of temporal or parietal bone
128
in an extradural haematoma, what kind of herniation can occur?
subfalcine herniation
| under falx cerebri
129
what is the normal ICP value?
5-13 mmHg
130
what is a tentorial herniation?
where the medial aspect of temporal lobes herniate over the tentorium cerebelli
131
what cranial nerve is particularly susceptible to tentorial herniation?
CN III
132
what is a transcalvarium herniation?
when brain herniates through any defect in the dura and skull
133
what are the 4 main clinical signs of rasied intracranial pressure?
papilloedema
nausea and vomiting
headache
neck stiffness
134
why do patients with a brain tumour often have a headache in the morning which gets better of the course of the day?
CO2 retention in the night causes brain to increase in size and so pushes against meninges, throughout the day the CO2 is blown off and so size of brain decreases
135
what patient group is most susceptible to brain abscesses?
IVDUs
136
what is the cause of vasogenic cerebral oedema?
defect in blood brain barrier
137
what is the most common type of cerebral oedema?
cytotoxic oedema
138
what is the cause of cytotoxic cerebral oedema?
ischaemia
139
what is the cause of hydrostatic cerebral oedema?
hypertension within cerebral blood vessels
140
what is the cause of interstitial cerebral oedema?
acute obstructive hydrocephalus
141
what is the cause of hypo-osmotic cerebral oedema?
large reduction in serum osmolality
142
what type of oedema is seen in hypertensive encephalopathy?
hydrostatic cerebral oedema
143
which part of the temporal bone does the middle meningeal artery course under?
squamous part of temporal bone
144
nontreated, nonfatal subdural haematomas are demarcated from the underlying brain by what?
neomembrane
145
what blood vessels cause subdural haemorrhages- arteries or veins?
veins (bridging veins that extend from brain into subdural space)
146
why is there progressive focal neurological signs/symptoms in a chronic subdural haemorrhage?
because venous blood leaks out slowly eventually building up pressure
147
what is he most common cause of bradykinesia?
parkinsons disease
148
if dementia procedes the motor symptoms of parkinsons disease or is present within the first year, what is the disease termed instead?
dementia with Lewy bodies
149
what is multiple sclerosis?
an inflammatory demyelinating disorder of the central nervous system
150
what are the 4 types of MS?
1. relapsing and remitting
2. secondary progressive
3. progressive relapsing
4. primary progressive
151
what happens to tone in pyramidal dysfunction?
increased tone
152
in pyramidal dysfunction do muscles become rigid or spastic?
spastic
153
in pyramidal dysfunction, are the flexors or extensors weak in the upper limbs?
extensors
154
in pyramidal dysfunction, are the flexors or extensors weak in the lower limbs?
flexors
155
what is dysarthria?
unclear articulation of speech
156
where is the problem in internuclear ophthalmoplegia?
medial longitudinal fasciculus
157
in internuclear ophthalmoplegia, is there a failure of abduction of adduction?
adduction
158
in internuclear ophthalmoplegia, is there nystagmus in the abducting or adducting eye?
abduction eye
159
what is the main symptoms of internuclear ophthalmoplegia?
diplopia
160
what 3 things can be used for fatigue/sleepiness in MS?
amantadine
modafinil (if sleepy)
hyperbaric oxygen
161
what is the name of the criteria for diagnosing MS?
McDonald criteria
162
what may be found in the CSF of a patient with MS?
oligoclonal bands
163
what is the treatment for an acute exacerbation of MS if mild?
symptomatic treatment
164
what is the treatment for an acute exacerbation of MS if moderate?
PO steroids
165
what is the treatment for an acute exacerbation of MS if severe?
IV steroids/ admit
166
what are the treatment options for spasticity in MS?
physiotherapy
oral baclofen or tizanidine
botulinum toxin
intrathecal baclofen/phenol
167
what are the treatment options for sensory symptoms in MS?
```
anti-convulsant eg gabapentin
anti-depressant eg amitriptyline
tens machine
acupuncture
lignocaine infusion
```
168
what can be used for detrusor hypersensitivity in MS?
anticholinergic eg oxybutynin
169
what type of MS does relapsing and remitting MS usually turn into?
secondary progressive MS
170
what are the first line disease modifying agents for MS?
interferon beta
copaxone
tecedria
171
what is the first line agent for relapsing and remitting MS?
tecfidera
172
what is the main side effect of tecfidera?
bowel disturbance
173
what are the second line disease modifying agents for MS?
monocloncal sntibody
| fingolimod
174
what are the major side effects of fingolimod?
cardiac problems
175
what severe side effect is associated with tysabri? (a drug use in severe relapsing and remitting MS)
progressive multifocal leukoencephalopathy
176
what is muscle tone like in REM sleep?
low muscle tone
177
do you tend to dream in REM or non-REM sleep?
non-REM
178
what is the length of a normal circadian rhythm?
25 hours
179
what is seasonal affective disorder?
when people have normal mental health throughout most of the year but experience depressive symptoms at the same time each year, usually winter
180
what is the most common REM parsomnia?
Rapid eye movement Behaviour Disorder (RBD)
181
what happens in RBD? (rapid eye movement behaviour disorder)
atonia is absent so sleeper can act out dreams, often violently and injuring themselves and bed partner
182
are sleep terrors a REM or non-REM parasomnia?
non-REM parasomnia
183
are restless legs or periodic limb movement syndrome REM or non-REM parasomnias?
non-REM parasomnias
184
what is sleep paralysis?
a phenomenon where the brain holds the body in paralysis but we are returning to conscious
185
what is a common vision which accompanies sleep paralysis?
an old hag at the edge of the bed
186
what is narcolepsy?
a neurological disorder with a decreased ability to regulate sleep cycles
187
what are the 5 main symptoms of narcolepsy?
```
excessive daytime sleepiness
cataplexy
sleep paralysis
REM behavioural disorder
hypnagogic hallucinations
```
188
what is cataplexy?
loss of muscle tone giving appearance of fainting, though patient is completely conscious
189
what is cataplexy usually brought on by?
strong emotion
190
what is the name for hallucinations which occur before you go to sleep? (abnormal)
hypnagogic hallucinations
191
what is the name for hallucinations which occur as you wake up? (normal)
hypnapompic hallucinations
192
what 3 investigations can help with diagnosing narcolepsy?
- overnight sleep study
- multiple sleep latency test
- lumbar puncture
193
what can be seen on lumbar puncture of a patient with narcolepsy?
low levels of hypocretin (a neuropeptide which regulates wakefulness)
194
what is a multiple sleep latency test?
measures time elapsed from the start of a daytime nap to first signs of sleep (sleep latency)
195
what are the 2 classes of insomnia?
reactive
| psychophysiological
196
why does reactive insomnia occur?
during a time of stress/anxiety
197
why does psychophysiological occur?
loss of ability to fall asleep easily- beds are no longer associated with only sleep
198
what is the most common subtype of motor neurone disease?
amylotrophic lateral sclerosis (ALS)
199
is increased tone an upper or lower motor sign?
upper
200
is weakness an upper or lower motor sign?
lower
201
is babinski's sign an upper or lower motor sign?
upper
202
is a spastic gait an upper or lower motor sign?
upper
203
is hyperreflexia an upper or lower motor sign?
upper
204
are fasciculations an upper or lower motor sign?
lower
205
are absent or reduced deep tendon reflexes an upper or lower motor sign?
lower
206
does amylotrophic lateral sclerosis have upper and motor lower neurone features?
both upper and lower motor neurone features
207
does primary lateral sclerosis have upper and lower motor lower neurone features?
upper motor neurone features
| no lower
208
does progressive muscular atrophy have upper and lower motor neurone features?
lower motor neurone features
| upper motor neurone feautres can be sublinical
209
does ALS-frontotemporal dementia have upper and lower motor neurone features?
both upper and lower motor neurone features
210
what is the prognosis for amylotrophic lateral sclerosis and ALS-frontotemporal dementia
poor
211
what is the prognosis for primary lateral sclerosis (a subtype of MND)?
good
212
what is the prognosis of progressive musclar atrophy (a subtype of MND)?
variable
213
what pattern of atrophy is typically seen in ALS?
split hand syndrome
| wasting of thenar muscle group, relative preservation of hypothenar muscle group
214
what is the hoffmann reflex?
| is this normal?
tapping of the distal phalynx of the 3/4th finger, causing the distal phalynx of the thumb to flex (can be normal)
215
what is the snout reflex?
tapping the midline of closed lips, causing lips to purse (abnormal)
216
what is pseudobulbar affect?
uncontrollable episodes of crying/laughing in response to something which should not cause that much emotion
may be mood-incongruent
217
is pseudobulbar affect an upper or lower motor sign?
upper
218
what bacteria produces botulinum toxin?
clostridium botulinum
219
how does botulinum toxin cause muscle weakness?
breaksdown proteins involved in vesicle formation, so reduces neurotranmitter release
220
what is lambert eaton myasthenic syndrome?
autoantibodies to voltage gated calcium channels on presynaptic membrane, reduced neurotransmitter release
221
what underling cancer is strongly associated with lambert eaton myasthenic syndrome?
small cell carcinoma
222
what is the most comon disorder of the neuromuscular junction?
myasthenia gravis
223
what is myasthenia gravis?
autoantibodies to acetyl choline receptors on the post-synaptic membrane, leads to reduced functioning of receptors causing muscle weakness and fatigue
224
75% of patients with myasthenia gravis have what underlying condition?
thymus hyperplasia or thymoma
225
at what age do women an men tend to get myasthenia gravis?
F- 20-30 years old
| M- 50-70 years old
226
the weakness in myasthenia gravis tends to fluctuate, as the day progresses does it generally get better or worse?
worse
227
what are the 3 most common weakness presentations of myasthenia gravis?
extraocular weakness
facial weakness
bulbar weakness
(fatiguable weakness)
228
in myasthenia gravis, is weakness usually proximal or distal?
proximal
229
what are the treatment options for myasthenia gravis?
acetylcholinesterase inhibitor
thmectomy
steroids/azathioprine
plasma exchange/immunoglobuline (n emergency)
230
why do people with myasthenia gravis tend to die?
- respiratory failure and aspiration pneumonia
| - side effects of immunosuppression
231
what is myotonia?
failure of muscle relaxation after use
232
what disease has progressive weakness with characteristic thumb sparing?
inclusion body myositis
233
what is the rhabdomyolysis triad?
myalgia
muscle weakness
myoglobinuria
234
what are the 2 main complications of rhabdomyolysis?
acute renal failure
| disseminated intravascular coagulation
235
what is the treatment of polymyositis/dermatomyositis?
steroids
236
what is the most common extra-axial brain tumour?
meningioma
237
what are the 4 most common symptoms of a brain tumour in an adult?
progressive neurological deficit
motor weakness
headache
seizures
238
what is the onset of a headache caused by a brain tumour?
slow onset
239
what usually exacerbates a headache caused by a brain tumour?
worse in the morning
coughing
leaning forward
240
what is cushings triad and what is it in response to?
increase blood pressure, decreased heart rate, irregular breathing
in response to very high IC{
241
who tends to get grade 1 astrocytic tumors?
children
242
where do children tend to get grade 1 astrocytic tumours?
in the cerebellum
243
what is the treatment of choice for a grade 1 astrocytoma?
surgery (Curative)
244
are grade 1 astrocytomas benign or malignant?
benign
245
if there is a grade 1 astrocytoma of the optic nerve, what diagnosis should be considered?
neurofibromatosis
246
why are grade 2 astrocytomas considered to be malignant even though they are technically low grade?
because they become grade 3 and 4 tumours with time
247
compare grade 1 and grade 2 tumours in terms of enhancement on contrast?
grade 1 enhance, grade 2 dont tend to
248
what is the treatment of a grade 2 astrocytoma?
surgery +/- radiation/chemotherapy
249
what is a glioblastoma?
grade 4 astrocytoma
250
why do you still do surgery in cases of grade 3 and 4 astrocytomas even though it is non-curative?
to improve quality of life
251
where do oligodendroglial tumours tend to occur?
frontal lobes
252
what is the main presentation of oligodendroglial tumours?
seizures (due to calcification)
253
what is the treatment for oligodendroglial tumours?
surgery + chemo/radiotherapy
254
what condition should you think of if a patient has multiple meningiomas?
neurofibromatosis 2
255
what are the 4 types of meningiomas? (classified by location)
parasagittal
convexity]sphenoid
intraventricular
256
if a meningioma is found incidentally why may you choose to do nothing about it?
most are benign and very slow growing
257
when is angiography of a brain tumour indicated?
if embolisation is planned
258
what is the name of a benign peripheral nerve sheath tumours?
shwannomas
259
what is the name of a malignant peripheral nerve sheath tumour?
malignant peripheral nevre sheath tumour
260
what does bilateral vestibular schwannomas indicate?
NF 2
261
what are the 3 major symptoms of vestibular schwannomas?
hearing loss
tinnitus
balance problems
262
what are the 4 major post-op complications of surgery on a vestibular schwannoma?
facial nerve palsy
corneal reflex
nystagmus
abnormal eye movement
263
if a patient wakes up in the morning with a headache that gets better as the day goes on what should you be thinking of?
raised ICP
264
if a patients headache is worse when they lie down what should you be thinking of?
raised ICP
265
what are the 5 main red flags of a headache?
new onset over 55 years old
known/prev malignancy
early morning headache
eacerbation by valsalva (eg coughing, sneezing etc)
266
are migraines usualy colourful or colourless?
colourles
267
if a visual disturbance is bright, what should you be thinking about instead of a migraine?
occipital lobe seizure
268
what is more common- migraine with or without aura?
without aura
269
what is the criteria for diagnosing a migraines?
at least 5 attacks lasting from 4 -72 hours
2 from: moderate/severe, unilateral, throbbing pain, worse on movement
1 from: autonomic features, photophobia, phonophobia
270
what is the pathophysiology of a migraine?
depolarisation somewhere in the cortex excites the trigeminal nerve causing it to release substances
-these dcause dilation of cranial blood vessels causing pain
(trigeminal vascular headache)
271
how long does an aura in association with migraine last?
20-60 mins, usually before the headache
272
what is the most common type of aura?
visual
273
what is the symptomatic treatment of migraines?
1. NSAIDs
+/- antiemetic
2. triptans
274
when should you give prophylaxis for migraines?
if there are more than 3 attackes per month or migrains are very severe
275
how long must you trial a prophylaxis drug for migraines for?
4 months to see benefit
276
what drugs are used for migrain prophylaxis?
```
propanolol
topiramate
amitriptyline
gapapentin
pizotifen
sodium valproate
```
277
what are the side effects of topieramate?
weight loss
paraesthesia
impaired concentration
278
what lifestyle advice should you give someone with migraines?
```
diet- avoid triggers, healthyh balanced diet
hydration
decrease caffeine
decrease stress
regular exercise
```
279
what are trigeminal autonomic cephalgias?
primary headaches characterised by unilateral trigeminal distribution pain with ipsilateral autonomic features
280
what are the 4 main types of trigeinal autonomic cephalgias?
cluster
paroxsymal hemicrania
hemicrania continua
SUNCT
281
what is a cluster headache?
severe unilateral headache that lasts 45-90 mins, up to 8 times per day
cluster bout may last up to a few months
282
what is the treatment for a cluster headaches?
high flow ozygen for 20 mins
subcut sumatriptan
steroids (reduce over 2 weeks)
verapamil (prophylaxis)
283
what is the differnece between paroxysmal hemicranias and cluster headaches?
paroxysmal hemicranias are shorter in duration and more frequent
284
compare age and sex of patients who get paroxysmal hemicranias and cluster headaches?
paroxysmal hemicranias-50-60s (F more then M)
| 30-40s (M more than F)
285
what is a SUNCT headache?
```
Short lived (less than 2 minutes)
Unilateral
Neuralgiaform headache
Conjunctival injections
Tearing
```
286
what is the treatment for paroxysmal hemicranias?
indomethicin
287
what is the treatment for SUNCT headaches?
lamotrigine
| gabapentin
288
what investigation can be done for those with new onset ipsilateral cranial autonomic features?
MRI brain and MR angiogram
289
who tends to get trigeminal neuralgias?
over 60 years old
| F more than M
290
what triggers trigeminal neuralgias?
touching face (usually V2/3 area)
291
what is the character of trigeminal neuralgia pain?
severe stabbing unilateral pain
292
how long does the pain of trigeminal neuralgia last?
1- 90 seconds but can occur up to 100 times per day (occurs in bouts before remission)
293
what is the treatment for trigeminal neuralgia?
carbamazepine, gabapentin, pheytoin, baclofen
| surgery (rare): ablation or decompression
294
what is the major difference between trigeminal autonomic cephalgias and trigeminal neuralgias?
trigeminal neuralgias dont have autonomic features
295
what tends to happen to the limbs and head in an epileptic fit?
posturing of limbs
| head turning
296
what is a tonic clonic seizure?
```
first tonic (stiff) phase
then clonic (jerky) phase
```
297
what are corpopedal spasms?
severly painful muscle cramps of hands and feet
298
why should you always do an ECG on a patient presenting with a new seizure?
might not be a seizure, could have a cardiac cause for collapse
299
why would you choose to get a CT scan of a patient presenting acutely with a new seizure?
- clinical or radiological skull fracture
- deteriorating GCS
- GCS not 15 after 14 hours
- head injury with seizure
- focal signs
- suggestion of other intracranial pathology
300
what are the 4 uses of an electroencephalogram? (EEG)
- classification of epilepsy
- confirmation of non-epileptic attacks
- surgical evaluation
- confirmation of non-convulsive status
301
how long should you stop driving if you have a seizure? (not epilepsy, first fit)
car- 6 months
| HGV- 5 years
302
how long should you stop driving if you have an epileptic seizure?
car- 1 years (3 years if you also get fits during sleep)
| HGV- 10 years
303
what decreases the risk of SUDEP in an epileptic patient?
taking medication
bed partner
mild epilepsy
304
what is an epileptic seizure?
abnormal synchronisation of neuronal activity
305
do older people or young people tend to have focal epilepsy?
older people
306
do older people or young people tend to have generalised epilepsy?
young people
307
can generalised epilepsy cause focal or generalised seizures?
generalised
308
can focal epilepsy cause focal or generalised seizures?
focal and generalised seizures
309
what is the difference between a simplex= and complex seizure?
simple- no loss of consciousness
| complex- loss of consciousness
310
what is the treatment of choice for primary generalised epilepsy?
sodium valproate
| lamotrigine in women of childbearing age
311
what kind of epilepsy is juvenile myoclonic epilepsy?
primary generalised epilepsy
312
what time of day does juvenile myoclonic epilepsy tend to have symptoms?
morning
313
what are the main 2 risk factors for seizures in generalised myoclonic epilepsy?
flashing lights
| sleep deprivaion
314
what is the treatment of choice for focal onset epilepsy?
carbamazepine
| or lamotrigine
315
what kind of epilepsy is complex partial seizures with hippocampal sclerosis?
focal epilepsy
316
why does complex partial seizures with hippocampal sclerosis occur?
brain doesnt fold properly during development, hippocampus is affected
317
when would you add on anti-convulsant drugs in epilepsy?
tried 3 anti-epileptic drugs, not suitable for surgery
318
what anti-epileptic drugs affect women's contraception?
hepatic-enzyme inducing drugs (eg carbamazepine)
319
describe how womens contraception is altered by hepatic-enyzme inducing drugs?
- OCP efficacy altered
- progesterone only pill doenst work
- progesterone implant doesnt work
- depot progesterone needs more frequent dosing
- morning after pill needs increased dose
320
what does the oral contraceptive pill do to lamotrigine?
reduces lamotrigines efficacy
321
why should sodium valproate not be given to women of childbearing age?
teratogenic
322
where do berry aneurysms/saccular aneurysms occur?
circle of willis (tend to be where vessels branch)
323
what is the name of the headache which happens just before you orgasm?
benign coital cephalgia
324
what is a traumatic tap on LP?
when you get blood in the needle from piercing arteries while doing a LP
325
what artery do you use to do cerebral angiography?
femoral artery
326
what is the gold standard for locating the artery which has caused subarachnoid haemorrhage?
cerebral angiography
327
what is the mainstay of treatment of an aneurysm that has previously caused a subarachnoid haemorrhage?
endovascular treatment
328
how long does it take for delayed ischaemia from a subarachnoid haemorrhage?
3-12 days
329
what drugs is used post-subarachnoid haemrrhages to stop vasospasm?
nimodipine (calcium channel blcker)
330
why is nimodipine given for 3 weeks after a subarachnoid haemorrhage?
to reduce vasospasm to reduce delayed ischaemia
331
if the headache from a subarahcnoid has not got better after a few days, what complication should you be thinking of?
hydrocephalus
332
what salt imbalance can occur as a complication of subarachnoid haemorrhage?
hyponatramia
333
why can hyponatraemia occur as a complication of subarachnoid haemorrhage?
SIADH
| cerebral salt wasting
334
what is the treatment of hyponatraemia due to subarachnoid haemorrhage? (how is this differnet to the normal treatment)
supplement sodium intake
fludrocortison
DO NOT FLUID RESTRICT
(usually you would fluid restrict)
335
why do you not fluid restrict to treat the hyponatraemia that can occur due to subarachnoid haemorrhage?
can encourage vasospasm
336
what investigation usually give the diagnosis of subarachnoid haemorrhage?
CT brain
| if not, then lumbar puncture if safe
337
what are the most common causes of intracerebral haemorrhage?
hypertension (50%)
aneurysm
AVM
338
what is the name for the microaneurysms that arise on small arteries within the brain that are secondary to hypertension and can lead to intracerebral haemorrhage?
charcot-bouchard microaneurysms
339
is the majority of the corticospinal tract crossed or uncrossed?
crossed
340
where does the majority of the corticospinal tract decussate?
medullary level
341
is the spinothalamic tract crossed or uncrossed?
uncrossed
342
where does the spinothalamic tract decussate?
spinal level
343
if there is a spinal cord lesion affecting the corticospinal tract, will it cause ipsilateral or contralateral symptoms?
ipsilateral
344
if there is a spinal cord lesion affecting the spinothalamic tract, will it cause ipsilateral or contralateral symptoms?
contralateral
345
are the dorsal column tracts crossed or uncrossed?
crossed
346
where do the dorsal columns decussate?
medullary level
347
if there is a spinal cord lesion affecting the dorsal columns, will it cause ipsilateral or contralateral symptoms?
ipsilateral
348
what sensation does the spinothalamic tract deal with?
pain and temperature
349
what sensation do the dorsal columns deal with?
fine touch, proprioception, vibration
350
what is the most common cause of acute spinal cord compression?
metastatic disease of the spine leading to collapse
351
what is spondylosis?
degeneration of the intervertebral discs ofthe spine- vey painful
352
what are the 4 main causes of acute spinal cord compression?
tumours
trauma
infection
spontaneous haemorrhage
353
what are the 3 main causes of chronic spinal cord compression?
degenerative disease- spondylosis
tumours
rheumatoid arthritis
354
what joints in the spine does rheumatoid arthritis affect?
the synovial facet joints
355
what kind of spinal cord injury can give you brown-sequard syndrome?
cord hemisection
356
what are the symptoms of brown-seqard syndrome?
below level of injury
- ipsilateral motor loss
- ipsilateral dorsal column loss (fine touch, proprioception, vibration)
- contralateral spinothalamic loss (pain and temp)
357
what causes central cord syndrome?
hyperflexion or extension injury to an already stenotic neck
358
where does the limb weakness occur in central cord syndrome?
predominantly distal upper limb weakness
| lower limb power preserves
359
where does the sensory loss occur in central cord syndrome?
'cape like' spinothalamic sensory loss (pain and temp)
| dorsal columns preserves (vibration, fine touch and proprioception)
360
compare acute and chronic spinal cord compression in terms of spinal shock?
acute compression- spinal shock
| chronic compression- no spinal shock
361
in chronic spinal cord compression, do LMN or UMN signs tend to predominate?
upper motor neuron signs
362
what are the two classes of intradural tumour within the spine?
extramedullary (eg meningioma, schwannoma)
| intramedullay (eg astrocytoma, ependymoma)
363
if a tumour that is within the spine is extradural, what kind of tumour is it most likely to be?
metastatic
364
why is dexamethasone given to patients with tumours (primary or mets) causing spinal compression?
reduces swelling in spinal cord
365
what is the treatment for an infection causing acute spinal compression?
antimicrobial therapy
surgical drainage
stabilisation
366
what is the treatment for a haemorrhage causing acute spinal compression?
```
reverse anticoagulation (ie give clotting factors like vit K)
surgical decompression
```
367
what is the treatment for degenerative disease causing spinal cord compression?
decompression +/- stabilisation
368
where is the location of the cause of a somatosensory aura?
parietal lobe (somatosensory cortex on postcentral gyrus)
369
where is the location of the cause of a visual aura?
occipital lobe (visual cortex)
370
what are the 3 types of functional attacks?
1. attacks with prominent motor activity
2. episodes of collapse with no movement
3. abreactive attacks (Fear, hyperventilationetc)
371
what is the usual duration of a functional attack?
10-20mins
372
what is status epilepticus?
recurrent epileptic seizures lasting more than 30 mins (no full recovery of consciousness between seizures)
373
what are the 3 kinds of status epilepticus?
- generalised convulsive status epilepticus
- non convulsive status (altered state)
- epilepsia partialis continua
374
what metabolic disorders can cause status epilepticus?
hyponatraemia, pyridoxine deficiency
375
treating an absent seizure with what drug can cause status epilepticus?
carbemazapine
376
what is the drug treatment of status epilepticus for immediate control?
lorazepam IV
if delay gaining IV access-
diazepam PR
(give 50ml 50% glucose if any suggestion of hypoglycaemia, give IV thiamine if any suggestion of alcoholism)
if persisting transfer to ITU and control with general anaesthesia
377
compare the difference in symptoms for a large sensory fibre and small sensory fibre peripheral neuropathy?
large: numbness, paraesthesia, unsteadiness
small: pain, dysasthesia
378
compare the difference in reflexes for a large sensory fibre and small sensory fibre peripheral neuropathy?
large: absent reflexes
small: present reflexes
379
what is pseudoathetosis?
abnormal writhing movements, usually of the fingers
380
what causes pseudoathetosis?
loss of proprioception
381
where is the nerve injured in a radiculopathy?
nerve root
382
where is the nerve injured in a plexopathy?
nerve plexus
383
what is the initial pattern of sensory loss or weakness in peripheral neuropathy?
glove and stocking
384
what is guillain barre syndrome?
progressively demyelinating condition with progressive paraplegia that occurs over days and lasts up to 4 weeks
sensory symptoms (such as pain) proceed weakness
-association: post infectious
385
why do people with guillain barre syndrome die?
autonomic failure- arrhythmias
386
what is the treatment of guillain barre syndrome?
immunoglobulin infusion
| plasma exchange
387
what causes the neuropathy in hereditary sensory motor neuropathy?
demyelination
388
what are the 3 main causes of chronic autonomic neuropathy?
diabetes
amyloidosis
hereditary autonomic neuropathy
389
what are the 2 main causes of acute autonomic neuropathy?
guillian barre syndrome
| porphyria
390
what are the SMART goals for neurological rehab?
```
specific
motivating
achievable
rational/relevant
time-defined
```
391
where within the brain is the problem if the movement disorder presents with pyramidal/upper motor neurone features? (such as pyramidal weakness, spasticity)
corticospinal tract
392
where within the brain is the problem if the movement disorder presents with hyperkinetic features? (such as dystonia, tics, myoclonus, chorea)
basal ganglia
393
where within the brain is the problem if the movement disorder presents with hypokinetic features? (such as rigidity, bradykinesia)
basal ganglia
394
where within the brain is the problem if the movement disorder presents with ataxia?
cerebellum
395
are increased deep tendon reflexes likely to be caused by an upper motor or lower motor problem?
upper motor
396
are decreased deep tendon reflexes likely to be caused by an upper motor or lower motor problem?
lower motor
397
are increased pathological reflexes likely to be caused by an upper motor or lower motor problem?
upper motor
398
is increased muscle tone likely to be caused by an upper motor or lower motor problem?
upper motor
399
is decreased muscle tone likely to be caused by an upper motor or lower motor problem?
lower motor
400
is increased muscle bulk likely to be caused by an upper motor or lower motor problem?
upper motor
401
is wasting of muscle bulk likely to be caused by an upper motor or lower motor problem?
lower motor
402
are fasiculations likely to be caused by an upper motor or lower motor problem?
lower motor
403
where anatomically is the location of the disease if there is fatiguable weakness?
neuromuscular junctions
404
what is the pattern of weakness that occurs with a parasagittal frontal lobe lesion?
paraparesis
405
what is the pattern of weakness that occurs with a cervical spinal cord UMN lesion?
pyramidal weakness of arms and legs
406
what is the pattern of weakness that occurs with a thoracolumbar spinal cord UMN lesion?
pyramidal weakness of legs
407
is polio a disease of upper or lower motor neurones?
lower
408
what is mononeuritis multiplex?
an asymmetrical neuropathy of multiple nerves
409
what muscle, named nerve and nerve root causes shoulder abduction? (after 30 degrees)
deltoid
axillary nerve
C5
410
what muscle, named nerve and nerve root causes elbow extension?
triceps
radial nerve
C7
411
what muscle within the forearm, named nerve and nerve root causes finger extension?
extensor digitorum
posterior interossus nerve (radial)
C7
412
what muscle, named nerve and nerve root causes index finger abduction?
1st dorsal interosseus
ulnar nerve
T1
413
what muscle (main muscle), named nerve and nerve root cause hip flexion?
iliopsoas
femoral nerve
L1,2
414
what muscles, named nerve and nerve root cause knee flexion?
hamstrings
sciatic nerve
S1
415
what named nerve and nerve root causes ankle dorsiflexion?
common peroneal nerve
| L4,5
416
what muscle, named nerve and nerve root causes great toe dorsiflexion?
extensor hallucis longus
common peroneal nerve
L5
417
what nerve roots supply the ankle reflex?
S1,2
418
what nerve roots supply the knee reflex?
L3,4
419
what nerve roots supply the biceps reflex?
C5,6
420
what nerve roots supply the triceps reflex?
C7,8
421
if there is a problem with the peroneal nerve, what tendon reflex is absent?
none
422
describe the cerebellar gait?
broad-based and unsteady
423
what is the DANISH mneumonic for remembering cerebellar tests?
```
Dysdiadochokinesis
Ataxia
Nystagmus
Intention Tremor
Speech
Hypotonia
```
424
what is dysdiadochokinesis?
clumsy fast alternating movements
425
how do you test for an intention tremor?
finger-nose test
| heel-shin test
426
what is hypomimia?
reduced facial expression
427
what is hypophonia?
soft speech
428
compare the visual field defect with temporal and parietal lobe lesions?
parietal- inferior homonymous quadrantanopia
| temporal- superior homonymous quadrantanopia
429
what is levodopa broken down into once in the brain?
dopamine
430
what type of drug can be used for tremor in parkinsons disease?
anticholinergics
431
why are COMT inhibitors sometimes given in addition to levodopa in parkinsons disease?
inhibits enxyme which breaks down levodopa
432
does parkinsons disease tend to be symmetrical or asymmetrical?
asymmetrical
