Neuro Flashcards
(158 cards)
1
Q
Parkinsonism DDx
A
IPD
Drug-induced parkinsonism
Vascular dementia
Parkinson’s plus: LBD, CBD, PSA, MSA
Toxins
Wilson’s
Post - Encephalitis
Demyelination in basal ganglia
Repetetive trauma
2
Q
Clinical features to diagnose PD
A
BRADYKINESIA + >1
Tremor
Rigidity
Postural instability/ gait disturbance
3
Q
Clinical features on examination of PD
A
Hypomimic face, quiet speech, shuffling gait, stooped posture, reduced arm swing, unilateral pill rolling tremor, postural instability, turning en bloc
4
Q
Features of Parkinson’s plus
A
Phantom limb: CBD
Restricted upgaze: PSP
Cerebellar signs and autonomic dysfunction: MSA
Dementia and hallucinations: LBD
5
Q
Non-motor features of PD
A
Anosmia
Pain
Mood disturbance
Sleep disorders
Constipation
Memory impairment
6
Q
Drugs which can cause parkinsonism
A
Antipsychotics (dopamine antagonists), prochlorperazine, metoclopramide
7
Q
Mx for drug-induced parkinsonism
A
Antimuscarinics e.g. trihexyphenidyl
8
Q
Clinical features to assess in neuro exam for suspected PD
A
Gait
Tremor (Distraction i.e. count backwards or tap thigh with other hand)
Cog wheel rigidity
Upgaze restriction
Cerebellary signs (past pointing, nystagmus)
LSBP
9
Q
Medical mx of PD
A
Levodopa + dopa decarboxylase inhibitor ie co-careldopa or co-beneldopa
Oral dopamine agonist: ropinirole, bromocriptine
Adjuncts: MAO-B inhibitors (selegeline), COMT inhibitors (entacapone)
Amantadine
10
Q
SE of oral dopamine agonists
A
Impulse control disorders and hallucinations, less motor SE
11
Q
Levodopa SE
A
Motor SE but also best for motor sx of PD
12
Q
ropinirole drug class
A
Oral dopamine agonists
13
Q
PD diagnosis and investigations
A
Mostly clinical diagnosis by neurologist
SWALLOW assessment
Micrographia
Anosmia
MMSE
DAT scan if ?drug-induced vs IPD/Parkinson’s plus
14
Q
Mx principles in PD
A
Urgent neurology referral to make diagnosis
MDT: Neurologist, specialist nurses, pT/OT, SLT, Dietitian, Parkinson’s uK/support groups, GP, psychologist
Non-medical: safety, driving and DVLA, patient education
Medical: Levodopa etc
Surgical: DBS
15
Q
Ix to differentiate between essential tremor and PD
A
DAT scan
16
Q
Screening tools for pD
A
Distraction + tremor
Arms out for postural tremor
Finger nose testing for cerebellar signs
Speech for cerebellar speech
Nystagmus
UPgaze
LSBP
17
Q
Things to consider in a younger patient with Parkinsonism
A
?Wilson’s - Kayser fLeischer rings (Serum ceruloplasmin and urinary copper)
18
Q
What constitutes bradykinesia?
A
Decrement in amplitude and frequency of repetitive movement
19
Q
Essential tremor features
A
AD
Comes on at a younger age
Diminished by mental activity
involves hands head “yes yes no no” , voice
Enhanced by maintaining posture
Improved with alcohol and beta blockers
20
Q
How would you complete your pD exam?
A
Cognitive assessment
LSBP
Handwriting
Drug chart
21
Q
L-DOPA SE
A
Dyskinesia
On/off symptoms
Hallucinations
Psychosis
N&V
Excessive day time sleepiness
22
Q
Vascular parkinsonism features
A
Legs >arms
sudden onset
pyramidal signs
23
Q
DDx postural tremor
A
BET
ANxiety
Hyperthyroidism
Salbutamol
Alcohol withdrawal
24
Q
What does SPECT stand for and when is it used?
A
Single photon emmission computed tomography (DaT scan)
Used to assess dopamine uptake in basal ganglia - helpful to differentiate between essential tremor and PD or drug-induced causes vs idiopathic/parkinson’s plus
25
Motor SE of levodopa
tardive dyskinesia
dystonia
26
What is tardive dyskinesia?
Repetitive, involuntary movements of face and jaw i.e. lip smacking and tongue protrusion
27
What is dystonia?
Involuntary abnormal sustained or repetitive muscle contraction
28
What gait do you suspect in unilateral spasticity?
Circumduction
29
What gait in bilateral UMN spasticity?
Scissoring
30
4 features of pyramidal UMN pathology
Increased tone (spastic, velocity dependent)
Power reduced in pyramidal pattern of weakness
Hyperreflexia
Upgoing plantars
31
FUELS
Flexors Upper Extensors Lower Stronger
32
At what level does the spinal cord end?
L1
33
What is the cauda equina?
After cord ends at L1, the lumbosacral nerve roots form the cauda equina
34
What is Brown-sequard
Hemisection of the spinal cord resulting in ipsilateral loss of JPS and vibration sense and weakness
contralateral loss of pain and temperature sensation
35
DDx for unilateral spasticity
SOL
Stroke
MS
CP
36
Causes of upgoing plantars and absent ankle jerk
Friedrich's ataxia
MND
SCDC
Tabes dorsalis
Dual pathology i.e. cervical myelopathy and peripheral neuropathy in an older patient
37
Features to look for on inspection of spastic paraperesis patient
Foot orthoses
Spinal surgery scars
Gait for scissoring
Presence of a catheter
Neuropathic joints
disuse atrophy
38
By definition, in a myelopathy, where must the lesion be above?
Must be above the level of L1 as this is where the cord ends
39
If spastic paraperesis and absence of sensory signs, which diagnoses?
MND (PLS)
HSP
40
Anterior spinal artery occlusion features
Spastic paraperesis
Involvement of corticospinal tracts -> pyramidal pattern of weakness
Involvement of spinothalamic -> loss of pain and temperature sensation
Dorsal columns spared (jPS and vibration)
41
Posterior spinal artery occlusion features
Sensory ataxia, impaired proprioception
Loss of JPS and vibration sense
42
birth injury or illness around the neonatal period, intellectual impairment, spastic paraparesis, brisk reflexes, upgoing plantars.
Cerebral palsy
43
spastic paraperesis, cerebellar signs, pes cavus, upgoing plantars, absent ankle jerk, peripheral sensory neuropathy including dorsal columns
Friedrich's ataxia
44
Spastic paraparesis, brisk reflexes, upgoing plantars, cerebellar signs, and a history of visual or sphincter disturbance. There may be sensory signs, dorsal column more commonly than spinothalamic.
MS
45
Spastic paraparesis, brisk reflexes, upgoing plantars, wasting, faciculations. Absence of sensory signs.
MND
46
What are fasciculations almost pathognomic of?
ANterior horn cell disease i.e. MND
47
spastic paraparesis, cerebellar signs and dorsal column signs
friedrich's ataxia/ demyelination as differential
48
spastic paraperesis + small hand muscle wasting + fasciculations
MND
Cervical myelopathy
49
Spastic paraperesis + UMN signs in upper limb
Cervical myelopathy
Bilateral strokes
50
Spastic paraperesis + INO/RAPD
Demyelination
51
After examining spastic paraparesis, how would you complete your exam?
PR - Check for anal tone and saddle anaesthesia
UMN examination - any LMN signs suggestive of MND, any UMN signs suggestive of cortical pathology, any wasitng/fasciculations
Cerebellar examination: eyes, speech
Bulbar symptoms (syringomyelia)
Fundoscopy: optic neuritis
History: FH, spinal trauma, history of bowel/bladder disturbance, visual impairment
52
Which subtype of MND results in purely UMN features?
Primary lateral sclerosis PLS
53
Possible sites of lesion in spastic paraperesis
Spinal cord
Anterior horn cell
Parasagittal (meningioma)
54
Common causes of spastic paraperesis
MS
Cord compression/myelopathy/trauma
MND
55
Rarer causes
Anterior spinal cord syndrome (Stroke)
Inflammatory: NMO, SLE, sjogrens
Syringomyelia
HSP
HTLV-1
SCDC
Friedrich's ataxia
Parasagittal falx meningioma
56
Why can a parasagittal falx meningioma cause a SP?
Compresses at the midline i.e. the leg motor cortex areas
57
Causes of cord compression
Disc
Bone
Tumour
Abscess
58
Treatment of cord compression
Emergency requiring urgent spinal MRI and neurosurgery referral/discussion
Urgent surgical decompression +/- steroids and radiotherapy
59
Cauda equina symptoms
Back pain
B/L LMN signs in legs and sensory loss in lumbosacral dermatomes with sphincteric function impairment
60
Intrinsic abnormality of spinal cord causing SP
Demyelination
Spinal cord infarction
Transverse myelitis due to infection
CTDs - SLE, Sjogrens
61
Extrinsic compression of spinal cord causes
Spondylosis
Vertebral disc disease like tumour or haematoma
Cord compression from bone fracture
Congenital abnormality like CP or spina bifida
62
Degenerative conditions causing SP
HSP
PLS
63
Anterior cord syndrome causes
Infarct
Compression by vertebral disc disease
Anterior tumour
64
Which tracts affected in anterior cord syndrome
Corticospinal and spinothalamic
65
Causes of posterior cord syndrome
Demyelination
Posterior spinal artery infarct
Compression (disc, bone, tumour, abscess)
Taboparesis
SCDC
66
Demyelinating causes of SP
MS, NMO, SCDC, Transverse myelitis (HSV VZV HIV paraneoplastic), HTLV-1/ tropical spastic paraperesis
67
what is taboparesis
combination of tabes dorsalis (due to tertiary syphilis) and spastic paraperesis
Spastic paraperesis, syphilis, dorsal column involvement
68
Causes of transverse myelitis
Demyelinating: MS, NMO
Post-infective (HSV VZV HIV)
Autoimmune: SLE, Sjogrens, sarcoid
Paraneoplastic
69
spastic paraperesis + dorsal column loss
Demyelination
Friedrichs
SACDC
Taboparesis (syphilis)
70
SP and cerebellar signs
MS (Demyelination)
FA
SCA
71
Ix for MS
MRI spine and brain (lesions disseminated in time and space)
VEPs
LP - CSF for protein, lymphocytes, unpaired oligoclonal bands
72
Bloods to request in SP
FBC, UE, LFT, Bone profile, anti-AQP4, anti-MOG, BBV screen, HTLV1, syphilis, anti neuronal antibodies, ACE, ANA, ESR, Complement, anti dsDNA, B12, serum electrophoresis
73
Why may you request an EMG in sP?
To look for fasciculations and fibrillations seen in MND
74
Cancers which commonly metastasise to bone
Solid: lung, prostate, kidney, breast, thyroid
Haem: MM
75
Flaccid paraperesis DDx
AHC disease i.e. MND, poliovirus, west nile virus
Acute spinal infarct
Myopathy
NMJ disorder ie MG, botulism
Neuropathy: lead poisoning, porphyria, HMSN
76
Causes of SCDC
B12 deficiency:
- Nitrous oxide
- Dietary i.e. vegans
- Malabsorption: pernicious anaemia, crohn's, gastric or ileal resection, bacterial overgrowth
77
HMSN types
HMSN 1 - Demyelinating (AD)
HMSN 2 - Axonal (AD)
However there are many more types and inheritance pattern variable (AD, AR, X linked etc)
78
Ix for HMSN/CMT
NCS: Demyelinating - reduced velocity, axonal - reduced amplitude
Above will guide genetic testing
79
HMSN features on examination
Pes cavus
Hammer toes
Foot drop
High stepping gait
Loss/reduced ankle reflex
Symmetrical distal wasting "inverted champagne bottle"
claw hands
Charcot joints
Ankle foot orthoses
Variable loss of sensation in stocking distribution
Palpation: thickened nerves
80
HMSN DDx
Diabetic neuropathy
Alcohol related neuropathy
Lead toxicity
GBS
CIDP
vasculitis and mononeuritis multiplex in a younger patient
81
What does pes cavus indicate
Motor neuropathy during development
82
Palpable lateral popliteal nerve
CMT
83
nerves in cavernous sinus
III IV V1 V2 VI
84
nerves in cerebellopontine angle lesions
V VII VIII
85
DANG THERAPIST
Diabetes
Alcohol
Nutrition - b1 B6 B12
GBS
Toxins - phenytoin, amiodarone, isoniazid, nitrofurantoin, chemo
HSMN
Environmental ie lead
Relapsing i.e CIDP
Amyloid
Paraneoplastic/porphyria (myeloma, MGUS)
Infection - HIV, syphilis, leprosy
Systemic - sarcoid, hypothyroidism
Tumour i.e. nerve sheath tumour
86
3 types of diabetic neuropathy
Diabetic symmetric neuropathy
Diabetic amyotrophy
Autonomic neuropathy
87
What would NCS show in diabetic neuropathy?
Length dependent, symmetrical, axonal loss
88
Causes of predominantly motor peripheral neuropathy
Lead
Porphyria
CIDP/GBS
MMN
89
Causes of a central sensory neuropathy
Posterior cord syndrome -> dorsal column involvement
90
what is mononeuritis multiplex
asymmetrical sensory and motor peripheral neuropathy caused by damage to 2 separate isolated peripheral nerves
91
Miller Fisher triad/ symptoms
Ophthalmoplegia areflexia ataxia
Descending paralysis
92
Antibodies in Miller Fisher
ANti-GQ1B
93
signs of diabetic autonomic neuropathy
Postural hypotension
Gastroparesis
ED
Gustatory sweating
94
Signs of diabetic amyotrophy
asymmetric pain and weakness of quads (lumbosacral plexopathy)
Loss of knee jerks
95
DDx thickened peripheral nerves
CMT
Leprosy
Acromegaly
Amyloidosis
Neurofibromatosis
96
Common medications that cause neuropathy
PAIN
phenytoin
Amiodarone
Isoniazid
nitrofurantoin
97
Investigations for peripheral neuropathy
LSBP
CBG
Urine dip + ACR
Fundoscopy
Bloods
FBC, UE, LFT, TFT, Bone profile, B12/Folate, Hba1c, ANA/ANCA/ESR, Virology, serum electrophoresis, immunoglobulins, anti-neuronal antibodies
LP if ? GBS/CIDP
Screen for malignancy with imaging
NCS
EMG
Nerve biopsy
Genetic testing ?cmt
98
What is a charcot joint?
A neuropathic joint where impaired joint position sense and sensation of pain leads to chronic damage to joints
99
Mx of peripheral neuropathy
MDT (Endo, diabetes specialist nurse, alcohol cessation services, GP, dietitian, physioOT, podiatry)
Minimise further risk ie dietary changes, better glycaemic control, alcohol cessation
DVLA Considerations
Orthotics, regular foot care and checks
Medical: TCAs/gabapentic/neuropahtic agents for pain
100
Ix if suspecting myeloma as cause of peripheral neuropathy
urine BJP
Serum electrophoresis
Bone profile
FBC
serum immunoglobulins
Skeletal survey
101
causes of a mononeuritis multiplex
DM
Vasculitis: GPA, PAN
Infection: HIV, ;leprosy
AMYLOID
Sarcoid
CKD
Paraneoplastic
102
Signs on exam of an MG patient?
Ptosis
Complex ophthalmoplegia
Thymectomy scar (midline sternotomy
Fatiguability
Dysphagia
Dysarthria
NG tubes/feeding tubes
103
Reflexes in MG compared to LEMS
Reflexes preserved in mG but reduced in LEMS
104
What does strength of neck flexion correlate with in MG?
Respiratory muscle weakness
105
Associated autoimmune diseases in MG
Graves
Hashimoto thyroiditis
DM
RA
SLE
106
MG DDx
LEMS
Miller Fisher variant of GBS
Botulism
Kearns sayres
107
Precipitants of an acute MG crisis
Infection
Medications
- Abx: fluoroquinolones, macrolides
- Lithium
- Penicillamine
- Anti hypertensives
- Phenytoin
Stress/ surgery
Pregnancy
Medication non compliance
108
DDx bilateral ptosis
MG
MD
Senile
Congenital
Bilateral horner's
Bilateral IIIrd nerve palsy
Oculopharyngeal muscular dystrophy
CPEO - Kearn's Sayre (chronic progressive external ophthalmoplegia)
109
Ix for MG
Bedside:
- fvc < 1.5L -> ICU
- aBG (t2rf)
- O2 sats
- Review drug chart and stop any offending drugs
Bloods
- FBC, UE, CRP, TFT (concurrent graves)
- Anti-nACHR, Anti-MUSK
Electrophysiology
- Single fibre EMG
- NCS
CT mediastinum for thymoma
TPMT levels as may require azathioprine
110
what additional feautures may you test on examination of a pt with suspected MG?I
Fatiguability on upgaze
Fatiguability on shoulder abduction
Midline sternotomy scar
Nasal speech
Swallow impairment
Complex ophthalmoplegia
Signs of other autoimmune diseases ie SLE, RA, Thyroid disease
111
Why may you send TPMT levels in MG patient?
If starting on azathioprine
112
Mx of acute MG crisis
Consider ICU/Intubation if FVC < 1.5l/ Airway compromise
Swallow assessment
oxygen
IV neostigmine
IV steroids
IVIG or plasma exchange
113
General mx of MG
MDT: neurologist, SALT, physio
Acetylcholinesterase inhibitor: pyridostigmine
Steroids
Steroid sparing agents (aza, MMF, ciclosporin)
Thymectomy
IVIG and plasma exchange
Surgical: Thymectomy
114
complications of MG
Myasthenic crisis
Cholinergic crisis
T2RF
Aspiration pneumonia
115
SE of pyridostigmine
cholinergic crisis (SLUDGE - Salivation, lacrimatkino, urinary incontinence, diarrhoea, GI hypermotility, emesis)
116
Difference between LEMS and MG
LEMS: Proximal myopathy, rarely affects eyes, areflexia, autonomic symptoms
117
MG gold standard investigation
EMG
118
How long to observe ocular MG before confirming diagnosis
2 years, if after 2 years still not developed to generalised then can conclude ocular mG
119
Young adult, wheelchair, ataxic, pes cavus, dysarthric, bilateral cerebellar signs
Friedrich's ataxia
120
DDx absent ankle jerks and upgoing plantars
SCDC
MND
Conus medullaris lesion
Friedrich's ataxia
Taboparesis (tertiary syphilis)
Dual pathology ie stroke + peripheral neuropathy
121
What is friedrich's ataxia
chronic neurodegenerative condition due to a mutation in the gene frataxin coded on Chr 9, trinucleotide repeat disorder (GAA) which demonstrates anticipation phenomenon
Autosomal recessive usually
122
Which other systems can be affected in FA?
Eyes: optic atrophy
Diabetes
Heart: HCM
Scoliosis
Dysarthria and swallow impairment
123
Biggest cause of death in FA
HCM
124
Ix in pt with suspected FA
Ix:
Bedside: urine dip, CBG, Fundoscopy
Full CVS exam
ECG
CXR
Echo
MRI brain and spine to rule out other differentials
Genetic testing
Can also offer prenatal genetic testing
125
DDx complex ophthalmoplegia
MG
Thyroid eye disease
Mitochondrial: Chronic progressive external ophthalmoplegia (Kearns sayre)
Oculopharyngeal muscular dystrophy
Miller-Fisher variant of GBS
psp
Cavernous sinus pathology (3,4,V1,V2,6)
126
DDx myasthenia gravis
LEMS
Oculopharyngeal muscular dystrophy
Botulism
Miller Fisher variant GBS
Kearns-sayres
127
Types of MND
Amyotrophic lateral sclerosis
Primary lateral sclerosis
Progressive muscular atrophy
Progressive bulbar palsy
128
Features of each type of MND
ALS - Mixed UMN LMN
PLS - Only upper
PMA - Only lower (best prognosis)
PBP - Only lower affecting the brain stem (worst prognosis)
129
How to differentiate between pseudobulbar and bulbar palsy
Pseudobulbar = UMN, spastic tongue and brisk jaw jerk
Bulbar = LMN, fasciculations, hyporeflexic, nasal speech
130
Where does MND never affect?
Sensation
Bladder
Eyes
131
How would you complete your examination in suspected MND?
"To complete my examination I would like to do a full assessment of UL/CN/LL and a speech and swallow assessment, cognition assessment and respiratory function"
132
MND DDx
Multifocal motor neuropathy
Kennedy's disease (X-linked spinomuscular atrophy)
GBS
MG
Myopathy
Polio
Syringomyelia (would have sensory sx)
Cervical radiculomyelopathy (would have sensory)
SACDC (would have dorsal column loss)
133
How to differentiate between MMN and mND
MND shows conduction block on NCS
134
What other neurolofical condition is ALD strongly associated with?
FTLD
135
What age is mND commonly seen
>50
136
Investigations for suspected MDN
Bedside: Obs (o2 sats), ABG, lung function tests
Bloods: CK, TFTs, anti-GM1, CRP/ESR, malignancy screen if ?paraneoplastic, HIV, lyme, syphilis
Imaging
MRI brain and spine to exclude radiculopathy/myelopathy
Special tests
EMG: fibrillation and fasciculations
NCS: Normal motor and sensory condcution
Spirometry
Muscle biopsy (inclusion body myositis)
LP if ? CIDP
137
Main cause of death in MND
Respiratory muscle weakness and ventilatory failure
138
Features of kennedy;s disease
X-linked recessive
bulbar palsy
tongue and chin fasciculations
gynaecomastia and subfertility
Sparing of UMNs
SLOW rate of progression - distinguishes it from ALS
139
Pattern of weakness in MND
Tends to be distal and asymmetric, with disease progression it ascends and becomes bilateral
140
MMN autoantibody
Anti-GM1 ganglioside antibodies
141
General mx of MND5
MDT: Neurologist, dietitian, PT/OT, SALT, Psychologist, palliative care, GP
Conservative: end of life planning, advanced diectives, DNAR discussions
DVLA considerations
Medical: NIV could be trialled
Riluzole has been shown to prolong survival by 3 months but has many SE
PEG for feeding
antispasmodics for spIasticity
142
Is MND inherited?
5% of cases are familial
143
MS investigations
MRI brain and spinal cord with contrast
LP for unpaired oligoclonal bands
VEPs for optic neuritis
144
MS DDx
NMO
Inflammatory: behcets, sarcoid, SLE, sjogrens, CNS vasculitis
Infection: HIV, CNS syphilis, lyme
145
MS associations
Genetics
Environment: vit D deficiency, smoking
EBV
146
Why does lhermitte's phenomenon happen
cervical cord plaques
147
where do you commonly see MS plaques in the brain?
Periventricular
Juxtacortical
Infratenorial
148
Diagnostic criteria for MS
McDonald - dissemination in time and space
149
why do MRI with contrast in MS?
Allows a timestamp as if they enhance with contrast, it is < 3 months old but if they dont then > 3 months old
150
MS during pregnancy and after
Reduced relapse rates during but increased after
151
Mx of MS
MDT: MS specialist nurse, neurologist, physio, OT, psychologist, social worker, physician
Acute relapse: steroids (PO methypred 500mg 5 days or IV 1g 3 days)
Maintenance: DMTs
- Interferon beta, natalizumab, ocrelizumab (anti-cd20)
Symptomatic treatments
- Laxatives, antispasmodics, ISC/anticholinergics, antidepressants, neuropathic agents
152
How do steroids alter disease trajectory in MS?
They have no role in altering prognosis but resolve the symptoms of the relapse sooner
153
are MS DMTs safe in pregnancy
Natalizumab and interferon beta safe until 34 weeks gestation
154
RISK OF MS IN CHILD OF AFFECTED MOTHER?
2%
155
Ocrelizumab mOA
Anti-CD20
156
Causes of transverse myelitis
Myelin:
- MS
- NMO
Inflamm:
- SLE, Behcet, sarcoid, sjogren
- CNS Vasculitis
Infection
- Bacterial: syphilis, lyme, TB
- Viral: HIV, VZV, CMV, HSV
157
investigations in transverse myelitis
MRI spine with contrast
LP for oligoclonal bands, CSF VDRL, ACE, Cytology
Serology: anti-MOG/AQP4, ANA, Anti Ro/La, ACE, dsDNA
158
transverse myelitis mx
IV methylprednisolone
PLEX
If fails
IVIG
Rituximab (NMO)
Azathioprine (SLE)
