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Neuro Flashcards

1
Q

at what age does epilepsy usually develop?

A

before 20 or over 65

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2
Q

what are focal seizures?

A

in an isolated part of the brain (usually temporal lobe)

affect speech/motor/hearing/memory

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3
Q

do partial seizures impair consciousness?

A

some do - partial complex - do not know you are having eg psychomotor (automatisms)
some don’t -partial simple - myoclonic, jacksonian

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4
Q

what are secondary generalised seizures?

A

begin in one part of the brain and spread to both sides

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5
Q

what is a generalised seizure?

A

affecting both hemispheres of the brain

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6
Q

what is an atonic seizure?

A

‘drop attack’, muscles go floppy

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7
Q

what is a tonic-clonic seizure?

A

generalised
loss of consciousness
muscles stiff (tonic)
violent muscle contractions (clonic)

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8
Q

some features of an epileptic seizure?

A 
prodromal phase - irritability/confusion 
aura 
post ictal confusion, drowsiness, headache lasting 5-30 mins 
seizure lasts for 30-120 secs 
stereotypy 
cyanosis 
can occur from sleep
lateral tongue bite
positive ictal symptoms eg head turning
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9
Q

some features of non epileptic seizures?

A

situational
longer duration
very fast or very slow post ictal recovery
eyes closed
pelvic thrusting
ictal crying
no cyanosis, tongue biting, incontinence or injury

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10
Q

investigations for ?epilepsy?

A

EEG
MRI
ECG
serology

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11
Q

2 drugs for focal epilepsy?

A

carbamazepine

lamotrigine

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12
Q

2 drugs for generalised seizures?

A

sodium valproate

lamotrigine

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13
Q

how does lamotrigine work?

A

decreases sodium currents and glutamate transmission

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14
Q

how does carbamazepine work?

A

prevents repeated firing through sodium channels

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15
Q

how does sodium valproate work?

A

potentiates GABA activity

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16
Q

side effect of sodium valproate?

A

teratogenic
liver damage
hair loss

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17
Q

side effect of carbamazepine?

A

agranulocytosis

aplastic anaemia

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18
Q

side effect of lamotrigine?

A

stevens johnson syndrome

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19
Q

how is status epilepticus defined?

A

seizure for more than 5 mins

or 3 seizures in 1 hour

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20
Q

treatment of status epilepticus?

A

ABCDE
secure airway
oxygen (high flow)
check cardiac, resp function, glucose

IV lorazepam
repeat after 10 mins if not successful
IV phenytoin or phenobarbitol

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21
Q

what is the pathophysiology of parkinsons?

A

death of dopaminergic cells in the substantia nigra

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22
Q

what is a lewy body?

A

collection of alpha synuclein

in lewy body dementia and also sometimes parkinsons

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23
Q

classic 3 features of parkinsons?

A

bradykinesia
tremour - pill rolling
rigidity - cogwheel

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24
Q

what is the gait/posture like in parkinsons?

A

stooped posture

shuffling ‘festinant’ gait with decreased arm swing

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25
what is hypomimia?
lack of facial expression | sign of parkinsons
26
autonomic symptoms of parkinsons?
urinary frequency (not incontinence) dribbling postural hypotension constipation
27
how is parkinsons diagnosed?
usually clinical | DATSCAN to visualise DA-ergic activity in striatum
28
what is first line for parkinsons, how does it work?
levodopa (DA precurser) with carbidopa (peripheral decarboxylase inhibitor)
29
some side effects of levodopa w/ carbidopa?
``` dystonia chorea dyskinesia nausea psychosis ```
30
what are ripinirole & bromocriptine? a side effect?
DA agonist used in parkinsons pulmonary fibrosis
31
what is selegiline, how is it used?
MOA-B inhibitor - stops breakdown of DA and NA | used for depression & parkinsons
32
what is entecapone?
COMT inhibitor similar to carbidopa carbidopa + entecapone may extend 'on' time of levodopa
33
what can be given to help tremour? what is a side effect?
anticholinergic eg procyclidine | anti cholinergic burden = confusion
34
what happens when drugs for parkinsons stop working?
on dyskinesias = hyperkinetic movement off dyskinesias = painful dystonic posturing unpredictable freezing
35
is parkinsons symmetrical?
no
36
how to distinguish parkinsons from pressure hydrocephalus? (produces a magnetic gait)
parkinsons doesnt have incontinence
37
how to determine parkinsonian tremour from essential tremour?
``` PD = pill rolling essential = worse on intention, better with alcohol and more family history ```
38
define stroke?
acute sudden onset neurological deficit due to cerebrovascular pathology symptoms persisting for more than 24hrs or death
39
what are the main vessels in the anterior cerebral circulation? - 6
``` posterior communicating middle cerebral - anterior choroidal internal carotid anterior cerebral anterior communicating ```
40
what main arteries branch off basilar?
``` posterior cerebral superior cerebellar pontine anterior inferior cerebellar -- vertebral arteries - posterior inferior cerebellar & spinal are branches ```
41
what are brocas & wernickes area?
``` wernicke = understanding words brocas = forming words/speaking ```
42
where is wernickes area? what is it supplied by?
parietal/temporal lobe opposite side to dominant hand supplied by middle cerebral artery
43
where is brocas area, what is it supplied by?
frontal lobe opposite side to dominant hand supplied by middle cerebral artery
44
what parts of the brain does the anterior cerebral artery supply?
front & top - so frontal cortex and some of the motor cortex (esp upper limbs)
45
what does the middle cerebral artery supply?
sides of brain inc brocas, wernickes, motor (esp lower limbs) and sensory
46
what is the most common artery to have a stroke in?
middle cerebral
47
what does the posterior circulation supply, what are the symptoms of a stroke there?
cerebellum and brainstem | dysarthria, dysphasia, diplopia, dizziness, ataxia, quadrantanopia, reduced GCS
48
what is a lacunar infarct & how does it present?
of the deep ppenetrating arteries produces an isolated deficit, eg one hand weakness no visual field defect or cortical malfunction
49
how do you differentiate stroke from bells palsy?
stroke = lower face weakness but forehead spared | bells palsy = forehead affected
50
are the motor symptoms ipsilateral or contralateral to the infarct?
contralateral
51
what is the bamford classification?
for ischaemic stroke, total anterior = 3/3 and partial anterior = 2/3 hemiplegia homonymous hemianopia higher cortical dysfunction eg speech
52
what is the first investigation in suspected stroke?
non contrast CT head to exclude haemorrhagic
53
if you are going to do a thrombectomy how will you find the clot?
CT angiogram
54
what is gold standard for ischaemic stroke investigation?
diffusion weighted MRI head
55
what is endarterectomy? what inv for it?
to remove atherosclerotic plaques | doppler
56
what screening programme for stroke in the community?
FAST
57
what is first line for stroke if presented within 4.5 hrs of onset?
alteplase (tissue plasminogen activator) | + aspirin
58
contraindications for thrombolysis? 5
``` hypertension bleeding elsewhere surgery in the last 3 months brain malignancy over 4.5 hrs since onset ```
59
when should you do a thrombectomy in ischaemic stroke?
within 6hrs or if you can prove the tissue is viable | there is a risk of reperfusion injury so only do if it will be worthwhile
60
should you lower BP in stroke?
no, this increases the risk of hypoperfusion
61
secondary prevention after stroke?
aspirin for 14 days clopidogrel atorvastatin bp control
62
risk factors for ischaemic stroke/TIA?
``` age hypertension diabetes hypercholesterolaemia smoking AF thrombophilia sickle cell ```
63
what is a crescendo TIA?
2 or more TIA within a week | high risk of stroke
64
what is the definition of TIA?
symptoms of a stroke with complete resolution within 24hrs
65
what is the pathophysiology of TIA?
ischaemia without infarction (the tissue does not die)
66
what score assesses risk of another TIA or stroke?
``` ABCD2 Age (over 60 = 1) BP (over 140 or 90 = 1) Clinical features (speech impaired = 1, unilateral weakness =2) Duration (10 mins+ = 1, 1hr + = 2) Diabetes ``` if more than 4 admit
67
surgical treatment for TIA?
endarterectomy if 70% or more stenosis | stent eg carotid stent
68
long term treatment for TIA?
aspirin + clopidogrel for 2 weeks - then just clopidogrel statins BP control
69
what is the usual epidemiology of extradural haemorrhage?
young patient with traumatic head injury esp skull fracture
70
what are the 3 layers of meninges?
outer: dura mater - tough fibrous - periosteal and meningeal middle: arachnoid mater: loose connective tissue inner: pia mater - thin, tightly adhered to brain PADS
71
in an extradural haemorrhage where is the blood?
between the skull and the dura mater - usually tightly stuck!
72
where are the dural venous sinuses?
between the two layers of dura, the periosteal and meningeal layers
73
what artery is most commonly implicated in an extradural haemorrhage?
meningeal artery rupture | at the pteron (frontal bone joins parietal bone)
74
typical history of extradural haemorrhage?
blow to side of head lucid period for a few hours (these vessels bleed slowly) -- loss of consciuosness
75
what does an extradural haemorrhage look like on CT?
hyperdense bright white lemon shaped doesnt cross suture lines skull x ray may also show fracture
76
management of extradural haemorrhage?
ICU / intubate mannitol - to decrease ICP craniotomy
77
where is the blood in a subdural haemorrhage?
between the dura and arachnoid
78
typical history in subdural haemorrhage? | what vessels are typically affected?
acute - car crash with accelleration-deceleration chronic - elderly or alcoholic with trivial fall weeks ago tear of bridging veins - in elderly/alcoholic this is more likely as brain is shrunken veins so bleeding can be slow -- chronic
79
what do you see on CT in a subdural haemorrhage?
crescent/banana shaped bleeding - all way to midline at each side acute (white) or chronic (grey) blood midline shift
80
presentation of subdural haemorrhage?
``` acute = reduced worsening GCS chronic = progressive confusion focal neurological symptoms raised ICP (vomitting/reduced ICP/blurred vision) ```
81
treatment for subdural haemorrhage?
burr hole craniotomy mannitol
82
where is the bleeding in a subarachnoid haemorrhage?
between the arachnoid and pia mater | where the CSF should be
83
what vessels are most often implicated in subarachnoid haemorrhage?
usually caused by ruptured berry anneurysm | in circle of willis, esp junctions, in anterior comm/ int carotid/ MCA
84
typical history/epidemiology for subarachnoid haemorrhage?
sudden onset thunderclap headache while playing sport female 45-60/connective tissue disorders
85
symptoms of subarachnoid haemorrhage?
sudden onset worse ever headache, occipital (at back) meningism - photophobia, neck stiffness vision/speech changes confusion
86
what do you see on CT in subarachnoid haemorrhage?
star shaped | hyperattenuation in subarachnoid space
87
apart from CT head, what other investigations might be helpful in subarachnoid haemorrhage?
lumbar puncture for xanthochromia - yellow colour indicates bilirubin from blood in csf space angiography to find the source
88
treatment for subarachnoid haemorrhage?
endovascular coiling/clipping to stop bleeding nimodipine (calcium channel blocker) to prevent vasospasm secondary to bleeding lumbar drain for CSF, if hydrocephalus develops
89
what is the Cushing reflex?
in ischaemic stroke increasing BP, decreasing heart rate, erratic breathing BP increases in response to hypoperfusion in brain carotid sinus baroreceptors detect increased BP -- slow heart rate irregular breathing because brainstem is compressed by raised ICP
90
what does agonal breathing suggest?
herniation of the brainstem
91
some triggers for migraine in susceptible people?
``` chocolate/wine/cheese/caffeine oral contraceptive menstruation bright lights strong smells lack of sleep ```
92
how long does a migraine last?
4-72 hours
93
what is the pain like in migraine?
unilateral throbbing/pulsating moderate-severe
94
apart from pain, some presentations of migraine?
``` prodromal fatigue/mood changes nausea photophobia phonophobia aura cannot carry out daily activities, want to lie in a dark room ```
95
what is a hemiplegic migraine?
unilateral weakness, ataxia, altered consciousness
96
some common features of migraine aura?
flashing lights zig zag lines in vision ringing in ears
97
what is a silent migraine?
aura but no headache
98
acute management of migraine? 3
NSAIDS/paracetamol triptans eg sumatriptan antiemetic eg metoclopramide
99
what are triptans for & how do they work?
``` for acute treatment of migraine 5ht agonist causes vasoconstriction inhibits peripheral pain receptors reduces CNS activity ```
100
prophylaxis of migraine?
propanolol topiramate amitriptyline riboflavin
101
some triggers for tension headache?
``` stress posture lack of sleep eye strain depression alcohol skipping meals dehydration ```
102
what is the pain like in tension headache?
bilateral mild-moderate pressing/tight sensation photophobia or phonophobia but not both and no nausea
103
10 headache red flags?
``` new onset over 50 immunosupressed neck stiffness history of cancer history of trauma jaw claudication visual disturbance changes with posture started by coughing/laughing etc = increased ICP fever seizure papilloedema vomitting change in personality ```
104
epidemiology of cluster headache?
male 20-50 smoker
105
what is the pathophysiology of cluster headache?
hyperactivity of trigeminal-autonomic reflex arc vasodilation and trigeminal stimulation histamine & mast cells autonomic nervous system activated
106
presentation of cluster headache?
``` severe 'boring' 'hot poker' pain over one eye myosis, ptosis, red/swollen eye nasal discharge and tears sweating on one side of face photophobia agitation/restlessness ```
107
how long does a cluster headache last?
15 min - 3hrs
108
episodic vs chronic cluster headache?
``` episodic = pain free for 1 month + chronic = no pain free months ```
109
management of cluster headache?
neuro referral acute - sumatriptan, high flow oxygen prophylaxis - verapamil, prednisolone, lithium
110
what medications cause medication over use headache?
10 days/month: ergotamine triptans opioids 15 days/month: nsaid paracetamol aspirin
111
what is the pain like in trigeminal neuralgia?
``` in one or more distributions of the trigeminal nerve no radiation severe stabbing pain unilateral secs-mins triggered by stimuli ```
112
management of trigeminal neuralgia?
carbamazepine | surgery to decompress or damage the nerve
113
Some factors that contribute to the epidemiology of MND?
smoking pesticides SOD1 & C90RF genes
114
what are upper motor neurones?
go from cortex to anterior horn of spinal cord
115
what are lower motor neurones?
go from the spinal cord to the muscle
116
does MND affect upper or lower motor neurones?
can be either or both if it is affecting only upper motor neurones it is called primary lateral sclerosis if it affecting only lower motor neurones it is called primary muscular atrophy if it is affecting upper and lower it is called amyotrophic lateral sclerosis (this is most common)
117
what is the most common onset of MND?
limb
118
features of upper MND affecting the limbs?
pyramidal weakness -- extensors in arms and flexors in legs spasticity brisk reflexes
119
features of lower MND affecting the limbs?
weakness wasting fasciculations
120
some features of bulbar MND?
dysarthria - speech is slurred or quiet excessive saliva choking jaw spasm
121
what type of respiratory failure is seen in MND?
``` type 2 (because it is a problem with the muscles so you are unable to both breathe oxygen in AND co2 out) ```
122
when is the breathlessness worst in MND?
at night or when lying flat
123
some general symptoms of MND?
``` foot drop tripping/falling difficulty using hands fatigue, sleep disturbance anorexia frontotemporal dementia emotional lability ```
124
is MND symmetrical?
no
125
3 signs that suggest it is not MND?
Symmetry incontinence sensory disturbance (MND is specifically of the MOTOR neurones) relapsing-remitting pattern (MND is gradually worsening)
126
investigations for MND affecting upper neurones?
MRI brain and spine - need to exclude other things
127
investigations for lower motor neurone pathology? (eg in MND)
nerve conduction studies - test how well the nerve conducts the signal EMG (electromyography) - tests how well the muscle responds to impulses
128
what is riluzole?
antioxidant, may improve symptoms in MND or extend life by a few months
129
motor neurones that are spared in MND?
``` oculomotor nerve onufs nucleus (controls bladder/continence) ```
130
most common cause of meningitis in neonates?
group B strep
131
most common cause of meningitis in adults?
s pneumoniae
132
n meningitidis is a common cause of meningitis, especially in which populations?
adults/students
133
h influenzae is a cause of meningitis, most commonly affecting ____
children
134
listeria monocytogenes is a cause of meningitis, most commonly in which populations?
``` immunocomp elderly neonates cancer diabetic pregnant ```
135
some viral causes of meningitis?
HSV | VZV
136
define meningitis?
inflammation of the meninges, which cover the brain and spinal cord
137
why is a rash associated with meningitis?
n meningitidis is a common cause of meningitis | meningococcal sepsis = disseminated intravascular coagulation, the 'rash' is the red spots produced by the tiny clots
138
classic triad of meningism?
photophobia neck stiffness headache
139
apart from meningism, some features of meningitis?
``` vomitting fever impaired consciousness seizures kernigs sign brudzinskis sign non blanching purpuric rash, if meningoccoccal ```
140
what is kernigs sign?
meningitis patient lying on back flex hip and straighten knee = back pain
141
what is brudzinskis sign?
patient lying on back | flex neck -- knees and hips with flex too
142
what is the CSF like in bacterial meningitis?
cloudy neutrophils/granulocytes high protein low glucose
143
what is the CSF like in viral meningitis?
lymphocytes high protein normal glucose
144
what is the CSF like in fungal meningitis?
lymphocytes high protein low glucose
145
do you need to send a CSF if you have meningism + rash?
no, you can do a blood test for n meningitidis instead
146
if a CSF contains gram pos cocci what is it most likely to be?
strep pneumoniae
147
if a CSF contains gram pos bacilli what is it likely to be?
h influenzae | listeria
148
what empirical antibiotics should you give for ?meningitis while you are waiting for results?
cefotaxine / ceftriaxone | + amoxicillin if you suspect listeria
149
what should you give to contacts of someone known to be infected with n meningitidis?
ciprofloxacin
150
what drug reduces the risk of developing complications after meningitis?
dexamethasone
151
potential complications of meningitis?
``` hearing loss epilepsy cognitive impairment memory loss focal neurological deficits ```
152
some differentials for MND?
MS spinomuscular atrophy muscular dystrophy myasthenia
153
what is the most common cause of encephalitis?
HSV
154
what is encephalitis?
inflammation of the brain parenchyma
155
features of encephalitis?
``` fever headache fatigue confusion change in behaviour/psychosis focal neurological defect eg aphasia/hemiparesis/cerebellar seizures ```
156
investigations for encephalitis?
MRI head to see inflammation - frontal/temporal CSF ``` throat swab for virus serology blood culture FBC, CRP, UE EEG - non specific ```
157
what can the EEG show in encephalitis?
periodic lateralised discharges at 2Hz (not specific)
158
empirical management for encephalitis?
aciclovir | gancyclovir
159
what virus causes chickenpox/shingles?
varicella zoster -- chickenpox lies dormant -- reactivates -- shingles -- now called herpes zoster
160
what can happen if you develop chickenpox for the first time in adulthood?
pneumonitis (can be fatal) | foetal varicella syndrome, if you catch it in pregnancy -- causes maldevelopment of foetus
161
what is a chickenpox rash classically like?
macule-papule-vesicle-pustule-crust | centrifugal distribution
162
where does the chickenpox virus usually lay dormant?
dorsal route ganglion trigeminal nerve olfactory nerve
163
presentation of shingles?
``` macular -- vesicular rash in dermatomal distribution, one side of midline, thoracic pain/itching/tingling/neuropathy malaise, myalgia headache fever ```
164
investigations for shingles? | & a specific stain?
serology viral PCR tzank - confirms presence of herpesvirus but doesnt differentiate which
165
management of shingles?
aciclovir or valaciclovir | iv immunoglobulin
166
what is ramsey-hunt syndrome?
``` complication of shingles paralysis of facial nerve rash on ear/mouth tinitus hearing loss ```
167
what is the epidemiology of MS?
under 50 more females more further from the equator may be related to EBV exposure in teenage
168
is MS in the CNS or PNS?
CNS
169
what is the pathophysiology of MS?
autoimmune lymphocytes cross the BBB -- destroy oligodendrocytes demyelination & loss of axons remyelination -- remission for a period (but symptoms may reappear eg when axons stretched by a hot shower)
170
some presenting features of MS?
``` optic neuritis nystagmus focal weakness - face/arms/legs spasticity vertigo paresthesia cerebellar ataxia sensory loss ```
171
what is optic neuritis & why can it happen in MS?
painful unilateral visual loss demyelination of optic nerve relative afferent pupillary defect: consensual but not direct constriction
172
what is internuclear opthalmoplegia in MS?
dysfunction of the fibre than connects CN 3, 4 and 6 for co ordinated eye movement
173
where is the problem in a conjugate lateral gaze disorder?
CN6 - affected eye cannot abduct
174
what are two 'pre-MS' syndromes?
radiologically isolated: changes apparent on MRI, but no symptoms clinically isolated: 1 episode of symptoms but you need at least 2 to call it MS
175
3 patterns of disease course in MS?
relapsing-remitting -- partial or full recovery between, minimal disability secondary progressive - - relapsing-remitting which becomes progressive, - - or, gradually worsening with relapses superimposed primary progressive -- gradually worsens from onset
176
what is Lhermitte's sign?
sensations shooting down spine when bending neck | associated with MS
177
investigations for MS?
MRI w/ contrast - shows immune activity in CNS | lumbar puncture : oligoclonal bands in CSF indicates immune activity in CSF
178
what signs might you find on a bedside examination of a patient with MS?
``` brisk reflexes eyes don't move together pyramidal weakness unco-ordinated babinskis sign lhermittes sign ```
179
what is 1st and 2nd line acute treatment for MS relapses?
1st -- oral methylprednisolone | 2nd -- IV steroids
180
treatment for MS symptoms?
``` amitryptiline baclofen anti cholinergics (to treat incontinence) ```
181
drugs that prevent MS relapses?
``` natalizumab - stops lymphocytes crossing BBB alemtuzumab: anti CD20 betaferon/IFN1beta daclizumab stem cell transplant ```
182
are brain tumours generally malignant or benign?
55% are malignant
183
are brain tumours usually primary or secondary?
secondary / metastatic more common
184
what grading system do brain tumours follow, how does it work?
WHO classicification 1 - slow growing benign 2 - cytological atypia eg large hyperchromic nuclei 3 - anaplasia, mitotic 4 - microvascular proliferation or necrosis
185
what is the most common type of brain tumour?
glioma
186
what is an empendymoma?
from lining of ventricle/central canal | a glioma
187
what is oligodendroglioma? how can it be identified? what does it cause?
``` 40s and 50s frontal cortex = behavioural changes grade 2 or 3 calcification deletion of 1p1qq glioma ```
188
what is glioblastoma mutliformae?
glioma from astrocytes very malignant, grade 4 de novo or develop from grade 2 astrocytoma
189
what is a diffuse astrocytoma?
grade 2 type of glioma can develop into glioblastoma multiformae which is much more malignant
190
what is an anaplastic astrocytoma?
``` grade 3 (anaplastic) type of glioma ```
191
what is a pilocytic tumour?
glioma grade 1 in children good prognosis
192
what is mengingioma?
generally benign | cause symptoms because take up space = nerve lesions & raised ICP
193
what is a hemangioblastoma?
brain tumour from blood vessels develops in cerebellum in middle age usually low grade
194
what is acoustic neuroma?
aka schwanoma - cn 8
195
what is medulloblastoma?
brain cancer small blue cell cerebellum in children grade 4
196
focal neurological manifestation of a frontal cortex problem?
hemiparesis | personality change
197
focal neurological manifestation of a temporal lobe problem?
dysphasia | amnesia
198
focal neurological manifestation of a occipital lobe problem?
contralateral visual defect
199
focal neurological manifestation of a parietal lobe problem?
hemisensory loss
200
in brain tumour what is the headache like?
worse on coughing/bending/lying/in morning constant disturbs sleep
201
some symptoms of raised ICP?
``` headache vomitting seizures papilloedema 3rd and 6th CN palsies visual field defects ```
202
investigations for ?brain tumour?
MRI (then maybe fMRI) CT contrast stereotactic biopsy for histology -- MGMT methylation predicts response to treatment --IDH-1 mutation indicates glioma replication
203
what chemotherapy is commonly used for brain tumour?
PCV - procarbazine, lomustine, vincristine | temozolamide
204
what is usually 1st line for glioma?
radiotherapy
205
which tumours are most likely to metastasise to the brain?
``` lung breast prostate colorectal renal malignant melanoma ```
206
in lateral tentorial herniation what is compressed?
posterior cerebral and superior cerebellar arteries cerebellum and midbrain CN 3
207
how is peripheral neuropathy defined?
axonal or demyelinating damage to several nerves
208
5 aetiology of peripheral neuropathy?
``` Diabetes Alcohol Vit b12 deficiency Infective eg guillian barre, lyme Drugs - isoniazid, amiodarone ``` gluten sensitivity CKD amyloid, sarcoid paraneoplastic
209
schwann cells vs oligodendrocytes?
both produce myelin schwann - peripheral oligodendrocytes - cns
210
5 mechanisms of damage in peripheral neuropathy?
demyelination / schwann cell damage axonal degradation - eg charcot marie tooth compression wallerian - trauma - axon separated from cell body infarction - eg diabetes, arteritis infiltration - leprosy, cancer
211
what are the 4 types of sensory fibre?
A alpha A beta A delta C
212
what are A alpha fibres?
``` sensory neurones large myelinated proprioception if there is damage to them you fall over when you close your eyes ```
213
what are A beta fibres?
large, myelinated | fine touch, vibration
214
what are A delta fibres?
small myelinated pain & cold damage = loss of sensation or severe neuropathic pain
215
what are C fibres?
``` sensory unmyelinated slow pain very small so vulnerable to damage damage = loss of pain or neuropathic pain ```
216
what motor neurones are affected in peripheral neuropathy, & when? what symptoms?
lower motor neurones, motor neurone involvement is a late sign muscle cramp weakness atrophy - distal muscles - foot arches, pes cavus fasciculations
217
what pattern of neurones are affected in symmetrical sensorimotor neuropathy?
longest first - so starts in toes and ascends sensory then motor sensory - pain, tingling, numbness
218
what pattern of neurones are involved in asymetrical sensory peripheral neuropathy? what causes this?
patchy dorsal route ganglion paraneoplastic sjorens gluten
219
what is mononeuritis multiplex?
peripheral neuropathy aka asymmetrical sensorimotor | loss of motor & sensory in two separate areas
220
what is assymetrical sensorimotor peripheral neuropathy most associated with?
systemic vasculitis
221
what will you see on clinical examination of someone with peripheral neuropathy?
decreased reflexes sensory deficits weakness wasting
222
investigation of peripheral neuropathy?
nerve conduction studies - - if demyelination, conduction will be slow - - if the axon is damaged, impulse will be smaller
223
treatment for cramps in neuropathy?
quinine
224
treatment for pain in peripheral neuropathy?
amitryptiline | gabapentin
225
what is myasthenia gravis?
autoantibodies to the Ach receptor, causing muscle weakness
226
what condition is myasthenia gravis associated with?
thymoma and thymic hyperplasia
227
what normally happens at the neuromuscular junction to trigger muscle contraction?
depolarisation of lower motor neurone = calcium channels open calcium influx into LMN calcium = exocytosis of Ach from vesicles Ach crosses synapse and binds to postsynaptic receptors ach binding opens the intrinsic channel, potassium out sodium in voltage gated sodium channels open = depol along t tubule depol = opening of calcium stores in sarcoplasmic reticulum calcium = contraction
228
as well as anti-AchR antibodies, what other antibodies might (less commonly) be found in myasthenia gravis?
anti-musk (muscle specific kinase)
229
some ocular manifestations of myasthenia gravis?
ptosis upward gaze complex opthalmoplegia double vision (because of difficulty with eye movement)
230
some general features of myasthenia gravis?
``` fatiguability muscle weakness dysarthria dysphagia shortness of breathing fatigue when chewing head drop ```
231
are antibodies always present in myasthenia gravis?
no, in fact anti-AchR antibodies only present in 80% pts and only 50% of ocular
232
what are 2 investigations for myasthenia gravis? | what will you see?
single fibre EMG decremental potentiation - response decreases as stimulus is repeated - this will tell you there is fatiguability tensilon test tensilon = ach esterase inhibitor this will tell you if the symptoms are caused by myasthenia or not (definitive/confirm)
233
what is the treatment for myasthenia gravis?
1st line - pyridostigmine (Ach esterase inhibitor) 2nd line - azathiopurine other immunosuppressants eg prednisolone, methotrexate rituximab good for MuSK Ab +ve
234
what is myasthenic crisis?
``` complication of myasthenia gravis respiratory difficulty SOB, reduced breath sounds, reduced chest expansion normal saturation, normal ABG decreased FVC ```
235
how to treat myasthenic crisis?
IV immunoglobulin steroids plasma exchange
236
how is Huntingtons inherited?
autosomal dominant | anticipation so if parents are borderline but dont have symptoms, their child could still have it
237
what kind of mutation is seen in Huntingtons?
``` trinucleotide repeat (CAG) on chr 4, huntingtin / HTT gene ```
238
what does the mutation in Huntingtons code for & what is the effect of the mutation?
CAG codes for glutamine too many CAG repeats = build up of glutamine = misfolding/aggregation = loss of GABA producing cells, loss of inhibitionn
239
how is movement affected in Huntingtons?
it can be initiated but then is hard to stop or change
240
clinical presentation of Huntingtons?
``` cognitive / mood changes chorea - involuntary abnormal movements eye movement disorders dysarthria dysphagia dementia infections ```
241
management of Huntingtons disease?
antipsychotic eg olanzapine tetrabenazine - DA depleting benzodiazepine
242
what infections does guillian barre follow?
GI eg campylobacter jejuni EBV CMV
243
what is the pathophysiology of guillian-barre?
autoimmune molecular mimicry antibodies to nerves eg myelin sheath or axon = peripheral neuropathy
244
is guillian barre symmetrical?
yes
245
presentation of guillian barre?
``` following an infection ataxia ascending flaccid motor weakness, starts at feet hyporeflexia facial weakness reduced sensation neuropathic pain respiratory involvement ```
246
timeframe of guillian barre?
develops within 4 weeks of infection peaks 2-4 weeks after that takes months to years to recover
247
how is guillian barre diagnosed?
clinical diagnosis Brighton criteria CSF - high protein, normal glucose and white cells nerve conduction studies - low signal
248
treatment for guillian barre?
heparin/apixaban plasma exchange IV immunoglobulins
249
3 causes of spinal cord compression?
``` cancer (metastatic myeloma, bone tumour, glioma) disc herniation infection eg epidural abscess haematoma spinal stenosis ```
250
what part of the spine is most commonly compressed by tumours?
thoracic
251
3 classifications of spinal cord compression caused by tumour?
intramedullary - in the vertebral canal leptomeningeal - where the meninges should be extradural - compressing the dura from the outside
252
what is the pain like in spinal cord compression? | what makes it worse?
radicular (spreading down spinal root to legs) or local | worse when lying/coughing
253
presentation of spinal cord compression?
back pain progressive motor weakness - umn and lmn sensory loss bladder/bowel dysfunction, retention
254
describe the motor impairment in a spinal cord lesion?
LMN signs at the level of the lesion -- wasting, weakness, hyporeflexia UMN signs BELOW the level of the lesion -- hyperreflexia, contralateral spasticity, extensor plantar reflex
255
describe the sensory impairment in spinal cord compression?
ascending numbness parasthesia 1-5 caudal levels below the lesion less common than motor symptoms
256
what is the gold standard investigation for spinal cord lesion?
MRI
257
some differentials for spinal cord compression?
MS MND guillian barre spinal cord compression
258
treatment of spinal cord compression?
IV dexamethasone surgical decompression - eg remove tumour, discectomy etc epidural steroid injections
259
3 places that can be stenosed in spinal cord stenosis & the names for them?
central spinal canal = central stenosis nerve root canals = lateral stenosis intervertebral foramina = foramina stenosis
260
3 causes of spinal stenosis?
``` congenital age related degeneration herniated disk thickening of ligaments eg ligamentum flavum fractures tumour spondylolisthesis (slipped disk) ```
261
presentation of spinal cord stenosis?
``` gradual intermittent neurogenic claudication leg weakness worse when standing saddle anaesthesia lower back/buttock/leg pain ```
262
investigations for spinal stenosis?
MRI CT angiogram and ABPI to exclude peripheral artery disease
263
what is cauda equina syndrome?
compression of the bundle of nerves at the bottom of the spinal column, 'the cauda equina'
264
what is the most common cause of cauda equina syndrome?
herniated lumbar disk
265
what is the piece of dura in the middle of the cauda equina called?
conus medullaris
266
what happens to the nerves in the cauda equina?
they still exit the spinal cord at their respective vertebral level for the cauda equina nerves this is L3-L5, S1-S5, C0
267
what do the nerves of the cauda equina supply?
sensation to bladder rectum & perineum parasympathetic to bladder & rectum motor to anal & rectal sphincters motor to lower limbs
268
clinical presentation of cauda equina?
saddle anaesthesia urinary retention and/or urinary incontinence faecal incontinence bilateral sciatica bilateral severe motor weakness in legs # erectile dysfunction loss of anal tone on PR exam
269
how can you distinguish cauda equina from spinal cord compression?
cauda equina only affects lower motor neurones spinal cord compression affects both UMN and LMN so you will also see some hyperreflexia depending on the cause spinal cord compression could be gradual onset (eg in spinal stenosis), cauda equina is always a sudden onset
270
what investigations for cauda equina?
urgent MRI spine bladder USS to check for urinary retention check reflexes and anal tone
271
treatment for cauda equina?
emergency lumbar decompression surgery
272
what nerve is compressed in carpal tunnel syndrome? | what is the function of this nerve?
palmar digital cutaneous branch of the median nerve - - sensory function to first 3.5 fingertips (not the palm though, this is a different branch that doesnt go through the carpal tunnel) - - thumb motor function (thenar muscles) -- abductor pollicis brevis, opponens pollicis, flexor pollicis brevis (not the adductor!)
273
the carpal tunnel is formed by what?
flexor retinaculum, aka transverse carpal ligament
274
clinical presentation of carpal tunnel syndrome?
gradual onset, intermittent, worst at night, wakes you up sensory changes to first 3.5 fingers - numbness, paraethsia, burning, pain reduced thumb grip strength/difficulty with fine movements
275
what relieves carpal tunnel syndrome?
shaking the hand
276
what is phalins test?
for carpal tunnel | fully flex the wrist and hold it - pos if it causes symptoms
277
what is tinnels test?
for carpal tunnel | tap the carpal tunnel- pos if it produces symptoms
278
what is the kameth and stoddart questionnaire?
shows the likelihood of carpal tunnel
279
what is gold standard investigation for ? carpal tunnel syndrome?
nerve conduction studies
280
risk factors for carpal tunnel?
``` diabetes hypothyroid obesity repetitive strain acromegaly perimenopause RA ```
281
management of carpal tunnel syndrome?
rest wrist splints steroid injection cut the flexor retinaculum
282
what do the dorsal spinal columns transmit?
proprioception | fine touch
283
which spinal cord pathway has gracilis and cuneate nuclei and what are these for?
dorsal spinal column gracilis = medial = legs cuneate = lateral = arms
284
what does the spinothalamic tract transmit?
pain | temperature
285
where do the dorsal spinal columns decussate?
medulla
286
where do the spinothalamic tracts decussate?
spinal cord
287
what does the corticospinal tract transmit?
motor
288
where does the corticospinal tract decussate?
85% decussates in the medulla, this is the lateral tract 15% decussates in the spinal cord, this is the medial tract remember that corticospinal tract is motor so impulses travel down from brain to spine thus the lateral tract is contralateral to the brain but ipsilateral to the muscles it innervates
289
damage to the anterior spinal artery causes what effect?
damages the lateral spinothalamic tract | -- lose pain and temperature sensation
290
how does B12 deficiency affect the spinal cord and what is the effect of this lesion?
B12 deficiency = posterior spinal cord syndrome | affects dorsal columns = bilateral loss of proprioception and fine touch
291
what does syringomyelia cause?
syringomyelia = development of fluid filled cyst in spinal cord cape like distriibution - loss of sensation over arms
292
does spinal cord lesion affect upper or lower motor neurones?
usually both
293
how is continence affected in spinal cord lesions?
UMN pathology increased sphincter tone retention and constipation
294
is there is a spinal cord lesion above the level of T6 what happens?
autonomic dysreflexia hypertension bradycardia sweating and flushing
295
if all limbs are affected where is the spinal cord lesion?
cervical
296
if only the legs are affected where is the spinal cord lesion?
thoracic
297
if the diaphragm is affected where is the spinal cord lesion?
above C3
298
investigation for ?spinal cord lesion?
MRI whole spine
299
what kind of nerves are carried in spinal nerves? (ie sympathetic, motor etc)
all kinds - autonomic, sensory and motor
300
what is an afferent fibre?
afferent = sensory | annie is sensitive
301
what is an efferent fibre?
efferent = motor | has an effect on the muscle
302
what nerve is damages in elbow trauma and what functions does this nerve provide?
ulnar nerve (C7-T1 via brachial plexus) for wrist flexion, crossing fingers, sensory to little and 4th fingers lesion = claw hand
303
wrist drop indicates damage to which nerve? | what else is the nerve for?
radial nerve for spreading hands and opening fist sensation to dorsal thumb
304
a heavy rucksack or broken rib commonly causes damage to the ___
brachial plexus
305
what happens when the phrenic nerve is damaged?
loss of innervation to diaphragm | = orthopnoea and diaphragm is raised on CXR
306
lung cancer, thymoma and TB commonly damage which nerve?
phrenic
307
foot drop indicates damage to which nerve?
common peroneal (branch of sciatic), aka common fibular nerve
308
pelvis fracture commonly damages which nerve?
sciatic | L4 - S3
309
common peroneal nerve is from which spinal levels and could be damaged by what?
L4-S1 | trauma to fibular head
310
which nerve innervates plantar flexion and sensation on the sole of the foot?
tibial
311
damage to what nerve causes burning thigh pain?
lateral cutaneous L2-L3
312
what condition is highly associated with Alzheimers?
Down's, everyone with Down's will get Alzheimer's
313
what is the most common type of dementia?
Alzheimer's
314
pathological features of Alzhiemer's? (histology etc)
beta amyloid plaques tau containing tangles synaptic degradation atrophy of the centre of the brain
315
presentation of Alzheimers?
``` MEMORY - short term and make new language attention/concentration personality change eg aggression disorientation time and place ```
316
investigations for Alzheimers?
MRI MMSE to rule out other causes: U&E thyroid tests B12
317
what is pyridostigmine?
Ach esterase inhibitor | used for myasthenia gravis and alzheimers
318
who is frontotemporal dementia more common in?
under 65s
319
what is the pathophysiology of frontotemporal dementia?
frontal and temporal atrophy | no plaques, but tau positive & TD43 negative inclusions
320
what is the presentation of frontotemporal dementia?
behavioural problems progressive aphasia - difficulty forming language semantic dementia - loss of vocabulary
321
how is frontotemporal dementia inherited?
dominant
322
drugs for frontotemporal dementia?
SSRI
323
what is the pattern of onset in vascular dementia?
stepwise | stable symptoms with a sudden increase which you do not recover from
324
presentation of vascular dementia?
``` visual disturbance UMN signs attention deficit depression incontinence emotional disturbance if the original infarct was subcortical, may get dysarthria, parkinsons memory loss ```
325
investigations for vascular dementia?
MRI to look for previous infarcts cognitive impairment screen have they had strokes before?
326
what is in a cognitive impairment screen?
``` orientation attention language visuospatial motor ```
327
what is an eosinophyllic intracytoplasmic neuronal inclusion body?
lewy bodies
328
how is lewy body dementia diagnosed?
``` dementia + 2 of: fluctuating concentration visual hallucinations spontaneous Parkinsonism SPECT/PET scan shows low DA transmission ```
329
what are red flags for spinal cord compression? - 3
loss of bowel/bladder function UMN in lower limbs LMN in upper limbs
330
what is brown sequard syndrome?
hemisection of the spinal cord | in exams is typically A&E knife injury + loss of sensation
331
presentation of brown sequard syndrome?
ipsilateral hemiplegia (loss of proprioception, vibration sensation and potentially spastic pareparesis) contralateral pain and temperature loss below lesion complete loss of sensation at site of penetration
332
first line investigation for brown-sequard (or any penetrating trauma?)
plain radiograph can do MRI/neuro exam later
333
treatment for brown sequard?
spine immobilisation steroids physio
334
what is charcot marie tooth?
inherited peripheral neuropathy
335
the 4 types of charcot marie tooth syndrome?
1 - unstable myelin - children, weakness and loss of sensation starting from feet and going up 2 - axonal - like type 1 but later onset 3 - marked segmental demyelination - floppy baby 4 - demyelination - males more common
336
how is duchenne muscular dystrophy inherited?
x linked - males
337
what is the problem in duchenne muscular dystrophy?
lack of dystrophin (which should strengthen muscle)
338
presentation of duchenne muscular dystrophy?
``` cannot run, hop or jump fatigue recurrent falls under 3 milestones delayed speech is slurred ```
339
investigation for duchenne muscular dystrophy?
raised serum creatinine kinase | muscle biopsy
340
complications of duchenne muscular dystrophy?
``` learning difficulties resp failure cardiomyopathy osteoporosis infections ```
341
what is clozepine?
an antipsychotic, dopamine antagonist | important because can cause Parkinsonism
342
what is CN1?
olfactory nerve | for smelling!
343
how can the olfactory nerve be damaged?
trauma to cribriform plate
344
a left parietal lesion of the optic radiation causes what kind of vision deficit?
Quadrantanopia of inferior right quadrant PITS - parietal lesion = inf loss, temporal lesion = superior loss)
345
optic nerve vs optic tract?
optic nerve is from the eye to the optic chiasm | optic tract is from the chiasm to the lateral geniculate body
346
if one pupil is not constricting to direct or consensual light stimulation to the other eye, where is the problem?
CN3 - the pupil is not constricting
347
if the right pupil constricts in response to light shone in the left eye, but when you shine the light on the right neither constrict - where is the problem?
CN2 - the optic nerve | as the pupil is not detecting the light
348
what does CN3 innervate?
CN3 is the occulomotor nerve superior and inferior and medial rectus inferior oblique pupillary sphincter lps to lift eyelid
349
signs of a lesion to CN3?
ptosis pupil does not accomodate to light absent pupillary light reflex outward deviation - as there is function of the lateral rectus to look out (CN6) but not inf oblique (CN3) to counteract it
350
what does CN4 innervate? | how does damage to it present?
CN4 = trochlear nerve innervates superior oblique - looks in and down damage = diplopia when walking downstairs
351
what does the superior oblique muscle do and what is it innervated by?
looks in and down (even tho is superior oblique) | trochlear nerve CN4
352
what does the superior rectus muscle do and what is it innervated by?
looks up | occulomotor nerve CN3
353
what does the inferior oblique muscle do and what innervates it?
looks up and in | cn3 occulomotor nerve
354
what are the 3 branches of the trigeminal nerve?
v1 - opthalmic - forehead sensation v2 - maxillary - cheeks sensation v3 - mandibular - chewing + sensation on anterior 2/3 tongue
355
how can the trigeminal nerve be damaged?
trigeminal neuralgia herpes zoster nasopharyngeal carcinoma acoustic neuroma
356
medial deviation of eyes at rest indicates a problem with which nerve?
abducens CN6 abducens innervates lateral rectus abducens damaged = unopposed medial rectus
357
what is CN7?
facial nerve - facial expression
358
what are the parasympathetic functions of the facial nerve?
lacrimation | salivation
359
causes of facial nerve dysfunction?
bells palsy temporal bone fracture herpes zoster
360
what is CN8?
Vestibulocochlear - hearing and balance
361
aminoglycosides cause damage to which nerve?
vestibulocochlear CN 8
362
what is CN9?
glossopharyngeal sensory to pharynx, taste on post 1/3 tongue parasympathetic - parotid gland
363
which cranial nerves innervate the tongue?
facial - taste on ant 2/3 glossopharyngeal - taste on post 1/3 trigeminal - sensation hypoglossal - motor
364
how can you test the glossopharngeal nerve?
gag reflex
365
what is CNX?
vagus nerve sensory and motor to pharynx and larynx speech, cough parasymp to GI tract and viscera
366
which cranial nerve innervates the accessory muscles?
CN 11, accessory
367
how can you test the accessory nerve?
ask pt to shrug their shoulders or turn head
368
how can you test CN12?
CN 12 is hypoglossal | ask pt to stick tongue out, it will deviate to weak side
369
some general causes of cranial nerve damage?
``` polio guillian barre MS tumour vasculitis stroke lupus syphilis TB/fungal meningitis ```
370
in ischaemic stroke how does the hemiplegia change over time?
initially flaccid, then becomes spastic as UMN lesion
371
where is the clot if there is hemianopia?
posterior circulation
372
risk factors for intracerebral haemorrhage?
hypertension age / smoking // alcohol / diabetes anticoagulation/ thrombolysis microanneurysms
373
what is hydrocephalus caused by?
CSF obstruction | raised ICP
374
when can you test CSF for xanthrochromia?
after 12hrs | only if ICP is fine
375
when there has been a latent period after subdural haemorrhage why does it suddenly get worse?
clot starts to autolyse = draws water in
376
when is sumatriptan contraindicated?
heart disease
377
what is wernickes encephalopathy?
ataxia opthalmoplegia confusion vitamin B1 deficiency - thiamine chronic alcoholics flapping tremour management - B vitamin infusion
378
most common origin of secondary brain tumour?
non small cell lung cancer
379
what is korsakoffs?
ecephalopathy can develop from wernickes
380
what kind of acteylcholine receptors are affected in myasthenia gravis?
nicotinic
381
if there is automatisms where is the seizure?
temporal lobe
382
if there is motor features eg jacksonian march where is the seizure?
frontal lobe
383
presentation of progressive bulbar palsy?
``` dysarthria dysphagia nasal regurg of fluids choking lmn lesions of tongue 'trouble initiating swallow' ```
384
acute vision loss suggests suggests stroke in
posterior circulation
385
what is the most common cause of meningitis in pregnancy?
listeria
386
what is 1st line for ?meningitis?
blood cultures lumbar puncture = gold standard use when CT shows is fine
387
what is the prophylactic antibiotic for contacts of listeria?
ciprofloxacin
388
3 contraindications for lumbar puncture?
raised ICP focal neurology haemodynamically unstable eg bradycardia, hypotension decreased GCS
389
how is sumatriptan given in acute cluster headache?
subcutaneous
390
what are risk factors for Alzheimer's?
Down's syndrome depression reduced physical activity lonliness
391
3 causes of guillian barre?
camp CMV EBV mycoplasma
392
how is guillian barre diagnosed?
CSF shows raised proteins with no immune cells
393
what ABCD2 score is high risk?
6
394
as well as paralysis of facial muscles, what might you see in bells palsy?
``` loss of taste hearing loss (as cn7 innervates the stapedius muscle) ```
395
locked in syndrome is caused by damage to which vessels?
pontine
396
signs of raised ICP?
``` papilloedema vomitting seizures extensor posturing pupil dilation (cn3 palsy) cn6 palsy headache decreased consciousness ```
397
3 symptoms of frontotemporal dementia?
``` change in speech disinhibition social withdrawal impulsivity loss of personal awareness primitive hyperreflexia stereotypy ```
398
what treatment is first line for MS?
methylprednisolone
399
what is delirium tremens?
alcohol withdrawal
400
what is Romberg's test?
for peripheral neuropathy ask patient to close their eyes and stand on one leg if either proprioception or vestibular function is compromised they will fall over --> pos rhombergs test pos rhombergs indicates peripheral neuropathy eg vit b12 deficiency, ehlers danlos, or vestibular dysfunction if they sway but dont fall over this indicates cerebellar pathology
401
progressive weakness that gets better with exertion is
lambert eaton myasthenic syndrome | related to small cell lung cancer
402
apart from the neuropathy, how does vit B12 deficiency present?
``` anaemia yellow tinge angular cheilitis depression etc fatigue glossitis ```
403
what kind of motor neurones are found in the anterior horn cells?
lower
404
what is gowers sign?
in duchenne muscular dystrophy | use arms to get up from sitting
405
if you suspect MS is it best to do an MRI or lumbar puncture?
MRI is best it is less invasive CSF to look for oligochromal bands is reserved for atypical cases
406
which dementia is associated with hallucinations & recurrent falls / syncope?
lewy body
407
gambling is linked with what parkinsons drugs?
dopamine agonists eg ropinarole
408
what cranial nerves are involved in the reflex that makes you blink when something touches the cornea?
sensing - trigeminal nerve. if this is damaged the opposite eye wont blink either motor - facial nerve. if this is damaged one eye will not blink, when you touch it or the other one. but the other eye will respond in both situations
409
nystagmus is a problem with which cranial nerve?
vestibulocochlear
410
of the 6 eye movement muscles, which 2 are not innervated by CN3?
LR6 SO4 (lardy arse sofa) lateral rectus - 6 (abducens) superior oblique - 4
411
who gets Felty's syndrome?
50-70s white with long standing rheumatoid arthritis
412
what are the 3 components of charcots neurological triad and who does it affect?
MS dysarthria (scanning/stuccato speech) intention tremour nystagmus

phase 2a (10 decks)

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