Neuro Flashcards
(200 cards)
1
Q
How quickly do you need to give thrombolysis?
A
Within 4.5 hours of onset of symptoms
2
Q
Give 5 contraindications to thrombolysis:
A
- Seizure at onset of stoke
- Symptoms suggestive of SAH (thunderclap headache)
- Stroke or serious head injury in the preceding three months
- Current anticoagulation (INR>1.7)
- Significant bleeding
3
Q
What is a thrombectomy?
A
Mechanical retrieval of a clot if seen in the proximal anterior circulation
4
Q
Give 10 investigations you might do on a patient admitted with a possible stroke:
A
- Routine obs
- Neuro exam
- Bloods (FBC, U&E, LFT, CRP, lipids, coagulation factors)
- NIH Scale
- ECG
- CT Head
- MRI Head
- Angiography
5
Q
Following thrombolysis, a patient’s GCS drops to 7 and their condition is worsening. What might be happening?
A
Haemorrhagic transformation and/or raised ICP
6
Q
Give 5 possible long term stroke complications:
A
- Aspiration pneumonia
- Pressure sores
- Depression
- Cognitive impairment
- Seizures (often caused by termporal lobe haemorrhagic strokes)
7
Q
Define stroke:
A
A clinical syndrome consisting of rapid onset neurological deficit which is the result of a vascular lesion and is associated with infarction of central nervous tissue
8
Q
What are the two types of stroke?
A
- Ischaemic e.g. embolism, thrombosis (87%)
2. Haemorrhagic (13%)
9
Q
Give 6 risk factors for stroke:
A
- HTN
- Diabetes Mellitus
- Smoking
- Hyperlipidaemia
- Obesity
- Alcohol
- AF
10
Q
Give 4 signs of raised ICP:
A
- Decreasing GCS
- Papilloedema
- Midline shift or herniation on imaging
- Vomiting
- Severe headache
11
Q
Two types of haemorrhagic stroke:
A
- Intracerebral (75%)
2. Subarachnoid (25%)
12
Q
Give 3 signs of meningism:
A
- Neck stiffness
- Photophobia
- Positive Kernig’s sign
13
Q
What is a positive kernig’s sign?
A
Severe stiffness causing an inability to straighten the leg when the hip is flexed to 90 degrees
14
Q
Give 2 causes of an SAH:
A
- Berry aneurysm
- Clotting disorder e.g. warfarin
- Traumatic and infectious aneurysms
- Dural Ateriovenous Malformation (AVM)
15
Q
Give 6 classic symptoms of an SAH:
A
- New severe headache (NB: 30% of SAH occur during sleep)
- N&V
- Prodromal sentinel headache (occaisonally)
- Confusion
- Visual changes (loss/diplopia)
- Sudden, often transient, LOC at onset
- Thunderclap headache (25%)
- Orbital pain
- Photophobia
- Onset during sex
16
Q
Give 6 classic signs of an SAH:
A
- Altered GCS
- Meningism
- Hyperpyrexia
- Sensory motor deficits
- Cardiac arrhythmias
- Seizures
- Rentinal haemorrhages (Terson’s syndrome)
- CN palsies
17
Q
What is Terson’s syndrome?
A
Occurs in 8-19% of SAH. Intraocular/vitreous haemorrage of the eye.
18
Q
A patient comes in with a suspected SAH. CT Head confirms the diagnosis, what is the next step?
A
- Start nimodipine
- CT angiogram
- Possible neurosurgical clipping or endovascular coiling of aneurysm depending on site, clinical condition and comorbidity
19
Q
What type of drug is nimodipine?
A
A calcium channel blocker
20
Q
A patient with a confirmed SAH needs to be started on Nimodipine, what dose/frequency/route should you give? How long should they continue this treatment?
A
If systolic BP>100, give 60mg 4-hourly
If systolic BP<100, give 30mg 2-hourly
Given PO/NG
Continue for 21 days
21
Q
What is the prognosis for SAH?
A
30% die, usually out of hospital
30% recover completely
30% recover with some disability
22
Q
When might you do an LP in a patient with a suspected SAH?
A
If the CT head is negative, but there is still a high suspicion of SAH (provided there are no contraindications on the CT).
The LP should ideally take place over 12 hours after the onset of the headaches.
23
Q
What might an LP in a patient with an SAH show?
A
Xanthochromia (yellow discolouration)
24
Q
What might a CT head in a patient with an SAH show?
A
Hyperdense (bright) areas of acute blood in the basal cisterns and sulci. Looks like a star shaped pattern.
25
Why do you give nimodipine in SAH?
To prevent vasospasm
26
What supportive treatment do you give after thrombolysis? (6)
1. Cautious BP control
2. Oxygen
3. Glucose control
4. IV fluids
5. TEDs
6. NGT if swallow impaired (BUT! Do not insert for 24 hours following, risk of bleeding)
27
24 hours after thrombolysis you need to start your patient on aspirin - what must you make sure has been done first?
A follow up head CT to confirm no haemorrhagic changes post-thrombolysis
28
A patient with an ischaemic stroke is NOT suitable for thrombolysis. What is the next alternative step in their treatment?
Consider thrombectomy.
| If not suitable for thrombectomy, start 300mg aspirin PO for 2 weeks then 75mg daily.
29
Following an iscaehmic stroke, what dose/frequency/duration of aspirin do you give?
300mg for 2 weeks then lifelong clopidogrel
NB: always give PPI cover!
30
What is CHA2DS2-VASc?
Determines the 1 year risk of a thromboembolic event in a non-anticoagulated patient with non-valvular AF
31
Components of CHA2DS2-VASc:
1. Age (<65, 65-74, >75)
2. Sex (F=1, M=0)
3. Congestive HF (1)
4. HTN (1)
5. Previous stroke/TIA/TE (2)
6. Vascular disease (e.g. MI, PAD) (1)
7. Diabetes (1)
32
Give 2 groups at increased risk of subdural haematoma:
1. Eldery
2. Alcoholics
Due to cerebral atrophy (and weakened/stretched bridging veins from the cortex to one of the draining venous sinuses)
33
Give 3 symptoms of subdural haematoma:
1. Headache
2. Drowsiness
3. Alternating consciousness
34
What might you see on a head CT of a patient with a subdural haematoma?
Crescent shape haemorrhage
35
What causes an extradural haematoma?
Trauma to the temporal bone damaging the middle meningeal artery
36
How is consciousness level affected by an acute extradural haematoma?
Rapid deterioration in conscious level, associated with focal neurological signs
37
How do you treat a extradural haematoma?
Immediate surgical drainage
38
What score is used to calculate the risk of a stroke in a patient who has had a TIA?
ABCD2
39
What are the components of ABCD2?
```
Age >60 (1)
BP > 140/90 (1)
Unilateral weakness (2)
Speech disturbance without weakness (1)
Duration <10 mins (0)
Duration 10-59 mins (1)
Duration >60 mins (2)
Diabetes (1)
```
40
Give 3 causes of optic neuritis
Inflammation of the optic nerve, can be caused by:
1. MS
2. Infection e.g. Lyme, syphilis, HIV
3. B12 deficiency
41
Give 5 features of optic neuritis:
1. Pain on eye movement
2. Poor visual acuity
3. Relative afferent pupillary defect (RAPD)
4. Dyschromatopsia (deficiency in perception of colours)
5. Usually resolves in ~6 weeks
NB: Give steroids to reduce pain and increase speed of recovery
42
Name 3 patterns of MS:
1. Relapsing and remitting (stepwise progression of disability, or increases then decreases)
2. Secondary progressive (starts as R&R, then changes to linear increase in disability)
3. Primary progressive (increasingly disabled from first onset)
43
Described the pathophysiology of MS:
A cell mediated autoimmune condition
Repeated episodes of inflammation of the nervous tissue in the brain and spinal cord
Leads to loss of the myelin sheath
44
What is internuclear ophthalmoplegia?
An ocular movement disorder.
Seen as:
- Impaired adduction in one eye
- Nystagmus in the other eye
45
What is internuclear ophthalmoplegia a common sign of?
Multiple sclerosis
46
What lesion results in internuclear ophthalmoplegia?
A lesion in the medial longitudinal fasciculus
47
Give 5 signs of MS:
1. UMN signs
2. Optic neuritis
3. Internuclear opthalmoplegia
4. Lhermitte's sign (electric shock feeling)
5. Uhtoff's sign (increasing body temp further slows nerve conduction and worsens symptoms)
48
What is the difference between Clinically Isolated Symptoms (CIS) and Mutliple Sclerosis (MS)?
CIS: First episode of symptoms due to acute inflammatory demyelination
MS: Multiple lesions differing in both space and time
49
How would you manage a relapse episode in a patient with MS?
1. IV methylprednisolone 500mg/day given over four hours (PO medication also available)
2. Give gastric protection - ranitidine 150mg BD or omeprazole 20mg OD
50
Name two precautions to be aware of when giving steroids in an MS relapse:
1. Give gastric protection (omeprazole 20mg OD or ranitidine 150mg BD)
2. Avoid use of steroids on more than 3 occaisons per year or for longer than 3 weeks on any one occaison
51
Name 3 DMARDs used in MS:
1. Beta interferon
2. Ocrelizumab
3. Alemtuzumab
4. Fingolimod
5. Stem cell transplants
52
Give 4 signs of Giant Cell Arteritis:
1. Jaw claudication
2. Scalp tenderness
3. Anorexia
4. Anaemia
5. Fatigue
6. Age > 70
7. Elevated ESR & CRP
53
How long does a migraine typically last?
6-8 hours
54
Give 5 signs of a migraine:
1. Aura
2. Photophobia
3. Phonophobia
4. N&V
5. Gradual onset over 45-60mins
6. Associated with a trigger (varies from person to person)
55
How do you manage an acute migraine?
High dose aspirin (900mg dispersable)
Triptans - tablets, nasal spray or injection (most powerful)
56
What is the mechanism of action of a triptan?
5HT-1-receptor agonists
57
Give 3 contraindications for triptans:
1. Uncontrolled HTN
2. Coronary heart disease or cerebrovascular disease
3. Coronary vasospasm
58
How do you manage chronic migraines?
1. Address any triggers
2. Prophylaxis:
- Propranolol 80-160mg daily in divided doses, OR;
- Topiramate, OR;
- Amitriptyline (at night)
3. Botulinum injections (if very severe)
59
Give 3 features of a cluster headache:
1. Unilateral pain behind the eye
2. High severity pain
3. Sudden onset ('clockwork' headache, always the same time everyday)
60
Why are they called cluster headaches?
They occur in 'clusters' i.e. Lots of attacks in a week, then remission for a period of time
61
Acute management of a cluster headache: (2)
1. Oxygen
| 2. Triptan (SC or nasal)
62
Prophylaxis of cluster headaches:
Verapamil (calcium channel blocker)
240-960 mg daily, in 3-4 divided doses
63
3 features of a tension headache:
1. Tight band around forehead
2. Often related to stress
3. More gradual onset, more variable in duration, more constant in quality and less severe than migraine
64
Management of tension headache: (3)
1. Simple analgesics (ibuprofen)
2. Amitriptyline (SE dry mouth, start at night)
3. Lifestyle modification
65
How does trigeminal neuralgia present?
2 seconds of stabbing pain in unilateral trigeminal nerve distribution
Face screws up with pain
66
What is glaucoma?
Drainage of the aqueous humour of the eye suddenly becomes occluded, leading to increased ocular pressure.
67
Give 5 signs of glaucoma:
1. Unilateral vision loss
2. Pain
3. Red eye
4. N&V
68
An acute headache can be an emergency, what 3 conditions should be careful to rule out?
1. Meningism
2. GCA/temporal arteritis
3. Glaucoma
69
Give 2 groups at a higher risk of developing Bell's Palsy:
1. Diabetics
| 2. Pregnant women
70
Which cranial nerve is affected in Bell's Palsy?
Facial Nerve (VII)
71
What is the function of the facial nerve? (3)
1. Control of muscles of facial expression
2. Control of hearing via stapedius muscle
3. Taste sensation to the *anterior two-thirds* of the tongue
72
A 49 year old woman presents to A&E with a drooping face on the right side. She says she noticed it when she looked in the mirror this morning and she also feels like everything is sounding louder. What is the likely diagnosis?
Bell's Palsy - a lower motor neuron lesion of the ipsilateral (R) facial nerve (VII).
73
Give 3 symptoms of Bell's Palsy:
1. Acute unilateral facial drooping
2. Hyperacusis (everything sounds louder)
3. Disturbance in taste to the anterior two-thirds of the tongue
74
Is the forehead involved in Bell's Palsy? Why/why not?
Yes the forehead is affected. In a LMN lesion the forehead is affected, in UMN lesions the forehead/upper face is spared.
75
Prognosis of Bell's Palsy:
Most recover fully within 3-4 months.
| Around 15% have permanent moderate to severe weakness.
76
How do you manage Bell's Palsy? (3)
1. Oral prednisolone within 72 hours of onset
2. Advise about eye care & prescription of artificial tears/eye lubricants
3. Advice to return if no improvement in 3 weeks (then refer to ENT)
77
Give four key features of Parkinson's disease:
1. Bradykinesia (gradual slowing of movement)
2. Rigidity (cog wheel)
3. Tremor (in 70% of pts)
4. Postural instability
Other features include:
1. Depression
2. Autonomic dysfunction (constipation, urinary freq)
3. Anosmia
4. Dementia
78
Describe the pathophysiology of Parkinson's: (4)
- Insufficient dopamine
- Depigmentation of the substantia nigra
- Relative overactivity of ACh
- Presence of lewy bodies
79
Name the three types of drug used in the management of motor symptoms & an example of each:
1. Levodopa - e.g. Co-beneldopa, entacapone
2. Dopamine agonists e.g. Apomorphine
3. MAO-B inhibitors e.g. Selegiline
80
How does Levodopa work to improve symptoms in Parkinson's?
Levodopa is a dopamine pre-cursor which is decarboxylated to form dopamine in the brain, this makes up for the lack of endogenous dopamine and stimulates dopaminergic receptors.
81
What type of medication is Entacapone?
A COMT inhibitor - slows the breakdown of levodopa in the brain and periphery
82
What neurological emergency must you look out for in a patient taking an MAO-B inhibitor and an SSRI?
Serotonin syndrome: pyrexia, agitation, tremor, sweating, diarrhoea
83
How does carbamazepine work? What is it used to treat?
Binds to sodium channels increasing their refractory period. Epilepsy.
84
What is expressive dysphagia?
| What type of lesion would cause expressive dysphasia?
Reduced ability to produce language, laboured speech, non-fluent.
A lesion of Broca's area, located in the (left) inferior posterior frontal lobe.
85
What is receptive dysphasia?
| What type of lesion would cause receptive dysphasia?
A lack of comprehension and understanding of language.
| A lesion of Wernicke's area, located in the (left) temporal lobe.
86
Vertical diplopia indicates a palsy/lesion of which cranial nerve? (double vision going down the stairs)
Trochlear nerve (IV) - supplies the superior oblique muscle responsible for intorsion/depression
87
A 'down and out' eye position indicates a palsy of which cranial nerve?
Oculomotor nerve (III) - supplies almost all the extraocular muscles
88
A constantly adducted eye indicates a palsy of which cranial nerve?
Abducens (VI) - supplies the lateral rectus muscle responsible for abduction
89
What is Horner's syndrome? (3 features)
1. Ptosis
2. Miosis (pupil constriction)
3. Anhidrosis (absence of sweating on the ipsilateral side of face)
90
Give 3 causes of Horner's syndrome:
1. A central lesion e.g. in a stroke or MS
2. A pre-ganglionic lesion e.g. trauma or tumour
3. A post-ganglionic lesion e.g. carotid aneurysm
91
What bacteria is the most common cause of meningitis in adults?
Strep. pneumoniae
92
What is an epileptic seizure?
A clinical manifestation of disordered electrical activity in the brain (paroxysmal discharge of cerebral neurons)
93
Give 3 differentials for a blackout episode:
1. Syncope
2. Epilepsy
3. Non-epileptic attacks
94
Give 3 causes of syncope:
1. Vasovagal
2. Orthostatic (primary or secondary)
3. Cardiac (e.g. arrythmia, valvular disease)
95
Give 3 possible triggers of an epileptic seizure:
1. Sleep deprivation
2. Flashing lights
3. Menstruation
4. Alcohol and alcohol withdrawal
96
Give 4 features of a non-epileptic attack:
1. Waxing and waning course
2. Pelvic thrusting
3. Eyes closed
4. Arms flexing and extending
97
How does the recovery period after syncope, an epileptic seizure and a non-epileptic attack differ?
Syncope: little/no confusion, quick
Seizure: confusion/headache, possible amnesia, may take several hours, needs sleep
NEA: atypically quick recovery
98
What is the first-line drug used in an acute epileptic seizure?
Benzodiazepines e.g. Lorazepam - 4mg IV bolus, repeat after 10-20 minutes if seizure continues
99
Give 5 causes of epilepsy:
1. Head injury
2. CNS infection (meningitis, encephalitis)
3. Brain neoplasm
4. Neurodegenerative disease e.g. Alzheimer's
5. Genetic diseases/syndromes
6. Drugs e.g. alcohol withdrawal
7. Metabolic disorders e.g. hyponatremia
100
What AED might you give to a 25 year old woman with recurrent epileptic seizures?
Iamotrigine
Levetiracetam
(if not tolerated and/or pregnancy prevention is definitely in place then you might give sodium valproate)
101
What is diaphoresis?
Excessive sweating
102
What area of the brain does the posterior cerebral artery supply?
Medial and lateral parts of the posterior cerebrum. Such as: the occipital lobe, the inferomedial surface of the temporal lobe, midbrain, thalamus and the choroid plexus of the 3rd and lateral ventricles
103
What area of the brain does the anterior cerebral artery supply?
Anteromedial portions of the cerebrum. Such as portions of the primary motor and somatosensory cortices responsible for the leg, foot and trunk.
104
What area of the brain does the middle cerebral artery supply?
The majority of the lateral part of the brain. Such as: the majority of the primary motor and somatosensory cortices.
105
Give 3 associated effects of a lesion in the anterior cerebral artery:
1. Contralateral hemiparesis
2. Contralateral sensory loss
3. Affects lower extremities more than upper (trunk, leg, foot)
106
Give 5 associated effects of a lesion in the middle cerebral artery:
1. Contralateral hemiparesis
2. Contralateral sensory loss
3. Affects upper extremities more than lower
4. Contralateral homonymous hemianopia
5. Aphasia
107
What is homonymous hemianopia?
Vision loss on the same side of the visual field in both eyes. E.g. you can't see the left half of your visual field in both eyes
108
Give 2 associated affects of a lesion in the posterior cerebral artery:
1. Contralateral homonymous hemianopia with macular sparing
| 2. Visual agnosia
109
What is visual agnosia?
A disorder of recognition in which a person cannot arrive at the meaning of some or all categories of previously known non-verbal visual stimuli.
110
What is amaurosis fugax? Give two examples of conditions that can cause it:
A sudden curtain descends across the visual field. Caused by:
1. Giant cell arteritis/temporal arteritis
2. Stroke with a lesion in the retinal/opthamic artery
111
What is Weber's syndrome?
A stroke affecting the branches of the posterior cerebral artery that supply the medial portion of the midbrain e.g. parts of the substantia nigra, corticospinal fibers, corticobulbar tract and oculomotor fibers.
112
Give 2 features of Weber's syndrome:
1. Ipsilateral CN III palsy
| 2. Contralateral weakness of upper and lower extremities
113
What causes Wallenberg's syndrome?
Also known as Lateral Medullary Syndrome, occurs following an occlusion of the posterior inferior cerebellar artery.
114
Give 2 cerebellar and 2 brainstem features of Wallenberg's syndrome:
```
Cerebellar:
1. Ataxia
2. Nystagmus
Brainstem:
1. Ipsilateral: dysphagia, facial numbness, CN palsy
2. Contralateral limb sensory loss
```
115
Give 3 common signs of motor neuron disease:
1. Mixed UMN and LMN signs
2. Fasciculations
3. Foot drop
4. Absence of sensory signs/symptoms
5. Wasting of the small hand muscles/tibialis anterior
116
What are bulbar symptoms in MND?
Speech and swallowing difficulties - resulting in increased risk of aspiration and therefore pneumonia
117
Give 3 features of MND that might help you differentiate it from an alternative diagnosis:
1. Does not affect external ocular muscles
2. No cerebellar signs
3. Abdominla reflexes are usually preserved, if present sphincter dysfunction is a late feature
118
Name the only drug proven to have disease-modifying efficacy in MND:
Riluzole - a neuroprotective glutamate-release inhibitor
119
What is 'the phenomenon of anticipation' in Huntington's disease?
Huntinton's is a trinucleotide repeat disorder (CAG), because of this the disease may present at an earlier age in successive generations
120
When do features of Huntington's typically start to present? Give 4 typical features of Huntington's disease:
After 35 years of age.
1. Chorea
2. Personality changes (irritability, apathy, depression) and intellectual impairment
3. Dystonia
4. Saccadic eye movements (rapid intermittenet eye movement when attempting to move from fixing on one point to another)
121
What is dystonia?
Involuntary muscle contraction of the large trunk and limb muscles causing repetitive or twisting movements.
Results in prolonged abnormal posture, e.g. sustained head retraction or foot inversion.
122
Give 3 signs of chorea:
1. Movements move from one area of the body to another
2. Milkmaid sign: 'squeeze my finger at a constant pressure' - patient squeezes intermittently, can't maintain pressure
3. Darting tongue sign: patient cannot stick out tongue and hold it there still
123
Give 2 examples of dystonic movements:
1. Spasmodic torticollis (AKA wry neck) - unilateral deviation of the neck
2. Writer's cramp - muscles of the hand and forearm tighten on attempting to write and pain might occur
124
What is chorea?
Involuntary movements that are rapid, brief, irregular and repetitive. Typically affect the mouth, face, limbs and trunk.
125
What is Creutzfeldt-Jakob disease? Give 4 key features:
A neurodegenerative illness. It can be sporadic, hereditary, iatrogenic (neurosurgery), or caused by eating infected meat (mad cow disease).
1. Progressive ataxia
2. Dementia
3. Choreiform movements
4. Dystonic movement
126
What is progressive supranuclear palsy?
The most common atypical Parkinsonian syndrome. Strongly associated with tau pathology. Affects eye movements, cognition and posture.
127
Give 4 characteristics of progressive supranuclear palsy:
1. Postural instability
2. Akinesia
3. Cognitive dysfunction
4. Occular motor dysfunction (vertical gaze dysfunction!!)
128
What are glial cells in the brain? What are their roles?
Supporting cells of the CNS, they provide nutrition, insulation and help with signal transmission. Includes astrocytes, oligodendrocytes and ependymal cells.
129
What is the most common type of primary brain tumour?
Glioma
130
How are brain tumours managed? (4)
1. Resect tumour where possible
2. Treat hydrocephalus for symptom relief
3. External beam radiotherapy
4. Chemo that can cross the BBB e.g. temozolomide
131
What spinal level is the cauda equina?
~L2
132
4 causes of cauda equina:
1. Trauma
2. Infection
3. Tumour
4. Herniation of a lumbar disc
133
5 features of cauda equina:
1. Bilateral sciatica
2. Bowel and/or bladder dysfunction
3. Sexual dysfunction
4. Low back pain
5. Lower limb motor weakness and sensory deficit
134
How might spinal compression present? (4 features)
1. Progressive weakness of the legs with UMN pattern and eventual paralysis
2. Onset in hours to days (fast)
3. Arms only affected if the lesion is above the thoracic spine
4. Sensory loss below the lesion
135
What is carpal tunnel syndrome?
Entrapment of the median nerve against the carpal tunnel.
136
Give 5 features of carpal tunnel:
1. Pain and paraesthesia in the hand
2. Worse at night
3. Loss of sensation along the distribution of the median nerve
4. Tinel's sign
5. Phalen's sign
137
What is tinel's sign:
Lightly percuss over the median nerve at the wrist to produce pain or paraesthesia in the median nerve distribution
138
What is phalen's sign:
Flex wrist for 60 seconds to produce pain in the median nerve distribution
139
Where is the median nerve distribution in the hand?
Anterior: Almost all of the palm excluding the little finger and half of the fourth finger.
Posterior: fingertips of the thumb, index and half the fourth finger.
140
Give 3 groups at increased risk of carpal tunnel:
1. Diabetics
2. People with hypothyroidism
3. Pregnant people
141
What is Brown-Sequard syndrome?
A lesion in one half of the spinal cord. Seen in trauma, neoplasia, MS, spinal cord herniation or vascular events.
142
3 features of Brown-Sequard syndrome:
1. Ipsilateral UMN weakness below the lesion = severed corticospinal tract
2. Ipisilateral loss of proprioception and vibration = severed dorsal column
3. Contralateral loss of pain and temperature sensation = severed spinothalamic tract
143
What is Guillain-Barre syndrome? Give 3 triggers/causes:
An acute inflammatory demyelinating polyneuropathy.
1. Campylobacter jejuni
2. CMV
3. Other preceding infection
4. No cause is found in 40%
144
Give 4 features of Guillain-Barre syndrome:
1. Progressive ascending limb weakness that peaks at 4 weeks
2. Autonomic dysfunction (sweating, bp changes, raised pulse, arrhythmias)
3. Reflexes usually lost
4. Pain
145
How do you manage Guillain-Barre syndrome? (3)
1. IV immunoglobulin
2. Monitor FVC for respiratory muscle involvement - ventillate if needed
3. Plasma exchange possible if needed
146
Give 6 contrasting UMN and LMN signs:
UMN:
1. Spastic paralysis
2. Hyperreflexia
3. Hypertonic
4. Disuse atrophy
5. NO fasiculations
6. Positive babinski sign
LMN:
1. Flaccis paralysis
2. Hyporeflexia
3. Hypotonic
4. Wasting atrophy
5. No babinski sign
147
What is Myasthenia Gravis?
An autoimmune disease mediated by antibodies to nicotinic acetylcholine receptors on the postsynaptic side of the NM. Involves both B and T cells.
148
Give 3 classic signs of myasthenia gravis:
1. Ptosis
2. Diplopia
3. Myasthenic snarl/smiling
4. Normal tendon reflexes
149
How might myasthenia gravis present?
Increasing and relapsing muslce fatigue.
Muslce groups affected in order: extraocular, bulbar, face, neck, limb girdle, trunk.
Other classic signs: ptsosis, snarl, diplopia
150
Give 3 features of managing myasthenia gravis:
1. Anticholinesterase drug e.g. pyridostigmine
2. Immunosuppression e.g. prednisolone
3. Thyrectomy (beneficial in younger patients)
151
Explain the pathogenesis of Huntington's disease: (inheritance and how the brain is affected)
An autosomal dominant condition.
Expansion of a CAG repeat on chromosome 4.
Presence of mutant Huntingtin protein.
Leads to loss of neurons in the caudate nuclear and putamen.
Causes depletion of ACh and GABA.
Dopamine is spared!
152
How do you manage Giant Cell Arteritis? (4)
1. Prednisolone PO immediately, OR;
2. IV methylprednisolone if visual loss
3. Urgent temporal artery biopsy within 2 weeks of starting steroids
4. Continue steroids for 2 years
153
5 key features of giant cell arteritis:
1. Age > 50 years
2. New onset or new type of headache
3. Tender temporal artery/Scalp tender (combing hair hurts)
4. Elevated ESR
5. +/- Amaurosis fugax (emergency!!)
154
What is Giant cell arteritis?
A systemic immmune mediated vasculitis affecting medium and large sized arteries
155
Give 4 non-motor symptoms of Parkinson's disease:
1. Depression
2. Autonomic dysfunction (constipation, urinary freq, postural hypotension)
3. Anosmia
4. Dementia
5. Psychosis
6. Sleep disturbance
156
What is encephalitis? Give 3 typical causes:
Inflammation of the brain parenchyma.
1. Viral e.g. HSV, EBV, varicella zoster virus
2. TB
3. Listeria
157
Give 4 features of encephalitis:
1. Preceding flu-like illness
2. Decreasing GCS or coma
3. Fever
4. Altered behaviour/confusion
5. Headache
6. Memory loss
158
Give 4 possible investigations for encephalitis:
1. LP (with PCR test for HSV, VZV and enteroviruses)
2. FBC and blood film
3. Other bloods: cultures, U&E, creatinine, LFTs, glucose, ESR and CRP
4. MRI/CT
5. EEG
159
What drug might you give for encephalitis in a patient with EBV?
Acyclovir
160
What is meningitis, what is the most common cause?
Inflammation of the meninges, most commonly caused by a virus e.g. enterovirus, HSV, VZV
161
5 key signs/symptoms of meningitis:
1. Fever
2. Headache
3. Stiff neck
4. Photophobia
5. Kernig's sign
6. Back rigidity
162
3 categories of symptoms seen in dementia:
1. Cognitive impairment
2. Psychiatric disturbances
3. Difficulties with ADLs
163
What is Lewy Body dementia? How might you differentiate it from other types of dementia clinically (3 signs)?
Dementia caused by the deposition of abnormal protein within neurons in the brainstem and neocortex.
An early hallmark sign is visual hallucinations. Patients also experience fluctuating levels of awareness and attention. There are also signs of mild Parkinsonism.
164
What is Alzheimer's disease? Give 3 pathological features seen in the brain:
The most common cause of dementia, involved progressive degeneration of the cerebral cortex.
1. Amyloid plaques
2. Neurofibrillary tangles
3. Less ACh
165
Investigations for dementia: (4)
1. Cognitive assessment (MoCA)
2. MRI/CT to exclude other pathologies (e.g. tumour)
3. Bloods to exclude other causes
4. SPECT to differentiate type of dementia
166
Pharmacological management of dementia
1. AChE inhibitors e.g. donepezil
2. NMDA antagonist e.g. Memantine
3. Managment of other symptoms e.g. antidepressants (avoid TCAs as worsen cognition
167
What 3 types of cell are damaged by hyperglycaemia in diabetes mellitus?
1. Retinal endothelium
2. Mesangial cells in the glomeruli
3. Schwann cells in peripheral nerves (excessive oxidation causes damage)
168
Give 3 possible causes of a chronic peripheral neuropathy;
1. Diabetes mellitus
2. Coeliac disease
3. Alcohol abuse
4. CKD
169
What drug might you give to manage pain in a patient with peripheral neuropathy?
Amitriptyline
| Gabapentin
170
What is the most common cause of bacterial meningitis is adults?
Strep. pneumoniae
171
What is hemiballismus? What causes it?
Uncontrollable thrashing movements associated ith lesions of the subthalamic nucleus e.g. in a stroke
172
Guillian-Barre syndrome is classically triggered by an infection with what bug? How might this present? (3)
Campylobacter jejuni
1. Back pain
2. GI symptoms (diarrhoea)
3. Ascending weakness
173
Inferior homonymous quadrantanopia results from a lesion in which lobe of the brain?
Parietal lobe
| PITS: parietal = inferior, temporal = superior
174
Superior homonymous quadrantanopia is caused by a lesion in which lobe of the brain?
Temporal lobe
| PITS: parietal = inferior, temporal = superior
175
What is thoracic outlet syndrome?
A disorder involving compression of the brachial plexus, subclavain artery or subclavian vein at the site of the thoracic outlet.
176
Who is the typical patient you might meet with thoracic outlet syndrome (age, gender, physical features) and what causes it?
Patients are typically young thing women with long necks and drooping shoulders.
It's caused by trauma in anatomically predisposed people. It can be vascular or neurogenic.
177
2 signs/symptoms of neurogenic thoracic outlet syndrome:
1. Painless muscle wasting of the hand
| 2. Sensory symptoms e.g. numbness, tingling
178
2 signs/symptoms of vascular thoracic outlet sydrome:
Painful diffuse arm swelling with distended veins (if subclavian vein compressed)
Painful claudication leading to ulceration and gangrene (if subclavian artery compressed)
179
What do the dorsal columns conduct?
Light touch
Vibration
Proprioception
180
What does the lateral corticospinal tract conduct?
Limb motor information
181
What does the ventral corticospinal tract conduct?
Axial muscle information
182
What dose the lateral spinothalamic tract conduct?
Pain
| Temperature sensation
183
What does the anterior spinothalamic tract conduct?
Crude touch
184
What is Erb-Duchenne paralysis? What causes it?
An injury to the brachial plexus, commonly affecting the union of C5 and C6, occurs during breech delivery. Affects the suprascaular nerve, musculocutaneous nerve and axillary nerve.
185
What classic sign will Erb-Duchenna paralysis present with?
Waiter's tip:
Affected arm is held by the side and rotated medially. Elbow is extended with a pronated forearm and flexed wrist on the affected side.
186
Elhers-Danlos syndrome is a risk factor for which type of brain haemorrhage?
Sub-arachnoid
187
What does relative afferent pupillary defect indicate?
An optic nerve lesion or severe retinal disease
188
How long are you not allowed to drive (a car or motorcycle) for following a one-off seizure that was found to have no underlying structural or EEG abnormalities?
6 months
189
A patient with epilepsy wants to know if they can apply for a driving licence - how long will they have to have been seizure free for in order to qualify?
12 months
190
A patient with long standing epilepsy is trying to conceive, they are still taking their AED, what medication changes need to be advised?
Add 5mg of folic acid
191
5 features associated with narcolepsy:
1. Onset in teenage years
2. Hypersomnolence
3. Cataplexy (sudden loss of muscle tone often triggered by emotion)
4. Sleep paralysis
5. Vivid hallucinations on going to sleep or waking
192
What is the gold standard investigation for narcolepsy?
Multiple sleep latency EEG
193
How do you manage narcolepsy?
Daytime stimulant: modafinil
Nightime: sodium oxybate
194
What are 5-HT3 antagonists? Where in the brain do they act?
Antiemetics used in the management of chemo related nausea
Act on the medulla oblongata
195
Lip smacking and post-ictal dysphagia are localising features of a seizure in which lobe of the brain?
Give two other common features of seizures of this type:
temporal lobe
hallucinations
amnesia/deja-vu sensations
196
What is autonomic dysreflexia?
A clinical syndrome that occurs in patients who have had a spinal injury at or above T6
197
Features of autonomic dysreflexia: (4)
1. Extreme hypertension
2. Flushing and sweating above level of cord lesion
3. Agitation
4. Haemorrhagic stroke if untreated
198
Triggers for autonomic dysreflexia:
Faecal impaction or urinary retention
199
What drug might be useful in managing tremor in drug-induced parkinsonism?
Procyclidine
200
Cabergoline has been associated with which condition?
pulmonary fibrosis
