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1
Q

describe clasp knife rigidity

A

assoc with UMN sx increased tone that is velocity dependent ie the faster you move the pts mulsce the greater the resistence until it finally gives way

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2
Q

what will an anterior cerebral artery occlusion result in?

A

weak, numb contralateral leg +/- similar milder arm sx

face is spared

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3
Q

what will a MCA occlusion result in

A

lateral part of each hemisphere - contralateral hemiparesis, hemisensory loss, contralateral homonymous hemianopia - dysphagia if dominant side

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4
Q

PCA - occlusion will result in?

A

supplies occipital lobe = contralateral homonymous hemianopia

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5
Q

when would you suspect subclavian steal syndrome?

A

brainstem ischaemia can occur typically after use of the arm - suspect if BP differs by >20 mmHg

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6
Q

what is the most common headache

A

tension

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7
Q

what should you remember to ask in headache hx

A 
analgesia, sex , food 
photophobia 
rash 
weakness 
focal signs
vomiting 
worse on waking, lying down, coughing or bending forward 
any head trauma 
travelled anywhere 
pregnant 
change in pattern of usual headaches
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8
Q

investigation and management of trigeminal neuralgia

A

must do MRI to rule out other cuases
tx with carbemazepine
lamotrigine or gaba
surgery may be necessary

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9
Q

what are possible migraine triggers

A 
chocolate 
hangovers 
orgasms 
cheese/caffeine 
oral contraceptive
lie-ins 
alcohol 
travel 
exercise
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10
Q

wht is the management of migraine

A

propanolol and topiramate for prophylaxis
attack tx - oral triptan combined with NSAID or paracetamol + anti-emetic
Non-pharm - warm or cold packs on the head, acupuncture NICE recommends or transcutaneous nerve stimulation

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11
Q

what are the causes of blackouts

A 
vasovagal (may have limb jerking)
situation syncope 
carotid sinus syncope 
epilepsy 
stokes-adam attacks - transient arrhythmias 
hypoglycaemia 
orthostatic hypotension 
dissociative seizures 
non-epileptic attack disorder
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12
Q

what are the cuases of conductive hearing loss

A

wax, otosclerosis, ottitis media, glue ear

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13
Q

what are the cuases of sensioneural hearing loss

A

Presbyacusis, acoustic neuroma, toxin, MS, stroke, vasculitis

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14
Q

how would you describe a spastic gait

A

stiff, circumduction of legs +/- scuffing of toe of shoes = UMN lesion

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15
Q

what non-neuro considerations must you take into account in paralysed pts

A

avoid pressure sores - appropriate pressure relief mattresses
prevent thrombosis in paralysed limbs by freqent movement + pressure stockings + LMWH
bladder care
bowel evacuation
exercise to avoid inappropriate loss of function in partially paralysed limbs

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16
Q

what is the acute management of a stroke?

A

protect the airway
maintain - consider endotracheal tube homeostasis - blood glucose, BP
screen swallow
supportive O2
CT/MRI within 1 hour
Thrombolysis - after ensuring no CI repeat CT 24 hr after lysis to exclude bleed
thrombectomy

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17
Q

what are the contraindications to thrombolysis

A 
major haemorrhage 
recent surgery or trauma
previous CNS bleed 
AVM 
severe liver disease
seizures at presentation 
blood glucose 
known clotting disorder
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18
Q

what investigations should you do following a stroke

A 
BP 
24 hr ECG to look for AF /CXR
doppler+/- CT angiography 
check glucose lipids
vasculitis? ANCA 
Young stroke screen - prothrombotic states, hyperviscosity, thrombocytopena, genetic tests
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19
Q

Re-enablement post stroke

A 
MDT 
Barthels score - assess functioning 
rehab early to prevent complications 
swallow screen - salt input 
avoid further injury - OT social worker 
bladder and bowel care 
positioning 
monitor progress
monitor mood 
physio 
involve family/carer
advance directives
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20
Q

what is the management of meningitis

A

Urgent admission to hospital

U/E FBC, LFT, glucose , coag, consider throat swabs - 1 for bacteria, 1 for viral, CXR, consider HIV, TB test
Blood cultures
serum pneumococcal and meningococcal PCR
LP within 1 hour if no signs of riased ICP

A-E approach
rule out sepsis - sepsis 6
IV dexamethasone if features of meningism
antibiotics - based on trust local guidelines - usually ceftrixone or discuss with microbiology
Low threshold for ICU
Isolate pt for 24 hours

If meningococcal infection - prophylaxis needed for close contacts = ciprofloxacin
if pneumococcal no prophylaxis required

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21
Q

what investigations should be performed in suspected encephalitis?

A

blood cultures, serum for viral PCR, toxoplasma IgM titre, malaria film
Contrast enhanced CT
LP
EEG

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22
Q

hat is the tx of viral encephalitis

A

start aciclovir within 30 mns of pt arriving IV for 14 days for HSV
Supportive therapy in high dependency unit or ITU
Sx tx e.g. for seizures

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23
Q

what is the initial management of a head injury

A

A-E
O2 if sats <92% or hypoxic on ABG
Intubate and hyperventilate if needed
immobilise neck until C-spine injury excluded

Stp blood loss and support circulation
treat for shock if required

treat seizures

access GCS if less than 8 involve anaesthetics
assess for anterograde and retrograde amnesia

rapid examination survery
Ix - U/E glcuose, FBC, Blood alcohol, toxicology scree, ABGs and clotting

Neuro exam +hx 
evaluate wounds
check for CSF leak 
Palpate for any neck tenderness 
Radiology
24
Q

what is cushings response

A

BRADYCARDIA
Hypertension
Cheyne-Stokes respiration

25
what investigations should you perform in signs of raised ICP
``` U/E, FBC, LFT, glucose, serum osmolality, clotting, blood culture consider toxicology screen CXR - source of infection e.g. abscess CT head THen consider if LP is safe ```
26
what is the emergency management of raised ICP
``` involve senior A-E Correct hypotension, maintain Mean arterial pressure >90 mmHg and treat seizures Brief exam and hx - any clues e.g. rash elevate bed 30-40 degrees ``` If intubated hyperventilate the pt to reduce CO2 - this causes cerebral vasoconstriction and reduces ICP Osmotic agents e.g. mannitol may be useful If cerebral oedema ?dexameth ``` restrict fluid monitor pt closely aim to make a diagnosis treat cuase or exacerbting features - hyperglycaemia and hyponatraemia ``` definitive tx
27
what is the management of SAH?
``` Refer to neurosurgery immediately Resusitate this patient in an A-E approach Stop any anticoagulant e.g the DOAC Analgesic Stool softener and anti-emetic ``` Investigations + Digital subtraction angiogram - DSA CT angiogram Maintain cerebral perfusion but aim for BP to be less than 160 Prescribe Nimodipine Consetn pt for surgery if applicable Surgery – endovascular coiling is method of choice or surgical clipping. Ongoing - Manage complications e.g. Hydrocephalus, rebleeding, cerebral ischaemia - Manage cerebral salt wasting syndrome – fluids +/- Na+ - Rehab - MDT approach
28
where is the most common dural venous sinus thrombosis?
sagittal sinus
29
what are common cuases of intracranial venous thrombosis
pregnancy, COCP, head injury, dehydration, tumours and extracranial malignancy, recent LP Infection, drugs, vasculitis
30
how will a intracranial venous thrombosis appear on ct head
delta sign after 1 week
31
management of intracranial venous thrombosis
senior help anticoagulate endovascular thrombolysis of anticoag doesnt work monitor for signs of rasied ICP
32
what is the management of an extradural haematoma
stabilise and transfer urgentyl to a neurosurgical unit or clot exacuation +/- ligaton of the bleeding care of the airway and measures to decrease ICP
33
what is the management of a subdural haematoma
reverse clottign abnormalities urgently. Surgical management depends on the size of clot its chronicity and the clinical picture if large they may require vacuation via craniotomy or burr hole washout address cause of the truama - e.g. falls and abuse
34
what are the 2 types of delirium
hypoactive - in whihc pt = slow and withdrawn | hyperactive restlessness, mood liability agitation and aggression
35
what are the causes of delirium
Pain, Infection, Nutrition, Constipation, Hydration, Medication, Environment (PINCH ME)
36
what is the management of delirium
Identify and tx the underlying cuase - reorientate the patient - explain where they are and who you are, hunt down hearing aids and glassess, visible clocks and calenders - encourage family and friends to visit - monitor fluid balance and encourage oral intake, think of constipation - mobilise - practise sleep hygiene - avoid or remove catheters, IV cannulae, monitoring leads and other devices - watch out for infection and physical discomfort - review medication - provide support
37
how is dementia diagnosed
``` hx + collateral cognitive testing - AMTS or similar MSE - depression hallucinations examination - parkinsons medication review - drug induced cognitive impairment ```
38
what investigations should you perform in dementia
look for reversible causes - TSH, B12, folate, thiamine, calcium MSU, FBC, ESR, LFT,UE ?MRI to rule out other pathologies normal-pressure hydrocepahlus consider EEG if delirum or frontotempora dementia
39
how do you manage dementia
integrated memory services for further assessment and management medications - avoid drugs that hinder cognition Cholinesterase inhibitor therapy with rivastigmine, donepezil, or galantamin depression capacity - advanced care directive, lasting power of attourney
40
how do you investigate Causda equina?
ASIA chart Urgent MRI spine FBC, UE, LFT, Ca CRP
41
what is the management of cauda equina
Analgesia, VTE prophlaxis neurosurgery for decompression and discectomy VTE prophlaxis counselling and advice + physiological support regarding sexual dysfunction MDT planning Spinal injury rehab with a pt centred appraoch involving lots of therapists and staff Important to think about bladder, bowel, skin, PT/OT - alterations to house and long term follow up planning Bladder management as UTIs are major cuase of morbidity with aim to presever renal function and contiencne - pt may get urinary retention and overflow incontinence so risk of autonomic dysreflexia teach self-catheterisation or indwelling catheter importnatn to have a bowel regimen - use of laxatives, stook, softeners, digital stimulation and suppositiories othosis to improve foot drop
42
how do you investigate Causda equina?
ASIA chart Urgent MRI spine FBC, UE, LFT, Ca CRP
43
what is the management of cauda equina
Analgesia, VTE prophlaxis neurosurgery for decompression and discectomy VTE prophlaxis counselling and advice + physiological support regarding sexual dysfunction MDT planning Spinal injury rehab with a pt centred appraoch involving lots of therapists and staff Important to think about bladder, bowel, skin, PT/OT - alterations to house and long term follow up planning Bladder management as UTIs are major cuase of morbidity with aim to presever renal function and contiencne - pt may get urinary retention and overflow incontinence so risk of autonomic dysreflexia teach self-catheterisation or indwelling catheter importnatn to have a bowel regimen - use of laxatives, stook, softeners, digital stimulation and suppositiories othosis to improve foot drop
44
describe MSA
may have predom parkinsoniasm or cerebellar features autonomic dysfucntion - orthostatic hypotension symmetrical sx, rapid progresson
45
describe progressive supranuvela palsy
vertical gaze palsy - esp downward postural instability fronal lobe abnormaities
46
describe corticobasal degeneration
asymmetric motor anormlaities usually affects one limb plus cognitive impairment
47
dx of parkinsons disease
made clinically - dopaminergic trail, could cnsider MRI, serum caeruloplasmin, genetic testing, and dopamine transporter imaging
48
what ist the mx of parkinsons
physical and occupational therapy, including gait and balance training, stretching and strength exercises and speech therapy MDT approach - physical and non-pharmacological therapies, progressive resistance exercises, gait training, music and dance therapy pt education DVLA advice manage comorbidities screening for non motor sx - depression, anxiety and fatigue, cognitive impairment, autonomic dysfunction, and sleep disturbances, cognitive training and vitamin and dietary supplements medical - dopaminergic medication 1st llne for young or mild pts = MOA-B inhibitor , dopamine agonists and monitor for adverse features, carbidopa/levodopa - explain the up and down sx + COMT inhibitors - entracapone may increase the amount of levodopa for therapeutic benefit DBS for refractory apomorphine injections as sx worsen
49
how is multiple sclerosis diagnosed
McDonald criteria, MRI brain/cord, FBC, metabolic panel, TSH, Vit B12, anti-NMO, CSF and evoked potentials
50
mx of ALS
Currently no cure but aim is to provide symptomatic management and palliative intervention refer to neuro MDT approach Riluzole is yhr only drug that modifies disease course start at time of diagnosis - monitor LFTs and FBCs MDT clinics - resp therapists, physios and OTs, dietician , SALT conultant and a social worker immunisations - pneumococcal and influenza and covid informing pts, cunselling, end of life care, advance directives manage the ses excessive saliva - postiiton, oral care and glycopyrranium bromide dysphagia - blednd tube, percutaneous endoscopic gastrostomy, mucolytic - carbocysteine spasticity - exercise and baclofen consider opoids and NIV in end of care screen for sx of depression in every clinic
51
how do you diagnose ALS
El Escoral diagnostic, brain/cord MRI may rule out structural causes, LP to exclude inflam + neurophysiology, EMG
52
what are the 3 main differentials of a sudden onset headache
brain haemmorhages meningitis GCA
53
what ix do you do in myasthenia gravis
neurophysiology spirometry CT thorax Serum ACh receptor
54
what is the management of Myasthenia gravis
ach inhibitor - pyridostigmine physio and OT psychological support corticosteroids can cause initial worsening, start at low dose with gradual increase immunosuppressant and thymectomy
55
how do you diagnose epilepsy
EEG | MRI
56
how do you dx GBS?
``` nerve conduction studies LP LFTs Spirometry Antiganglioside antibody - antiGQ1b antibodies potential stook culture for cause ```
57
how do you manage GBS
Plasma exchange - IVIG serial peak flow pulse and BP monitored until thye are off venilaor support DVT prophylaxis intubation and ventilation esp if bulbar dysfunction manage the pain - gabapentin or carbamazepine rehab - - strengthening exercises hypotension managaed with a fluid bolus

ISCE (10 decks)

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