Neurology Flashcards
(128 cards)
1
Q
Define meningitis
A
Infection of the meninges associated with infection
2
Q
Types of meningitis
A
Bacterial - serious infection with 5-10% mortality
- 0-3 months = GBS, E.coli, listeria monocytogenes
- 1 month - 6 years = Neisseria meningitides, streptococcus pneumonia
- 50 + = listeria monocytogenes, strep pneumonia
Viral - more common, less severe, usually self-limiting
3
Q
Risk factors for meningitis
A
Less than 5 or 65 + Non-immunisation Immunodeficiency Cancer - leukaemia and lymphoma Asplenia - increased risk of overwhelming infection with encapsulated bacteria - strep pneumoniae, n. meningitis Summer and autumn Exposure to mosquitos
4
Q
Pathophysiology of meningitis
A
Pathogens reach the CNS by haematogenous spread or direct extension
Cross BBB via infection of endothelial cells or migrating leukocytes
Pathogens multiple in subarachnoid space stimulating immune response
Release of inflammatory mediators and activated leucocytes and endothelial damage causes
- cerebral oedema
- raised ICP
- decreased cerebral blood flow
5
Q
Presentation of meningitis
A
Headache N+V Photophobia Neck stiffness - resistance to passive neck flexion Fever Altered mental state/confusion Seizures - strep pneumonia and h. influenzea Infants - hypothermia - irritability - lethargy - poor feeding - apnoea - high pitched cry Focal neurological deficit - dilated non-reactive pupil - ocular motility abnormality - abnormal visual field defects - gaze palsy - arm or leg drift - facial palsy - balance problems Rash Kerning's sign - severe stiffness of hamstring causing inability to straight leg when hip is flexed at 90 Brudzinski's sign - severe neck stiffness causes patient hip and knees to flex when the neck is flexed
6
Q
Ix for meningitis
A
LP
CSF gram stain, culture, viral PCR and antigen detection - identify causative organism
Blood culture
FBC - leukocytosis, anaemia and thrombocytopenia
CRP - elevated
Blood gas - acidosis
Clotting profile
CT head - brain infarct, cerebral oedema, hydrocephalus in bacterial
MRI - if focal neuro signs present
7
Q
Features of meningitis of LP
A
Bacterial - polymorphonocular pleocytosis - elevated protein - low glucose Viral - elevated WCC - normal or elevated protein - normal or low glucose
8
Q
When is LP contraindicated
A
Cardioresp instability Focal neuro signs Signs of raised ICP Coagulopathy Thrombocytopenia
9
Q
Mx of meningitis
A
Viral
- supportive care
- antiviral therapy - HSV, varicella zoster or CMV
Bacterial
- empirical abx until organism identified - meropenem 1g
- ceftriaxone for strep pneumoniae and h.influenzae
- gentamycin and ampicillin for GBS
- benzylpenicillin for n.menigitidis
- dexamethasone
10
Q
Complications of meningitis
A
Hearing impairment - inflammation of cochlear hair cells Local vasculitis - cranial nerve palsies Local cerebral infarction Subdural effusion Hydrocephalus - fibrin blocks Cerebral abscess
11
Q
DDx for meningitis
A
Encephalitis
- abnormal cerebral function with fever
- ix with CT or MRI head
12
Q
Prophylaxis for meningitis
A
· Rifampicin/ciprofloxacin to eradicate nasopharyngeal carriage of all household contacts for meningococcal meningitis or Hib infection
· Household contacts of patient who has had men C should receive the men C vaccine
13
Q
Define encephalitis
A
Inflammation of the brain parenchyma associated with neurological dysfunction
14
Q
Epidemiology of encephalitis
A
Peak incidences at < 1 year and > 65 years
15
Q
Risk factors for encephalitis
A
<1 or > 65 years Immunodeficiency Viral infection Insect bites Swimming in warm freshwater Vaccination - a/w acute disseminated encephalomyelitis
16
Q
Pathophysiology of encephalitis
A
Most commonly caused by viruses - herpesvirus - enterovirus Pathogens reach CNS by haematogenous spread or retrograe axonal transport Colonise the brain paranchyma
17
Q
Presentation of encephalitis
A
Insidious onset Fever Rash Altered mental state and confusion Focal neurological deficit Meningismus Signs of resp/GI infection Seizures
18
Q
Ix for encephalitis
A
FBC - elevated WCC Peripheral blood smear LFTs - abnormal in rickettsia, CMV, EBV Blood culture Throat swab Nasopharyngeal aspirate Sputum culture LP CT head - hypodense lesion MRI head - hyperintense lesion, oedema and breakdown of BBB EEC - background slowing
19
Q
Mx of encephalitis
A
IV acyclovir
20
Q
DDx of encephalitis
A
Meningitis
21
Q
Define idiopathic intracranial hypertension
A
Raised ICP with no known cause
22
Q
Epidemiology of IIH
A
Incidence of 1/100,000
Mean age at diagnosis 30
23
Q
Risk factors for IIH
A
Female Weight gain Sleep apnoea Nalidixic acid use Nitrofurantoin Isotretinoin Thyroid replacement therapy Previous inflammation - meningitis
24
Q
Pathophysiology of IIH
A
Increased resistance to CSF absorption via arachnoid granulations and/or nerve root sheaths
ICP must then rise for CSF to be absorbed
25
Presentation of Idiopathic Intracranial Hypertension
Headache - severe, daily headaches, pulsatile
Visual field loss - usually mild
Transient visual obscuration - transient visual loss that lasts for < 30 secs
Pulse-synchronous tinnitus
Photophobia
Retrobulbar pain - pain with eye movements
Optic disc swelling
Decreased visual acuity - normally only if longstanding
Ocular motility defects
Diplopia
Relative afferent pupillary defect
26
IX for idiopathic intracranial hypertension
Visual field testing - enlargement of physiological blind spot and loss of inferonasal
Fundoscopy - grading of papilloedema
MRI brain - axial and sagittal views, assess for intracranial and intraorbital pathology
LP - L3/4
- opening pressure > 250mmH2O indicated raised ICP
- must exclude intracranial mass lesion by CT or MRI
27
Features of IIH on fundoscopy
o Stage 0 (normal optic disc) – 3-4mm to the nasal side of the fovea. Vertically oval with a central depression (optic cup). Normally orange/pink in colour
§ Retinal nerve fibre layer is prominent at nasal, superior and inferior poles in inverse proportion to disc diameter
§ Radial nerve fibre layer striations may be seen, without tortuosity
o Stage 1 (very early papilloedema)
§ Disruption of the normal radial nerve fibre layer with grey opacity accentuating nerve fibre layer bundles
§ Subtle grey halo with temporal gap. Obscures underlying retinal details but leaves temporal disc margin normal
o Stage 2 (early papilloedema)
§ Complete peripapillary halo
§ Elevation of the nasal border
§ No major vessel obscuration
o Stage 3 (moderate papilloedema)
§ Obscuration of one or more segments of major blood vessels leaving the disc
§ Complete peripapillary halo, which has an irregular outer fringe
§ Elevation of all borders
o Stage 4 (marked papilloedema)
§ Total obscuration of a segment of a major blood vessel on the disc
§ Elevation of whole nerve head, including the cup
§ Complete border obscuration
§ Complete peripapillary halo
o Stage 5 (severe papilloedema)
§ Obscuration of all vessels, both on the disc and leaving the disc
28
Mx of IIH
Conservative
- weigh reduction
- elimination of possible causal factors - medications, low sodium diet, advise mild fluid restriction
- optical prism glasses - diplopia
Medical
- Acetazolamide - reduce intra-ocular pressure, avoid 1st trimester
- Furosemide - reduce BP
- Topiramate
- Amitriptyline - 1st line analgesia
Surgical
- CSF shunting - relieves headache in 50% and may help recover vision and reduce papilloedema
- optic nerve sheath fenestration - may help recover vision and reduce papilloedema
29
Complications of IIH
Irreversible visual loss
Brain herniation
- preceded by Cushing reflex - hypertension, irregular breathing and bradycardia
30
Define epilepsy
Recurrent seizure disorder secondary to increased neuronal excitability
31
Types of epilepsy
Generalised - discharge in both hemispheres
- absence - interruption in activity often with blank stare of inaction
- Typical
- Atypical
- Myoclonic absence
- Eyelid myoclonia
- motor
- clonic - rhythmic muscular jerking
- tonic - extension or flexion of extremities
- tonic-clonic - tonic then clonic
- myoclonic - brief arrhythmic muscular jerking
- atonic - brief loss of muscle tone - drop attack
Focal - seizures arise from one part of hemisphere
- frontal - clonic movements or tonic with upper arms raised
- temporal - lip smacking
- occipital - stereotyped visual hallucinations
- parietal - contralateral dysaesthesias
32
Risk factors for epilepsy
```
Fhx
Metabolic/neurodegenerative disorders
Head trauma
Autism - focal
Hx of febrile seizures
```
33
Presentation of epilepsy
Depends on type
Incontinence
Tongue biting
Post-ictal phenomena - sleepiness, headaches, amnesia, confusion
34
Ix for epilepsy
EEG - seizures provoked if not video EEG or 24 hr EEG
Blood glucose, FBC, metabolic panel - ix metabolic or infective causes
ECG - rule out convulsive syncope
35
Mx of epilepsy
Valproate
Lamotrigine
Carbamazepine
Monotherapy 1st
36
Define Idiopathic Parkinson's Disease
Neurodegenerative disorder characterised by cardinal features of
- resting tremor
- rigidity
- bradykinesia
- postural instability
37
Epidemiology of Idiopathic Parkinson's disease
Most common neurodegenerative disorder
- prevalence of 1.6%
Incidence increases with age
Mean onset 65 years
38
Presentation of Idiopathic Parkinson's Disease
```
Bradykinesia - slowness of movements, progressive reduction in amplitude of repeated movements, delay in initiating movements
Resting tremor - 4-6Hz pill rolling tremor
Cogwheel rigidity
Postural instability
Masked face - loss of facial movement and expression
Hypophonia
Micrographia
Stooped posture
Shuffling gait
Conjugate gaze disorders
Dementia
Constipation, depression and fatigue
Progressive symptoms
```
39
Ix for Idiopathic Parkinson's Disease
Diagnosis made on Parkinson's exam
- observation, basic movements, fine movements, tone, gait, pull test
Dopaminergic agent trial - improves symptoms
MRI brain - normal with age related changes
Functional neuroimaging - decreased basal ganglia dopamine uptake
40
Mx of Idiopathic Parkinson's Disease
Levadopa + co-careldopa
- benefits last 5-10 years
- SE - excessive movements and nausea
Physical activity
- under supervision with falls prevention
Trihexyphenidyl or propranolol for tremor
41
DDx for Idiopathic Parkinson's Disease
Essential tremor - fast, postural and kinetic, improves with rest, involves head and neck
Dystonic tremor - task-specific, flurries, thumb extension
Progressive supranuclear palsy - vertical gaze palsies, significant postural instability, midbrain atrophy on MRI
Multi-system atrophy - poor response to levodopa, autonomic dysfunction, pyramidal or cerebellar dysfunction
Lewy-body dementia - hallucinations and fluctuating mental state first
Drug induced parkinsonism
42
Define Amyotrophic Lateral Sclerosis
Most common motor neurone disease
| Upper and lower motor neurone findings
43
Epidemiology of Amyotrophic Lateral Sclerosis
Mean onset is 57
| Prevalence of 5 per 100,000
44
Pathophysiology of Amyotrophic Lateral Sclerosis
Progressive loss of cortical, bulbar and ventral cord motor neurones
After motor cell death, retrograde axonal degeneration follows
Subsequent denervation and reinnervation in corresponding muscles
45
Presentation of Amyotrophic Lateral Sclerosis
```
Upper extremity weakness
Stiffness with poor coordination
Spasticity, unsteady gait
Painful muscle spasms
Difficulty getting out of chairs
Foot drop
Head drop/stooped posture/lumbar lordosis
Muscle atrophy
Hyper-reflexia
Dyspnoea
Dysphagia
Dysarthria
```
46
Ix for Amyotrophic Lateral Sclerosis
Generally diagnosed due to progression of symptoms and no other explanation
EMG - evidence of ongoing, chronic denervation
Repetitive nerve stimulation - modest decrease in motor action amplitude
MRI brain and spine - normal
47
Mx of Amyotrophic Lateral Sclerosis
```
Riluzole - slows disease progression
- monitor LFTs every 3 months and neutrophils
BiPAP - for resp symptoms
Baclofen + physio - spasticity
Supportive care
```
48
Differentials of Amyotrophic Lateral Sclerosis
Primary lateral sclerosis - isolated UMN disorder, weakness and spasticity
Progressive muscular atrophy - isolated LMN disorder, weakness and fasciculations
49
Define MS
Inflammatory CNS demyelination causing episodic neurological dysfunction in 2 areas
50
Types of MS
Relasping- remitting - active/not active within a specified time - assess annually
Progressive - primary (from onset) or secondary (after an initial relapsing course)
51
Epidemiology of MS
Incidence of 6 per 100,000
Commonly diagnosed aged 20-40
3 times more likely in females
52
Pathophysiology of MS
Lymphocytes activated by infection or metabolic stress
Enter CNS via receptor or endothelial cells
Breach in BBB -> further influx of inflammatory cells
Demyelination occurs by direct toxicity and macrophage activity
Multi-focal demyelination and loss of oligodendrocytes
53
Presentation of MS
Optic neuritis
- sudden onset, reduced visual acuity, reduced visual fields, red desaturation and RAPD
Abnormal sensation
- numbness, tingling, patch of burning/wetness
Foot dragging/slapping
- gradual weakness onset with activity, resolves with rest
Leg cramping
Fatigue
Urinary frequency
- damage to CNS causes detrusor instability
Bowel dysfunction
Spasticity/increased muscle tone and hyperreflexia - often asymmetrical
Incoordination
- wide based gait or limb ataxia
Memory problems
54
Ix for MS
MRI brain
- hyper-intensities in periventricular white matter
MRI spinal cord
- demyelinating lesions, particularly cervical spine
FBC, metabolic panel, TFTs, B12 - exclude alternate diagnoses as normal in MS
55
Mx of MS
```
Modafinil
- for fatigue not improved by lifstyle modification
Oxybutynin - for urinary symptoms
Gabapentin - for pain
Gentle stretching + beclofen - hypertonia
Propranolol - tremor
Physio - gait distrubance
Acute relapse
- Methylprednisolone - 3-5 days high dose to relieve symptoms
- plasma exchange
Relapsing-remitting
- immunomodulators
Primary progressive
- ocrelizumab - monoclonal antibody
Secondary progressive
- methyprednisolone
```
56
Define Myasthenia Gravis
Chronic autoimmune disorder of post-synaptic membrane at the neuromuscular junction
57
Epidemiology of MG
15 per 100,000
Bimodal peak
- women 20-30s
- men 50-70
58
Differentials of children presenting with myasthenic symptoms
```
Transient neonatal myasthenia
- occurs in 10-15% of babies born to mothers with MG
- disappears after a few weeks
Congenital myasthenia
- rare
Juvenile myasthenia gravis
- more common in females
```
59
Pathophysiology of MG
Abnormal antibodies generated which attack normal synaptic tissues
Destruction of nicotinic acetylcholine receptor or related protein MuSK (Muscle-Specific Kinases)
60
Presentation of MG
Painless fatigability of specific muscles
- progressively worse during activity
- resolves with rest
Ptosis - weakness of levator palpebrae superiororis
Diplopia - weakness of extraocular muscles
Dysphagia - facial and oropharyngeal muscles
Dysarthria - nasal speech
Facial paresis
Proximal limb weakness
Shortness of breath
61
Ix for MG
Serum AChR antibody analysis
MuSK antibodies
Pulmonary function tests
62
Mx of MG
```
Emergency
- intubation and mechanical ventilation
- plasma exchange or IV Ig
- supportive care - DVT prophylaxis, ulcer prophylaxis, nutrition, hydration
- short term corticosteroid
- Rituximab
Ongoing disease
- Pyridostigmine - acetylcholinesterase inhibitor
- immunosuppressant
```
63
Define vestibular schwannoma (acoustic neuroma)
Benign cerebellopontine angle tumour
| - grows from superior vestibular component of vestibulocochlear nerve
64
Epidemiology of vestibular schwannoma
1. 5 per 100,000
| 3: 2 F:M
65
Pathophysiology of vestibular schwannoma
Tumour growth occurs due to p22 abnormalities
- sporadic
- familial autosomal dominant - neurofibromatosis type 2
66
Presentation of vestibular schwannoma
```
Unilateral hearing loss
Progressive episodes of dizziness
Facial numbness - starts with tongue and jaw
Tinnitus
Headaches
Swallowing difficulties
```
67
Ix for vestibular schwannoma
Audiogram - asymmetrical sensorineural hearing loss
Gadolinium-enhanced MRI head - uniformly dense mass extending into internal acoustic meatus
Auditory brainstem reflexes - asymmetrical hearing losss
68
Mx of vestibular schwannoma
Observation - small or non-growing tumours
Focused radiation - hearing preserved in 70%
- risks = secondary malignancy, hydrocephalus, hearing loss
Surgery - hearing preserved in 70%
- risks = hearing loss, facial weakness, CSF leak
69
Define dementia
Chronic or progressive syndrome of brain disease leading to disturbance of multiple higher cortical functions
70
Epidemiology of dementia
1% of over 60s
| 45% of over 95s
71
Risk factors for dementia
```
Age
Female
Genetics
Smoking
Alcohol
Obesity
Hypertension
CVS disease
Psychosocial
- no physical activity
- depression
```
72
Define Alzheimer's
Deposition of amyloid plaques and neurofibrillary tangles (tau proteins)
73
Presentation of Alzehmier's
```
Short term memory loss
Problems with language - shrinking vocab
Disorientation
Mood swings
Apraxia with fine motor tasks
```
74
Medications for Alzehmier's
Acetylcholinesterase inhibitors
| Memantine
75
Define vascular dementia
Stepwise cognitive decline with progressive vascular occlusions
76
Presentation of vascular dementia
Symptoms may include cognitive decline and memory impairment
- stepwise
Focal neurological signs may be present
Brain imaging shows cerebrovascular disease
77
Define Lewy Body Dementia
Abnormal deposits of alpha-synuclein (Lewy-bodies) in the brain
78
Presentation of Lewy Body Dementia
```
Symptoms of parkinsonism
Impaired cognition
Sleep disorders
Visual hallucinations
Fluctuations in attention
Slowness of movement
Mood changes
```
79
Define Parkinson's disease dementia
Parkinson's disease well established before cognitive symptoms
80
Features of frontotemporal dementia
Changes in behaviours, social conduct, impulsivity, loss of comprehension
MRI shows frontal/temporal lobe atrophy in later disease
81
Ix for dementia
Physical exam - looking for other causes (infection, focal neurology)
Bloods - U+Es, B12, folate, TFTs
ECG, CXR, EEG, MSU
CT/MRI - cerebral atrophy in late stages
82
Mx for dementia
MDT - psychiatrist, GP, occupation therapist, support worker
Psychological intervention - cognitive stimulation therapy, cognitive rehab
Comorbidities
- vascular risk modification
- avoid polypharmacy
- depression screen
Risk assessment - driving, career strain, social care
Future planning - follow up, power of attorney, will
83
Define polyneuropathy
Generalised disease of peripheral nerves
84
Epidemiology of polyneuropathy
```
5% of population
Often a neurological manifestation of systemic illness
- hypothyroidism
- HIV
- Hep C
- SLE
- chronic renal failure
- paraneoplastic
- B12 deficiency
```
85
Presentation of polyneuropathy
Glove and stocking distribution
Symmetrical numbness with paraesthesia and dysesthesia in feet and lower extremities
Distal impairment of temperature, pinprick and vibration - small-diameter sensory fibres
Balance and gait impaired
Atrophy of muscles and ankle weakness
Autonomic involvement - diarrhoea, constipation, sweating, orthostatic light-headedness
Reduced or absent distal reflexes
86
Investigations for polyneuropathy
```
FBC
ESR
Fasting glucose
Cholesterol panel
TSH
Vit B12 levels
Hepatitis serology
HIV and antinuclear antibodies
Nerve conduction, EMG - distinguish axonal and demyelinating disease
```
87
Causes of polyneuropathy
```
Axonal
- axons degenerate distal-to-proximally
- longer axons affected first
- diabetes
- alcohol
- hypothyroidism
- B12/folate deficiency
Demyelinating
- Guillain-Barre syndrome
- paraneoplastic syndromes
```
88
Mx of polyneuropathy
```
Treat cause
Axonal
- minimise exposure to offending agent
Demyelinating
- IV IgG, glucocorticoids, plasma exchange
Pain
- gabapentin/carbazepine/TCA
```
89
Features of diabetic neuropathy
Occurs in 50% of diabetic patients
| - greater hyperglycaemia = greater risk
90
Define spondylosis
Spontaneous degenerative disease of the disc or facet joints of the spine
91
Types of spondylosis
Cervical
| Lumbar - most common cause of lower back pain in adults
92
Risk factors for spondylosis
Increasing age
Genetic influence
Trauma/excessive exertion
93
Pathophysiology of spondylosis
Loss of hydration of nucleus pulposus and narrowing
Stress increases on facet joints
Loss of disc height, herniation and nerve root irritation
94
Presentation of cervical spondylosis
Often asymptomatic
Spontaneous onset neck pain
Cervical muscle pain and spasm - scalene, trapezius, interscapular
Headaches or occipital pain
Numbness/arm weakness
Radiating arm pain - radiculopathy
Reflex changes - decreased in radiculopathy, increased in myelopathy
95
Presentation of lumbar spondylosis
Persistent low back pain - worsens with axial loading
Radicular leg pain - nerve root compression
Restricted lumbar motion
Positive straight leg raise - pain reproduced by passively raising extended leg
96
Ix for spondylosis
```
X-ray (cervical/erect lumbar)
- osteoporosis, fractures, vertebral mets, degenerative changes
- osteophytes
- disc space narrowing
- foraminal stenosis
- endplate sclerosis
- ligament calcification
MRI spine
- signs of degeneration - decreased signal on T2 weighted
- disc height
- annular tears
```
97
Mx of spondylosis
```
Physiotherapy
NSAIDs
Muscle relaxants if spasms present - diazepam
Dexamethasone
- facet joint injections for pain
- orally for radiculopathy
Surgical decompression
Immobilisation
Facet joint blocks - local anaesthetic + local corticosteroid
```
98
Define Bell's Palsy
Acute unilateral peripheral facial nerve palsy
99
Epidemiology of Bell's Palsy
28 per 100,000
| 15-45 years
100
Risk factors for Bell's Palsy
Pregnancy
Recent URTI
FHx
101
Pathophysiology of Bell's Palsy
Reactivation of HSV-1
- destruction of ganglion cells and infection of Schwann cells
- demyelination and neural inflammation
102
Presentation of Bell's Palsy
Unilateral symptoms
All nerve branches
Facial weakness - raising eyebrows, clenching eyes shut, puff out cheeks
Dry eye - loss of blink
Pain - post-auricular and otalgia
Synkinesis - involuntary synchronous movement of facial region with voluntary movement of another region
Hyperacusis - increased sound perception in ipsilateral ear
- impairment of stapedius reflex
Dysgeusia - taste disturbance
103
Ix for Bell's Palsy
Clinical presentation
104
Scoring system for Bell's Palsy
Grade 1 = normal
Grade 2 = slight weakness/asymmetry
Grade 3 = obvious weakness, intact ability to close eye
Grade 4 = obvious weakness, inability to fully close eye
Grade 5 = barely perceptible movement
Grade 6 = no movement
105
Mx of Bell's Palsy
```
Prednisolone - 10 day course
Eye protection
- artificial tears
- overnight eyelid taping
Surgical decompression
```
106
Define Carpal Tunnel Syndrome
Entrapment neuropathy of median nerve within the carpal tunnel
- rapid pressure can lead to ischaemia and nerve scarring
- demyelination and axonal loss
107
Risk factors for carpal tunnel syndrome
```
Myxoedema
Obesity
DM
Idiopathic
Acromegaly
Neoplasm
Trauma
RA
Amyloidosis
Pregnancy
```
108
Presentation of carpal tunnel syndrome
Night-time worsening - waking through the night
Numbness in median nerve distribution
- palmar surface of first 3.5 digits and distal dorsal surface of first 3 digits
- thenar eminence
Intermittent symptoms with gradual onset
Weakness/atrophy of thenar muscles
109
Ix for carpal tunnel syndrome
Phalen's test
- hold wrists in flexion for 60 seconds to elicit symptoms
Tinel's sign
- tap carpal tunnel to elicit pain
EMG - focal slowing of conduction in median sensory across carpal tunnel
110
Mx of carpal tunnel syndrome
```
Wrist splint
NSAIDs
Corticosteroids injection
Thiazides - if oedema present
Surgical release
```
111
Causes of ulnar nerve palsy
```
Elbow
- trauma at medial epicondyle
- compression in cubital tunnel
Wrist
- lacerations to anterior wrist
```
112
Presentation of ulnar nerve palsy
Elbow
- flexion of wrist accompanied by abduction - flexor carpi ulnaris and flexor digitorum profundus
- loss of abduction and adduction of fingers - interossei
- loss of movement in 4th and 5th digits - medial 2 lumbricals and hypothenar muscles
- loss of thumb adduction - adductor pollicis
- loss of sensation over medial hand
Wrist
- motor as above
- dorsal sparing
- loss of sensation over palmar aspect of medial 1.5 fingers
113
Define ischaemic optic neuropathy (CN II)
Sudden-onset, painless, monocular visual loss in older adults
114
Presentation of ischaemic optic neuroapthy
With arteric involvement
- headache, malaise, myalgia and jaw claudication
Segmental swelling of pallid optic disc
ESR > 46
CRP elevated
Temporal artery biopsy - focal areas of inflammation, giant cells seen
115
Risk factors for ischaemic optic neuropathy
Hypertension
Diabetes
Smoking
116
Viral infection of CII mononeuropathy
Child with recent viral infection or immunisation
Presenting with peri-occular pain
Triad of visual loss, swollen optic disc and macula star
Diagnosed on clinical presentation
117
Features of vascular malformations of CN V
Unilateral often progressive paroxysmal pain
- lasts seconds to minutes
- precipitated by triggers - touch, chewing
- commonly V2/3 distributions
118
Diagnosis of CNV mononeuropathies due to vascular malformation
Brain MRI
| - aberrant vessel at cerebellopontine angle
119
Presentation of Herpes Zoster
CN V mononeuropathy
3-4 days burning pain +/- vesicular rash
Erythematous maculopapular rash followed by clear vesicles
- does not cross midline
Diagnosed on clinical presentation
120
Presentation of Ramsay Hunt Syndrome
```
Shingles outbreak in CN VII
Unilateral facial weakness
- affects upper and lower face
- constant dull ear pain
- hearing loss, tinnitus or vertigo
Erythematous herpetic rash of ipsilateral ear or mouth
```
121
Features of cerebrovascular accident affecting CN VII
```
Acute onset
Contralateral limb weakness
Dysphagia
Dysarthria
Sparing of upper facial muscles
```
122
Features of neural presbycusis
```
Age-related disorder of CN VIII
Difficulty in speech discrimination
Slow gradual hearing loss
Usually bilateral
Normal otoscopic exam
Bilateral sensorineural hearing loss - usually high frequency
```
123
Features of drug effect of CN VIII
```
New-onset vestibulocochlear nerve dysfunction after starting medication
- aminoglycosides
- platinum based chemotherapeutic agents
- salicylates
- quinine
- loop diuretics
Tinnitus bilateral
Rinne's test positive
```
124
Features of iatrogenic CN X nerve damage
Recent thoracic neck surgery
- horse voice
No palatal droop or uvular deviation
Laryngoscopy shows ipsilateral vocal fold paralysis
125
Features of apical lung tumour on CN IX, X
New-onset hoarseness
Hx of smoking
Cough
Decreased air entry, decreased percussion note or normal auscultation
126
Ix for CN IX, X mononeuropathies
Laryngoscopy - ipsilateral vocal cord paralysis
CXR - apical lung tumour
Chest CT - lung tumour and relationship surrounding structures
CT-guided thoracoscopic biopsy - malignant cells present
127
Features of iatrogenic damage to CN XI
Isolated accessory nerve palsy - weakness of sternocleidomastoid and trapezius muscles, mild scapular winging
Recent lymph node biopsy, neck dissection, jugular vein cannulation or carotid enterectomy
High-resolution USS - hypoechoic tubular structure in posterior triangle
Nerve conduction studies - prolonged latencies
EMG - signs of denervation
128
Features of cerebrovascular accident damage to CN XII
Acute, onset contralateral limb weakness with associated cranial nerve deficits
Progressive bulbar palsy
- difficulty chewing, swallowing and talking
- tongue weakness
- deviated to ipsilateral side on protrusion
- fasciculations
Contralateral hemiplegia with facial sparing, contralateral loss of position and vibration sensation
Brain MRI - ischaemic regions appear high-density
