Neuro Flashcards

Question

cauda equina symptoms and signs tests to do Management

Answer 1

``` Severe bilateral back pain Reduced LL sensation Bladder/bowel dysfunction (esp urinary retention) LL motor weakness Impotence ``` o/e - Perianal anaesthesia aka saddle - Loss of anal tone (PR) - LL weakness and loss of reflexes - Urinary retention’s Tests - PR - Post void bladder scan - whole spine MRI Management - Early neurosurgical review for urgent decompression - High dose steroids e.g. dexamethasone to reduce any localized swelling - In cases caused by malignancy, radio/chemotherapeutic can be used

Answer 2

A At least 5 attacks fulfilling criteria B-D B Headache attacks lasting 4-72 hours* (untreated or unsuccessfully treated) C Headache has at least two of the following characteristics: 1. unilateral location* 2. pulsating quality (i.e., varying with the heartbeat) 3. moderate or severe pain intensity 4. aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs) D During headache at least one of the following: 1. nausea and/or vomiting* 2. photophobia and phonophobia E Not attributed to another disorder (history and examination do not suggest a secondary headache disorder or, if they do, it is ruled out by appropriate investigations or headache attacks do not occur for the first time in close temporal relation to the other disorder) NICE criteria the following points are noted: NICE suggests migraines may be unilateral or bilateral NICE also give more detail about typical auras: Auras may occur with or without headache and: are fully reversible develop over at least 5 minutes last 5-60 minutes

Answer 3

Immediate: ABC, High flow Oxygen, BM, temperature ``` 5 mins - No IV access - Buccal midazolam 0.5mg/kg - Iv access - IV lorazepam 0.1mg/kg Gain IV access if not already. Send blood samples ``` ``` 15 mins - IV lorzepam 0.1mg/kg This step should be in hospital Call for senior help Start to prepare phenytoin for 4th step Re-confirm it is an epileptic seizure ``` 25 mins - Phenytoin 20 mg/kg by intravenous infusion over 20 mins or (if on regular phenytoin) - Phenobarbital 20 mg/kg intravenously over 5 mins 45 mins Rapid sequence induction of anaesthesia using thiopental sodium 4 mg/kg intravenously

Answer 4

Trigeminal neuralgia is a pain syndrome characterised by severe unilateral pain. Causes The vast majority of cases are idiopathic but compression of the trigeminal roots by tumours or vascular problems may occur Red flags - Sensory changes - Deafness or other ear problems - History of skin or oral lesions that could spread perineurally - Pain only in the ophthalmic division of the trigeminal nerve (eye socket, forehead, and nose), or bilaterally - Optic neuritis - A family history of multiple sclerosis - Age of onset before 40 years Management - Carbamazepine is first-line - failure to respond to treatment or atypical features (e.g. < 50 years old) should prompt referral to neurology

Answer 5

Syndrome of spontaneous, continuous lower limb movements that may be associated with paraesthesia. Symptoms/signs Uncontrollable urge to move legs (akathisia). Symptoms initially occur at night but as condition progresses may occur during the day. Symptoms are worse at rest Paraesthesias e.g. 'crawling' or 'throbbing' sensations movements during sleep may be noted by the partner - periodic limb movements of sleeps (PLMS) Causes/associations - FH - iron deficiency anaemia - uraemia - diabetes mellitus - pregnancy Diagnosis = clinical but do FBC to exlude Fe deficiency anaemia Management - Simple measures: walking, stretching, massaging affected limbs - Treat any iron deficiency dopamine agonists are first-line treatment (e.g. Pramipexole, ropinirole) - Benzodiazepines - Gabapentin

Answer 6

Dual antiplatelet with aspirin + modified release dipyramidole Proplem with clopidogrel is usually GI e.g. diarrhoea

Answer 7

Ipsilateral: facial pain and temperature loss, Horner syndrome, Ataxia, nystagmus Contralateral: limb/torso pain and temperature loss Lateral medullary syndrome Wallenberg syndrome Most commonly survived stroke that affects the brainstem

Answer 8

1) Demyelination (Schwann Cell damage --> slowing of conduction) caused by pressure e.g. entrapment or by inflammation e.g. GBS Nerve conduction: Decreased conduction velocity 2) Axonal degeneration: Conduction velocity initially normal. Typical in toxic neuropathies Nerve conduction: Decreased amplitude of impulse - Compression: Focal demyelination at point of compression --> disruption of conduction e.g. Carpal Tunnel Syndrome - Infarction: Micro-infarction of vasa nevorum occurs in diabetes and arteritis. Wallerian degeneration occurs distal to infarct - Infiltration: By inflammatory cells in leprosy, granulomas (e.g. sarcoid) and by neoplastic cells

Answer 9

Blood: FBC, ESR, CRP, U&Es (renal function), LFTs, Glucose, Autoantibodies, Vit B12, Serum protein electrophoresis Nerve conduction studies; Axonal degeneration = reduced amplitude Demyelination = reduced conduction velocity Also characterise whether sensory and/or motor fibres involved and localise site of abnormality EMG Fine need inserted into muscle to discern whether partial or complete innervation present and if re--innervation occuring Nerve biopsy Sural nerve most commonly as purely sensory and so resulting deficit is trivial Can confirm vasculitis or other inflammatory process CSF May be helpful in GBS or CIDP, when protein raised, without inflammatory cells

Answer 10

2 or more peripheral nerves affacted ``` Causes : WAARDS PLC W = Wegener's A = Aids A = Amyloid R = RA D = DM = most common S = Sarcoidosis P = PAN L= Leprosy C = Carcinomatosis ``` Investigations - as for peripheral nerve disorders + EMG helps define site of lesion: Blood: FBC, ESR, CRP, U&Es (renal function), LFTs, Glucose, Autoantibodies, Vit B12, Serum protein electrophoresis Nerve conduction studies; Axonal degeneration = reduced amplitude Demyelination = reduced conduction velocity Also characterise whether sensory and/or motor fibres involved and localise site of abnormality EMG Fine need inserted into muscle to discern whether partial or complete innervation present and if re--innervation occuring Nerve biopsy Sural nerve most commonly as purely sensory and so resulting deficit is trivial Can confirm vasculitis or other inflammatory process CSF May be helpful in GBS or CIDP, when protein raised, without inflammatory cells

Answer 11

Motor 1) Flexor carpi ulnaris 2) Flexor digitorum profundus Then all small muscles of hand except APB. OPB, Lateral 2 lumbricals and part of FPB Sensory Ulnar 1 and 1/2 fingers Causes of ulnar nerve palsy Entrapment usually at elbow here nerve compressed within cubital tunnel, which lies behind medial epicondyle - Can follow ulnar fracture - Micro injury by leaning on elbow - Vibrating tools and cyclists - Stretching of ulnar nerve e.g. sleeping with elbow bent to more than 90degrees

Answer 12

Causes - Most common is fibular neck injury due to compression e.g. surgical positioning, crossing legs, trauma ``` Presentation - Weakened dorsiflexion, foot drop - Weakened foot eversion So foot inverted and foot drop Numb dorsum of foot + lateral lower leg ``` Differentials - L5 radiculopathy: Weakened dorsiflexion, weakened foot eversion, weak foot inversion, weakened hip internal rotation _ abduction. Numbness over dorsum and lateral leg - Sciatic nerve injury: Weakness of dorsiflexion. plantar flexion, foot eversion, foot inversion - Cortical lesion: UMN signs e.g. babinski reflex present Management Conservative: PT, orthopaedic devices e.g. splints Medical: Corticosteroid injections may help, neuropathic pain treatment Surgical: If disorder doesn’t go away

Answer 13

Myotome: Long toe extensor Dermatome: On the dorsum of the foot at the third metatarsal phalangeal joint. Reflex

Answer 14

1) Peripheral neuropathy 2) Bilateral radiculopathy but more commonly.. 3) Cauda equine syndrome/ Conus medullaris syndrome 4) MND 5) Spastic paraplegia

Answer 15

Guillan barre syndrome = Acute inflammatory demyelination polyradiculoneuropathy (AIDP) Cause No precipitant in 40%; 1-3 weeks after rest infections/diarrhoea (campylobacter esp) Pathophysiology Infecting organisms induce antibody responses against peripheral nerves Classification - AIDP - AMAN (acute motor (+/- sensory) axonal neuropathy) - Miller fisher: Opthalmoplegia (ocular muscle palsies) + ataxia + areflexia

Answer 16

Weakness and sensory loss progress proximally, ASCENDING over days/weeks - Often starts with sensory loss Loss of tendon reflexes = almost invariable In mild cases, spontaneous recovery begins but in 20% resp failure and fascial muscles become weak, sometimes progressing to complete paralysis Autonomic features may develop: Arrhythmias, Tachy, Labile BP, Sweating, Urinary retention; Constipation Investigations - Nerve conduction studies: Demyelinating (AFTER 10d) - Image spine to ensure no Cauda equina - LP shows high protein!! + normal cells (AFTER 1 week) - FVC - worry if downward trajectory (ITU if below 1) - Assess swallow - Continuous heart monitoring Management - IVIg 1st line (check IgA first as deficiency can --> bad reaction) - Plasma exchange NO STEROIDS Prognosis Recovery graduate but occurs in 80%

Answer 17

Chronic inflammatory demyelinating polyradiculopathy - Clinical features and pathology similar to GBS but rarely preceding infection - Often milder syndrome than GBS Management - Corticosteroids +/- immunosuppression

Answer 18

Hereditary motor and sensory neuropathy. Usually AD ``` CMT1 = demyelinating with hypertrophy of nerves CMT2 = Axonal degeneration ``` Presentation - onset at puberty - Distal wasting over lower limbs --> champagne bottles - Pes cavus - 1/3 have postural tremor - 1/2 have thickening of peripheral nerves - Absent ankle jerk - Sensory features not as marked as motor Investigations - Genetic tests: PMP22 gene mutation - Nerve conduction studies - reduced velocity in CMT1 Management = Supportive PT/OT/Podiatry/ Orthoses (ankle braces)

Answer 19

Prevents ACh vesicle release Presentation - Descending flaccif paralysis - Anti-cholinergic effects: Mydriasis, Cycloplegia, Day mouth, Constipation Management Benpen + antiserum

Answer 20

Ischaemic due to infarct (85%) 1) Vascular: Thrombotic; Large artery stenosis; Small vessel disease (lacunar) 2) Cardioembolic (30% of stroke) - AF/arrhythmia; Endocarditis/valve disease; MI; PFO 3) Haem Hyoperfusion (severe hypotension e.g. Cardiac arrest may lead to infarction in watershed areas between vascular territories); Prothrombotic hyper coagulable states Intracerebral haemorrhagic stroke HIgh BP; Trauma; Aneurysm rupture; Anticoagulants; Thrombolysis Other - Watershed stroke (sudden drop in BP e.g. sepsis) - Carotid artery dissection - Vasculitis - PAN/HIV - Cerebral vasospasm secondary to SAH - Venous sinus thrombosis - Anti-phospholipid syndrome, thrombophillia

Answer 21

1. Total anterior circulation stroke (TACS) 1. Total anterior circulation stroke (TACS) Large cortical stroke affecting the areas of the brain supplied by both the MCA and ACA All three of the following need to be present for a diagnosis of TACS: • Unilateral weakness (and/or sensory deficit) of the face, arm and leg • Homonymous hemianopia • Higher cerebral dysfunction (dysphasia, visuospatial disorder) 2. Partial anterior circulation stroke (PACS) Less severe form of TACS, in which only part of the anterior circulation has been compromised. Two of the following need to be present for a diagnosis of PACS: • Unilateral weakness (and/or sensory deficit) of the face, arm and leg • Homonymous hemianopia • Higher cerebral dysfunction (dysphasia, visuospatial disorder) 3. Posterior circulation syndrome (POCS) Damage to the area of the brain supplied by the posterior circulation (e.g. cerebellum and brainstem). One of the following need to be present for a diagnosis of POCS: • Cranial nerve palsy and a contralateral motor/sensory deficit • Bilateral motor/sensory deficit • Conjugate eye movement disorder (e.g. horizontal gaze palsy) • Cerebellar dysfunction (e.g. vertigo, nystagmus, ataxia) • Isolated homonymous hemianopia 4. Lacunar syndrome (LACS) Subcortical stroke that occurs 2 to small vessel disease. No loss of higher cerebral functions (e.g. dysphasia). One of the following needs to be present for a diagnosis of LACS: • Pure sensory stroke • Pure motor stroke • Senori-motor stroke • Ataxic hemiparesis The homonymous hemianopia is always the same side as the hemiplegia!!

Answer 22

5 Vivid red flags to unfurl 1) Early postural instability and vertical gaze palsy ± falls; rigidity of trunk > in limbs; symmetrical onset; speech and swallowing problems; little tremor→ progressive supranuclear palsy: (PSP, Steele–Richardson–Olszewski syndrome). 2) Neurology Early autonomic features, eg impotence/incontinence, postural ↓ bp; cerebellar + pyramidal signs; rigidity > tremor→multiple system atrophy (msa; Shy–Drager). 3) Neurology Fluctuating cognition with visual hallucinations and early dementia→Lewy body dementia ([link]). 4) Neurology Akinetic rigidity involving one limb; cortical sensory loss (eg astereognosis); apraxia (even autonomous interfering activity by affected limb—the ‘alien limb’ phenomenon)→cortico-basal degeneration (cbd). 5) Neurology Pyramidal signs (legs), eg in diabetic/hypertensive patient who falls247 or has gait problems, eg ataxia (no festination)→vascular parkinsonism (2–5% of ‘pd’).

Answer 23

Bitemporal hemianopia = lesion at optic chiasm - Upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour - Lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma Homonymous hemianopia - Incongruous defects: lesion of optic tract - Congruous defects: lesion of optic radiation or occipital cortex - Macula sparing: lesion of occipital cortex Main points 1) Left homonymous hemianopia means visual field defect to the left, i.e. Lesion of right optic tract 2) Homonymous quadrantanopias: PITS (Parietal-Inferior, Temporal-Superior) 3) Incongruous defects = optic tract lesion; congruous defects = optic radiation lesion or occipital cortex

Answer 24

Acute: 100% oxygen (80% response rate within 15 minutes), subcutaneous triptan (75% response rate within 15 minutes) Prophylaxis: Verapamil is the drug of choice. There is also some evidence to support a tapering dose of prednisolone NICE recommend seeking specialist advice from a neurologist if a patient develops cluster headaches with respect to neuroimaging Trigger: alcohol

Answer 25

- 60% = Glioma and metastatic disease 20% = Meningioma 10% = Pituitary lesions In paediatric practice medulloblastomas (neuroectodermal tumours) were the commonest lesions, astrocytomas now account for the majority. Tumours arising in right temporal and frontal lobe may reach considerable size before becoming symptomatic. Whereas tumours in the speech and visual areas will typically produce early symptoms. Diagnosis MRI Scanning provides the best resolution. Treatment Dexamethasone can be used to reduce oedemax Usually surgery, even if tumour cannot be completely resected conditions such as rising ICP can be addressed with tumour debulking and survival and quality of life prolonged. - Curative surgery can usually be undertaken with lesions such as meningiomas. - Gliomas have a marked propensity to invade normal brain and resection of these lesions is nearly always incomplete.

Answer 26

Temporal lobe (HEAD) - Hallucinations (auditory/gustatory/olfactory), - Epigastric rising/Emotional, - Automatisms (lip smacking/grabbing/plucking), - Deja vu/Dysphasia post-ictal) ``` Frontal lobe (motor) - Head/leg movements, posturing, post-ictal weakness, Jacksonian march ``` Parietal lobe (sensory) Paraesthesia Occipital lobe (visual) Floaters/flashes

Answer 27

wet, wobbly and whacky = urinary incontinence, gait ataxia, and dementia respectively. Causes Normal pressure hydrocephalus is a reversible cause of dementia seen in elderly patients. - It is thought to be secondary to reduced CSF absorption at the arachnoid villi. - These changes may be secondary to head injury, subarachnoid haemorrhage or meningitis. Imaging Hydrocephalus with an enlarged fourth ventricle Typically an absence of substantial sulcal atrophy Management - Ventriculoperitoneal shunting - Around 10% of patients who have shunts experience significant complications such as seizures, infection and intracerebral haemorrhages

Answer 28

Occurs due to a lesion of the medial longitudinal fasciculus (MLF), a tract that allows conjugate eye movement. - Vascular disease - MS Features - Impaired adduction of the eye on the same side as the lesion - Horizontal nystagmus of the abducting eye on the contralateral side

Answer 29

Tuberous sclerosis (TS) is a genetic condition of autosomal dominant inheritance. Like neurofibromatosis, the majority of features seen in TS are neurocutaneous. Cutaneous features Depigmented 'ash-leaf' spots which fluoresce under UV light Roughened patches over lumbar spine (Shagreen patches) Adenoma sebaceum (angiofibromas): butterfly distribution over nose Fibromata beneath nails (subungual fibromata) café-au-lait spots* may be seen Neurological features developmental delay epilepsy (infantile spasms or partial) intellectual impairment Also retinal hamartomas: dense white areas on retina (phakomata) rhabdomyomas of the heart gliomatous changes can occur in the brain lesions polycystic kidneys, renal angiomyolipomata lymphangioleiomyomatosis: multiple lung cysts

Answer 30

Type 1 - CAFE SPOT ``` Cafe-au-lait spots Axillary, inguinal freckling Fibroma Eye: Lisch nodules (iris) Skeletal: bowing leg Pedigree/FH : AD Optic tumour(glioma) ``` T1 has peripheral predominance T2 has central predominance Type 2 - Few skin/skeletal malformation - Vestibular schwannomas/ CNS tumours

Answer 31

The mnemonic CHOCOLATE is useful for remembering the common precipitants. ``` Chocolate Hangovers Orgasms Cheese Caffeine The oral contraceptive pill Lie-ins Alcohol Travel Exercise ``` Management acute: triptan + NSAID or triptan + paracetamol Prophylaxis: topiramate or propranolol - Topiramate is also recommended by NICE as first-line prophylaxis against migraine. However, in female and of child-bearing age a beta-blocker (such as propranolol) is a better choice.

Answer 32

The second most common primary brain tumour in adults * Meningiomas are typically benign, extrinsic tumours of the central nervous system. They arise from the dura mater of the meninges and cause symptoms by compression rather than invasion. * They typically are located at the falx cerebri, superior sagittal sinus, convexity or skull base. * Histology: Spindle cells in concentric whorls and calcified psammoma bodies * Investigation is with CT (will show contrast enhancement) and MRI, and * Treatment will involve either observation, radiotherapy or surgical resection.

Answer 33

Vstibular schwannomas (sometimes referred to as acoustic neuromas) account for approximately 5% of intracranial tumours and 90% of cerebellopontine angle tumours. The classical history of vestibular schwannoma includes a combination of vertigo, hearing loss, tinnitus and an absent corneal reflex. Features can be predicted by the affected cranial nerves: cranial nerve VIII: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus cranial nerve V: absent corneal reflex cranial nerve VII: facial palsy Bilateral vestibular schwannomas are seen in neurofibromatosis type 2. Patients with a suspected vestibular schwannoma should be referred urgently to ENT. It should be noted though that the tumours are often slow growing, benign and often observed initially. MRI of the cerebellopontine angle is the investigation of choice. Audiometry is also important as only 5% of patients will have a normal audiogram. Management is with either surgery, radiotherapy or observation.

Answer 34

Cause Alcohol - B1 (thiamine deficiency) Triad: 1) Ophthalmoplegia/nystagmus, 2) Ataxia and 3) confusion may occur Treatment = Pabrinex If not treated Korsakoff's syndrome may develop as well. This is termed Wernicke-Korsakoff syndrome and is characterised by the addition of 4) antero- and retrograde amnesia and 5) confabulation .

Answer 35

Classically seen in young, overweight females. ``` Risk factors obesity female sex pregnancy drugs*: oral contraceptive pill, steroids, tetracycline, vitamin A, lithium - tetracycline antibiotics - isotretinoin - contraceptives - steroids - levothyroxine - lithium - cimetidine ``` ``` Features headache blurred vision papilloedema (usually present) enlarged blind spot sixth nerve palsy may be present ``` Management weight loss Diuretics e.g. acetazolamide Topiramate is also used, and has the added benefit of causing weight loss in most patients repeated lumbar puncture surgery: optic nerve sheath decompression and fenestration may be needed to prevent damage to the optic nerve. A lumboperitoneal or ventriculoperitoneal shunt may also be performed to reduce intracranial pressure

Answer 36

Most neurologists now start antiepileptics following a second epileptic seizure. NICE guidelines suggest starting antiepileptics after the first seizure if any of the following are present: the patient has a neurological deficit brain imaging shows a structural abnormality the EEG shows unequivocal epileptic activity the patient or their family or carers consider the risk of having a further seizure unacceptable Sodium valproate is considered the first line treatment for patients with generalised seizures with carbamazepine used for focal seizures. Generalised tonic-clonic seizures sodium valproate second line: lamotrigine, carbamazepine Absence seizures* (Petit mal) sodium valproate or ethosuximide sodium valproate particularly effective if co-existent tonic-clonic seizures in primary generalised epilepsy Myoclonic seizures** sodium valproate second line: clonazepam, lamotrigine Focal seizures carbamazepine or lamotrigine second line: levetiracetam, oxcarbazepine or sodium valproate *carbamazepine may exacerbate absence seizures **carbamazepine may exacerbate myoclonic seizures

Answer 37

CT: Crescents Source of bleeding: Shearing of bridging veins between cortex and venous sinus.

Answer 38

Features eye is deviated 'down and out' ptosis pupil may be dilated (sometimes called a 'surgical' third nerve palsy) ``` Causes diabetes mellitus vasculitis e.g. temporal arteritis, SLE false localizing sign* due to uncal herniation through tentorium if raised ICP --- eep posterior communicating artery aneurysm pupil dilated often associated pain cavernous sinus thrombosis ``` Weber's syndrome: = ipsilateral 3rd palsy with contralateral hemiplegia -caused by midbrain strokes other possible causes: amyloid, multiple sclerosis

Answer 39

Motor response 6. Obeys commands 5. Localises to pain 4. Withdraws from pain 3. Abnormal flexion to pain (decorticate posture) 2. Extending to pain 1. None Verbal response 5. Orientated 4. Confused 3. Words 2. Sounds 1. None Eye opening 4. Spontaneous 3. To speech 2. To pain 1. None

Answer 40

Myotome: Finger flexors Dermatome: On the dorsal surface of the proximal phalanx of the little finge

Answer 41

Causes: Many 1) Extension of sepsis from middle ear or sinuses 2) Trauma or surgery to the scalp 3) Penetrating head injuries and embolic events from endocarditis The presenting symptoms will depend upon the site of the abscess (those in critical areas e.g.motor cortex) will present earlier. Raised ICP signs Although fever, headache and focal neurology are highly suggestive of a brain abscess the absence of one or more of these does not exclude the diagnosis, fever may be absent and even if present, is usually not the swinging pyrexia seen with abscesses at other sites. Assessment of the patient includes imaging with CT scanning . MRI: Diffusion restricting! Treatment is usually surgical, a craniotomy is performed and the abscess cavity debrided. The abscess may reform because the head is closed following abscess drainage.

Answer 42

Can stop if seizure free for >2 years and withdraw over 2-3 months

Answer 43

Wide-based gait, loss of the heel to toe pattern and instability. ``` Causes - cerebellar injury (PASTRIES) Posterior fossa tumour Alcohol S Multiple sclerosis Trauma Rare causes Inherited (Freidrich's ataxia) Epilepsy treatments Stroke ```

Answer 44

Essential tremor (previously called benign essential tremor) is an autosomal dominant condition which usually affects both upper limbs Features postural tremor: worse if arms outstretched Improved by alcohol and rest Most common cause of titubation (head tremor) Management propranolol is first-line primidone is sometimes used

Answer 45

Grade 0 No muscle movement Grade 1 Trace of contraction Grade 2 Movement at the joint with gravity eliminated Grade 3 Movement against gravity, but not against added resistance Grade 4 Movement against an external resistance with reduced strength Grade 5 Normal strength

Answer 46

Overview usually combined with a decarboxylase inhibitor (e.g. carbidopa or benserazide) to prevent peripheral metabolism of L-dopa to dopamine reduced effectiveness with time (usually by 2 years) no use in neuroleptic induced parkinsonism ``` Adverse effects Dyskinesia 'On-off' effect Postural hypotension Cardiac arrhythmias nausea & vomiting Psychosis reddish discolouration of urine upon standing ```

Answer 47

Phenytoin is used in the management of seizures. Mechanism of action binds to sodium channels increasing their refractory period Adverse effects Phenytoin is associated with a large number of adverse effects. These may be divided into acute, chronic, idiosyncratic and teratogenic. Phenytoin is also an inducer of the P450 system. Acute initially: dizziness, diplopia, nystagmus, slurred speech, ataxia later: confusion, seizures Chronic common: !!!gingival hyperplasia!!! (secondary to increased expression of platelet derived growth factor, PDGF), hirsutism, coarsening of facial features, drowsiness megaloblastic anaemia (secondary to altered folate metabolism) !!Peripheral neuropathy!! enhanced vitamin D metabolism causing osteomalacia lymphadenopathy dyskinesia ``` Idiosyncratic fever rashes, including severe reactions such as toxic epidermal necrolysis hepatitis Dupuytren's contracture* aplastic anaemia ???Drug-induced lupus??? ``` Teratogenic associated with CLEFT PALATE and congenital heart disease Monitoring Phenytoin levels do not need to be monitored routinely but trough levels, immediately before dose should be checked if: adjustment of phenytoin dose suspected toxicity detection of non-adherence to the prescribed medication

Answer 48

Broca's (expressive) aphasia - lesion of the inferior frontal gyrus. - It is typically supplied by the superior division of the left MCA - Speech is non-fluent, laboured, and halting - Comprehension is normal Wernicke's (receptive) aphasia - lesion of the superior temporal gyrus. - It is typically supplied by the inferior division of the left MCA This area 'forms' the speech before 'sending it' to Broca's area. Lesions result in sentences that make no sense, word substitution and neologisms but speech remains fluent - Comprehension is impaired Conduction aphasia - Classically due to a stroke affecting the arcuate fasiculus - the connection between Wernicke's and Broca's area - Speech is fluent but repetition is poor. Aware of the errors they are making - Comprehension is normal Global aphasia Large lesion affecting all 3 of the above areas resulting in severe expressive and receptive aphasia

Answer 49

e.g. bromocriptine, ropinirole, cabergoline, apomorphine Ergot-derived dopamine receptor agonists (bromocriptine, cabergoline) have been associated with - pulmonary, retroperitoneal and cardiac fibrosis. - -> echocardiogram, ESR, creatinine and chest x-ray should be obtained prior to treatment and patients should be closely monitored Potential for IMPULSE CONTROL DISORDERS and excessive daytime somnolence More likely than levodopa to cause hallucinations in older patients. Nasal congestion and postural hypotension are also seen in some patients

Answer 50

``` Neurological sequalae Sensorineural hearing loss (most common) Other neurological: epilepsy, paralysis Infective: sepsis, intracerebral abscess Pressure: brain herniation, hydrocephalus ```

Answer 51

Haloperidol for intracranial causes (raised ICP, direct effect of tumour) Prochlorperazine for vestibular causes Metoclopramide for gastrointestinal causes

Answer 52

``` P450 Inhibitor Gastrointestinal: nausea Increased appetite and WEIGHT GAIN Alopecia: regrowth may be curly Ataxia Tremor Hepatotoxicity Pancreatitis Thrombocytopaenia Teratogenic hyponatraemia hyperammonemic encephalopathy: L-carnitine may be used as treatment if this develops ```

Answer 53

``` Features rhinorrhoea needle track marks pinpoint pupils drowsiness watering eyes yawning ``` Complications Viral infection secondary to sharing needles: HIV, hepatitis B & C Bacterial infection secondary to injection: infective endocarditis, septic arthritis, septicaemia, necrotising fasciitis Venous thromboembolism Overdose may lead to respiratory depression and death psychological problems: craving Social problems: crime, prostitution, homelessness Opioids are substances which bind to opioid receptors. This includes both naturally occurring opiates such as morphine and synthetic opioids such as buprenorphine and methadone

Answer 54

``` Cardiovascular effects myocardial infarction both tachycardia and bradycardia may occur hypertension QRS widening and QT prolongation aortic dissection ``` ``` Neurological effects seizures mydriasis hypertonia hyperreflexia ``` Psychiatric effects agitation psychosis hallucinations ``` Others ischaemic colitis is recognised in patients following cocaine ingestion. This should be considered if patients complain of abdominal pain or rectal bleeding hyperthermia metabolic acidosis rhabdomyolysis ``` Mechanism of action cocaine blocks the uptake of dopamine, noradrenaline and serotonin

Answer 55

``` Thrombocytopenia Lateness Pressure Unstable Coagulation disorder Infection at LP site Neurology (focal near signs) ``` GCS <9 or a drop of 3 or more

Answer 56

Kernig’s: Straightening leg ̄c hip @ 90 Brudzinski’s: lifting head → lifting of legs

Answer 57

``` Investigations suggested by NICE full blood count CRP coagulation screen blood culture whole-blood PCR blood glucose blood gas ``` Lumbar puncture if no signs of raised intracranial pressure Bacterial: Cloudy; Glucose low (<1/2 plasma), Protein high (>1g/l), WCC 10-5,000 polymorphs Viral: Clear/cloudy, Glucose (60-80% of plasma), Protein normal/raised, WCC 15-1,000 lymphocytes TB: Slight cloudy, Glucose low (1/2 plasma), Protein high (>1g/l), WCC 10-10,000 lymphocytes Abx therapy Community: benpen 1.2g IV/IM <50: ceftriaxone 2g IVI/IM BD >50: ceftriaxone + ampicillin 2g IVI /4h If viral suspected: aciclovir Dexamethasone 0.15mg/kg IV QDS - reduced neuro sequelae

Answer 58

Features fever, headache, psychiatric symptoms, seizures, vomiting focal features e.g. aphasia peripheral lesions (e.g. cold sores) have no relation to presence of HSV encephalitis Pathophysiology HSV-1 responsible for 95% of cases in adults typically affects temporal and inferior frontal lobes Investigation CSF: lymphocytosis, elevated protein PCR for HSV CT: medial temporal and inferior frontal changes (e.g. petechial haemorrhages) - normal in one-third of patients MRI is better EEG pattern: lateralised periodic discharges at 2 Hz Management Intravenous aciclovir should be started in all cases of suspected encephalitis STAT - 10 mg/kg every 8 hours for at least 14 days in encephalitis Phenytoin for seizures

Answer 59

``` Headache n/v Seizures Drowsiness → coma Cushing’s reflex: ↑BP, ↓HR, irregular breathing 6th CN palsy (may be false localising) Cheyne-Stokes respiration Pupils – constriction → dilatation Papilloedema, loss of venous pulsation @ disc ``` ``` Causes  Haemorrhage  Tumours  Infection: meningitis, encephalitis, abscess  Hydrocephalus  Status  Cerebral oedema ```

Answer 60

``` CT head immediately GCS < 13 on initial assessment GCS < 15 at 2 hours post-injury suspected open or depressed skull fracture. any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign). post-traumatic seizure. focal neurological deficit. MORE than 1 episode of vomiting ``` CT head scan within 8 hours of the head injury - for adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury: age 65 years or older any history of bleeding or clotting disorders dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs) more than 30 minutes' retrograde amnesia of events immediately before the head injury If a patient is on warfarin who have sustained a head injury with no other indications for a CT head scan, perform a CT head scan within 8 hours of the injury

Answer 61

Pronated and medially rotated brachial trunks C5-6.

Answer 62

riptans are specific 5-HT1B and 5-HT1D agonists used in the acute treatment of migraine. They are generally used first-line in combination therapy with an NSAID or paracetamol. Prescribing points should be taken as soon as possible after the onset of headache, rather than at onset of aura oral, orodispersible, nasal spray and subcutaneous injections are available Adverse effects 'triptan sensations' - tingling, heat, tightness (e.g. throat and chest), heaviness, pressure Contraindications patients with a history of, or significant risk factors for, ischaemic heart disease or cerebrovascular disease

Answer 63

Anterior cerebral artery Contralateral hemiparesis and sensory loss, lower extremity > upper Middle cerebral artery Contralateral hemiparesis and sensory loss, upper extremity > lower Contralateral homonymous hemianopia Aphasia

Answer 64

As intracranial pressure rises to pathological levels, normal brain structures are forcefully displaced. This is called herniation. Subfalcine Displacement of the cingulate gyrus under the falx cerebri Central Downwards displacement of the brain Transtentorial / uncal herniation Displacement of the uncus of the temporal lobe under the tentorium cerebelli. Clinical consequences include an ipsilateral fixed, dilated pupil (due to parasympathetic compression of the third cranial nerve) and contralateral paralysis (due to compression of the cerebral peduncle) Tonsillar Displacement of the cerebellar tonsils through the foramen magnum. This is called ‘coning’. In raised ICP this causes compression of the cardiorespiratory centre. In Chiari 1 malformation, tonsillar herniation is seen without raised ICP Transcalvarial Occurs when brain is displaced through a defect in the skull (e.g. a fracture or craniotomy site)

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