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Neurological Presentations Flashcards

1
Q

What can cause focal damage to cerebral hemispheres?

A

Vascular events
Tumours
Trauma
Localised inflammatory/infective lesions

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2
Q

What can cause generalised/multifocal cerebral dysfunction?

A

Degenerative disorders e.g. Alzheimer’s, dementia with Lewy bodies
Multiple infarcts
Demyelination

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3
Q

What are the normal functions of the frontal lobe?

A

Primary motor cortex at the precentral gyrus, controls motor function on opposite side of the body

UMN cell bodies are in primary motor cortex

Frontal eye field

Broca’s area - in dominant hemisphere only, expressive centre of speech

Prefrontal cortex - personality, emotional expression, initiative

Cortical micturition centre

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4
Q

What is the blood supply of the frontal lobe?

A

Anterior cerebral artery and middle cerebral artery

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5
Q

What are symptoms of lesions from the frontal lobe?

A

Contralateral weakness due to damage of precentral gyrus, UMN pattern

Gait apraxia - slow, shuffling, upright, wide-based
Due to damage in premotor and suppl. motor area

Conjugate eye deviation

Focal seizures

Expressive dysphasia - intelligence in tact, cannot find the right words

Personality, behavioural change

Anosmia

Primitive reflexes usually inhibited by prefrontal cortex, suppressed as baby grows

Incontinence

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6
Q

What are the functions of the parietal lobe?

A

Primary somatosensory cortex - postcentral gyrus, receives somatosensory from contralateral side

Language - arcuate fasciculus connects with Broca’s to Wernicke’s (in temporal) through parietal lobe

Numbers - dominant hemisphere

Integration of somatosensory, visual and auditory information, visual pathways

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7
Q

What is the blood supply of the parietal lobe?

A

Middle cerebral artery

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8
Q

What are symptoms of lesions from the parietal lobe?

A

Cortical contralateral sensory loss

Visual disturbances e.g. contralateral homonymous inferior quadrantanopia

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9
Q

What are syndromes of the dominant parietal lobe?

A

Wernicke’s dysphasia - impaired comprehension, gibberish, poor insight

Gerstmann’s - inability to differentiate right and left sides of the body

Cannot carry out a series of tasks

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10
Q

What are the functions of the temporal lobe?

A

Wernicke’s area - comprehensive of written and spoken language

Auditory and vestibular system

Limbic system

Visual pathway - lower part of optic radiations pass deep

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11
Q

What is the blood supply of the temporal lobe?

A

Posterior cerebral - medial part of the lobe

Middle cerebral - lateral part

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12
Q

What are symptoms from lesions of the temporal lobe?

A 
Wernicke's receptive dysphasia
Visual disturbances
Memory impairment
Emotional disturbances - aggression, rage, hypersexuality
Cortical deafness
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13
Q

What are the different types of dysphasia?

A

Broca’s - expressive
Wernicke’s - receptive
Conduction - damage to arcuate fasciculus, non-sensical but patient aware
Global - lesions of both Broca’s and Wernicke’s; mostly stroke of left middle cerebral artery territory
Nominal - inability to name objects

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14
Q

What is the function of the occipital lobe?

A

Perception of vision

Recognition of what is visualised

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15
Q

What are symptoms of occipital lobe defects?

A

Contralateral homonymous hemianopic field defect
Cortical blindness - retention of pupillary reflexes
Visual agnosia - impairment of perception or identification
Visual illusions

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16
Q

What are the most common causes of transient loss of consciousness?

A

Syncope
Seizures

Hypoglycaemia
Narcolepsy/cataplexy
Hyperventilation
Vertebrobasilar ischaemia
Vertebrobasilar migraine
Psychogenic or non-epileptic attacks
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17
Q

What would you ask about in a history for loss of consciousness?

A

Before - triggers? prodromes - visual, auditory, palpitations? change of colour?

During - Duration? convulsions? continence? tongue biting?

After - time for recovery

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18
Q

What are the 5P’s and 5C’s of loss of consciousness

A 
Precipitant
Prodrome
Palpitations
Position
Post event

Colour
Convulsions
Continence
Cardiac hx
FH of sudden cardiac death
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19
Q

What investigations would you request for a patient who has come in with loss of consciousness?

A 
FBC, U&E, Blood glucose
BP - lying and standing
EEG
ECG - 24hr
Imaging with MRI
Carotid sinus massage
Table tilt test
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20
Q

What 3 things characterise syncope?

A

Loss of consciousness
Transient - recover by themselves
Global cerebral hypoperfusion

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21
Q

What are your differentials for LOC?

A

NEURO: RICP, epilepsy, Parkinson’s, Lewy Body dementia

CARDIAC: arrhythmias, HOCM, aortic stenosis

METABOLIC: diabetic autonomic failure, uraemia, hypoglycaemia

DRUGS: diuretics, antihypertensive

OTHER: hyperventilation induced, carotid hypersensitivity

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22
Q

What are the central causes for vertigo?

A 
vertebrobasilar ischaemia 
posterior circulation stroke 
Acoustic neuroma 
MS
Alcohol
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23
Q

What are the peripheral causes for vertigo?

A 
Viral labyrinthitis 
Vestibular neuronitis 
BPPV
Meniere's 
Ototoxic drugs
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24
Q

What are some bedside examinations you’d want to do in a patient presenting with vertigo? Describe the results in terms of where the lesion is

A

Rombergs

  • proprioception or vestibular system issue
  • they fall towards the side of the lesion
  • normal if cerebellar cause

Uttunberg

  • march on spot with eyes shut
  • rotate towards the side of a labyrinthine lesion

Head impulse

  • patient fixes eyes and examiner moves head
  • catch up saccade will occur when head rotated to side of lesion if peripheral lesion

Skew deviation
- cover eyes and if central lesion then vertical correction will occur when eye uncovered

Dix-hallpike - BPPV

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25
What is ataxia? Describe an ataxic gait
Disorder of co-ordination, balance and speech Wide based, appear drunk, can't stand with feet together
26
Where can a lesion be to cause ataxia? What type of ataxia would you get at these locations?
Cerebellar vermis = gait ataxia Cerebellar hemisphere = peripheral ataxia (finger-nose test) Can also be due to poor proprioception: - peripheral sensory neuropathy - DCML
27
What can cause a bilateral ataxia? What would you seen on examination of ataxia was bilateral?
- Alcohol (cerebellar degeneration) - B1 and B12 deficiency - MS - CJD and other intracranial infections - Drugs Patient veers from side to side
28
What can cause a unilateral ataxia? What would you seen on examination of ataxia was bilateral?
- Cerebellar or brainstem stroke - SOL Patients veers to the side of the lesion
29
What is friedreich's ataxia? What pattern of inheritance does it show?
Genetic progressive neurodegenerative movement disorder Unsteady posture, frequent falling, progressive difficulty in walking Autosomal recessive Kyphoscoliosis Absent ankle jerks but extensor plantars Optic atrophy Associated with HCOM and diabetes
30
What is ataxic telangiectasia and what are the signs, symptoms and associated diseases?
AR inherited combined immunodeficiency disorder: - cerebellar ataxia - telangiectasia (including ocular) - recurrent chest infections Associated with lymphoma and leukaemia
31
What is athetosis? What can cause it?
Slow involuntary writhing movements affecting the extremities Asphyxia, neonatal jaundice, Huntington's and cerebrovascular disease
32
What is dystonia?
Sustained muscle contraction frequently causing twisting movements or abnormal postures because of con-contraction of antagonistic muscles
33
How is dystonia managed?
Focal - botulinum injections | Generalised - L Dopa if <40, Anticholinergics, tetrabenazine, deep brain stimulation
34
What is chorea?
Continuous, irregular, jerky movements occurring at random locations
35
What can cause chorea?
Hereditary - Huntington's, benign hereditary, Wilson's Infection - syndenham's , HIV, meningitis/encephalitis Vascular - infarct, polycythaemia Metabolic - glucose, hyperthyroid, hypocalcaemia Immune - SLE, anti-phospholipid, pregnancy Drugs - Dopamine antagonist, oral contraceptive, amphetamines and cocaine
36
What is spasmodic torticollis?
Shortened sternocleidomastoid means the head is tilted and chin tilted the opposite way
37
What is myoclonus?
Sudden shock like muscle jerks that are frequently repetitive
38
What are tics?
Rapid repetitive stereotyped movements Can be voluntarily suppressed - lead to internal tension Triggered by stress or boredom
39
What are the types of tics?
Motor - eye blinking, head jerk, nose twitch, shoulder shrug, facial grimace Vocal - throat clear, grunting, coughing, sniffing Other - vulgar words, repeating words, vulgar gestures
40
What is a tremor? What are the types and what could cause them?
Rhythmical oscillatory movement of body part Resting: Parkinson's Postural: anxiety, alcohol, thyroid, essential, Wilsons Action: cerebellar disease
41
What is an essential tremor? Describe the tremor seen in this disorder
Autosomal dominant postural tremor - Symmetrical - affects UL (+/- head) - Low amplitude - High frequency - Not present in sleep - Improve with alcohol
42
How are essential tremors managed?
Propranolol and Primidone
43
What would you investigate when determining the cause for a tremor?
``` Neurological exam Type of tremor Medication history Thyroid function LFT Copper levels Imaging ```
44
What is characteristic of polyneuropathies?
Motor and/or sensory disorder of multiple peripheral or cranial nerves Symmetrical Widespread Worse distally
45
What would be a typical history of someone with a sensory peripheral neuropathy?
- glove and stocking distribution of paraesthesia - problem with small objects like buttons - burning their fingers
46
What would be a typical history of someone with a motor peripheral neuropathy?
- becoming clumsy handed - falling more - wasting hand muscles - high stepping gait
47
What are the autonomic signs of polyneuropathy?
Postural hypo Reduced sweating Ejaculatory failure Horner's ``` Constipation Nocturnal diarrhoea Urine retention Erectile dysfunction Holmes-adie pupil ```
48
What can cause primarily sensory polyneuropathy?
``` Diabetes Uraemia (renal failure) Alcohol Reduced B1 Reduced B12/folate Leprosy ```
49
What can cause primarily motor polyneuropathy?
- Guillain-Barre - Chronic inflammatory demyelinating polyradiculoneuropathy - Charcot-marie tooth - Lead poisoning - Diptheria
50
What causes mixed polyneuropathy i.e. sensory and motor?
Hypothyroid/glycaemia Malignancy - paraneoplastic (SCLC), polycythaemia vera Autoimmune: polyarteritis nodosa, RA, sjogrens, sarcoid Infection - lyme, HIV Drugs: isoniazid, phenyotin, metronidazole
51
What are your differentials for motor weakness?
``` V: stroke I: GBC, sepsis, encephalopathy T: cord injury, RICP A: MS, myasthenia, poly/dermatomyositis, cushings, thyroid dysfunction, SLE, Duchenne M: hypoglycaemia, hypokalaemia, hypercalcaemia I: N: MSCC, hypercalcaemia D: statins, alcohol, steroids ```
52
What is the neurological disturbance in fibular neuropathy?
Lateral leg and dorsal foot sensation loss | Foot drop
53
What causes meralgia paraesthetica? In whom and how does it present?
Compression of the lateral femoral cutaneous nerve anywhere along its course (L2/L3 and around ASIS) RF: obesity, pregnancy, tense ascites - Tingling/burning in upper antero-lateral thigh - Worse on standing
54
Which body parts are most affected by diabetic sensory neuropathy?
Feet > hands
55
How would a polyneuropathy as a result of B1 deficiency present?
Feet > Hands Burning and shooting pains Reduced reflexes Muscle weakness
56
What is the sensory disturbance in B6 excess/deficiency?
PATCHY sensory loss of extremities
57
What is the sensory disturbance in B12 deficiency?
Transient and MIGRATORY | Loss of proprioception and vibration
58
What drugs can cause sensory disturbance?
``` Chemotherapy agents Antiretrovirals Phenytoin Metronidazole and nitrofurantoin Isoniazid ```
59
What is the sensory disturbance in migraine with aura?
Acute spreading loss Typically from hand up ipsilateral arm to face and tongue Last <1hr
60
What primary care investigations would you want to do for someone presenting with a polyneuropathy?
``` HBA1C TFTs LFTs (alcohol abuse) Vitamin levels CRP, WCC (infection?) ```
61
Which side of the brain are the speech centres found?
Dominant hemisphere | Left (most of the time even if left handed people)
62
What is neuropathic pain? | How does it present?
Pain due to a dysfunctional nervous system Shooting, electrical burning pain Can be continuous or intermittent Spontaneous
63
What are some causes of neuropathic pain?
Peripheral: - diabetes, alcohol, herpes, radiculopathy, tumour infiltration, trigeminal neuralgia Central: - MS, post-stroke, chemotherapy
64
How is neuropathic pain managed?
1. amitriptyline, duloxetine, gabapentin, pregabalin 2. switch drugs don't add ``` Flare: tramadol Localised area (e.g. herpes): capsaicin cream ```
65
What are the CI's and ADR's associated with neuropathic pain meds?
Amitriptyline - CI in arrhythmia, heart block, post MI - ADR - Anticholinergic syndrome, drowsiness, long QT Duloxetine ADR - GI upset, drowsy, dry mouth Gabapentin - Caution in diabetes - ADR - dizzy, drowsy, unsteady Pregablin ADR - headache, dizzy, drowsy
66
What is first line management for trigeminal neuralgia?
Carbamazepine
67
Where can lesions be to affect bladder control? What conditions would typically affect bladder control at each of these levels?
CENTRAL: - Stroke, MS, head injury, dementia, parkinsons SUPRASACRAL (often about T12) - spinal cord injury, MS, spina bifida, cervical spondylosis SACRAL (S2,3,4) and PERIPHERAL - spinal cord injury, spina bifida, cauda equina, peripheral neuropathy eg diabetes
68
Describe the bladder and sphincter dysfunction in someone with a lesion above T12
overactive/spastic bladder so that bladder volume is low and there are involuntary contractions - the sphincter control is uncoordinated with bladder contraction - patient gets urge incontinence
69
Describe the bladder and sphincter dysfunction in someone with a lesion at S2,3,4 or peripheral
- flaccid and underactive bladder so that bladder volume is high - underactive sphincter control - patients get urinary retention
70
Describe a hemiplegic gait and state what would cause it
Knee is extended and the foot dropped Circumduct the leg to compensate Cause: contralateral brain lesion
71
Describe a diplegic/ paraplegic gait and state would would cause it
Legs adducted giving a scissoring movement Circumduct legs to compensate Cause: bilateral brain lesion (CP), spinal cord lesion, MND
72
Describe a neuropathic gait (due to peripheral neuropathy)
High steppage and then slam the foot down in order to sense when it's on the floor
73
Describe a myopathic gait and state what would cause it
Waddling - laterally flex torso away and circumduct the leg Cause: polymyalgia rheumatica, muscular dystrophy
74
Describe an antalgic gait
Shortened stance phase on affected leg
75
Describe a frontal gait and state what would cause it
Wide based and a normal arm swing are what differentiate it from Parkinonism gait as everything else is the same i.e. shuffling, hesitation to start, en bloc turning Cause: frontal lobe pathology
76
What are causes of proximal weakness?
CONGENITAL MIND Normal sensation ``` Congenital - mitochondrial Metabolic - Cushing's, thyroid Inflammatory - dermato/polymyositis, inclusion body myositis Neuromuscular - MG, LE Dystrophies - Becker's ```
77
What are causes of bilateral UMN signs?
Pyramidal weakness - 3Ms MS MND (normal sensation) Myelopathy Others
78
What are causes of unilateral UMN signs?
Pyramidal weakness Intracranial - CVA, SOL, MS Brainstem - MS Spinal cord - particular sensory level, trauma, SOL, abscess
79
What are causes of bilateral LMN signs?
Distal weakness ``` If abnormal sensation distally Sensorimotor polyneuropathy - VIT DIM Vasculitis - SLE, RA, PAN Infection - herpes, HIV, syphilis Toxins - alcohol, TB, drugs Diabetes Inherited - Charcot Marie Metabolic - B12 def, B1 ``` Normal sensation - Distal motor neuropathy GBS Lead poisoning Myotonic dystrophy Progressive muscular atrophy
80
What are causes of unilateral LMN signs?
Weakness depends on lesion Radiculopathy Plexopathy - Erbs, Klumpke's, thoracic outlet syndrome Nerve palsy - median (idiopathic, pregnancy), ulnar (compression at elbow, fractures), radial (elbow, humeral shaft fracture, saturday night palsy), axillary (shoulder dislocation), common peroneal (plaster cast compression, trauma, diabetes, leprosy)
81
What are causes of both UMN and LMN signs?
MND Dual pathology - e.g. cervical myelopathy, and polyneuropathy Cervical radiculomyopathy
82
What are causes of absent ankle (and knee) jerks, and extensor plantars?
Subacute combined degeneration of the cord Freidrich's ataxia MND
83
What are causes of cerebellar disease?
``` MS Alcohol Vascular Inherited - ataxia telangiectasia SOL ```
84
What are causes of optic atrophy?
MS, ischaemia, temporal arteritis, compression
85
What are causes of unilateral facial nerve LMN signs?
``` Bell's palsy Ramsay Hunt Brainstem - SOL, stroke TB Nerve infiltration ```
86
What are causes of bilateral facial nerve LMN signs?
``` Bilateral Bell's Sarcoid Autoimmune - MG GBS Amyloidosis ```
87
What are causes of a bulbar palsy?
MND Brainstem/infarct, SOL MG GBS
88
What are the causes of pseudobulbar palsy?
``` MND brainstem infarct MS internal capsule infarct Neurodegenerative disorders ```
89
What can cause CN3-6 lesion?
Cavernous sinus thrombosis
90
What can cause a homonymous hemianopia?
Stroke, cerebral SOL
91
What can cause a bitemporal hemianopia?
pituitary tumour | aneurysm
92
What can cause tunnel vision?
glaucoma | retinitis pigmentosa
93
What causes a central scotoma?
``` MS temporal arteritis compression glaucoma DM methanol ```
94
What can cause a homonymous quadrantopia?
pits pariteral - inferior temporal - superior
95
What can cause monocular vision?
central retinal artery occlusion vitreous haemorrhage trauma papilloedema
96
What can cause chorea?
huntington's, drugs, stroke HIV
97
What can cause hemiballism?
stroke, sol, trauma, hiv
98
What can cause athetosis?
Asyphxia neonatal jaundice thalamic stroke
99
What can cause dystonia?
``` Primary dystonia Brain trauma Wilson's PD Huntington's encephalitis stroke SOL ```
100
What can cause myoclonus?
``` epilepsy metabolic psychological toxins/drugs SOL PD MS CJD ```

Neuro & Special Senses (12 decks)

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