Neurology Flashcards

Question

Identify the hallmark pathological feature of Parkinson's Disease.

Answer 1

Synuclein-Filled Lewy Bodies within the substantia nigra.

Answer 2

Parkinsons' Disease is characterised by: 1. tremour (occurs at rest, alleviated with movement, asymmetric, "pin-rolling...") 2. bradykinesia (slowed movement) 3. rigidity (cog-wheel or lead-pipe rigidity) 4. mask-like facies 5. postural instability 6. dementia 7. sleep disturbances 8. other neurological manifestations (e.g. orthostatic hypotension, oesophageal motility issues, urinary hesitancy / urgency, loss of smell)

Answer 3

Parkinson's Disease requires BRADYKINESIA plus ONE of the following for a diagnosis: 1. rigidity 2. resting tremour (between 4 to 6 hZ) 3. postural instability NOT contributed to by primary visual, vestibular, cerebellar or proprioceptive dysfunction

Answer 4

MECHANISM OF ACTION Levodopa is a dopamine pre-cursor. It has the ability to cross the blood-brain barrier and be converted into dopamine by the dopamine decarboxylase enzyme. This helps to alleviate the symptoms of Parkinson's Disease, specially bradykinesia, tremour and rigidity. Carbidopa is a peripheral dopamine decarboxylase inhibitor. This drug CANNOT cross the blood brain barrier, therefore, remains in peripheral circulation to prevent excessive accumulation of dopamine. APPROPRIATE DOSE 50mg + 12.5 mg TDS, PO increasing to 100mg + 25mg TDS, PO over 1 to 2 weeks. ``` SIDE EFFECTS ✔️ psychosis ✔️ poor sleep and vivid dreams ✔️ mood disturbances ✔️ nausea and vomiting ✔️ diarrhoea and constipation ✔️ heart palpitations ```

Answer 5

1. dopamine agonists 2. MAO-B inhibitors 3. acetylcholine antagonists (e.g. benztropine)

Answer 6

✔️ reduced independence with activity of daily living ✔️ increased reliance on others (family members, carers etc). ✔️ dementia (particularly Lewy Body) ✔️ depression ✔️ aspiration pneumonia ✔️ increased cardiovascular risk ✔️ death

Answer 7

Dementia is a progressive and non-reversible reduction in cognition, executive functioning, speech and language, memory and visuospatial awareness. It is an umbrella term that encompasses multiple conditions characterised by a similar cognitive decline. ``` Subtypes of dementia include: ✔️ Alzheimer's Disease ✔️ vascular dementia ✔️ Pick's Disease / frontotemporal dementia ✔️ Lewy Body dementia ✔️ Parkinson's Disease ✔️ Motor Neuron Disease ```

Answer 8

1. amnesia: difficulty with memory (long or short term) 2. agnosia: difficulty recognising familiar faces / objects 3. apraxia: difficulty with coordinated movements 4. aphasia: difficulty with communication and speech

Answer 9

``` ✔️ dementia ✔️ delirium ✔️ depression ✔️ drugs ✔️ subdural hematoma (acute, subacute or chronic) ```

Answer 10

Bedside Ix ✔️ urine dipstick + urine MCS ✔️ blood glucose levels ``` Laboratory Ix ✔️ FBC + WCC ✔️ Inflammatory markers ✔️ UECs ✔️ eLFTs ✔️ coags ✔️ TFTs ✔️ Iron studies + B12 + folate ✔️ syphilis serology ✔️ blood glucose level ✔️ blood culture (if sepsis suspected) ✔️ toxicology (?) ``` Imaging Ix ✔️ non-contrast CT head ✔️ CXR / chest CT

Answer 11

EDUCATION ✔️ provide adequate education to the patient and their family ✔️ refer to a support group ✔️ refer to a dementia specialist (e.g. psychology services) ENVIONRMENT ✔️ encourage patient to stay in a familiar environment for as long as possible (e.g. their home) ✔️ time-orientating cues ✔️ familiar faces (e.g. family members, carers) ✔️ establish a routine DRUGS AND MEDICATIONS ✔️ cease any non-essential medications ✔️ cease or change any medications that may contribute to BPSD or delirium ``` GENERAL HEALTH ✔️ optimise general health and wellbeing ✔️ manage other medical conditions appropriately ✔️ encourage physical activity ✔️ smoking cessation ✔️ reduce alcohol consumption ```

Answer 12

1. acetylcholinesterase inhibitors --> help improve symptoms in the short term; do not address the underlying degenerative nature of the disease 2. antidepressants --> improve / alleviate mood symptoms 3. atypical antipsychotics --> behavioural and psychotic symptoms of dementia 4. benzodiazepines --> can assist with acute aggression / agitation

Answer 13

BPSD are common complaints in the end stages of dementia. The most common presentations include: ✔️ hallucinations (e.g. visual, auditory) ✔️ delusions ✔️ aggression and agitation ✔️ depression and anxiety ✔️ apathy and disinhibition ✔️ irritability or indifference ✔️ "twightlighting" ✔️ night time behaviours (e.g. wandering) BPSD require both pharmacological and non-pharmacological interventions.

Answer 14

Delirium is a transient and reversible reduction in consciousness / orientation and awareness / cognition. It is usually of an acute onset and can be treated.

Answer 15

D = drugs (e.g. medications, drug intoxication, drug withdrawals) E = electrolyte imbalances (e.g. hyponatremia, hypokalaemia, magnesium, calcium and phosphate) L = low oxygen (e.g. anaemia, hypoxia, congestive cardiac failure) I = infection (e.g. UTI, pneumonia) R = retention (e.g. urinary, fecal) I = increased ICP (e.g. malignancy, tumour, bleed) U = uremia M = metabolic (e.g. low blood glucose, thyroid dysfunction)

Answer 16

Bedside Ix ✔️ blood glucose level ✔️ urine dipstick + MCS ✔️ ECG ``` Laboratory Ix ✔️ FBC + WCC ✔️ ESR + CRP ✔️ UECs ✔️ blood culture ✔️ iron studies + B12 + folate ✔️ CMP ``` Imaging Ix ✔️ CXR ✔️ abdo XR ✔️ non-contrast CTB or MRI

Answer 17

1. Identify and treat / reverse the underlying cause (if possible). 2. Keep the patient in a quiet and well-lit room. 3. Space and time orientating features should be present. 4. Optimise hearing and vision. 5. Have a family member / support person close by for familiarity. 6. Continually re-assess the patient to ensure no important diagnoses have been missed. 7. Avoid using benzodiazepines. 8. Consider atypical antipsychotics, including: ✔️ olanzapine ✔️ risperidone ✔️ haloperidol

Answer 18

GBS is a believed to be an auto-immune mediated polyneuropathy that occurs following viral infection. It is acute, rapidly progressive but usually self-limiting. GBS is an example of a LOWER MOTOR NEURON disease.

Answer 19

``` ✔️ symmetrical flaccid paralysis ✔️ loss of sensation distally ✔️ loss of deep tendon reflexes ✔️ facial and oropharyngeal involvement in 50% of cases ✔️ respiratory paralysis in 10% of cases ```

Answer 20

✔️ myasthenia gravis ✔️ botulism toxin ✔️ poliomyelitis ✔️ tick paralysis

Answer 21

IV immunoglobulin is the first-line treatment for GBS. Do NOT give corticosteroids, as these usually worsen the disease progression.

Answer 22

Myasthenia gravis is an autoimmune condition in which autoantibodies are produced against the acetyl choline receptor at the neuromuscular junction. This leads to early activation at the NMJ and inadequate muscle contraction with nerve stimulation.

Answer 23

✔️ symmetrical fatiguable muscle contraction --> NOT associated with sensory changes, changes to reflexes or abnormalities with coordination ✔️ ptosis ✔️ dysarthria or dysphagia ✔️ respiratory muscle weakness --> may lead to respiratory failure

Answer 24

1. Endophonium test --> endophonium is an acetyl cholinesterase inhibitor; prolongs the presence of acetyl choline within the synaptic cleft of the NMJ and temporarily alleviates symptoms 2. anti-ACh-R autoantibodies 3. anti-musK autoantibodies 4. chest CT / MRI (85% of patients with MG have thymic hyperplasia) 5. spirometry --> used to assess forced vital capacity over time

Answer 25

``` ✔️ thymectomy --> around 85% of patients achieve remission afterwards ✔️ corticosteroids ✔️ IV immunoglobulin ✔️ anti-cholinesterase inhibitors ✔️ symptomatic relief ```

Answer 26

Bell's Palsy is a neurological condition characterised by acute onset, unilateral lower motor neuron weakness of the facial nerve in the absence of an identifiable cause. The exact pathophysiology is unknown; believed to be related to auto-immune inflammation post-viral infection.

Answer 27

✔️ unilateral facial drooping and muscle weakness (no sparing of the forehead) ✔️ dryness of the eye and mouth ✔️ taste disturbances ✔️ hyperacusis

Answer 28

Corticosteroids.

Answer 29

1. Nystagmus 2. Intention tremor 3. Scanning speech

Answer 30

✔️ blurred vision (optic neuritis) ✔️ limb weakness / paraesthesia without autonomic dysfunction ✔️ ataxia, facial numbness, diplopia ✔️ first episode of trigeminal neuralgia ✔️hemiplegia ✔️ tingling in spine of limb / neck flexion (Lhermitte’s Phenomenon) ✔️tonic spasms

Answer 31

Multiple sclerosis (MS) is a chronic, degenerative disorder of the CNS, characterised by immune-mediated inflammatory process. This process results in demyelination of the white matter within the spinal cord and brain.