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Neuro Flashcards

1
Q

Causes of peripheral neuropathy

A

DAM IT BICH

  1. Drugs and toxins: isoniazid, vincristine, phenytoin, nitrofurantoin, cisplatinum, amiodarone, heavy metals
  2. Alcohol
  3. Metabolic: diabetes mellitus, uraemia, hypothyroidism
  4. Immune-mediated: Guillain-Barre syndrome
  5. Tumour – lung carcinoma, multiple myeloma
  6. B- Vitamin B12 or B1 deficiency
  7. Infiltrative: amyloid
  8. Connective tissues disease – SLE, polyarteritis nodosa
  9. Hereditary
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2
Q

Causes of a predominantly motor neuropathy

A
  1. Guillain-Barre syndrome and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP)
  2. Hereditary motor and sensory neuropathy (Charcot-Marie-Tooth disease)
  3. Acute intermittent porphyria
  4. Diabetes mellitus
  5. Lead poisoning
  6. Multifocal motor neuropathy
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3
Q

Causes of predominantly sensory neuropathy

A
  1. Diabetes
  2. Carcinoma (e.g. lung, ovary, breast)
  3. Paraproteinaemia
  4. Sjogren’s syndrome
  5. Syphilis
  6. Vitamin B12 deficiency
  7. Vitamin B6 intoxication
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4
Q

Causes of a painful peripheral neuropathy

A
  1. Diabetes mellitus
  2. Alcohol
  3. Vitamin B12 or B1 deficiency
  4. Carcinoma
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5
Q

Causes of mononeuritis multiplex

A

ACUTE
Diabetes mellitus
Polyarteritis nodosa or connective tissue disease – SLE, rheumatoid arthritis

CHRONIC
Multiple compressive neuropathies: especially with joint-deforming arthritis 
Sarcoidosis
Acromegaly 
Carcinoma
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6
Q

Signs of a radial nerve lesion

A
  • Wrist and finger drop (wrist flexion normal)
  • Triceps loss (elbow extension loss) if lesion is above the spiral groove
  • Sensory loss over the anatomical snuff box
  • Finger abduction appears to be weak because of the difficulty of spreading the fingers when they cannot be straightened
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7
Q

Features of hereditary motor and sensory neuropathy

A
  • Pes cavus (short, high-arched feet with hammer toes)
  • Clawing of the toes
  • Distal muscle atrophy owing to peripheral nerve degeneration, not usually extending above the elbows or above the middle one-third of the thighs
  • Absent reflexes
  • Downgoing plantars
  • Slight to no sensory loss in the limbs
  • Thickened nerves (lateral popilteal)
  • Optic atrophy; Argyll Robertson pupils (rare)
  • Small muscle wasting of the hand and clawing
  • Scoliosis
  • High stepping gait
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8
Q

Features of a complete brachial plexus lesion

A
  • Lower motor neurone signs affect the whole arm
  • Sensory loss (whole limb)
  • Horner’s syndrome
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9
Q

Features of an upper brachial plexus lesion (Erb’s C5 C6)

A
  • Loss of shoulder movement and elbow flexion – hand is held in the ‘waiter’s tip’ position
  • Sensory loss is present over the lateral aspect of the arm and forearm, and over the thumb
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10
Q

Features of a lower brachial plexus lesion (Klumpke’s C8 T1)

A
  • True claw hand with paralysis of all the intrinsic muscles
  • Sensory loss along the ulnar side of the hand and forearm
  • Horner’s syndrome
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11
Q

Features of cervical rib syndrome

A
  • Weakness and wasting of the small muscles of the hand (true claw hand)
  • Sensory loss over the medial aspect of the hand and forearm
  • Unequal radial pulses and blood pressures
  • Subclavian bruit and loss of pulse on arm manoeuvring
  • Palpable cervical rib in the neck
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12
Q

Signs of a medial nerve lesion

A
  • THUMB ABDUCTION LOSS: Loss of abductor pollicis brevis with a lesion at or above the wrist: ask patient to abduct thumb vertically
  • Sensory loss over the thumb, index, middle and lateral half of the ring finger (palmar aspect only)
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13
Q

Causes of carpal tunnel syndrome

A
  • Idiopathic
  • Arthropathy – rheumatoid arthritis
  • Endocrine disease – hypothyroidism, acromegaly
  • Pregnancy
  • Trauma and overuse
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14
Q

Signs of an ulnar nerve lesion

A
  • Wasting of the intrinsic muscles of the hand
  • Weak finger abduction and adduction (loss of interosseous muscles)
  • Ulnar claw-like hand (a higher lesion cause less deformity, as an above-the-elbow lesion also causes loss of flexor digitorum profundus)
  • Froment’s sign: grasp a piece of paper between the thumb and lateral aspect of the forefinger – the affected thumb will flex (loss of thumb adductor)
  • Sensory loss over the little and medial half of ring finger (both palmar and dorsal aspects)
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15
Q

Causes of wasting of the small muscles of the hands

A

1) Nerve lesions
- Median and ulnar nerve lesions
- Brachial plexus lesions
- Peripheral motor neuropathy (including hereditary motor and sensory neuropathy)

2) Anterior horn cell disease:
- Motor neurone disease
- Polio
- Spinal muscular atrophies

3) Myopathy
- Myotonic dystrophy – forearms more affected than the hands
- Distal myopathy

4) Spinal cord lesions
- Syringomyelia
- Cervical spondylosis
- Tumour

5) Trophic disorders
- Arthropathies (disuse)
- Ischaemia including vasculitis

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16
Q

Signs of a femoral nerve lesion

A
  • Weakness of knee extension (quadriceps paralysis)
  • Slight hip flexion weakness
  • Preserved adductor strength
  • Loss of knee jerk
  • Sensory loss involving the inner aspect of the thigh and leg
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17
Q

Signs of a sciatic nerve palsy

A

Loss of power of all muscles below the knee causing a foot drop, so the patient may be able to walk, but cannot stand on the toes or heels
Knee jerk intact
Loss of ankle jerk and plantar response
Sensory loss along the posterior thigh and total loss below the knee

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18
Q

Signs of a common peroneal nerve palsy

A

Foot drop and loss of foot eversion only
Sensory loss (minimal) over the dorsum of the foot
Normal reflexes
Weakness of extensor hallucis longus

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19
Q

Causes of a foot drop

A 
Common peroneal nerve palsy 
L4, L5 root lesion
Sciatic nerve palsy
Lumbosacral plexus lesion 
Peripheral motor neuropathy
Distal myopathy 
Motor neurone disease 
Pre-central gyrus lesion
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20
Q

Signs of subacute combined degeneration of the cord

A
  • Symmetrical posterior column loss (vibration and position sense) causing an ataxic gait
  • Symmetrical upper motor neurone signs in the lower limbs with absent ankle reflexes
  • Peripheral sensory neuropathy
  • Optic atrophy (occasionally)
  • Dementia (occasionally)
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21
Q

Causes of extensor plantar response but absent ankle jerk

A
  • Subacute combined degeneration of the cord (Vitamin B12 deficiency)
  • Conus medullaris lesion
  • Combination of an UMN lesion with cauda equina compression or peripheral neuropathy (e.g. stroke plus diabetes)
  • Neurosyphilis (Tabes dorsalis)
  • Friedreich’s ataxia
  • Motor neurone disease
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22
Q

Signs of Brown Sequard

A

• Motor changes

o Upper motor neurone signs below the hemisection on the same side as the lesion
o Lower motor neurone signs at the level of the hemisection on the same side

• Sensory changes

o Pain and temperature loss on the opposite side of the lesion (the upper level of the sensory loss is usually a few segments below the level of the lesion)
o Vibration and proprioception loss on the same side
o Light touch is often normal
o There may be band of sensory loss on the same side at the level of the lesion (afferent nerve fibres)

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23
Q

Causes of Brown Sequard syndrome

A
  • Multiple sclerosis
  • Angioma
  • Glioma
  • Trauma
  • Myelitis
  • Postradiation myelopathy
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24
Q

Causes of spinothalamic loss only

A
  • Syringomyelia (‘cape’ distribution)
  • Brown-Sequard syndrome (contralateral leg)
  • Anterior spinal artery thrombosis
  • Lateral medullary syndrome (contralateral to the other signs)
  • Peripheral neuropathy (diabetes mellitus, amyloid, Fabry’s disease)
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25
Q

Causes of dorsal column loss only

A
  • Subacute combined degeneration
  • Brown-Sequard syndrome (ipsilateral leg)
  • Spinocerebellar degeneration (e.g. Friedreich’s ataxia)
  • Multiple sclerosis
  • Tabes dorsalis
  • Sensory neuropathy or gangliopathy (e.g. carcinoma)
  • Peripheral neuropathy from diabetes mellitus or hypothyroidism
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26
Q

Signs of syringomyelia

A
  • Loss of pain and temperature over the neck, shoulders and arms (‘cape’ distribution)
  • Amyotrophy (weakness, atrophy and areflexia) of the arms
  • Upper motor neurone signs in the lower limbs
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27
Q

Causes of proximal muscle weakness

A
  1. Myopathic
  2. Neuromuscular junction disorder – myasthenia gravis
  3. Neurogenic – motor neurone disease, polyradiculopathy
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28
Q

Causes of myopathy

A 
Hereditary muscular dystrophy 
Congenital myopathies 
Acquired (PACE PODS) 
- Polymyositis or dermatomyositis 
- Alcohol
- Carcinoma
- Endocrine (hypothyroidism, hyperthyroidism, Cushing’s syndrome, acromegaly, hypopituitarism) 
- Periodic paralysis
- Osteomalacia
- Drugs (steroids, statins)
- Sarcoidosis
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35
Q

Gait: Hemiparetic

A

the foot is plantarflexed and the leg swung in a lateral arc

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36
Q

Gait: Paraparetic

A

(scissor gait)

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37
Q

Gait: Extrapyramidal

A

(e.g. Parkinson’s Disease)

o Hesitation in starting, shuffling, freezing, festination (patient hurries forward), propulsion/retropulsion

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38
Q

Gait: Cerebellar

A

gait that is wide-based or reeling on a narrow base; the patient staggers towards affected side

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39
Q

Gait: Apraxic

A

(prefrontal lobe): feet appear glued to the floor when erect, but move more easily when supine

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40
Q

Gait: Posterior column lesion

A

(clumsy slapping down of the feet on a broad base)(clumsy slapping down of the feet on a broad base)

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41
Q

Gait: Distal weakness

A

(high-stepping gait)

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42
Q

Gait: Proximal weakness

A

Waddling Gait

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43
Q

Causes of Unilateral Cerebellar Disease

A
  1. Space-occupying lesion (tumour, abscess, granuloma)
  2. Ischaemia (vertebrobasilar disease)
  3. Paraneoplastic syndrome
  4. Multiple sclerosis
  5. Trauma
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44
Q

Causes of bilateral cerebellar disease

A
  • Drugs (e.g. phenytoin)
  • Friedreich’s ataxia
  • Hypothyroidism
  • Multiple sclerosis
  • Trauma
  • Arnold-Chiari malformation
  • Alcohol
  • Large space-occupying lesion, cerebrovascular disease
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45
Q

Causes of midline cerebellar disease

A
  • Paraneoplastic syndrome

* Midline tumour

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46
Q

Causes of cerebellar disease affecting the rostal vermis

A

Alcohol

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47
Q

Clinical features of Friedreich’s Ataxia

A
  • Cerebellar signs (bilateral) including nystagmus
  • Posterior column loss in the limbs
  • Upper motor neurone signs in the limbs (although ankle reflexes are absent)
  • Peripheral neuropathy
  • Optic atrophy
  • Pes cavus, cocking of the toes and kyphoscoliosis
  • Cardiomyopathy
  • Diabetes mellitus
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48
Q

Causes of pes cavus

A
  • Friedreich’s ataxia or other spinocerebellar degenerations
  • Hereditary motor and sensory neuropathy (Charcot-Marie-Tooth)
  • Neuropathies in childhood
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49
Q

Causes of spastic and ataxic paraparesis

A
  • Multiple sclerosis
  • Spinocerebellar degeneration
  • Syringomyelia
  • Bilateral upper pons or internal capsule infarction
  • Lesion at the craniospinal junction
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50
Q

Causes of Parkinsonism

A
  • Idiopathic (Parkinson’s Disease)
  • Drugs (phenothiazines, methyldopa)
  • Post-encephalitis
  • Other: toxins (carbon monoxide), Wilson’s disease, Progressive Supranuclear Palsy, Multiple-System Atrophy, syphilis, tumour
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51
Q

DDx for action tremor

A 
o	Thyrotoxicosis
o	Anxiety 
o	Drugs
o	Familial
o	Idiopathic (most common)
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52
Q

Causes of Chorea

A
  • Huntington’s disease
  • Sydenham’s chorea (rheumatic fever)
  • Senility
  • Wilson’s disease
  • Drugs (OCP, phenytoin, L-Dopa)
  • Vasculitis or connective tissue disease (e.g. SLE)
  • Thyrotoxicosis
  • Polycythaemia or other causes of hyperviscosity
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53
Q

Signs of an upper cervical spinal cord lesion

A

UMN signs in the upper and lower limbs

Paralysis of the diaphragm occurs with lesion above C4

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54
Q

Signs of a C5 spinal cord lesion

A

LMN weakness and wasting of rhomboids, deltoids, biceps and brachioradialis
UMN signs affect the rest of the upper and all of the lower limbs

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55
Q

Signs of S3-S4 spinal cord lesion

A

No anal reflex
Saddle sensory loss
Normal lower limbs

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56
Q

Signs of a C8 spinal cord lesion

A

LMN weakness and wasting of the intrinsic muscles of the hand
UMN signs in the lower limbs

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57
Q

Signs of mid-thoracic spinal cord lesion

A

Intercostal paralysis (not clinically detected)
Loss of upper abdominal reflexes at T7 and T8
UMN signs in the lower limbs
Sensory level on the trunk

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58
Q

Signs of T10-T11 spinal cord lesion

A

Loss of lower abdominal reflexes and upward displacement of umbilicus on contraction
UMN signs in the lower limbs

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59
Q

Signs of L1 spinal cord lesion

A

Cremasteric reflexes lost

UMN signs in the lower limbs

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60
Q

Signs of L4 spinal cord lesion

A

LMN weakness and wasting of the quadriceps

Knee jerk lost

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61
Q

Signs of L5 and S1 spinal cord lesion

A

LMN weakness of knee flexion and hip extension (S1) and abduction (L5)
Knee jerk present
No ankle jerk or plantar response
Anal reflex present

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62
Q

Causes of a spastic paraparesis

A 
MS
HIV
Trauma
Spinal cord tumour
MND
Syringomyelia
Subacute combined degeneration of the cord (associated peripheral neuropathy)
Tabes dorsalis
Transverse myelitis
Familial spastic paraplegia
OA of cervical spine 
Metastatic carcinoma
Anterior spinal artery thrombosis
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63
Q

Signs of hereditary spastic paraplegia

A

Minimal weakness
Profound spasticity - increased tone, clonus, brisk reflexes
No sensory change

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64
Q

Signs of spinocerebellar ataxia

A

Different syndromes:
Roussy Levy: Atrophy of lower limbs, loss of deep tendon reflexes

Refsum’s: Peripheral neuropathy, deafness, increased CSF protein

Machado Joseph disease: ophthalmoparesis, spasticity, dystonia, Parkinsonism

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65
Q

Signs of motor neurone disease

A

UMN and LMN involvement of either 2 limbs or more or 1 limb and bulbar
Fasciculations
Loss of reflexes
Upgoing plantars
Sensory and ocular movements not affected
Never cerebellar signs

66
Q

Clinical pattern in amyotrophic lateral sclerosis

A

Flaccid arms and spastic legs

67
Q

Clinical pattern in progressive muscular atrophy

A

Retention of deep tendon reflexes but severe muscular atrophy

68
Q

Clinical pattern in primary lateral sclerosis

A

Progression from UMN to LMN weakness

69
Q

Most common causes of lateral medullary syndrome

A

Occlusion of the intracranial vertebral artery

Occlusion of posterior inferior cerebellar artery

70
Q

Signs of a medial medullary syndrome

A

Ipsilateral paralysis and wasting of the tongue
Contralateral hemiplegia
Contralateral loss of vibration and joint position sense

71
Q

CN 2 (Optic)

A 
Pupils
Acuity
Fundoscopy
Fields
Blind spot
Color saturation
72
Q

CN 3/4/6 (Oculomotor, trochlear, abducens)

A

Eye movements

Accommodation

73
Q

CN 5 (Trigeminal)

A

Corneal reflex (sensory component)
Facial sensation
Clenching teeth and open mouth
Jaw jerk

74
Q

CN 7 (Facial)

A

Corneal reflex (blinking component)
Eyebrows up - check for symmetry of wrinkling
Eyes closed tight and try to open them up
Grin - assessing nasolabial folds
Taste on anterior 2/3rds of tongue

75
Q

CN 8 (Vestibulocochlear)

A

Whisper screening test
Rinne
Weber

76
Q

CN 9/10 (Glossopharyngeal, Vagus)

A

Uvula (Shy)
Gag reflex (CN 9 is sensation, CN 10 is the gagging)
Taste of posterior 3rd of tongue
Hoarse voice

77
Q

CN 11 (Accessory)

A

Trapezius strength

Sternocleidomastoid strength

78
Q

CN 12 (Hypoglossal)

A 
Tongue wasting/fasciculations
Tongue deviation (Proud)
79
Q

CAUSES OF PUPIL DILATION

A
  • Third nerve lesion
  • Adie’s pupil
  • Iritis
  • Mydriatics
80
Q

Features of Horner’s Syndrome

A

Ptosis
Meiosis
Anhydrosis

81
Q

Causes of a Horner’s Syndrome

A
  1. Carcinoma of the lung apex
  2. Neck – thyroid malignancy, trauma
  3. Carotid arterial lesion – carotid aneurysm or dissection, pericarotid tumour
  4. Brain stem lesions – vascular disease (lateral medullary syndrome), syringobulbia, tumour
  5. Retro-orbital lesions
  6. Syringomyelia (rare)
82
Q

Features of Lateral Medullary Syndrome

A
  • Horner’s syndome
  • Nystagmus (to the side of the lesion)
  • Ipsilateral cranial nerve V (pain and temperature), IX and X lesions
  • Ipsilateral cerebellar signs
  • Contralateral pain and temperature loss over the trunk and limbs
83
Q

Horner’s Syndrome Exam

A

EYES: Partial ptosis and constricted pupil (reacts normally to light)
FOREHEAD: anhidrosis
CRANIAL NERVES V/IX/X: lateral medullary syndrome
VOICE: hoarseness (recurrent laryngeal nerve palsy)
HANDS: clubbing, finger abduction (lower trunk brachial plexus C8/T1 lesion)
NECK: cervical lymphadenop.athy, thyroid carcinoma, carotid aneurysm or bruit
RESPIRATORY EXAMINATION: apical lung tumour
UPPER LIMB NEUROLOGICAL EXAM: dissociated sensory loss (syringomyelia)

84
Q

Causes of Bilateral Anosmia

A 
URTI
Meningioma of olfactory groove (late)
Ethmoid tumours
Head trauma (including cribiform plate fracture)
Meningitis
Hydrocephalus
Congenital (Kallman's syndrome)
85
Q

Causes of Unilateral Anosmia

A

Meningioma of the olfactory groove (early)

Head trauma

86
Q

CAUSES OF ABSENT LIGHT REFLEX BUT INTACT ACCOMMODATION REFLEX

A
  1. Midbrain lesion (e.g. Argyll Robertson pupil)
  2. Ciliary ganglion lesion (e.g. Adie’s pupil)
  3. Parinaud’s syndrome
  4. Bilateral afferent pupil defects
87
Q

CAUSES OF ABSENT CONVERGENCE BUT INTACT LIGHT REFLEX

A
  • Cortical lesion (e.g. cortical blindness)

* Midbrain lesions

88
Q

CAUSES OF PUPIL CONSTRICTION

A
  • Horner’s syndrome
  • Argyll Robertson pupil
  • Pontine lesion (often bilateral but reactive to light)
  • Narcotics
89
Q

CAUSES OF PUPIL DILATION

A
  • Third nerve lesion
  • Adie’s pupil
  • Iritis
  • Mydriatics
90
Q

Adie’s Syndrome Cause and Signs

A

CAUSE
• Lesion in the efferent parasympathetic pathway

SIGNS
• Dilated pupil
• Decreased or absent reaction to light (direct and consensual)
• Slow or incomplete reaction to accommodation with slow dilation afterwards
• Decreased tendon reflexes
• Patients are commonly young women

91
Q

Cause of Argyll Robertson Pupil

A 
•	Lesion of the iridodilator fibres in the midbrain, as in:
o	Syphilis
o	Diabetes mellitus 
o	Alcoholic midbrain degeneration 
o	Other midbrain lesions
92
Q

Signs of Argyll Robertson Pupil

A
  • Small, irregular, unequal pupil
  • No reaction to light
  • Prompt reaction to accommodation
  • If tabes is associated (syphilis), decreased reflexes
93
Q

Causes of Papilloedema

A
  • Space-occupying lesion (causing raised intracranial pressure) or a retro-orbital mass
  • Hydrocephalus (associated with large ventricles)
  • Benign intracranial hypertension
  • Hypertension (grade IV)
  • Central retinal vein thrombosis
  • Cerebral venous sinus thrombosis
94
Q

Causes of Hydrocephalus

A

o Obstructive
o Communicating
 Increased formation of CSF – choroid plexus papilloma
 Decreased formation of CSF – tumour causing venous compression, subarachnoid space obstruction from meningitis

95
Q

Causes of Benign intracranial HTN

A 
Idiopathic
Drugs:COCP, Nitrofurantoin, tetracycline, steroids 
Addison’s disease
Vitamin A
Lateral sinus thrombosis
96
Q

Causes of optic atrophy

A 
Chronic papilloedema or optic neuritis
Optic nerve pressure or division
Glaucoma
Ischemia
Familial - retinitis pigmentosa, Leber's disease, Friedreich's ataxia
97
Q

CAUSES OF OPTIC NEUROPATHY

A
  • Multiple sclerosis
  • Toxic: ethambutol, chloroquine, nicotine, alcohol
  • Metabolic: Vitamin B12 deficiency
  • Ischaemia: diabetes mellitus, temporal arteritis, atheroma
  • Familial – Leber’s disease
  • Infective – infectious mononucleosis
98
Q

CAUSES OF PTOSIS

WITH NORMAL PUPILS

A
  • Senile ptosis
  • Myotonic dystrophy
  • Fascioscapulohumeral dystrophy
  • Ocular myopathy, e.g. mitochondrial myopathy
  • Thyrotoxic myopathy
  • Myasthenia gravis
  • Botulism
  • Fatigue
  • Congenital
99
Q

CAUSES OF PTOSIS WITH CONSTRICTED PUPILS

A
  • Horner’s syndrome

* Tabes dorsalis

100
Q

Causes of a unilateral 6th nerve palsy

A

Central:

  • Vascular
  • Tumour
  • Wernicke’s encephalopathy
  • Multiple sclerosis

Peripheral

  • Diabetes, other vascular lesions
  • Trauma
  • Idiopathic
  • Raised intracranial pressure
101
Q

CAUSES OF PTOSIS WITH DILATED PUPILS

A

• Third nerve lesion

102
Q

Cause of jerky vertical nystagmus

A

Brain stem lesion:

  • Upbeat nystagmus suggests a lesion in the floor of the fourth ventricle
  • Downbeat nystagmus suggests a foramen magnum lesion

Toxic – phenytoin, alcohol (may also cause horizontal nystagmus)

103
Q

Features of a Third Nerve Palsy

A
  • Complete ptosis (partial ptosis may occur with an incomplete lesion)
  • Divergent strabismus (eye ‘down and out’): limited adduction and elevation
  • Dilated pupil unreactive to direct or consensual light and unreactive to accommodation
104
Q

How to Exclude a 4th nerve palsy in a 3rd nerve palsy

A

• Always exclude a fourth (trochlear) nerve lesion when a third nerve lesion is present. Do this by:
o Tilting the patient’s head to the same side as the lesion. The affected eye will intort if the lesion is intact
o Asking the patient to look down and across to the opposite side from the lesion and look for intortion

105
Q

Causes of a 3rd nerve palsy

A

Central

  • Vascular (e.g. brain stem infarction)
  • Tumour
  • Demyelination
  • Trauma

Peripheral
Compressive lesions:
-Aneurysm (usually on the posterior communicating artery)
-Tumour causing raised intracranial pressure
-Nasopharyngeal carcinoma
-Orbital lesions
-Basal meningitis
Infarction: diabetes mellitus, arteritis (pupil is usually spared)
Trauma
Cavernous sinus lesions

106
Q

CLINICAL FEATURES OF A SIXTH NERVE PALSY

A
  • Failure of lateral aBduction
  • Affected eye is deviated inwards in severe lesions
  • Diplopia – maximal on looking to the affected side; the images are horizontal and parallel to each other; the outermost image is from the affected eye and disappears on covering this eye
107
Q

Causes of a bilateral 6th nerve palsy

A

Trauma
Wernicke’s encephalopathy
Raised intracranial pressure
Mononeuritis multiplex

108
Q

CAUSES OF BILATERAL LOWER MOTOR NEURONE FACIAL WEAKNESS

A
  • Guillain-Barre syndrome
  • Bilateral parotid disease (e.g. sarcoidosis)
  • Mononeuritis multiplex (rare)
109
Q

Cause of Jerky horizontal nystagmus

A

o Vestibular lesion – chronic lesions cause nystagmus to the side of the lesion
o Cerebellar lesion – unilateral disease causes nystagmus to the side of the lesion
o Internuclear ophthalmoplegia – nystagmus is in the abducting eye, with failure of adduction on the AFFECTED SIDE. This is the result of a medial longitudinal fasciculus lesion. The most common cause in young adults with bilateral involvement is multiple sclerosis; in the elderly consider brainstem infarction

110
Q

Features of a supranuclear palsy and how it is distinguished from 3rd/4th/6th nerve palsy

A

• Loss of vertical upward gaze and sometimes downward gaze. Clinical features (distinguishing from third, fourth and sixth nerve palsy)
o Both eyes affected
o Pupils often unequal
o No diplopia
o Reflex eye movements (e.g. on flexing and extending the neck) intact

111
Q

Features of progressive supranuclear palsy

A

o Loss of vertical downward gaze first, later vertical upward gaze and finally horizontal gaze
o Associated with pseudobulbar palsy, long tract signs, extrapyramidal signs, dementia and neck rigidity

112
Q

Features and Causes of Parinaud’s Syndrome

A

Loss of vertical upward gaze often associated with convergence-retraction nystagmus on attempted convergence and pseudo-Argyll Robertson pupils

Causes:
Central: pinealoma, multiple sclerosis, vascular lesions

Peripheral: trauma, diabetes mellitus, other vascular lesions, idiopathic, raised intracranial pressure

113
Q

Causes of a 5th nerve palsy

A

Central (pons, medulla and upper cervical cord)

  • Vascular
  • Tumour
  • Syringobulbia
  • Multiple sclerosis

Peripheral (posterior fossa)

  • Aneurysm
  • Tumour (skull base, e.g. acoustic neuroma)
  • Chronic meningitis

Trigeminal ganglion (petrous temporal bone)

  • Meningioma
  • Fracture of the middle fossa

Cavernous sinus (associated third, fourth and sixth nerve palsies)

  • Aneurysm
  • Thrombosis
  • Tumour

Other

  • Sjogren’s syndrome
  • SLE
  • Toxins
  • Idiopathic
114
Q

Causes of a 7th nerve palsy

A

Upper motor neurone lesion (supranuclear)

  • Vascular
  • Tumour

Lower motor neurone lesion

  • Pontine (often associated with nerves V, VI): Vascular, tumour, syringobulbia, multiple sclerosis
  • Posterior fossa: Acoustic neuroma, Meningioma
  • Petrous temporal bone: Bell’s Palsy, Ramsay Hunt Syndrome, Otitis media, Fracture
  • Parotid: Tumour, Sarcoid
115
Q

Interpretation of Rinne’s Test

A
  • Normal – the note is audible at the external meatus
  • Nerve deafness – the note is audible at the external meatus (air and bone conduction reduced equally)
  • Conduction (middle ear) deafness – no note is audible at the external meatus – negative result
116
Q

Interpretation of Weber’s test

A
  • Normal – sound is heard in the centre of the forehead
  • Nerve deafness – sound is transmitted to the normal ear
  • Conduction deafness – sound is heard louder in the abnormal ear
117
Q

Causes of Sensorineural deafness

A

Degeneration (Presbycusis)
Trauma (high noise exposure, fracture of the petrous temporal bone)
Toxic (aspirin, ETOH, streptomycin)
Infection (Congenital rubella/syphillis)
Tumor (acoustic neuroma)
Brain stem lesions
Vascular disease of the internal auditory artery

118
Q

Causes of conductive deafness

A

Wax
Otitis media
Otosclerosis
Paget’s disease of the bone

119
Q

Causes of 9th and 10th nerve palsies

A

Central
o Vascular: e.g. lateral medullary infarction
o Tumour
o Syringobulbia
o Motor neurone disease (vagus nerve only)

Peripheral (posterior fossa)
o	Aneurysm
o	Tumour
o	Chronic meningitis 
o	Guillain-Barre syndrome (vagus nerve only)
120
Q

Causes of 12th nerve palsy (UMN lesion)

A

o Vascular
o Motor neurone disease
o Tumour
o Multiple sclerosis

121
Q

Causes of 12th nerve palsy (Unilateral LMN lesion)

A

Central

  • Vascular – thrombosis of the vertebral artery
  • Motor neurone disease
  • Syringobulbia

Peripheral (posterior fossa)

  • Aneurysm
  • Tumour
  • Chronic meningitis
  • Trauma
  • Arnold-Chiari malformation
  • Fracture or tumour of the base of the skull
122
Q

Causes of a 12th nerve palsy (Bilateral LMN lesion)

A

o Motor neurone disease
o Arnold Chiari malformation
o Guillain-Barre syndrome
o Polio

123
Q

Causes of multiple cranial nerve palsies

A

Think of Cancer first!

  • Nasopharyngeal carcinoma
  • Chronic meningitis (carcinoma, tuberculosis, sarcoidosis)
  • Guillain-Barre syndrome, including Miller-Fisher variant
  • Brain stem lesions – usually vascular disease causing crossed sensory or motor paralysis (i.e. cranial nerve signs on one side and contralateral long tract signs)
  • Arnold-Chiari malformation
  • Trauma
  • Lesion of the base of the skull
  • Mononeuritis multiplex (e.g. diabetes mellitus)
124
Q

Upper limb reflexes

A
  • Biceps: C5, C6
  • Triceps C7, C8
  • Supinator C5, C6
  • Finger: C8
125
Q

FACIO-SCAPULO-HUMERAL SYNDROME

A
  • Inspection: wasting of the masseter and temporalis muscles
  • Winging of the scapulae
  • Foot drop
  • Facial weakness (inability to close eyes tightly, whistle or puff out the cheeks)
126
Q

Signs of a pseudobulbar palsy

A 
Stiff and spastic tongue
Slow thick and indistinct speech
Brisk jaw jerk
UMN lesions of the limbs
Emotional lability
127
Q

Causes of pseudobulbar palsy

A

Stroke
Multiple sclerosis
MND
Creutzfeldt-Jakob disease

128
Q

Signs of a bulbar palsy

A 
Flaccid tongue with fasciculations
Nasal speech 
Prominent nasal regurgitation
Normal or absent jaw jerk
Normal effect
129
Q

Causes of a bulbar palsy

A 
MND
Polio
GBS
Myasthenia gravis
Myopathy
130
Q

CAUSES OF UPPER LIMB DRIFT

A
  • Upper motor neurone weakness (usually downwards owing to muscle weakness)
  • Cerebellar lesion (usually upwards owing to hypotonia)
  • Posterior column loss (any direction owing to joint position sense loss)
131
Q

Upper Limb myotomes

A
  • Shoulder abduction: C5,6
  • Shoulder adduction C6, C7, C8
  • Elbow flexion: C5, C6
  • Elbow extension: C7, C8
  • Wrist flexion: C6, C7
  • Wrist extension C7, C8
  • Fingers extension: C7, C8
  • Finger flexion C7, C8
  • Finger abduction: C8, T1
132
Q

Causes of a sciatic nerve lesion

A

Pressure
Trauma
Vasculitis
Tumour

133
Q

Causes of weakness of all muscles of the foot

A

Peripheral neuropathy
Root or plexus lesion - Cauda equina
Anterior horn cell disease - MND
Sciatic nerve lesion

134
Q

Signs of LMN lesion

A

Weakness
Wasting
Decreased or absent reflexes
Fasciculations (prominent in anterior horn cell disease unless far advanced)

135
Q

Features of Myotonic dystrophy

A

Autosomal dominant

distal wasting and weakness in all 4 limbs

hyporeflexia

frontal baldness

partial ptosis -failure to bury the eyelashes

horizontal smile

weak neck flexion (cf. extension)

Iridescent cataracts from subcapsular fine deposits

tests

  • make a tight fist and then open the fingers as rapidly as possible - if fingers unfurls slowly = myotonia
  • tap the thenar eminance - if thumb slowly abducts then falls back to original position = percussion myotonia

Ask for Glycosuria - diabetes

136
Q

Signs of UMN lesion

A

Weakness more marked in upper limb abductor and extensor muscles and lower limb flexor muscles
Spasticity
Clonus
Increased reflexes and extensor plantar response

137
Q

Causes of Fasiculation

A 
Benign idiopathic fasciculation
Motor neuron disease
Motor root compression
malignant neuropathy
Spinal muscular atrophy/bulbospinal muscular atrophy (Kennedy Syndrome)
Any motor neuropathy (less likely)
138
Q

Signs of a lateral medullary syndrome

A
  • Nystagmus
  • Ipsilateral Horner’s syndrome
  • Ipsilateral involvement of 5th, 6th, 7th and 8th cranial nerves
  • Bulbar palsy
  • Ipsilateral cerebellar signs
  • Contralateral pain and temperature sensory loss
139
Q

Causes of an INO

A

Lesion in the medial longitudinal fasiculus

MS
Vascular disease
Tumour (pontine glioma) 
Inflammatory lesions of the brain stem
Drugs (phenytoin, carbamazepine)
140
Q

Signs of an INO

A

Adduction of the eye is impaired on the affected side

Nystagmus in the non affected eye on abduction

141
Q

Impairment with conductive aphasia

A

Can read, write, and speak normally

CANNOT repeat words/phrases

142
Q

Causes of hemiplegia

A

Cerebral infarction resulting from thrombotic or embolic occlusion of a cerebral artery (80%)

Intra-cerebral or subarachnoid haemorrhage (20%)

Elderly:
Vascular event
Tumour
Subdural haematoma
Syphilis 
Young:
MS
Tumour
Trauma
Embolism (AF, valvular heart disease) 
Connective tissue disorder
Syphilis 
Intra-cranial infection
143
Q

Foster Kennedy Syndrome

A

Optic atrophy on affected side with and papilloedema in the opposite fundus

Seen in Frontal lobe tumors

144
Q

Site of lesion for receptive aphasia

A

Wernicke’s area

-Posterior part of the first temporal gyrus in the dominant lobe

145
Q

Site of lesion for expressive aphasia

A

Broca’s area

-Posterior part of the frontal gyrus in the dominant lobe

146
Q

Site of lesion for conductive aphasia

A

Arcuate Fasciculus

-Connection between Broca’s and Wernicke’s areas

147
Q

Site of lesion for nominal aphasia

A

Angular gyrus in the temporal lobe

Other causes: encephalopathy, pressure effect rom a space occupying lesion

148
Q

NCS: Amplitude

A

How many axons are excited

-Low amplitude = axonal problem

149
Q

NCS: Latency

A

Represents velocity of the fastest conducting fibres

-Increased latency = demyelinating problem

150
Q

EMG: Neurogenic pattern

A

Fibrillations and positive sharp waves
Fasciculations
Morphology: Large amplitude, increased duration
Recruitment: Decreased

151
Q

EMG: Myopathic pattern

A

Fibrillations and positive sharp waves
Morphology: Small amplitude
Recruitment: Increased

152
Q

Myasthenia Gravis Investigations

A
  • Acetylcholine receptor AB positive (Associated with thymoma - Consider CT chest)
  • Muscle specific kinase antibody positive
  • EMG: Decrement in amplitudes with repeated nerve stimulation

BPT Shorts (6 decks)

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