NEURO Flashcards
1
Q
STROKE
What are the causes of ischaemic strokes?
A
small vessel occlusion by thrombus
atherothromboembolism (e.g. from carotid artery)
cardioembolism (post MI, valve disease, IE)
hyper viscosity
hypoperfusion
vasculitis
fat emboli from a long bone fracture
venous sinus thrombosis
2
Q
STROKE
What are the causes of haemorrhagic stroke?
A
Bleeding from the brain vasculature
- Hypertension - stiff and brittle vessels, prone to rupture
- Secondary to ischaemic stroke - bleeding after reperfusion
- Head trauma
- Arteriovenous malformations
- Vasculitis
- Vascular tumours
- Carotid artery dissection
3
Q
STROKE
What are some important differentials of stroke?
A
- Metabolic (hypo or hyperglycaemia, electrolytes)
- Intracranial tumours, hemiplegic migraine
- Infection (meningitis)
- Head injury, seizure (focal > Todd’s paralysis)
4
Q
STROKE
What other investigations may you do in stroke?
A
- ECG 72h tape to look for paroxysmal AF, MI.
- ECHO to check for endocarditis or CHD
- CTA/MRA or carotid doppler USS to look for dissection or carotid stenosis
5
Q
STROKE
What are some contraindications to treatment with alteplase?
A
- Haemorrhagic stroke
- Recent surgery
- GI bleeding
- Pregnancy
- Hx of intracranial haemorrhage
- Active cancer
6
Q
STROKE
What medication and general management may be given in stroke prevention?
A
- Antiplatelets (lifelong clopidogrel or aspirin + dipyridamole if cardiac disease)
- Anticoagulation if have AF but wait 2w post-stroke
- Manage co-morbidities (HTN, DM)
- Cholesterol >3.5mmol/L diet + 80mg atorvastatin
- VTE assessment + monitor for infection
7
Q
STROKE
What is the CHA2DS2-VaSc score
A
- Congestive heart failure
- HTN
- Age 65-74 (1), ≥75 (2)
- Diabetes
- Prev stroke/TIA (2)
- Vascular disease
- Sex female
- 1 = consider anticoagulation, ≥2 = anticoagulate
8
Q
STROKE
What is the HAS-BLED score?
A
- HTN >160mmHg
- Abnormal liver/renal function
- Stroke
- Bleeding Hx or predisposition
- Labile INR
- Elderly >65y
- Drug/alcohol use
- ≥3 = high risk of bleeding
9
Q
SAH
What is the pathophysiology of a subarachnoid haemorrhage (SAH)?
A
- tissue ischaemia - less blood, O2 and nutrients can reach the tissue due to bleeding loss -> cell death
- raised ICP - fast flowing arterial blood is pumped into the cranial space
- space occupying lesion - puts pressure on the brain
- brain irritates meninges - these inflame causing meningism symptoms. This can obstruct CSF outflow -> hydrocephalus
- vasospasm - bleeding irritates other vessels -> ischaemic injury
10
Q
SAH
What is the management of SAH?
A
- NIMOPIDINE for 3 weeks -> CCB which prevents vasospasm so reduces cerebral ischaemia
- surgery = endovascular coiling
- IV fluids - maintain cerebral perfusion
- ventricular drainage for hydrocephalus
11
Q
EDH
What are some differentials for EDH?
A
- Epilepsy,
- CO poisoning,
- carotid dissection
12
Q
EDH
What is the management for EDH?
A
STABILISE PATIENT
URGENT SURGERY
clot evacuation
ligation of bleeding vessel
IV MANNITOL
- to reduce ICP
airway care
- intubation and ventilation
13
Q
SDH
What is the pathophysiology of a SDH?
A
- bleeding from bridging veins into the subdural space forms a haematoma
- then bleeding stops
- weeks/months later the haematoma starts to autolyse - massive increase in oncotic and osmotic pressure. Water is sucked in and haematoma enlarges
- gradual rise in ICP over weeks
- midline structures shift away from side of clot - causes tentorial herniation and coning
14
Q
SDH
What is the management of SDH?
A
SURGERY
1* = irrigation via burr-hole craniostomy
2* = craniotomy
IV MANNITOL - to reduce ICP
address cause of trauma
15
Q
EPILEPSY
Define epilepsy
A
Recurrent, spontaneous, intermittent abnormal electrical activity in part of the brain, manifesting seizures
16
Q
EPILEPSY
what is the treatment for absence (petit mal) epilepsy?
A
Sodium Valproate for Males & women unable to childbear,
Ethosuximide to females of childbearing potential
17
Q
STATUS EPILEPTICUS
What are some causes of status epilepticus?
A
- Poor adherence #1
- Infections (meningitis, encephalitis)
- Worsening of primary cause of epilepsy (e.g. brain tumour growing)
18
Q
LOC
What are the potential causes of LOC?
A
CRASH
- Cardiogenic (more alarming)
- Reflex (neurally mediated)
- Arterial
- Systemic
- Head
19
Q
PARKINSON’S DISEASE
What are 4 differential diagnoses to consider in Parkinson’s disease?
A
Parkinson’s plus syndromes –
- Progressive supranuclear palsy
- Multiple system atrophy
- Lewy Body dementia
- Corticobasal degeneration
20
Q
PARKINSON’S DISEASE
What is progressive supranuclear palsy?
A
- Early falls, cognitive decline or both sides being equally affected
- Occurs above nuclei of CN3, 4 + 6 so difficulty moving eyes
- Impaired vertical gaze (down worse = issues reading or descending stairs)
- Ocular cephalic reflex present (caused by supranuclear issue) where they tilt/turn their head to look at things rather than moving eyes
21
Q
PARKINSON’S DISEASE
What is multiple system atrophy?
A
- Neurones in multiple systems in the brain degenerate
- Degeneration in basal ganglia > Parkinsonism
- Degeneration in other areas > early autonomic (postural hypotension + falls, bladder/bowel dysfunction) + cerebellar (ataxia) dysfunction
22
Q
PARKINSON’S DISEASE
What is corticobasal degeneration?
A
- Early myoclonic jerks, gait apraxia, agnosia + alien limb
23
Q
PARKINSON’S DISEASE
What investigations would you do in Parkinson’s disease?
A
DaTscan
Functional neuroimaging - PET
Can confirm by reaction to levodopa
24
Q
PARKINSON’S DISEASE
What is the management of Parkinson’s disease?
A
- Lifestyle: education, exercise, physio, MDT
young onset + fit
- Dopamine agonist (ropinirole)
- MAO-B inhibitor (rasagiline)
- L-DOPA (co-careldopa)
frail + co-morbidities
- L-DOPA (co-careldopa)
- MAO-B inhibitor (rasagiline)
25
HUNTINGTON'S DISEASE
What is the pathophysiology of Huntington's disease?
- Less GABA causes less regulation of dopamine to striatum causing increased dopamine levels resulting in excessive thalamic stimulation and subsequently increased movement (chorea)
26
HUNTINGTON'S DISEASE
How does Huntington's disease present?
● Main sign is hyperkinesia
● Characterised by:
○ Chorea, dystonia, and incoordination
● Psychiatric issues
● Depression
● Cognitive impairment, behavioural difficulties
● Irritability, agitation, anxiety
27
HUNTINGTON'S DISEASE
What investigations would you do for Huntington's disease?
- GENETIC TESTING - with pre- + post-test counselling (cannot give to children have to be old enough to decide themselves), high risk of suicide with diagnosis
- MRI HEAD - shows atrophy of striatum
28
HEADACHES
What is the management of acute glaucoma?
- Immediate expert help + IV acetazolamide (carbonic anhydrase inhibitor)
29
TRIGEMINAL NEURALGIA
What is the pathophysiology of trigeminal neuralgia?
What is affected?
- Compression of trigeminal nerve results in demyelination + excitation of the nerve resulting in erratic pain signalling
- Affects all 3 ophthalmic (V1), maxillary (V2) + mandibular (V3) branches but V3 mostly
30
TRIGEMINAL NEURALGIA
What are the causes of trigeminal neuralgia?
Compression of trigeminal nerve by a loop of vein or artery
Aneurysms
Meningeal inflammation
Tumours
31
MIGRAINE
What are the triggers of migraines?
CHOCOLATE –
- Chocolate
- Hangovers
- Orgasms
- Cheese/caffeine
- Oral contraceptives
- Lie-ins
- Alcohol
- Travel
- Exercise
32
MND
What are the 4 types of MND?
Best and worse prognosis?
- Amyotrophic lateral sclerosis (ALS)
- Progressive bulbar palsy (worst prognosis)
- Progressive muscular atrophy (best prognosis)
- Primary lateral sclerosis
33
MND
What is progressive bulbar palsy?
What does it affect?
What does it need to be differentiated from?
- Only affects CN 9–12 (brainstem motor nuclei) so LMN of them
- Primarily affects muscles of talking, chewing, tongue palsy + swallowing
- Progressive pseudobulbar palsy = destruction of UMN so same as bulbar but small spastic tongue with no fasciculations
34
MND
What is...
i) progressive muscular atrophy?
ii) primary lateral sclerosis?
i) Anterior horn cells affected so LMN signs only, distal > proximal
ii) Loss of cells in motor cortex so UMN signs only
35
MND
What is the general clinical presentation of MND?
- Insidious + progressive muscle weakness affecting limbs, trunk, face + speech
- Often first noticed in upper limbs, may be fatigue when exercising
- May have stumbling spastic gait, weak grip + clumsiness
- Dysarthria, dysphagia, emotional lability in pseudobulbar palsy
- NO SENSORY SYMPTOMS
36
MND
What are UMN signs?
Hypertonia or spasticity,
brisk reflexes
upgoing plantars,
muscle wasting
37
MND
What are some important differentials of MND and how can they be differentiated?
- Cervical spine lesion as may present with UMN signs
- Myasthenia gravis but MND NEVER affects eye movements
- Multiple sclerosis but MND NEVER affects sphincters or sensation
38
MND
What are some investigations for MND?
Head/spine MRI
Blood tests = muscle enzymes, autoantibodies
Nerve conduction studies
EMG
Lumbar Puncture
39
MND
What medication may be given in MND?
- RILUZOLE – Na+ blocker inhibits glutamate release
- Drooling - ORAL PROPANTHELINE or ORAL AMITRIPTYLINE
- Dysphagia: NG tube
- Spasms: ORAL BACLOFEN
- Non-invasive ventilation
- Analgesia e.g. NSAIDs - DICLOFENAC
40
MULTIPLE SCLEROSIS
What are some classic sites for MS?
- Periventricular white matter lesions
- Predilection for distinct sites – optic nerves, corpus callosum, brainstem + cerebellar peduncles
41
MULTIPLE SCLEROSIS
What is the diagnostic criteria for MS?
McDonald criteria –
- Multiple CNS lesions (≥2)
- Sx that last >24h
- Disseminated in space (Clinically or on MRI) and time (>1m apart)
42
MULTIPLE SCLEROSIS
What are the symptoms of MS?
DEMYELINATION –
- Diplopia (CN VI)
- Eye movement pain (optic neuritis, v common)
- Motor weakness
- nYstagmus
- Elevated temp worsens
- Lhermitte's sign
- Intention tremor
- Neuropathic pain
- Ataxia
- Talking slurred (dysarthria)
- Impotence
- Overactive bladder
- Numbness
43
MULTIPLE SCLEROSIS
In terms of the symptoms of MS, what is the pattern of motor weakness?
i) Pyramidal pattern so extensors weaker than flexors in upper limb, flexors weaker than extensors in lower
44
MULTIPLE SCLEROSIS
What are some signs of MS?
- UMN = spastic paraparesis, brisk reflexes, hypertonia
- Sensory = loss of sensation, cerebellar signs
- Relative afferent pupillary defect
- Internuclear ophthalmoplegia
- Optic atrophy (pale optic disc) in chronic MS
45
MULTIPLE SCLEROSIS
What is relative afferent pupillary defect?
- Seen on swinging light test (retina or optic nerve lesion – afferent issue)
- The affected and normal eye appears to dilate when light is shone on the affected eye
46
MULTIPLE SCLEROSIS
What is internuclear ophthalmoplegia?
- CN VI/medial longitudinal fasciculus lesion
- Disorder of conjugate lateral gaze with;
– Decreased adduction of ipsilateral eye
– Nystagmus on abduction of contralateral eye
47
MULTIPLE SCLEROSIS
What is the management of MS remissions?
- First line = beta-interferons (1b) to decrease # relapses + lesions on MRI but SEs = depression, flu Sx + miscarriage
- 2nd line = DMARDs (monoclonal antibody) - natalizumab, dimethyl fumarate
48
MULTIPLE SCLEROSIS
What is the general symptomatic management for MS?
Spasticity
- BACLOFEN (GABA analogue, reduces Ca2+ influx)
- TIZANIDINE (alpha-2 agonist)
- BOTOX INJECTION (reduces ACh in neuromuscular junction)
urinary incontinence = catheterisation
incontinence
- DOXAZOSIN (anti-cholinergic alpha blocker drugs
49
MENINGITIS
What are the bacterial causes of meningitis?
N. meningitidis
S. pneumoniae
H. influenzae
50
MENINGITIS
What are the viral causes of meningitis?
Enterovirus (most common viral)
HSV
CMV
Varicella zoster virus
51
MENINGITIS
What is the management of bacterial meningitis
- IV cefotaxime
- + amoxicillin to cover listeria (potential contraction in birth) in <3m
- Dexamethasone to reduce frequency + severity of neurological sequelae
- Adjust treatment according to sensitivities
52
ENCEPHALITIS
What investigations would you do for encephalitis?
- Blood culture + CSF serology for viral PCR
MRI - shows areas of inflammation, may be midline shifting
EEG - periodic sharp and slow wave complexes
lumbar puncture
53
BRAIN ABSCESS
What are the most common causative organisms?
- Staph. aureus + strep. pnuemoniae
54
BRAIN ABSCESS
What is the management of brain abscess?
- CT guided aspiration via burr hole or craniotomy + abscess cavity debridement
- Craniotomy usually if no response to aspiration or if reoccurs
- Abx with IV ceftriaxone + metronidazole, ICP Mx with dexamethasone
55
BRAIN DEATH + COMA
What are lateralising signs?
Give an example of one
- Signs that occur from one hemisphere of the brain but not the other, helps to localise pathology
- Fixed dilated pupil (CN3 palsy)
56
BRAIN DEATH + COMA
What is the main differential of a third nerve palsy?
How can they be differentiated?
- Blind eye
- Blind eye will not give contralateral responsiveness but other causes will + if you shine light in good eye then dilated pupil will restrict
57
BRAIN DEATH + COMA
What are the components of 'eyes' in GCS?
E4 = opens spontaneously
E3 = opens to verbal command
E2 = opens to pain
E1 = no response
58
BRAIN DEATH + COMA
What are the components of 'verbal' in GCS?
V5 = orientated in TPP, answers appropriately
V4 = confused conversation, odd answers
V3 = inappropriate words (random, abusive)
V2 = incomprehensible sounds (groans)
V1 = no response
59
BRAIN DEATH + COMA
What are the components of 'motor' in GCS?
M6 = obeys commands
M5 = localises pain
M4 = withdraws away from painful stimulus
M3 = flexion to pain
M2 = extension to pain
M1 = no response
60
MYASTHENIA GRAVIS
What will patients with myasthenia gravis struggle with?
- Hairs, chairs + stairs (proximal muscle weakness)
- Speech, mastication, face + neck weakness
- Resp muscles (breathing difficulty + dysphagia dangerous features which indicates advancing disease)
61
MYASTHENIA GRAVIS
What are the signs of myasthenia gravis?
- Ptosis, diplopia (extra-ocular muscle weakness)
62
MYASTHENIA GRAVIS
What are some clinical signs of myasthenia gravis?
- Repeated blinking = ptosis
- Repeated abduction of one arm 20x + compare to other side
63
MYASTHENIA GRAVIS
What investigations would you do for myasthenia gravis?
mostly clinical examination
positive tensilon test
anti-AChR antibodies
TFTs
EMG
CT of thymus
crushed ice test - ice is applies to ptosis for 3 mins, if it improves it is likely to be myasthenia gravis
64
MYASTHENIA GRAVIS
What is the management of myasthenia gravis?
- Acetylcholinesterase inhibitors like pyridostigmine or rivastigmine
- Immunosuppression with prednisolone (acute) or azathioprine to suppress antibody production
- Thymectomy if thymoma or anti-AChR +ve disease
- Plasmapheresis for severe relapsing cases
65
GUILLAIN-BARRE
What is the pathophysiology of GBS?
- B cells produce antibodies against the antigens on the pathogen causing the preceding infection and these antibodies also match proteins on the nerve cells leading to demyelination and potentially axonal degeneration
66
GUILLAIN-BARRE
What are the causes of GBS?
- Often triggered by preceding illness 4w before symptoms
Bacteria
- Camplylobacter jejuni
- Mycoplasma pneumoniae
Viruses
- CMV
- EBV
- HIV
- Herpes zoster
67
GUILLAIN-BARRE
What are the investigations for GBS?
Nerve Conduction Studies (NCS) = diagnostic -> shows slowing of conduction
Lumbar Puncture at L4 = raised protein and normal WCC (cyto-protein dissociation)
bloods - FBC, U&E, LFT, TFT
Spirometry = respiratory involvement
ECG
68
GUILLAIN-BARRE
What is the main treatment for GBS?
- IVIg reduces duration + severity of paralysis but C/I if IgA deficiency as would cause anaphylaxis
- Plasma exchange
- Intubation, ventilation + ICU admission in severe cases in resp failure
69
BRAIN TUMOURS
What investigations would you perform for brain tumours?
- CT/MRI head (MRI gold standard)
- LP C/I if Sx of raised ICP until after imaging
- Audiogram + gadolinium enhanced MRI head for acoustic neuroma
- MR angiography may be useful to define site or blood supply of mass
70
NEUROPATHY
What is the pathophysiology of mononeuritis multiplex?
- Inflammation of vasa nervorum can block off blood supply to nerve causing sudden deficit
71
NEUROPATHY
What are the causes of peripheral neuropathy?
ABCDE –
- Alcohol
- B12 deficiency
- Cancer + CKD
- Diabetes + drugs (isoniazid, amiodarone)
- Every vasculitis
72
NEUROPATHY
In terms of peripheral neuropathy, what conditions show a...
i) mostly motor loss?
ii) mostly sensory loss?
i) GBS, chronic inflammatory demyelination polyneuropathy (chronic GBS), Charcot-Marie-Tooth disease
ii) DM, CKD, deficiencies
73
NEUROPATHY
What is Charcot-Marie-Tooth disease?
- Autosomal dominant condition.
- Characterised by high-arched feet, distal muscle weakness + atrophy (inverted champagne bottle legs), hyporeflexia, foot drop + hammer toes
74
NEUROPATHY
What muscles does the median nerve innervate?
LLOAF –
- Lateral lumbricals x2
- Opponens pollicis
- Abductor pollicis brevis
- Flexor pollicis brevis
75
NEUROPATHY
What is the clinical presentation of carpal tunnel syndrome?
- Aching pain in hand + arm (especially at night)
- Paraesthesia in radial 3.5 digits relieved by dangling hand over edge of bed + shaking (wake + shake)
- Difficulty with precision grip
- Sensory loss (radial 3.5 digits palmar + fingertips dorsally)
- Wasting of thenar eminence (APB, FPB + OP)
76
NEUROPATHY
In terms of the optic nerve, what does a...
i) L optic nerve lesion
ii) Optic chiasma lesion
iii) L optic tract lesion
iv) L Baum's loop lesion
v) L Meyer's loop lesion
cause?
i) No vision through L eye
ii) Bitemporal hemianopia
iii) Contralateral (R) homonymous hemianopia
iv) Inferior R homonymous quadrantanopia
v) Superior R homonymous quadrantanopia
77
NEUROPATHY
Where is Baum's loop located?
Where is Meyer's loop located?
How can you remember which is superior/inferior?
- Parietal lobe
- Temporal lobe
- PITS – Parietal Inferior Temporal Superior
78
NEUROPATHY
What does a CN7 lesion cause?
Face, ear, taste, tear –
- Muscles of expression
- Stapedius
- Anterior 2/3rd tongue
- Parasympathetic fibres to lacrimal + salivary glands
79
NEUROPATHY
What does a CN9/10 lesion cause?
- Swallow, gag + cough issues
- Uvula deviated away from side of lesion
80
NEUROPATHY
What are the investigations used in neuropathy?
- Neuropathy screen (symmetrical) = FBC, CRP/ESR, U+E, glucose, TFT, B12 + folate
- Vasculitis screen (asymmetrical) = first 3 + ANA, ANCA, anti-dsDNA, RhF, complement
- EMG + nerve conduction studies
81
CORD COMPRESSION
What are the signs of spinal cord compression?
- Motor, reflex + sensory level = normal ABOVE lesion
- LMN signs = AT level
- UMN signs = BELOW level
- Tone + reflexes usually reduced in acute cord compression
- ?Sign of infection like tender spine, pyrexia
82
CORD COMPRESSION
How does degenerative cervical myelopathy present?
- Pain, loss of motor or sensory function affecting neck, upper or lower limbs
- Loss of autonomic function
- Hoffman's sign +ve
83
SPINAL CORD INJURY
What is Brown-Sequard syndrome?
- Lateral hemisection of spinal cord
- Ipsilateral weakness below the lesion (lateral corticospinal)
- Ipsilateral loss of fine touch, proprioception + vibration (DCML)
- Contralateral loss of pain + temp (lateral spinothalamic)
84
ANTERIOR CORD SYNDROME
What is anterior cord syndrome?
- Anterior spinal artery occlusion or compression
- Bilateral spastic paresis (lateral corticospinal)
- Bilateral loss of pain + temp (lateral spinothalamic)
85
SPINAL CORD INJURY
What is posterior cord syndrome?
- Trauma or posterior spinal artery occlusion
- Loss of fine touch, proprioception + vibration (DCML)
86
MYOPATHY
What are the investigations for myopathies?
- CRP/ESR, creatinine kinase elevated
- Autoantibodies (anti-Jo-1), EMG, genetics + muscle biopsy
87
HYDROCEPHALUS
What is the purpose of CSF?
- Protects brain from damage
- Removes waste products from the brain
- Provides brain with nutrients to function properly
88
HYDROCEPHALUS
What is the usual flow of CSF in the brain?
- Lateral ventricles
- Foramen of Munro
- 3rd ventricle
- Cerebral aqueduct
- 4th ventricle
- Subarachnoid space (Medially by foramen of Magendie, Laterally by Luschka)
- Dural sinus via arachnoid granulations
89
HYDROCEPHALUS
What are the investigations for hydrocephalus?
- CT head = enlarged ventricles
- MRI head if suspected underlying lesion
- LP is both diagnostic + therapeutic (caution in obstructive as difference in cranial/spinal pressures can cause brain herniation)
90
HYDROCEPHALUS
What is the management of hydrocephalus?
- An external ventricular drain (EVD) is used in acute, severe hydrocephalus and is typically inserted into the right lateral ventricle and drains into a bag at the bedside
- Ventriculoperitoneal shunt = surgically implanted into brain to drain excess fluid (may become blocked or infected)
- Endoscopic third ventriculostomy = hole made in floor of 3rd ventricle to allow trapped CSF to escape to be reabsorbed
91
NEURO PHARMACOLOGY
Give some examples of anti-epileptic drugs (AEDs).
What is their mechanism of action?
- Carbamazepine, valproate, lamotrigine, levetiracetam, phenytoin, ethosuximide.
- Inhibit voltage-gated Na+ channels which prevents excitability of neurones > reduced firing > stops seizure, some promote GABA release
92
NEURO PHARMACOLOGY
What are some side effects and important information for...
i) carbamazepine?
ii) valproate?
iii) lamotrigine
i) Blurred vision, headache, drowsiness – agranulocytosis, aplastic anaemia, P450 inducer
ii) Teratogenic, hepatitis, hair loss, tremor, weight gain – some interactions with antidepressants
iii) Blurred vision, headache, drowsiness – Steven-Johnson syndrome + risk of leukopenia
93
NEURO PHARMACOLOGY
What are some side effects and important information for...
i) phenytoin?
ii) levetiracetam?
iii) ethosuximide?
i) Megaloblastic anaemia (folate), osteomalacia, teratogenic, P450 interactions – Steven-Johnson syndrome
ii) Headache, drowsiness – some interactions with antidepressants
iii) Night terrors, rashes
94
NEURO PHARMACOLOGY
What are the side effects of Levodopa?
- Postural hypotension
- Confusion
- Dyskinesias (abnormal movements)
- Effectiveness decreases with time (even with dose increase)
- On-off effect
- Psychosis
95
NEURO PHARMACOLOGY
Give some examples of dopamine receptor agonists.
What is the mechanism of action?
What are some side effects?
What monitoring is required?
- Bromocriptine, cabergoline, ropinirole
- Increases amount of dopamine in CNS
- Hallucinations (more than levodopa), postural hypotension
- ECHO, ESR, creatinine + CXR prior to Rx
96
NEURO PHARMACOLOGY
What are some adverse effects of dopamine receptor agonists?
- Pulmonary retroperitoneal + cardiac fibrosis
- Bromocriptine associated with gambling + other inhibition disorders (e.g. sexual)
97
NEURO PHARMACOLOGY
What are COMT + MAO-B inhibitors?
What is the mechanism of action?
- Catechol-o-methyltransferase (COMT) inhibitor = entacapone
- Monoamine oxidase-B (MAO-B) inhibitor = selegiline
- Inhibit enzymatic breakdown of dopamine
98
NEURO PHARMACOLOGY
Why are dopamine receptor agonists + COMT/MAO-B inhibitors used in Parkinson's disease?
- Delay use of levodopa + then used in combination to reduce levodopa dose as levodopa is most effective treatment
99
NEURO PHARMACOLOGY
What are some SEs + C/Is of triptans?
- Dizziness, dry mouth, sleepy, nausea
- C/I in CVD
100
MENIERE'S DISEASE
What is Ménières disease?
- Increased pressure in endolymphatic system due to increased volume of inner ear.
101
STROKE
what is the mechanism of action for alteplase / streptokinase (thrombolysis drugs for ischaemic stroke)?
- Converts plasminogen > plasmin so promotes breakdown of fibrin clot
- Alteplase (tPA) or can use streptokinase
102
EDH
Which vessels most commonly are affected in extradural haematomas?
which other vessels can be affected?
- Middle meningeal artery
- 25% venous if fracture disrupts the venous sinuses
103
SDH
what are the risk factors of SDH?
- Elderly - brain atrophy, dementia
- Frequent falls - epileptics, alcoholics
- Anticoagulants
- babies - traumatic injury (“shaking baby syndrome”)bridging veins stretched so more likely to rupture,
104
EPILEPSY
Define seizure
Paroxysmal event in which changes of behaviour, sensation, cognition + consciousness caused by excessive, hypersynchronous neurological discharges in the brain
105
PARKINSON'S DISEASE
what can exacerbate parkinson's disease?
Anticholinergics can precipitate confusion
106
MULTIPLE SCLEROSIS
In terms of the symptoms of MS, what is Lhermitte's sign?
Neck flexion causes electric shock sensation down spine
107
MULTIPLE SCLEROSIS
In terms of the symptoms of MS, what is Uhthoff's phenomenon?
symptoms worsening in heat e.g. in the shower/exercise
108
ENCEPHALITIS
What are the non-viral causes of encephalitis?
Bacterial meningitis
TB
Malaria
Lyme’s disease
109
MYASTHENIA GRAVIS
What medications can exacerbate myasthenia gravis?
Abx, CCBs, beta-blockers, lithium + statins
110
NEUROPATHY
What can cause mononeuritis multiplex?
Inflammatory or immune mediated vasculitis like granulomatosis with polyangiitis, polyarteritis nodosa, RA or sarcoidosis
111
RADICULOPATHY
What is radiculopathy?
Sx caused by pinching of a nerve root as they exit the spinal cord
112
MENIERE'S DISEASE
What causes it?
Idiopathic, trauma, endo
113
MENIERE'S DISEASE
How is it managed?
Bed rest, reassurance
114
SHINGLES
what are the risk factors for shingles?
- increasing age
- immunocompromised
- HIV, hodgkins lymphoma, bone marrow transplants
115
NEUROFIBROMATOSIS
what are the clinical signs of NF1?
- cafe-au-lait spots on the skin
- pea-sized lumps under skin
- skeletal abnormalities
- tumour on optic nerve
116
NEUROFIBROMATOSIS
what are the clincial signs of NF2?
- acoustic neuromas
- family history
- meningioma, schwannoma, juvenile cortical cataracts or glioma
117
NARCOLEPSY
what is the management?
1st line = sleep hygiene + lifestyle changes
can also consider pharmacotherapy
- modafinil
- pitolisant
- sodium oxybate
118
RADICULOPATHY
what are the causes?
- intervertebral disc prolapse
- degenerative diseases of the spine
- fracture (trauma or pathological)
- malignancy (metastatic)
- infection (extradural abscesses, osteomyelitis)
119
WERNICKE-KORSAKOFF SYNDROME
what are the clinical signs?
- mental confusion/amnesia
- vision problems
- coma
- tremor
- ataxia
- hypothermia
- low blood pressure
120
CATAPLEXY
what is it?
sudden muscle weakness triggered by strong emotions such as laughter, anger and surprise
121
CATAPLEXY
what happens during an attack?
- slurred speech
- impaired eyesight (double vision, unable to focus)
- hearing and awareness are undisturbed (remain conscious)
122
CATAPLEXY
what is the management?
sodium oxybate
tricyclic antidepressants (clomipramine)
SSRIs
123
EDH
what is the appearance of EDH on non-contrast head CT?
lens shaped haematoma = LEMON SHAPE
doesn’t cross suture lines
shows midline shift
124
SDH
what is the appearance of SDH on non-contrast head CT?
crescent shaped haematoma = BANANA SHAPE (clot turns from white to grey over time)
unilateral
shows midline shift
125
EPILEPSY
what is the treatment for generalised myoclonic epilepsy?
Sodium Valproate for Males & women unable to childbear,
Levetiracetam/Topiramate to females of childbearing potential
126
PARKINSON'S DISEASE
Give 2 histopathological signs of Parkinson’s disease
1. Loss of dopaminergic neurones in the substantia nigra
2. Lewy bodies
127
HUNTINGTON'S DISEASE
what are the signs of Huntington's disease?
Abnormal eye movements
Dysarthria
Dysphagia
Rigidity
Ataxia
128
MND
Does MND cause sensory loss or sphincter disturbance?
No (clinical feature of MS)
129
MND
What are LMN signs?
Hypotonia + muscle wasting,
reduced reflexes,
fasciculations (particularly tongue)
130
MND
What is the diagnostic criteria for MND?
LMN + UMN signs in 3 regions
El Escorial criteria
Presences of LMN and UMN degeneration and progressive history
Absence of other disease processes
131
MULTIPLE SCLEROSIS
What are the differential diagnosis’s of MS
SLE
Sjogren’s
AIDS
Syphilis
132
MENINGITIS
Give 4 potential adverse effect of a lumbar puncture
Headache
Paraesthesia
CSF leak
Damage to spinal cord
133
ENCEPHALITIS
Name the main triad of symptoms of encephalitis
Fever + headache + altered mental state
134
MYASTHENIA GRAVIS
What can weakness due to myasthenia gravis be worsened by?
Pregnancy
Hypokalaemia
Infection
Emotion
Exercise
Drugs
135
NEUROPATHY
What is the generic clinical presentation of mononeuritis multiplex?
Subacute presentation (months rather than years), painful, asymmetrical sensory + motor neuropathy
136
ANTERIOR CORD SYNDROME
what are the causes?
- iatrogenic - thoracic and thoracoabdominal AA repair
- aortic dissection
- atherothrombotic disease
- emboli
- vasculitis
137
ANTERIOR CORD SYNDROME
what are the symptoms?
- acute motor dysfunction
- loss of pain and temperature sensation below level of infarction
- autonomic dysfunction - neurogenic bowel/bladder
- acute onset back pain
138
ANTERIOR CORD SYNDROME
what are the investigations?
MRI - 'owls eyes' hyperintensities in anterior horns
lumbar puncture, CSF testing, blood and urine to rule out other causes
139
ANTERIOR CORD SYNDROME
what is the treatment?
- IV fluids to increase intravascular volume
- vasopressor medications to increase systemic vascular resistance
- lumbar drain to remove CSF
symptomatic management
- mechanical ventilation
- catheterisation
140
HORNER'S SYNDROME
what is the pathophysiology of horner’s syndrome?
unilateral damage to the sympathetic chain
141
HORNER'S SYNDROME
what are the causes of 1st order horner’s syndrome?
stroke, tumours of hypothalamus, spinal cord lesions
142
HORNER'S SYNDROME
what are the causes of 2nd order horner’s syndrome?
tumours of upper chest cavity, trauma to the neck
143
HORNER'S SYNDROME
what are the causes of 3rd order horner’s syndrome?
lesions to carotid artery, middle ear infections, injury to base of the skull
144
HORNER'S SYNDROME
what are the clinical features of horner’s syndrome?
MAPLE
Miosis
Anhydrosis
Ptosis
Loss of ciliospinal reflex
Endophthalmos (sunken eyeball)
145
HORNER'S SYNDROME
what are the investigations for horner’s syndrome?
clinical examination
MRI - detect lesions
146
BULBAR PALSY
what are the symptoms?
- dysphagia
- reduced/absent gag reflex
- slurred speech
- aspiration of secretions
- dysphonia
- dysarthria
- drooling
- difficulty chewing
- nasal regurgitation
- atrophic tongue
weak jaw/facial muscles
147
BULBAR PALSY
what are the investigations?
MRI
lumbar puncture
148
STRABISMUS
what is it?
where there is misalignment of the visual axes of the eyes; it may be latent or manifest and, if manifest, it may be constant or intermittent
149
STRABISMUS
what are the causes?
- congenital
- graves (restricted eye movement)
- myasthenia gravis
- intra-cranial process (mass, raised ICP, CNS infarction, inflammation of CNS)
150
STRABISMUS
what are the symptoms?
- diplopia
- eye misalignment
- amblyopia (decreased vision in an anatomically normal eye)
- abnormal eye movements
- visual confusion
- asthenopia (ocular discomfort)
151
STRABISMUS
what are the risk factors?
FHx of strabismus
prematurity
low birth weight
maternal smoking during pregnancy
152
STRABISMUS
what are the investigations?
- cover test
- simultaneous prism and cover test (SPCT)
- uncover test (UCT)
- alternate prism cover test (APCT)
- Hirschberg test
- Krimsky test
153
STRABISMUS
what is the management?
definitive treatment = extraocular muscle surgery
correction of refractive errors
treatment of amblyopia - eye patch
treatment for diplopia - patch, prisms, high prescription, orthoptic exercises
154
SCIATICA
what are the risk factors?
- previous injury
- overweight
- lack of core strength
- physically demanding job
- diabetes
- osteoarthritis
- inactivity
- smoking
155
SCIATICA
what are the causes?
- herniated/slipped disc - puts pressure on nerve root
- degenerative disc disease
- spinal stenosis
- spondylolisthesis
- osteoarthritis
- trauma
- cauda equina syndrome
156
MYOPATHY
what is myotonic dystrophy?
autosomal dominant genetic condition causing progressive muscle weakness
most common form of muscular dystrophy to occur in adults
157
MYOPATHY
what are the causes of myotonic dystrophy type 1 and 2?
type 1 - DMPK gene mutation on chromosome 19
type 2 = ZNF9 gene on chromosome 3
158
TIA
What are the causes of a transient ischaemia attack (TIA)?
- Artherothromboembolism of the carotid - main cause (can hear carotid bruit)
- Cardioembolism - in AF, after MI, valve disease/prosthetic valve
- Hyperviscosity - polycythaemia, sickle cell, high WBCC
- hypoperfusion - postural hypotension, decreased flow
159
TIA
what are the differential diagnosis’s for a TIA
Migraine aura
Epilepsy
Hypoglycaemia
Hyperventilation
retinal bleed
syncope - due to arrhythmia
160
TIA
what is the ABCD2 score?
Assesses risk of stoke in the next 7 days for those who have had a TIA
age
BP
clinical features - unilateral weakness, speech disturbance
duration of TIA
presence of diabetes mellitus
161
HYDROCEPHALUS
what are the causes of normal pressure hydrocephalus?
excess fluid builds up in the ventricles, which enlarge and press on nearby brain tissue
- injury
- bleeding
- infection
- brain tumour
- brain surgery
162
CHRONIC FATIGUE SYNDROME
what is it?
It is a disorder characterized by extreme fatigue or tiredness that doesn’t go away with rest and can’t be explained by an underlying medical condition.
163
CHRONIC FATIGUE SYNDROME
What are the causes?
unknown - could be:
- viruses (EBV, rubella, RRV)
- a weakened immune system
- stress
- hormonal imbalances
164
CHRONIC FATIGUE SYNDROME
what are the risk factors?
- sex (female)
- genetic predisposition
- allergies
- stress
- environmental factors
165
CHRONIC FATIGUE SYNDROME
what are the symptoms?
- severe fatigue that interferes with daily life for >6 months
- sleep problems
- feeling unrefreshed after night's sleep
- chronic insomnia
- memory loss
- reduced concentration
- orthostatic intolerance
- muscle pain
- frequent headaches
- multi-joint pain without redness or swelling
- frequent sore throat
166
CHRONIC FATIGUE SYNDROME
what are the differentials?
mononucleosis
lyme disease
MS
SLE
hypothyroidism
fibromyalgia
depression
sleep disorders
167
CHRONIC FATIGUE SYNDROME
what is the management?
no cure
- pacing activities
- reduce caffeine, nicotine and alcohol
- create sleep routine
- antidepressant medications
- complementary/alternative medicines
168
MENIERE'S DISEASE
what is the classical triad of symptoms?
vertigo
hearing loss - worse during attacks
tinnitus
169
SAH
give 3 possible complications of a subarachnoid haemorrhage
1. Rebleeding (common = death)
2. Cerebral ischaemia
3. Hydrocephalus
4. Hyponatraemia
170
EPILEPSY
how do lamotrigine and carbamazepine work?
Inhibit pre-synaptic Na+ channels so prevent axonal firing
171
EPILEPSY
how does sodium valproate work?
Inhibits voltage gated Na+ channels and increases GABA production
172
EPLILEPSY
give 4 potential side effects of anti-epileptic drugs (AEDs)
1. Cognitive disturbances
2. Heart disease
3. Drug interactions
4. Teratogenic
173
PARKINSONS DISEASE
what is the pathway for dopamine production?
Tyrosine --> L-dopa --> Dopamine
174
HYDROCEPHALUS
What are some causes of non-obstructive hydrocephalus?
- Commonly failure of reabsorption of arachnoid granulations (meningitis, post-haemorrhage)
- increased CSF production (choroid plexus tumour) but very rare
175
DIABETIC NEUROPATHY
what is the management for gastroparesis?
metoclopramide, domperidone or erythromycin
176
STROKE
What vessels can be affected in total anterior circulation syndrome (TACS)?
- ACA, MCA, carotid
177
STROKE
What vessels can be affected in a partial anterior circulation syndrome (PACS)?
- ACA, MCA, carotid (same vessels as TACS)
178
STROKE
What vessels can be affected in a posterior circulation syndrome (POCS)?
- PCA, vertebrobasilar artery or branches
179
STROKE
What vessels can be affected in lacunar syndrome (LACS) and what does that mean?
- Perforating arteries so no higher cortical dysfunction or visual field abnormality, subcortical stroke
180
STROKE
How would lateral medullary/Wallenberg's syndrome present?
What vessel is implicated?
- Cerebellar: ataxia, nystagmus
- Ipsi: dysphagia, facial numbness + CN palsy
- Contra: limb sensory loss
- Posterior inferior cerebellar artery
181
STROKE
How would lateral pontine syndrome present?
What vessel is implicated?
- Similar to Wallenberg's but ipsilateral facial paralysis + deafness
- Anterior inferior cerebellar artery
182
STROKE
What criteria must be met for a total anterior circulation syndrome (TACS)?
All three Hs –
- Hemiplegia (unilateral ± sensory deficit of face, arm leg)
- Homonymous hemianopia
- Higher cerebral dysfunction (dysphasia, visuospatial disturbance)
183
STROKE
What criteria must be met for a partial anterior circulation syndrome (PACS)?
- 2/3 of the criteria for TACS:
- Hemiplegia (unilateral ± sensory deficit of face, arm leg)
- Homonymous hemianopia
- Higher cerebral dysfunction (dysphasia, visuospatial disturbance)
184
STROKE
What criteria must be met for a posterior circulation syndrome (POCS)?
One of the following –
- Cranial nerve palsy + contralateral motor/sensory deficit
- Bilateral motor/sensory deficit
- Conjugate eye movement disorder (e.g. gaze palsy)
- Cerebellar dysfunction (ataxia, nystagmus, vertigo)
- Isolated homonymous hemianopia + cortical blindness
185
STROKE
What criteria must be met for a lacunar syndrome (LACS)?
One of following –
- Pure sensory stroke (thalamus)
- Pure motor stroke (posterior limb of internal capsule)
- Sensori-motor stroke
- Ataxic hemiparesis
186
STROKE
What areas can be affected in lacunar syndrome (LACS)?
- Thalamus, basal ganglia, internal capsule
187
NEUROPATHY
Roots of the ulnar nerve?
What causes ulnar neuropathy?
- C7–T1
- Elbow trauma or fracture, elbow arthritis
188
NEUROPATHY
What are the motor signs of ulnar neuropathy?
Weakness/wasting of –
- Interossei (can't do good luck sign)
- Medial lumbricals (claw hand)
- Hypothenar eminence
- +ve Froment's sign when grip paper between thumb + index finger
189
NEUROPATHY
What are the sensory signs of ulnar neuropathy?
- Sensory loss 1.5 fingers ulnar side on dorsal + palmar aspects
190
NEUROPATHY
Roots of the radial nerve?
What causes radial neuropathy?
- C5-T1
- Compression against humerus
191
NEUROPATHY
What are the motor signs of radial neuropathy?
What are the sensory signs?
- Wrist + finger drop (weak extension), can't open first
- Below fingertips on radial 3.5 fingers dorsally, part of thenar eminence
192
NEUROPATHY
Roots of sciatic nerve?
Causes of neuropathy?
Presentation?
- L4–S3
- Pelvic tumours or pelvic/femoral #
- M = foot drop, S = loss below the knee laterally
193
NEUROPATHY
Roots of common peroneal nerve?
Causes of neuropathy?
Presentation?
- L4–S1
- Damaged as winds round fibular head by trauma or sitting cross-legged (classic after night out)
- M = foot drop, weak ankle dorsiflexion + eversion with high steppage gait, S = loss over dorsal foot
