Neuro Flashcards
(274 cards)
1
Q
What is Myasthenia Gravis?
A
AI neuromuscular disease of nicotonic AChR resulting in impaired NMJ transmission
2
Q
In order state the muscle groups that are affected in MG
A
Extra-ocular Bulbar Face Neck Limb Trunk
3
Q
Give 3 symptoms of Myasthenia gravis
A
Diplopia, blurred vision, difficulty swallowing/chewing, difficulty climbing stairs
4
Q
Give 3 signs of Myasthenia gravis
A
Ptosis
Myasthenic snarl
Dysphonia (voice fades)
5
Q
What antibodies are present in 90% of PTs with MG?
If -ve for these ABs, what other antibodies can you look for?
A
Anti- AChR- Antibodies
MUSK Antibodies
6
Q
What other investigation could you perform for MG? What would you see?
A
Electromyography
Decreased muscle response to repeated stimuli
7
Q
What is the characteristic pattern of muscle weakness in MG patients?
A
Increasing muscle fatigue throughout day, improves with rest. PT struggles with repetitive movements.
8
Q
What class of drugs is used for symptomatic control of myasthenia gravis? Give an example
A
Anti-cholinesterase e.g. Pyridostigmine
9
Q
What is a myasthenic crisis?
A
Acute, life-threatening exacerbation of myasthenic symptoms + weakness of respiratory muscles that leads to respiratory failure.
10
Q
What is the treatment for myasthenic crisis?
A
Intubation + mechanical ventilation
Plasmaphoresis to remove anti-AChR ABs if bulbar symps
IVIg
11
Q
What is Lambert-Eaton Myasthenic Syndrome?
A
AI condition whereby pre-synaptic VG Ca2+ channels are attacked, resulting in disruption of synaptic transmission
12
Q
LEMS is often paraneoplastic to what type of cancer?
A
Small cell lung cancer
13
Q
Give 3 clinical features of Lambert-Eaton Myasthenic Syndrome
A
Proximal weakness- improves with exercise
Hyporreflexia
Autonomic symptoms: dry mouth, constipation + impotence
14
Q
What antibody would be detected in a LEMS PT?
A
Anti- VGCC ABs (75/95% PTs)
15
Q
What other investigation might you want to do in PT with LEMS symptoms?
A
CXR/CT- weakness symptoms may precede associated lung cancer
16
Q
What treatment is often combined with anti-cholinesterase’s for myasthenia gravis?
A
Immunosuppression e.g. Oral Prednisolone
17
Q
Give 3 differences between MG +LEMS
A
MG: increasing muscle weakness with activity, starts with weakness of extraocular, no autonomic symps, normal reflexes, post-synaptic AChR ABs
LAMS: decreasing muscle weakness with activity, starts with weakness of lower limbs, autonomic symps (constipation, dry mouth, impotence), hyporeflexia, pre-synaptic VGCC ABs
18
Q
What is a migraine?
A
Recurrent, throbbing, pulsatile headache often preceded by an aura, N&V + visual changes
19
Q
Name some triggers for migraine
A
Chocolate Hangovers Orgasms Cheese Oral contraceptive Lie-ins Alcohol Travel Exercise
20
Q
State the clinical features of a migraine
A
Unilateral Throbbing + pulsatile Can be preceded by an aura 4-72hrs Moderate-severe pain
21
Q
A PT presents with a headache. You suspect it is a migraine. What are the differential diagnoses?
A
Tension headache: often bilateral + band like
Cluster headache: autonomic symptoms
Meningitis: fever, neck stiffness, photophonia
SAH: sudden onset “thunderclap”
TIA: max deficit presents immediately
22
Q
What is an aura? What type of headache are they common in?
A
Transient, focal, neurological symptoms that usually precede headache e.g. visual (scotoma, zig-zags), paresthesia. MIGRAINES (25% have aura)
23
Q
How is migraine diagnosed? What other investigations might you consider if suspect something more sinister?
A
Clinical diagnosis
CT head [SAH]
24
Q
Give a possible reason why an episodic headache may become a chronic daily headache
A
Medication overuse headache (Paracetamol + opiates, triptans)
25
A PT develops a medication overuse headache, what do you do?
STOP ANALGESIA. Consider prevention when off other drugs.
26
What is a primary headache?
Primary headaches are headaches which are not associated with another underlying condition
27
What is a secondary headache?
Secondary headaches are headaches which occur as a result of underlying local or systemic pathology such as intracerebral haemorrhage, malignancy or infection.
28
What is diagnostic criteria for PT with migraine without aura?
5 attacks lasting 4-72hrs with:
1. 1 or more: N&V, photophobia, phonophobia
2. 2 or more: unilateral, pulsating/throbbing, mod-severe pain impairs routine activity
29
What is the diagnostic criteria for PT with migraine with aura?
2 attacks with:
1. Reversible aura symp (visual, paresthesia/numbness, speech, motor weakness)
2. 3 or more: unilateral aura, aura lasting 5-60mins, + aura symp, 1 aura symp over at least 5 mins, aura followed within 60mins of headache
30
What is the recommended treatment for mild-mod migraines?
NSAIDs e.g. Ibuprofen +/- anti-emetic
31
What group of drugs should be given to PT with severe migraine? Give an example
Triptan's e.g. Sumatriptan
32
What is 1st line prophylaxis for migraine?
Beta-blockers e.g. propanolol
33
Give 3 classes of drug used in prophylaxis of migraine
Beta-blocker- Propanolol
TCA: Amitriptyline
Anti-convulsant: Topiramate (CI in pregnancy)
34
What is the most common type of primary headache? Describe it
Tension headache: bilateral and band-like headache with feeling of pressure or tightening
35
Name 3 triggers of tension headaches
Stress, anxiety/depression, sleep deprivation, noise/fumes, overexertion, conflict, clenched jaw
36
Give 3 differences between tension headache and migraine
TH: bilateral, band-like non-pulsatile, N&V/aura/photophobia, not aggravated by routine activity
Migraine: unilateral, pulsatile/throbbing, no aura/ N&V, aggravated by routine activity
37
What is the diagnostic criteria for a tension headache?
Clinical diagnosis
1. Lasts 30mins-7days
2. 2 or more bilateral, band-like tightening, mild-moderate, not exacerbated by routine activity
3. Both of following- no N&V, no more than one of photo/phonophobia
38
A PT with a history of tension headaches requires some lifestyle advice to help. What would you tell them?
Good sleep hygiene
Stress relief
Exercise
Treat depression
39
What treatment would you advice for episodic tension headaches?
NSAIDs/aspirin/paracetamol
40
What treatment would you advice for chronic tension headaches?
TCA- Amitriptyline
41
What is a cluster headache?
Recurrent 15mins-3hr attacks of agonising, strictly unilateral headaches in peri-orbital/forehead regions
Primary headache
42
Give 3 clinical features of cluster headaches
Excruciating pain around eye, unilateral, abrupt onset, short recurring attacks in clusters (4-12wk episodes), PT restless
43
What autonomic signs may indicate a PT has cluster headaches? Where will these autonomic features present?
Lacrimation/bloodshot eye, Miosis +/- ptosis, rhinorrhoea
| Autonomic signs will present on ipsilateral side of headache
44
What demographic of population are most likely to have cluster headaches?
20-40yo males
45
What treatment would you use in acute cluster headache?
100% FiO2 Oxygen therapy
| Triptan e.g. Sumatriptan
46
What treatment would you use in prophylaxis for cluster headache?
Ca2+ channel blocker e.g. Verapamil
Corticosteroid e.g. Prednisolone
Avoid triggers e.g. alcohol
47
What is encephalitis?
Inflammation of brain parenchyma often as result of infection (HSV)
48
What is most common cause of encephalitis?
Herpes Simplex Virus
49
What demographic tend to develop encephalitis?
Younger (<20) + older (>50)
50
Give some features of an infectious prodrome that encephalitis PTs may present with?
```
Fever/Pyrexia
Headache
N&V
Lymphadenopathy
Rash
```
51
Give 3 symptoms of encephalitis
Fever
Headache
Photophobia
Confusion
52
Give 3 signs of encephalitis
ODD/ENCEPHALOPATHIC BEHAVIOUR
Focal neurological deficits (aphasia/ataxia)
Seizures
Decreased consciousness
53
Encephalitis may resemble meningitis, what factors are more likely to indicate encephalitis
Altered mental state, focal neurological deficits, seizures
54
Why might you want to take bloods in PT with encephalitis?
Blood cultures, viral PCR, Toxoplasma IgM titre, malaria film
55
What might a contrast CT scan show in PT with encephalitis?
Focal bilateral temporal lobe involvement (HSV encephalitis)
56
What is gold-standard diagnosis for encephalitis?
LP + viral PCR on CSF
57
What is 1st-line treatment for Herpes Simplex Encephalopathy? What are guidelines for treatment?
Aciclovir
| Start within 30mins of PT arriving, HSE progresses quickly. Start before definitive diagnosis
58
What is risk with aciclovir?
Nephrotoxicity- taper dose and hydrate PT!
59
What is a cerebral abscess?
Focal, suppurative (pus-filled) lesion in brain
| Rare but life-threatening
60
What are causes of cerebral abscess?
1. Direct spread from sinus/ear/dental infections
2. Skull fracture + subsequent inoculation
3. Haematogenous spread from infective loci (e.g. endocarditis)
61
What is clinical presentation of PT with cerebral abscess?
Fever, headache, focal neurological deficit, N&V, drowsiness/confusion, papilloedema, seizures
62
Give 3 symptoms of PT with cerebral abscess
Fever, headache, N&V, seizure, drowsiness, confusion, focal neuro symps
63
Give 3 signs of PT with cerebral abscess
Pyrexia, seizure, papilloedema, decreased mental state, raised BP/ bradycardia, focal neuro signs
64
Give 3 DD's for brain abscess
Encephalitis, meningitis, brain tumour/space-occupying lesion
65
State two results you would see in lab tests from cerebral abscess PTs
Raised CRP/ESR/WCC [Leukocytosis]
66
What investigation may you avoid in PT with cerebral abscess + why?
Lumbar puncture, tentorial herniation risk if raised ICP
67
What is investigation of choice for cerebral abscess?
CT head [+ contrast]: shows ring enhancement + radiolucent [black] space-occupying lesion
68
A PT CT shows a cerebral abscess. What is the treatment for this?
1. Burr-hole + surgical drainage of abscess
2. Take biopsy and send pus for culture
3. Prolonged ABX
69
What empirical ABX should be given to PT with suspected cerebral abscess?
1. 3rd generation cephalosporin (Ceftriaxone)
2. Metronidazole
3. +/- Vancomycin [if staph]
70
What is the difference between meningitis and encephalitis?
E: inflammation of brain parenchyma
M: inflammation of meninges
71
State 3 common causative organisms of bacterial meningitis in neonates
Listeria monocytogenes
E.coli
Group B Haemolytic strep (Strep agalactiae)
Strep pneumoniae
72
State 2 common causative organisms of bacterial meningitis in infants
Neisseria meningitidis
Strep. pneumoniae
Haemophilus influenza
73
State 2 common causative organisms of bacterial meningitis in adults
Neisseria meningitidis
| Strep pneumoniae
74
State 2 common causative organisms of bacterial meningitis in the elderly
Neisseria meningitidis
Strep pneumoniae
Listeria monocytogenes
75
Give 3 risk factors for meningitis
Young age, elderly, intra-thecal injection, immunocompromised, crowding, bacterial endocarditis
76
What would indicate meningococcal septicaemia?
Appearance of non-blanching purpuric rash
77
What is meningococcal septicaemia?
Dissemination of bacteria into blood stream (sepsis) + presenting as purpuric rash
78
How is bacterial meningitis spread?
Close contact via droplets or secretions from respiratory tract
79
How does pneumococcal disease usually enter body?
Colonises nasopharyngeal mucosa (spread via droplets/direct contact)
80
What can be said about neonates clinical presentation of meningitis? State some symps/signs of neonatal meningitis
NON-SPECIFIC (without classic triad)
Lethargy, high-pitched crying, hypo/hyperthermia, hypotonia, poor appetite, irritability, abnormal breathing, bulging fontanelle
81
What is classic triad of symptoms for meningitis?
Fever
Headache
Neck stiffness
82
State 3 non-specific symptoms of meningitis
Fever, headache, N&V, lethargy, irritability, muscle/joint pain, loss of appetite, leg pains
83
Give 3 signs of meningitis
+ve Kernig's sign, +ve Brudzinski's sign, seizures/focal neuro deficits, change in skin colour, shock (decreased BP + increased CRT), cold hands/feet
84
A PT presents with suspected meningitis, what is the first investigation you do?
BLOOD CULTURES- 1st thing in suspected meningitis
85
In a meningitic PT with no signs of septicaemia/shock/raised ICP, how should you acutely manage them?
1. Blood cultures first
2. Lumbar Puncture
3. Empirical ABs
LP delayed--> Give ABs
86
What empirical AB should you give to a PT with suspected meningitis in a primary care setting?
Benzopenicillin
87
What empirical AB should you give to a PT with suspected meningitis in a hospital setting?
IV Cefotaxime (+/- Amoxicillin- elderly/immunocompromised)
88
Why do you give IV Dexamethasone to meningitis PT?
Reduce neurological complications (hearing loss, motor or cognitive deficit)
89
What prophylactic AB should you give to contacts of meningitis PTs?
Ciprofloxacin stat
90
What is shingles?
Dermatological rash with painful blistering caused by reactivation of varicella zoster virus
91
Give an overview of the pathophysiology of shingles
- Initial VZV in childhood
- Virus lies dormant in DRG
- VZV reactivated in immunocompromised
- Virus replicates and travels through affected peripheral sensory nerve in dermatomal distribution
92
Where does VZV commonly reactivate in shingles?
Thoracic nerves + ophthalmic division of trigeminal nerve
93
What is the most common complication of herpes zoster infection?
Post-herpatic neuralgia (pain after 90 days of rash onset)
94
How can symptoms present in immunocompromised people?
Widespread across multiple dermatomes
95
What is the main prodromal symptom in a shingles PT? Give some other prodromal symptoms
PAIN
Headache
Fever/fatigue
96
Describe the rash seen in shingles PTs
Dermatomal distribution, does not cross midline, painful/itchy/tingly
97
Describe the course of the rash in herpes zoster
1. Erythematous maculopapular rash
2. Vesicular rash
3. Crusting + involution
98
What is Herpes Zoster Ophthalmicus?
Reactivation of VZV in ophthalmic division of trigeminal nerve
99
What are the risks of HZ ophthalmicus?
Corneal ulceration, optic neuritis, glaucoma, BLINDING
100
What is Herpes Zoster oticus?
Reactivation of VZV in facial and vestibulocochlear nerves (Ramsey Hunt Syndrome)
101
What are risks of HZ oticus?
7th nerve: facial paralysis
| 8th nerve: hearing loss/vertigo
102
What is Hutchinson's sign? What is significance of this sign?
Involvement of nasociliary nerve (HZOpth)--> Zoster lesion at tip of nose.
103
Why might Hutchinson's sign be significant in herpes zoster ophthamicus?
Prognostic factor for eye inflammation/permanent corneal denervation
104
When might you want to admit shingles PT?
Immunocompromised adult/child [systemic/widespread rash]
Serious complications [meningitis, encephalitis]
HZ Ophthalmicus (eye symps)
105
What is 1st line treatment for shingles?
Aciclovir- give IV if PT immunocompromised
106
What is guillain-barre syndrome?
Acute inflammatory and demyelinating condition of PNS, characterised by ascending and symmetrical muscle weakness
107
Who tends to develop GBS?
PTs with URT/GI infection 1-4wks previous
108
State some pathogens associated with GBS
Campylobacter jejuni, Cytomegalovirus, EBV, Mycoplasma pneumoniae
109
What is pathophysiology of GBS?
Cross-reactive auto-antibodies attack host's own axonal antigens--> demyelination--> Decreased peripheral nerve conduction
110
What is main clinical presentation of GBS?
Symmetrical ascending muscle weakness
111
Which muscles are most affected by GBS?
Proximal muscles- trunk, respiratory + cranial nerves (esp VII)
112
Give some other clinical features of GBS
Back/limb pain
| Tingling/numbness in extremities
113
Give 3 signs that a PT with GBS may present with
Dec. sweating, Inc. pulse, BP changes (autonomic)
Facial nerve palsy
Hyporreflexia
114
What investigations would be used to diagnose GBS? What would you see?
Nerve conduction studies (decreased conduction)
Lumbar puncture (raised protein, normal cell count/glucose)
Serological (bloods): detect causative pathogen
115
Why might you do lung function tests in GBS?
To determine respiratory muscle involvement [potential fatal].
116
When might you consider mechanically ventilating a GBS PT?
FVC < 1.5L
PaO2< 10kPa
PaCO2>6kPa
117
What are the treatment options for GBS?
V- Ventilation (if sig. respiratory involvement)
I- Immunoglobulins
P- Plasmapheresis
118
What is Wernicke's Encephalopathy?
Acute, reversible condition caused by severe thiamine (vitamin B1) deficiency
119
What is Korsakoff's syndrome?
Chronic, irreversible condition caused by thiamine deficiency
120
What is the main cause of Wernicke Korsakoff Syndrome? Give two other causes
CHRONIC ALCOHOLISM
Eating disorders
Prolonged vomiting (chemotherapy)
121
What is Wernicke-Korsakoff's syndrome?
Spectrum of disorders:
1. Wernicke's Encephalopathy [frequently progresses into...]
2. Korsakoff's syndrome
122
What is classic triad of symptoms for Wernicke's Encephalopathy?
1. Confusion
2. Ataxia/Gait ataxia
3. Ophthalmoplegia
123
What are the clinical features of a PT with Korsakoff's syndrome?
1. Severe memory impairment (anterograde/retrograde)
2. Confabulation
3. Lack of insight/apathy (personality changes if frontal lobe)
124
Give 3 differential diagnoses of Wernicke-Korsakoff's syndrome
Hepatic encephalopathy, drug use, dementia, cerebrovascular disease, post-ictal state
125
What is main way to diagnose Wernicke- Korsakoff's syndrome?
Clinical diagnosis
126
What other investigations might you do to diagnose Wernicke- Korsakoff's syndrome?
MRI brain: peri-ventricular haemorrhages/atrophy to mammillary bodies
Lab: low serum thiamine, dysfunctional LFTs, decreased red cell transkeletase
127
When do you treat Wernicke's encephalopathy?
Medical emergency- immediately! Stop progression Korsakoff's syndrome
128
How do you treat Wernicke's encephalopathy?
1. Immediate IV Thiamine/Vitamin B1
2. Add glucose if PT hypoglycaemic (thiamine first)
3. Give vitamin B1/6/12 + folic acid replacement
4. Stop drinking
129
How do you treat Korsakoff's syndrome?
Irreversible condition, thiamine supplementation, stop drinking and psychiatric/psychological therapy
130
What is cerebral palsy?
Group of disorders affecting movement + posture (motor disorder).
131
What causes cerebral palsy?
Damage to developing brain during in utero, neonatal or early infant stages
132
What are different types of cerebral palsy?
1. Spastic [75%]: spastic paresis (inability of voluntary movement + spasticity)
2. Ataxic: intention tremor, loss of balance/coordination
3. Dyskinetic: abnormal involuntary movements
PTs may have mixed type
133
How are the different types of cerebral palsy classified?
Dependant on part of brain affected + resultant motor dysfunction
134
State some antenatal RFs for cerebral palsy
Preterm birth, congenital malformations, intrauterine infections (HIV, toxoplasmosis), toxic/teratogenic agents, maternal GU/RESP infections
135
State some perinatal RFs for cerebral palsy
Neonatal sepsis, low birth weight, maternal GU/RESP infections
136
State some postnatal RFs for cerebral palsy
Head trauma, hypoxia, intracranial haemorrhage, meningitis
137
Is cerebral palsy a progressive disease?
BRAIN DAMAGE NOT PROGRESSIVE
| Clinical features may change as brain matures
138
Give some early signs that may indicate a PT has cerebral palsy
```
Fidgety/abnormal movements
Hand preference before 1yo (suggests weakness on other side)
Problems feeding
Abnormal tone
Failure to meet motor milestones
```
139
What clinical features can affect all types of cerebral palsy sufferers?
```
Delay reaching motor milestones
Intellectual disability
Pain
Seizures
Dysphagia/Dysarthria
```
140
Give some features of spastic cerebral palsy
```
Increased muscle tone (1 or more limbs)
Scissor gait
Toe walking
Muscle weakness/atrophy
MSK problems (scoliosis, hip dislocation)
```
141
Give some features of ataxic cerebral palsy
Abnormal coordination/balance
Poor precise movements
Intention tremor
142
Give some features of dyskinetic cerebral palsy
Abnormal involuntary movements
Dystonic: random, slow uncontrolled movements in limbs/trunk
Chorea: random, dance-like movements
143
How is cerebral palsy diagnosed?
Clinical diagnosis + parental observation
144
What other investigations may help to diagnose cerebral palsy?
Cranial ultrasound (neonates)
MRI (older infants)
To detect causative lesion
145
What is aim of treating cerebral palsy?
| What is essential in treating cerebral palsy?
Improve function + quality of life, non-curable. MDT ESSENTIAL
146
What members of MDT might be important in treating cerebral palsy PT?
Neurologist, speech therapist, physiotherapist, OT's, orthapaedic surgeon
147
What medical treatment might be useful for cerebral palsy PT + why?
BOTOX: reduce hypertonia (reducing associated pain + improving motor func)
DIAZEPAM: pain crisis, rapid effect
BACLOFEN: relieve spasticity, discomfort + improve motor function
148
Why might surgery be useful in cerebral palsy PTs?
```
Loosen muscles (hypertonia)
Relieve joint contractures
Aim: to improve function
```
149
What is Huntington's disease?
Neurodegenerative movement disorder characterised by involuntary and irregular movements
150
How is huntington's inherited? What is chance offspring will inherit?
Autosomal dominant- 50%
151
What triplet of bases is repeated in HD PTs? What AA does this encode?
CAG (36 or more times)
| Glutamine
152
What clinical features would you expect to see in prodromal phase?
Irritability
Lack of coordination (clumsiness)
Personality changes
Depression
153
What classic movements are seen in Huntington's PTs?
Chorea: involuntary, irregular movements of limbs, head and face, "dance-like"
154
Give some clinical features of huntington's disease?
Chorea--> Hypokinetic motor symptoms (dystonia)
Oculomotor disorders: hypometric saccades
Personality changes
Depression/psychosis
Motor impersistence: inability to sustain simple acts
155
What are the clinical features of advanced Huntington's?
Immobility, dementia, mutism
156
How do you diagnose huntington's?
Clinical- PT history/examination
Genetic testing
CT/MRI: striatal atrophy + neuronal loss in cortex, not useful in early disease
157
What is the meaning of anticipation (genetic)?
Increased severity and/or earlier manifestation of disease in next generation [seen in HD- more CAG repeats]
158
What is average age of onset for HD?
40yo
159
What general management options may be used in HD?
MDT: neurologists, speech therapists, physiotherapists
Genetic counselling (genetic testing may reveal offspring likely to have disease--> Depression)
Psychotherapy
160
What might you give to PT with depression caused by HD?
SSRIs e.g. Citalopram
161
What might you give to PT with psychosis caused by HD?
Atypical anti-psychotics e.g. Clozapine
162
A PT with HD presents with chorea, what medication options are there?
Dopamine-depleting agents- Tetrabenazine
| Neuroleptics- Clozapine
163
What is Bell's palsy?
Acute, unilateral facial nerve weakness or paralysis of rapid onset (<72hrs) and unknown cause
164
Name some other causes of VII nerve palsy
Infection: TB, meningitis, Lyme disease, HIV, Herpes Zoster
Brainstem lesion: stroke, tumour, MS
Systemic disease: DM, GBS, sarcoidosis
Local disease: Parotid tumour, orofacial granulomatosis, skull trauma
165
What is the motor function of facial nerve?
Muscles of facial expression, digastric and stylohyoid muscles
166
What is the sensory function of the facial nerve?
Anterior 2/3 of tongue
167
What is parasympathetic function of facial nerve?
Supply submandibular and sublingual glands--> Produce saliva (via chorda tympani). Lacrimal glands
168
If the facial nerve is dysfunctional, what is the general result?
Weakness/paralysis of facial muscles
169
If there is a central upper motor neuron lesion, what impact would this have on the facial muscles?
Resembles stroke paralysis
| Drooping of lower face + lid, FOREHEAD SPARED
170
If there is a peripheral lower motor neuron lesion, what impact would this have on the facial muscles?
Resembles Bell's palsy
| Drooping of lower face, lid and forehead. NO FOREHEAD SPARING
171
What are the risk factors for Bell's palsy?
Pregnancy
Diabetes mellitus
Obesity
Hypertension
172
What is the most common clinical presentation of Bell's palsy?
Rapid onset, facial muscle weakness in upper and lower face. Decreased ipsilateral movement, drooping of eyelid and corner of mouth, absence of nasolabial fold. Primarily unilateral
173
State some other symptoms of Bell's palsy
Ear/post-auricular pain
Difficulty chewing, changes in taste + dry mouth
Incomplete eye closure, watery or dry eye
Speech problems/drooling
174
How would you diagnose Bell's palsy?
Clinical examination- history + examination
CNVII: frown, whistle, inflate cheeks, show teeth, close eyes tightly. Observe asymmetries
Rule out other causes
175
How might you rule out other causes of CNVII palsy?
Bloods: VSV ABs, Borrelia ABs, ESR
| CT/MRI: space-occupying lesions, stroke, MS
176
What treatment may speed up recovery time in Bell's Palsy PTs if given within 72hrs?
Corticosteroids e.g. Prednisolone
177
What organ must you consider in management of Bell's Palsy? How?
EYE
- Artificial tears for lubrication
- Sunglasses to protect eye
- Tape eye during sleep
178
What is a bulbar palsy?
LMN palsy that affects nuclei of cranial nerves IX, X, XI, XII.
179
What is a pseudobulbar palsy?
UMN palsy that affects the corticobulbar tracts of V, VII, IX, X, XI, XII
180
Give 2 causes of a bulbar palsy
Brainstem stroke/tumours
Neurodegenerative disorders: MND, MS, syringobulbia
AI neuropathies: MG, GBS
Infectious neuropathies
181
Give 2 causes of a pseudobulbar palsy
Tumours/injury higher up on brain stem [than nuclei]
Stroke
Neurodegenerative disorders: MND, MS
182
State 3 clinical features of a bulbar palsy
Tongue: flaccid, fasciculating, wasting
Speech: quiet, hoarse or nasal
Dysphagia/drooling
Palatal movement absent
183
State 3 clinical features of a pseudobulbar palsy
```
Tongue: spastic, difficulty with protrusion, no wasting/fasciculations
Speech: dysarthria
Dysphagia/drooling
Palatal movement absent
Expressionless face
Emotional incontinence
```
184
State some supportive treatments that may be useful in PTs with bulbar or pseudobulbar palsy
```
Baclofen (spasticity in PBP)
Speech + language theraoy
PEG: dysphagia or recurrent aspiration pneumonia
Anti-cholinergics: drooling
SSRIs: pseudobulbar affect
```
185
Name a common complication of bulbar + pseudobulbar palsies
Recurrent aspiration pneumonia
186
What is narcolepsy?
Neurological condition of sleep/wake cycle characterised by irresistible attacks of inappropriate sleep
187
What are the classic tetrad of symptoms for narcolepsy?
Excessive daytime sleepiness
Cataplexy
Sleep paralysis
Hypogognic hallucinations
188
What is a typical PT for narcolepsy?
```
Adolescent male (approx. 15yo)
Second peak at 35yo
```
189
What is cataplexy?
Bilateral loss of tone in anti-gravity muscles
Provoked by emotions such as anger/excitement
Highly specific for narcolepsy
190
Give some clinical features of cataplexy
```
Falls
Dysarthria
Mutism
Phasic muscle jerking around mouth
No loss of awareness
```
191
What is sleep paralysis?
State whereby PT aware but unable to move, open eyes or speak
Can occur when PT falling asleep/awakening
192
What is difference between hypopompic and hypogognic hallucinations? Which is more common in narcolepsy?
Hypopompic: as PT waking up
Hypogognic: as PT going to sleep [more common]
193
How is narcolepsy diagnosed?
Primarily clinical- history + analysis of sleep patterns
Sleep studies
Measure CSF orexin levels
194
What is diagnostic criteria for narcolepsy without cataplexy?
Excessive daytime sleepiness most days ≥ 3 months
Must have confirmation by sleep studies (nocturnal polysomnography then MSLT)
Hypersomnia not better explained by another condition
195
What is diagnostic criteria for narcolepsy with cataplexy?
Excessive daytime sleepiness most days ≥ 3 months
Cataplexy
If possible... sleep studies
Hypersomnia not better explained by another condition
196
Give for differential diagnoses for excessive daytime sleepiness
Drug/toxins, obstructive sleep apnoea, sleep deprivation
197
Give differential diagnoses for cataplexy
Drop attack, syncope, seizures/epilepsy, TIA
198
What is normal sleep like in a PT with narcolepsy?
PTs usually have normal sleep + feel rested
199
What is first line treatment for narcolepsy?
Modafinil (CNS stimulant, non amphetamine)
200
What treatment can be used for narcolepsy?
Modafinil
| Methylphenidate (amphetamine)
201
What medication is most effective for cataplexy? What other group of drugs can be used?
Sodium oxybate
| SSRIs (Citalopram)/TCAs
202
What are risks with giving an amphetamine like Methylphenidate for narcolepsy?
Dependence
| Psychosis
203
What non-pharmacological advice might you give to a PT with narcolepsy?
Good sleep hygiene
Strategic daytime naps
Exercise (increase energy)
Education of family/friends
204
What is neurofibromatosis?
Genetic disorders causing lesions to nervous system, and in some cases the skeleton + skin
205
What are the two types of neurofibromatosis?
Neurofibromatosis type 1Neurofibromatosis type 2
206
How is neurofibromatosis inherited?
```
Autosomal dominant (50%)
De novo- new mutation (50%)
```
207
State two skin changes that may indicate type 1 neurofibromatosis
Freckling e.g. axillae/groin)
| Cafe au lait
208
How might the eye be affected by type 1 neurofibromatosis?
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Lisch nodules
Optic glioma (tumour of optic nerve)
```
209
State some of skeletal complications in type 1 neurofibromatosis
Scoliosis
| Bone fractures/ cortical thinning/ pseudoarthosis
210
State the different types of neurofibroma
Cutaneous neurofibromas
Spinal neurofibromas
Plexiform neurofibromas-
211
Give some other clinical features that may be a sign of type 1 neurofibromatosis
```
Macrocephaly
Hypertension
Short stature
GI bleeds/obstruction
Mild learning disability
```
212
What investigations may support diagnosis of neurofibromatosis?
```
History + dermatological examination
MRI: neurofibromas + meningiomas
Genetic testing
Slit lamp
X-ray
```
213
Who is important in treatment of neurofibromatosis?
MDT involvement- surgeons, neurologists, geneticist
214
What is the treatment option for a neurofibroma? When is this most likely to be done?
Surgical removal when pressing on vital structures
215
What type of neurofibromatosis does not tend to involve skin lesion? What does it tend to present with?
NF2 = no skin lesions
| CNS tumours common
216
What is a neurofibroma?
Benign peripheral nerve sheath tumours
217
What clinical features would indicate type 2 neurofibromatosis?
Hearing loss/tinnitus, vertigo- Bilateral vestibular schwannoma
Meningiomas
218
What diagnostic tests might you use if neurofibromatosis type 2 is suspected?
Hearing tests
| MRI
219
What management is there for PTs with vestibular schwannomas? What are the risks?
Surgical removal
| Risk of hearing loss/facial palsy
220
What is hydrocephalus?
Abnormal enlargement of cerebral ventricles as a result of excess CSF
221
What are the two classifications of hydrocephalus?
1. Obstructive/Non-communicating
| 2. Communicating
222
What age groups tend to suffer from hydrocephalus?
1. Congenital form: birth
| 2. Acquired form: all ages
223
Give 3 risk factors for congenital hydrocephalus?
1. Pre-eclampsia
2. Absence of ante-natal care
3. Maternal hypertension (pregnancy)
4. Alcohol use (pregnancy)
224
Give an overview of what happens in obstructive/non-communicating hydrocephalus
Flow of CSF OBSTRUCTED within ventricles or between ventricles and subarachnoid space
225
Give an overview of what happens in communicating hydrocephalus
- Communicating of CSF within ventricles intact
- Reduced absorption of CSF
- Increased production of CSF
226
Give 3 potential causes of congenital non-communicating hydrocephalus
1. Arnold-Chiari malformation
2. Dandy-Walker malformation
3. Intra-uterine infections
227
Give 3 potential causes of communicating hydrocephalus associated with an increase in CSF production
1. Choroid plexus papilloma
2. Choroid plexus carcinoma
3. Inflammation
228
Give 3 potential causes of communicating hydrocephalus associated with a decrease in CSF absorption
1. Arachnoid villi inflammation
2. Congenital absence of arachnoid villi
3. Subarachnoid/IV haemorrhage--> Inflammation--> Fibrosis--> Loss of villi
229
Give 3 potential causes of acquired non-communicating hydrocephalus
1. Aqueduct stenosis
2. Brain tumours: ventricular or posterior fossa e.g. Ependymoma
3. Inflammation
230
What proportion of hydrocephalus cases in adults are idiopathic?
1/3
231
Give some clinical features of an infant with hydrocephalus
Macrocephaly
Setting sun sign
Tense fontanelle/dysjunction of sutures/ dilated scalp veins
Increased limb tone
232
In what condition would you see the setting sun sign? Describe the sign
Downward deviation of ocular globes
Upper lids retracted
White sclera visible above eye
233
Give some acute clinical features you would expect to see in older children and adults with hydrocephalus
Vomiting
Headache
Papilledema
234
Give some gradual clinical features you would expect to see in older children and adults with hydrocephalus
```
Unsteady gait (spasticity in legs)
Large head (later presentation in adults)
6th nerve palsy
```
235
Give some adult specific features you may observe in a hydrocephalus PT
Cognitive impairment
Neck pain
blurred vision
Incontinence
236
What is primary investigation used to diagnose hydrocephalus in the antenatal or early infant (<6months) period?
Ultrasound
| Shows enlarged lateral ventricles
237
What is primary investigation used to diagnose hydrocephalus in infants (>6months) and adult period?
CT
238
What type of hydrocephalus would show generalised dilatation of ventricles on a CT scan?
Communicating hydrocephalus
239
If a PT has non-communicating hydrocephalus, what would you see in a CT scan?
Ventricles upstream of obstruction are dilated
240
What is the definitive treatment for hydrocephalus
Neurosurgery: CEREBRAL SHUNT to drain excess CSF
241
Name some interim medications that could be used to delay neurosurgery for hydrocephalus
Furosemide/acetazolamide: decreased CSF secretion
| Isosorbide: increases CSF absorption
242
State some interim therapies for hydrocephalus to delay neurosurgery
Medication
| Lumbar puncture
243
What is normal pressure hydrocephalus?
Ventricular dilatation in absence of raised CSF pressure
244
Why is diagnosis of normal pressure hydrocephalus important?
NPH is a reversible cause of dementia
245
Who tends to suffer from normal pressure hydrocephalus?
Elderly PTs (>60yo)
246
What is classic triad for normal pressure hydrocephalus?
```
Urinary incontinence (WET)
Dementia (WACKY)
Apraxic gait (WOBBLY)
```
247
Are signs of raised ICP observed in normal pressure hydrocephalus PTs?
No
248
What other condition may be confused with normal pressure hydrocephalus and why?
Parkinson's disease
| NPH PTs present with slow, broad-based + shuffling movements.
249
How do you differentiate between Parkinson's disease and normal pressure hydrocephalus?
NPH: less marked rigidity + tremor
| Give Levodopa therapy + observe reaction
250
What investigations are used to diagnose normal pressure hydrocephalus?
CT/MRI: showing ventricular enlargement
| LP/CSF tap: normal/mildly elevated CSF pressure, CSF removal should improve symps
251
What is diagnosis of normal pressure hydrocephalus based upon?
Triad (wet, wacky, wobbly)
Neuroimaging
Absence of ICP signs
Symp improvement on LP
252
What is primary treatment for normal pressure hydrocephalus?
Cerebral shunt (VP then VA)
253
What treatment is only advised for PTs who cannot be operated on?
Serial LPs
| Acetazolamide
254
What is Horner's syndrome?
Neurological disorder characterised by a triad of
1. Partial ptosis
2. Miosis
3. Anhidrosis
255
Give a brief overview of the pathophysiology of Horner's syndrome
Interruption of face's sympathetic supply
Can occur on 1st order neurons (brainstem, SC), 2nd order neurons (thoracic outlet, superior cervical ganglion) or 3rd order neurons (ICA)
256
Give 3 causes of horner's syndrome in first order neurons
1. Brainstem stroke/haemorrhage
2. Demyelinating disease (MS)
3. Brain tumours (pituitary/skull base)
4. Neck trauma- cervical vertebrae dislocation
5. Syringomyelia
6. Meningitis
257
Give 3 causes of horner's syndrome in second order neurons
1. Apical lung tumour (pancoast tumour)
2. Lymphadenopathy (TB, leukaemia, lymphoma)
3. Trauma/surgery to head/neck
258
Give 3 causes of horner's syndrome in third order neurons
1. Cluster headache
2. Herpes zoster infection
3. ICA dissection
259
What investigations might reveal the underlying pathology behind Horner's syndrome?
1. CXR: apical lung cancer
2. CT/MRI: Cerebrovascular event
3. CT angiography: carotid artery dissection
260
How do you manage Horner's syndrome?
Diagnose + treatment of underlying condition
261
What may be used to help confirm diagnosis of Horner's syndrome?
Cocaine drops: dilatation of normal eye, no dilatation in Horner's
Apraclonidine drops: no effect on normal pupil, dilatation of pupil in Horner's
262
What is a myelopathy?
Disease or disorder of the spinal cord
263
Spinal cord compression is an example of what type of syndrome?
Myelopathy
264
What is the most common cause of a myelopathy?
Osteophyte- disc compression
265
Give 3 causes of spinal cord compression
1. Tumours
2. Trauma
3. Infection
4. Haematoma
5. Prolapsed IV disc
6. Cervical spondylosis
266
What symptoms may a PT with spinal cord compression present with?
Motor weakness, sensory changes (numbness/paresthesia), sphincter disturbances, back/neck pain, erectile problems
267
What motor dysfunction would a cervical lesion present with?
Quadriplegia (paralysis of 4 limbs and trunk)
| If above C3,4,5--> Paralysis of diaphragm
268
What motor dysfunction would a thoracic lesion present with?
Paraplegia (paralysis of legs)
269
Give 4 red flags for sinister causes of back pain
```
Sphincter disturbance
Neurological deficit
Worse when supine/at night
Age: <20yo, >55yo
Fever, night sweats, weight loss
History of malignancy
```
270
In a myelopathy, which appears first, symptoms or signs? Give some examples
Signs
| Long tract/ upper motor signs: spastic gait, hypertonia, hyperreflexia, +ve Babinski, loss of fine finger movements
271
How serious is an acute spinal cord compression? Why?
MEDICAL EMERGENCY- swift diagnosis to prevent irreversible spinal cord injury + long term disability
272
What investigations may be useful in diagnosis of spinal cord compression?
MRI of full spine
X-ray of spine
Other investigations will depend on underlying cause
273
What medication should be given to a PT with spinal cord compression whilst they await definitive treatment?
Dexamethasone (corticosteroid)
| Analgesia
274
What is definitive treatment for spinal cord compression?
Surgery e.g. Laminectomy, posterior decompression
| Start before neurological deterioration (ideally 24hrs)
