Neurology Flashcards

Question

Thrombectomy Types and who to offer to

Answer 1

Thrombectomy within 6 hrs of onset, together with IV thrombolysis (if within 4.5 hrs) for: - Acute ischaemic stroke AND - Confirmed occlusion of the PROXIMAL ANTERIOR CIRCULATION (CTA or MRA evidence) Thrombectomy asap who were known to be well 6-24 hrs earlier (including wake-up strokes): - Confirmed occlusion of PROXIMAL ANTERIOR CIRCULATION (CTA or MRA) AND - Potential to salvage brain tissue, as shown by imaging, e.g. CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume

Answer 2

(Together with IV thrombolysis (if within 4.5 hrs): - Last known to be well up to 24 hrs earlier (including wake-up strokes AND - Acute ischaemia stroke and confirmed occlusion of PROXIMAL POSTERIOR CIRCULATION (basilar or posterior cerebral artery) AND - Potential to salvage brain tissue, as shown by imaging, e.g. CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume

Answer 3

- 1st line = Clopidogrel - If CI --> Aspirin + MR dipyridamole - Monotherapy with MR dipyridamole if aspirin CI - Statins - Carotid endarterectomy or stenting if carotid artery disease - Treat modifiable RFs - HTN, DM

Answer 4

- Stroke or TIA in the carotid territory and are not severely disabled - Should only be considered if: - **Carotid stenosis > 70% according ECST criteria** - (or > 50% according to NASCET criteria)

Answer 5

- Clopidogrel 75 mg OD | - Atorvastatin 80 mg - not immediately started

Answer 6

- Nurses - SALT - Dieticians - Physio - OT - Social services - Optometry and ophthalmology - Psychology - Orthotics

Answer 7

- Must remain normovolaemic - Hypovolaemia can worsen the ischaemic penumbra, as well as increase risk of other complications such as infection, deep vein thrombosis, constipation and delirium - Over-hydration can also complicate matters by leading to cerebral oedema, cardiac failure and hyponatraemia - Oral hydration is preferable in those who are able

Answer 8

- Carefully monitor, particularly if NBM - Those with hyperglycaemia have increased mortality - Maintain 4-11 mmol/L in those with acute stroke

Answer 9

Likely due to increased tissue acidosis from anaerobic metabolism, free radical generation, and increased blood brain barrier permeability post injury

Answer 10

Only use antihypertensive meds in stroke if: - Hypertensive encephalopathy - Hypertensive nephropathy - Hypertensive cardiac failure/myocardial infarction - Aortic dissection - Pre-eclampsia/eclampsia In these cases use intravenous labetalol, nicardipine and clevidipine as first-line agents In candidates from thrombolytic therapy -> reduce to 185/110 mmHg

Answer 11

1. Unilateral hemiparesis and/or hemisensory loss of face, arm, leg 2. Homonymous hemianopia 3. Higher cognitive dysfunction, e.g. dysphasia

Answer 12

Involves middle and anterior cerebral arteries

Answer 13

All 3 of primary criteria are present 1. Unilateral hemiparesis and/or hemisensory loss of face, arm, leg 2. Homonymous hemianopia 3. Higher cognitive dysfunction, e.g. dysphasia

Answer 14

Smaller arteries of anterior circulation | e.g. upper or lower division of middle cerebral artery

Answer 15

2 of the criteria are present: 1. Unilateral hemiparesis and/or hemisensory loss of face, arm, leg 2. Homonymous hemianopia 3. Higher cognitive dysfunction, e.g. dysphasia

Answer 16

Perforating arteries around the internal capsule, thalamus and basal ganglia

Answer 17

Presents with one of the following: 1. Unilateral weakness (and/or sensory deficit) of face and arm, arm and leg, or all three 2. Pure sensory stroke 3. Ataxic hemiparesis Strong association with HTN

Answer 18

Vertebrobasilar arteries

Answer 19

Present with one of the following: 1. Cerebellar or brainstem syndromes 2. Loss of consciousness 3. isolated homonymous hemianopia

Answer 20

Posterior inferior cerebellar artery

Answer 21

- aka Wallenberg's syndrome - Ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner's - Contralateral: limb sensory loss Cerebellar signs, contralateral sensory loss & ipsilateral Horner's

Answer 22

MIDBRAIN STROKE - Ipsilateral III palsy - Contralateral weakness

Answer 23

- Contralateral hemiparesis and sensory loss | - Lower extremities > upper

Answer 24

- Contralateral hemiparesis and sensory loss - Upper extremities > lower - Contralateral homonymous hemianopia - Aphasia

Answer 25

- Contralateral homonymous hemianopia with macular sparing | - Visual agnosia

Answer 26

- Ipsilateral CN III palsy | - Contralateral weakness of upper and lower extremity

Answer 27

- Ipsilateral: facial pain and temperature loss - Contralateral: limb/torso pain and temperature loss - Ataxia, nystagmus

Answer 28

- Symptoms are similar to Wallenberg's (see above) BUT - Ipsilateral: facial paralysis and deafness

Answer 29

Amaurosis fugax

Answer 30

'Locked-in' syndrome

Answer 31

- **Superior temporal gyrus** | - It is typically supplied by the **inferior** division of the left MCA

Answer 32

- Receptive aphasia - This area 'forms' the speech before 'sending it' to Broca's area - Lesions result in sentences that make no sense, word substitution and neologisms but speech remains fluent - 'word salad' - Comprehension is impaired

Answer 33

- **Inferior frontal gyrus** | - It is typically supplied by the **superior** division of the left MCA

Answer 34

- Expressive dysphasia - Speech is non-fluent, laboured, and halting - Repetition is impaired - Comprehension is normal

Answer 35

- A tissue plasminogen activator | - Converts plasminogen to the proteolytic enzyme plasmin, which lyses fibrin as well as fibrinogen

Answer 36

A transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction Replaced the previous time-based definition

Answer 37

Possible features include: - unilateral weakness or sensory loss. - aphasia or dysarthria - ataxia, vertigo, or loss of balance - visual problems - sudden transient loss of vision in one eye (amaurosis fugax) - diplopia - homonymous hemianopia

Answer 38

ABCD2 prognostic score | Though no longer recognised by NICE

Answer 39

- Do not do CT unless clinical suspicious of an alternative diagnosis that CT could detect - MRI - diffusion-weighted and blood sensitive is preferred - Done on same day if possible - Carotid imaging --> URGENT carotid doppler unless they are not a carotid endarterectomy candidate

Answer 40

Give aspirin 300 mg immediately UNLESS: - Bleeding disorder/on anticoagulant - need immediate admission for imaging to exclude a haemorrhage - Already taking low-dose aspirin regularly - just continue this - Aspirin is CI - discuss with team Advise the person not to drive until they have been seen by a specialist.

Answer 41

- Clopidogrel = 1st line (or aspirin and dipyridamole if CI)

Answer 42

- A crescendo TIA is where there are two or more TIAs within a week - This carries a high risk of developing in to a stroke

Answer 43

Acute, unilateral, idiopathic, facial nerve paralysis

Answer 44

- Aetiology is unknown - role of herpes simplex is investigated - Peak = 20-40 yrs old - More common in pregnancy

Answer 45

- LOWER motor neuron facial nerve palsy = FOREHEAD AFFECTED - Post-auricular pain (may precede paralysis) - Altered taste - Dry eyes - Hyperacusis (reduced tolerance to sound)

Answer 46

- Oral prednisolone within 72 hours of onset of Bell's palsy - Either continue 50 mg for 10 days or 60 mg for 5 days (followed by 5-day reducing regime of 10 mg a day) - Lubricating eye drops

Answer 47

- Ophthalmology review for exposure keratopathy if develop pain in the eye - If no signs of improvement in paralysis after 3 months then refer urgently to ENT - Refer to plastic for more long-standing weakness

Answer 48

- Most people with Bell's palsy make a full recovery within 3-4 months - If untreated around 15% of patients have permanent moderate to severe weakness

Answer 49

- Fever - Headache - Psych symptoms - Odd behavior - Seizures - Vomiting - Focal features, e.g. aphasia - Peripheral lesions, e.g. cold sores (have no relation to the presence of HSV encephalitis)

Answer 50

- HSV-1 responsible for 95% of cases in adults - Typically affects temporal and inferior frontal lobes - Primarily the temporal!! (esp if viral)

Answer 51

-CSF: lymphocytosis, elevated protein - PCR for HSV - Neuroimaging: - medial temporal and inferior frontal changes, e.g. petechial haemorrhages - normal in 1/3rd of patients - MRI is better - EEG pattern: lateralised periodic discharges at 2 Hz

Answer 52

- IV aciclovir should be started in all cases The prognosis is dependent on whether aciclovir is commenced early. If treatment is started promptly the mortality is 10-20%. Left untreated the mortality approaches 80%

Answer 53

- Neuropsychiatric disorder - Caused by thiamine (B1) deficiency - Commonly seen in alcoholics - Rarer causes: persistent vomiting, stomach cancer, dietary deficiency

Answer 54

Classic triad: - Nystagmus/ophthalmoplegia - Ataxia - Confusion/altered GCS Also peripheral sensory neuropathy

Answer 55

Petechial haemorrhages occur in a variety of structures in the brain including the mamillary bodies and ventricle walls - Decreased red cell transketeloase - MRI

Answer 56

Urgent replacement of thiamine (B1!!!) - IV Pabrinex for 5 days - Followed by oral thiamine

Answer 57

- If WE is not treated Korsakoff's syndrome may develop as well - This is termed Wernicke-Korsakoff syndrome and is characterised by the addition of antero- and retrograde amnesia and confabulation in addition to the WE symptoms

Answer 58

- Parkinsonism - Cerebellar signs - Autonomic disturbance - erectile dysfunction: often an early feature - postural hypotension - atonic bladder

Answer 59

- Myelin covers the axons of neurones in CNS, helps the electrical impulse move along quicker - Made up of Schwann cells in peripheral nervous system and oligodendrocytes in CNS - MS typically only affects CNS, so oligodendrocytes - Inflammation of the myelin and infiltration of immune cells that cause damage to the myelin - Affects the way electrical signals travel along the nerve - In early disease, re-myelination can occur and symptoms can resolve. In the later stages of the disease, re-myelination is incomplete and symptoms gradually become more permanent

Answer 60

- 3x more common in women - Typically presents in young adults (< 50 yrs) - Symptoms tend to improve in pregnancy and post-partum period - Much more common at higher latitudes (5 times more common than in tropics)

Answer 61

- Monozygotic twin concordance = 30% | - Dizygotic twin concordance = 2%

Answer 62

Might be influenced by a combination of: - Multiple genes - Epstein–Barr virus (EBV) - Low vitamin D - Smoking - Obesity

Answer 63

Lesions are disseminated in time and space 75% have significant lethargy - Optic neuritis = most common - Optic atrophy - Eye movement abnormalities - Focal weakness: bells palsy, horners syndrome, limb paralysis - Focal sensory symptoms: trigeminal neuralgia, numbness, paraesthesia (pins + needles) - LHERMITTE'S SIGN: electric shock sensation that travels down the spine and into limbs when flexing neck. It indicates disease in the cervical spinal cord in the dorsal column. It is caused by stretching the demyelinated dorsal column. - UTHOFF'S PHENOMENON: worsening of vision following rise in body temperature - Ataxia - Sexual dysfunction - Intellectual deterioration - Urinary incontinence When a patient presents with symptoms of a clinical “attack” of MS, for example, an episode of optic neuritis, there are usually other lesions of demyelination at the same time throughout the central nervous system, most of which are not causing symptoms.

Answer 64

6th nerve - double vision - Internuclear ophthalmoplegia: The internuclear nerve fibres are responsible for coordinating the eye movements to ensure the eyes move together. Ophthalmoplegia means a problem with the muscles around the eye. - Conjugate lateral gaze disorder: When looking laterally in the direction of the affected eye, the affected eye will not be able to abduct. For example, in a lesion affecting the left eye, when looking to the left, the right eye will adduct (move towards the nose) and the left eye will remain in the middle as the muscle responsible for making it move laterally is not functioning.

Answer 65

Clinically isolated symptoms: - MS can not be diagnosed with a single episode as can not be convinced by 'disseminated in time and space' Relapsing-remitting (85%): - Acute attacks (1-2 months) followed by periods of remission Secondary progressive - Relapsing-remitting patients who have deteriorated and have developed neurological signs between relapses Primary progressive (10%) - Progressive deterioration from the onset - More common in older people

Answer 66

- MRI scans can demonstrate typical lesions - Lumbar puncture of CSF - Visual evoked potentials

Answer 67

- High signal T2 lesions - Periventricular plaques - Dawson fingers: often seen on FLAIR images - hyperintense lesions perpendicular to corpus callosum

Answer 68

- Oligoclonal bands (and not in serum) | - Increased intrathecal synthesis of IgG

Answer 69

- Central scotoma. This is an enlarged blind spot. - Pain on eye movement - Impaired color vision - Relative afferent pupillary defect

Answer 70

- Delayed | - But well preserved waveform

Answer 71

- Treated with steroids - Recovery takes 2-6 weeks - 50% of optic neuritis patients will go on to develop MS within next 15 years

Answer 72

- No cure - focus is on reducing frequency and duration of relapses

Answer 73

- High dose steroids --> IV Methylprednisolone - 500mg orally daily for 5 days - 1g IV OD for 3–5 days where oral treatment has failed previously or where relapses are severe - Shortens the length of acute relapse - Do not alter degree of recovery (e.g. whether they return to baseline)

Answer 74

- Beta-interferon can reduce relapse rate - Natalizumab (recombinant monoclonal antibody) - Fingolimod

Answer 75

- Exercise to maintain activity and strength - Neuropathic pain can be managed with medication such as amitriptyline or gabapentin - Depression can be managed with antidepressants such as SSRIs - Urge incontinence can be managed with anticholinergic medications such as tolterodine or oxybutynin (although be aware these can cause or worsen cognitive impairment) - Spasticity can be managed with baclofen, gabapentin and physiotherapy

Answer 76

- Myasthenia gravis is an autoimmune disorder resulting in insufficient functioning acetylcholine receptors - Acetylcholine receptor antibodies (ACh-R) bind to the post-synaptic junction receptors, preventing acetylcholine from stimulating the receptor and triggering muscle contraction - As the muscles are used more, more of the receptors get blocked up (worse on exercise/speech etc when muscles are being used) - These antibodies also activate the complement system within the neuromuscular junction, leading to damage to cells at the postsynaptic membrane. This further worsens the symptoms. - Antibodies to acetylcholine receptors are seen in 85-90% of cases

Answer 77

- Seen in 15% of cases - Two antibodies: One against muscle-specific kinase (MuSK) and antibodies against low-density lipoprotein receptor-related protein 4 (LRP4). - MuSK and LRP4 and important proteins for the creation and organisation of the acetylcholine receptor. - Destruction of these proteins by autoantibodies leads inadequate acetylcholine receptors

Answer 78

- Affects men and women at different ages - Typically women < 40 yrs and men > 60 yrs - More common in women

Answer 79

THYMOMA (tumour of thymus gland) - 10-20% of patients with myasthenia gravis have a thymoma - 20-40% of patients with a thymoma develop myasthenia gravis

Answer 80

- Autoimmune disorders - pernicious anaemia, autoimmune thyroid disorders, rheumatoid, SLE - Thymic hyperplasia in 50-70%

Answer 81

- DIPLOPIA - extraocular muscle weakness: - Proximal muscle weakness: face, neck, limb-girdle - PTSOSIS - Dysphagia - Fatigue in jaw when chewing - Slurred speech - Progressive weakness with repetitive movements

Answer 82

- Repeated blinking will exacerbate ptosis - Prolonged upward gazing will exacerbate diplopia on further eye movement testing - Repeated abduction of one arm 20 times will result in unilateral weakness when comparing both sides - Check for a thymectomy scar. - Test the forced vital capacity (FVC).

Answer 83

- Test for antibodies (ACh-R, MuSK, LRP4) - CT or MRI of thymus gland - Normal CK - Single fibre electromyography: high sensitivity (92-100%) - Edrophonium test / tensilon test: - IV edrophonium chloride or neostigmine is given - Blocks breakdown of existing acetylcholine - Briefly and temporarily relieves weakness - Establishes a diagnosis

Answer 84

- Long-acting acetylcholinesterase inhibitors (e.g. pyridostigmine) - Immunosuppressions (Pred or Azathioprine) - Thymectomy if required - Monoclonal antibodies - rituximab (if other Tx not effective)

Answer 85

- Acute severe worsening of symptoms - Can be life threatening - Often triggered by another illness, e.g. RTI

Answer 86

- Plasmapheresis - IV immunoglobulins - May need NIV with BiPAP or full intubation and ventilation

Answer 87

- Penicillamine - Quinidine, procainamide - Beta-blockers - Lithium - Phenytoin - Antibiotics: gentamicin, macrolides, quinolones, - Tetracyclines

Answer 88

MG patients are typically resistant to depolarising NMBDs and may require significantly higher doses E.g. Suxamethonium

Answer 89

- Extension of sepsis from middle ear or sinuses - Trauma or surgery to the scalp - Penetrating head injuries - Embolic events from endocarditis

Answer 90

- Headache (dull, persistent) - Fever (though may be absent and not usually the pyrexia seen in other abscesses) - Focal neurology, e.g. oculomotor nerve palsy or abducens nerve palsy (2ndry to raised ICP) - Nausea, papilloedema, seizures

Answer 91

- IV antibiotics --> CEPHALOSPORIN and METRONIDAZOLE - ICP --> Dexamethasone - Surgery: craniotomy and abscess cavity is debrided

Answer 92

- Disorder of movement and posture due to NON-PROGRESSIVE lesion of the motor pathways in the developing brain

Answer 93

- Antenatal (80%), e.g. cerebral malformation and congenital infection (rubella, toxoplasmosis, CMV), trauma during pregnancy - Intrapartum (10%): birth asphyxia/trauma, pre-term birth - Postnatal (10%): intraventricular haemorrhage, meningitis, head-trauma, severe neonatal jaundice

Answer 94

- HAND PREFERENCE BEFORE 18 MONTHS - Abnormal tone in early infancy (increased or decreased) - Delayed motor milestones - Abnormal gait - Feeding difficulties

Answer 95

- Learning difficulties (60%) - Epilepsy (30%) - Squints (30%) - Hearing impairment (20%)

Answer 96

Spastic (70%): - Also known as pyramidal CP - Hemiplegia, diplegia or quadriplegia - Increased tone from damage to UMNs Dyskinetic: - Also known as extrapyramidal CP - Damage to basal ganglia and substantia nigra - Athetoid movements and oro-motor problems Ataxic: - Damage to cerebellum - Typical cerebellar signs Mixed: - A mix of some or all of the above

Answer 97

- They will have signs of an upper motor neurone lesion, with good muscle bulk, increased tone, brisk reflexes and slightly reduced power. - Power may be normal. - Look for athetoid movements that indicate extrapyramidal (basal ganglia) involvement. - Test for coordination to look for cerebellar involvement.

Answer 98

- Acquired brain injury | - Tumour

Answer 99

- MDT approach: physio, OT, SALT, dieticians - Spasticity: oral diazepam, oral/intrathecal baclofen, botulinum toxin type A, orthopaedic surgery - Anticonvulsants - Analgesia

Answer 100

- Autosomal dominant

Answer 101

- Most common in older age

Answer 102

- FINE tremor - Affecting all the voluntary muscles - Symmetrical - More prominent on voluntary movement - Worse if arms outstretched - Worse when tired, stressed, after caffeine - Improved by alcohol and rest (absent during sleep) - Most common cause of head tremor (titubation) - May also see jaw tremor and vocal tremor

Answer 103

- Propanolol = 1st line (non-selective beta-blocker) | - Primidone (barbiturate anti-epileptic)

Answer 104

- More common in females | - Past psych Hx not shown to be RF

Answer 105

- Diagnosed after at least 4 months of disabling fatigue affecting mental and physical function more than 50% of the time - In absence of other disease which may explain symptoms

Answer 106

Fatigue = central features - Sleep problems - insomnia, hypersomnia, unrefreshing sleep, disturbed sleep cycle - Muscle/joint pain - Headaches - Painful lymph nodes without enlargement - Sore throat - Cognitive dysfunction, e.g. difficulty thinking, inability to concentrate, impairment of short-term memory - Physical or mental exertion makes symptoms worse - General malaise or 'flu-like' symptoms - Dizziness - Nausea - Palpitations

Answer 107

Perform a large number of screening bloods to exclude other pathology: - FBC - U&Es - LFTs - Glucose - TFTs - ESR - CRP - Calcium - CK - Ferritin (only in young people) - Coeliac screen - Urinlaysis

Answer 108

- CBT - Graded exercise therapy (formal supervised programme) - 'Pacing' (organising activities to avoid tiring) - Low-dose amitriptyline - Referral to pain management clinic

Answer 109

7 - 15 mmHg in adults in supine position

Answer 110

- Idiopathic intracranial hypertension - Traumatic head injuries - Infection, e.g. meningitis - Tumours - Hydrocephalus - Brain abscesses

Answer 111

- Headache - worse on bending down, coughing etc. - Vomiting - Reduced GCS - Papilloedema - Cushing's triad

Answer 112

- Widening pulse pressure - Bradycardia - Irregular breathing

Answer 113

- CT/MRI to investigate the cause - Invasive ICP monitoring - catheter placed in lateral ventricles to monitor the pressure - may also be used to collect CSF samples and drain small amounts of fluid to relieve pressure

Answer 114

- Treat underlying cause - Head elevation to 30 degrees - IV mannitol - Controlled hyperventilation - Removal of CSF

Answer 115

- Aim is to reduce pCO2 → vasoconstriction of the cerebral arteries → reduced ICP - Leads to rapid, temporary lowering of ICP. - Caution needed as may reduce blood flow to already ischaemic parts of the brain

Answer 116

- Drain from intraventricular monitor - Repeated LP (e.g. in idiopathic intracranial hypertension) - Ventriculoperitoneal shunt (e.g. for hydrocephalus)

Answer 117

- Seizures provoked by fever in otherwise normal children

Answer 118

- Occur between 6 months and 5 years | - Seen in 3% of children

Answer 119

- Usually occur early on in viral infection as temp rises rapidly - Usually brief, lasting < 5 mins - Most commonly tonic-clonic

Answer 120

Simple: - < 15 mins - Generalised seziure - Typically no recurrence within 24 hrs - Should be complete recovery withing 1 hour Complex: - 15-30 minutes - Focal seizure - May reoccur within 24 hrs Febrile status epilepticus: - > 30 minutes

Answer 121

- Admit to paeds - Analgesia - Paracetamol (though do not decrease likelihood of recurrence) - Place in safe place, e.g. carpeted floor with pillow under head - Place in recovery position - CALL 999 IF LASTS > 5 MINS - If recurrences, try teaching parents how to use rectal diazepam or buccal midazolam

Answer 122

- Typically do not cause lasting damage | - One in three will have another febrile seizure

Answer 123

- 1.8% for the general population - 2-7.5% after a simple febrile convulsion (depending on other RFs present) - 10-20% after a complex febrile convulsion

Answer 124

- X-linked recessive - Mutation in gene encoding dystrophin, dystrophin gene on Xp21 - Dystrophin = part of large membrane associated protein in muscle which connects the muscle membrane to actin, part of the muscle cytoskeleton

Answer 125

- FRAMESHIFT MUTATION --> resulting in 1 or both of the binding sites being lost --> severe form

Answer 126

- NON-FRAMESHIFT INSERTION in dystrophin gene --> both binding sites are preserved --> milder form

Answer 127

- Progressive proximal muscle weakness from 5 years - Calf pseudohypertrophy - GOWER'S SIGN: child used arms to stand up from squatted position - 30% have intellectual impairment

Answer 128

- Develops after age of 10 yrs | - Intellectual impairment is much less common than duchennes

Answer 129

- Raised CK | - Genetic testing! (now replaced muscle biopsy)

Answer 130

- Largely supportive | - No effective Tx

Answer 131

- Most can not walk by 12 yrs | - Typically survive until 25-30 yrs

Answer 132

Dilated cardiomyopathy

Answer 133

- Androgen insensitivity syndrome - Becker muscular dystrophy - Colour blindness - Duchenne muscular dystrophy - G6PD deficiency - Haemophilia A,B - Hunter's disease - Lesch-Nyhan syndrome - Nephrogenic diabetes insipidus

Answer 134

- Lung (most common) - Breast - Bowel - Skin (namely melanoma) - Kidney

Answer 135

Supply = face, ear, taste, tear - Face: muscles of facial expression - Ear: nerve to stapedius - Taste: ANTERIOR 2/3rds of tongue - Tear: parasympathetic fibres to lacrimal glands and salivary glands

Answer 136

- Sarcoidosis - Guillain-Barre syndrome - Lyme disease - Bilateral acoustic neuromas (as in neurofibromatosis type 2) - Bell's palsy is relatively common so it accounts for up to 25% of cases of bilateral palsy, but this represents only 1% of total Bell's palsy cases

Answer 137

- Adult polycystic kidney disease - Ehlers-Danlos syndrome - Coarctation of the aorta

Answer 138

- Acute = trauma to brain - Chronic = primarily in elderly or alcoholics (brain atrophy -> tension on cerebral vein), or shaken baby syndrome (fragile bridging veins)

Answer 139

- Conservative Tx if small or no neuro deficit | - Surgical decompression with burr holes if confusion, neurological deficit or severe imaging findings

Answer 140

- Insidious onset of confusion - Neuro deficit - Fluctuating consciousness levels

Answer 141

- Crescent shape | - Not limited by suture lines

Answer 142

- Most often laceration of MIDDLE MENINGEAL ARTERY | - Often due to temporal head injury

Answer 143

- Fall in consciousness - Followed by a LUCID INTERVAL - Then second fall in consciousness as expanding haematoma and brain herniation

Answer 144

- Binconvex (lentiform) hyperdense collection | - Limited by suture lines

Answer 145

- If no neuro deficit -> cautious clinical and radiological observation - Definitive Tx = craniotomy and evacuation of haematoma

Answer 146

- Rebleeding (10%, most common in 1st 12 hrs, repeat CT, high mortality) - Cerebral ischaemia due to vasospasm (7-14 days after) - Hydrocephalus - Seizures - Hyponatraemia (due to SIADH)

Answer 147

- Prompt Tx within 24 hrs - Maintain cerebral perfusion (SBP of 160) and bed rest until Tx available - Nimodipine (CCB) for 21 days to reduce vasospasm risk - Endovascular coiling!!

Answer 148

- CT - LP if negative CT, 12 hrs after, see xanthochromia - Cerebral angiography after diagnosis to find causative vascular lesion

Answer 149

Paroxysmal changes in behaviour, sensation or cognitive processes that are caused by EXCESSIVE, HYPERSYNCHRONOUS, NEURONAL DISCHARGES in the brain

Answer 150

- First-line = CARBAMAZEPINE | - 2nd = lamotrigine, sodium valproate, oxcarbamazepine, topiramate

Answer 151

First-line = SODIUM VALPROATE - Avoid in pregnancy --> Use lamotrigine - others: topiramate, carbamazepine - AVOID carbamazepine in tonic/atonic/myoclonic

Answer 152

- Generally cannot drive for 6 months following a single seizure if unprovoked/no structural imaging changes - For patients with established epilepsy or multiple unprovoked seizures they must be fit free for 12 months before being able to drive - When epilepsy meds are being withdrawn can not drive for 6 months after last dose - If not seizures for 5 years generally a full license is restored

Answer 153

- Lamotrigine and carbamazepine are generally considered safe in pregnancy - Breast feeding is generally considered safe for those on antiepileptics - It is advised that pregnant women taking phenytoin are given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn

Answer 154

- Single seizure lasting > 5 mins | - OR >= 2 seizures within a 5-min period without returning to normal between

Answer 155

- ABCDE - 1st line in community = PR diazepam or rectal midazolam - 1st line in hospital = IV lorazepam - Repeat once after 10-20 min - if ongoing --> phenytoin or phenobarbital infusion - If no response within 45 mins from onset -> general anaesthesia

Answer 156

- Lip-smacking - Chewing - Fumbling - Grabbling - Abdo rising sensation or pain - Hallucinations - Dysphasia - Impaired awareness - No recollection after

Answer 157

- Assymetrical posturing - extending one arm/leg then another - Peddling leg movements - Jacksonian march - Do NOT lose awareness - Post-ictal weakness (Todd's paresis)

Answer 158

- Paraesthesia

Answer 159

- Floaters | - Flashes

Answer 160

- Degeneration of dopaminergic neurons in the SUBSTANTAI NIGRA - Decreased dopamine supply to striatum --> motor symptoms

Answer 161

One side is ALWAYS worse than the other Cardinal triad: - Bradykinesia - Resting tremor - Rigidity (cogwheel) - Depression in 40% - Postural instability and hypotension (due to autonomic failure)

Answer 162

- Mostly based on history and physical exam - SPECT: Lewy bodies - Loss of dark substantia nigra - DaTSCAN: poor dopamine supply to striatum

Answer 163

- Most marked at rest - Worse when tired or stressed - Improves with voluntary movement - Typically 'pill-rolling'

Answer 164

Drug-induced: - Motor symptoms are generally rapid onset and bilateral - Rigidity and resting tremor are uncommon

Answer 165

- Early incontinence - Early dementia - Symmetrical - Early falls - Diplopia (progressive supranuclear palsy)

Answer 166

- Levodopa - Given with dopa-decarboxylase inhibitor to stop it being converted into dopamine in peripheral nervous system - MoA: synthetic dopamine SEs: - Dyskinesia - Dry mouth - Anorexia - Palpitations - Postural hypotension - Psychosis - Drowsiness

Answer 167

- Ropinirole, cabergoline, bromocriptine and pramipexole - MoA: Acts directly on post-synaptic receptors - First-line for < 60 yrs - SEs: gambling, hypersexuality

Answer 168

COMT: Entacapone MAO-B: Rasagaline, Selegiline MoA: Prevent breakdown of dopamine by Catechol-O-Methyl and Monoamino-oxidase in synaptic cleft

Answer 169

risk of acute akinesia or neuroleptic malignant syndrome if medication is not taken/absorbed (for example due to gastroenteritis) and advise against giving patients a 'drug holiday' for the same reason

Answer 170

Antimuscarinics: - Procyclidine - Benzotropine - Trihexyphenidyl (benzhexol)

Answer 171

- Nisseria meningitidis (gram negative diplococcus) - Streptococcus pneumoniae (gram positive diplococcus) - Listeria monocytogenes (in immunocompromised and babies, gram positive bacilli)

Answer 172

- CHIARI MALFORMATION = strong association - Trauma - Tumours - Idiopathic

Answer 173

A collection of CSF fluid within the spinal cord | - Compression of the spinothalamic tract fibres decussating in the anterior white commissure of the spine

Answer 174

SLOWLY PROGRESSIVE NEURO SYMPTOMS - Cape-like - Loss of sensation to temp but preservation of light touch, proprioception and vibration - E.g. burn hand without realising - Spastic weakness - Neuropathic pain - Upgoing plantars - Sometimes autonomic features

Answer 175

- Full spine MRI to exclude tethered cord or tumour | - Brain MRI to exclude Chiari malformation

Answer 176

- Treat cause of syrinx | - If persistent --> shunt can be placed

Answer 177

s a generalized seizure and involve loss of consciousness

Answer 178

A psychogenic non-epileptic seizure (previously called a pseudoseizure) should be considered in a patient who remains conscious during whole-body convulsions, exhibits no post-ictal state and can remember what happened

Answer 179

- Usually develops within 24-48 hours following LP but may occur up to one week later - May last several days - Worsens with upright position - Improves with recumbent position

Answer 180

- Supportive initially (analgesia, rest) - If pain continues for more than 72 hours then specific treatment is indicated, to prevent subdural haematoma - Treatment options include: blood patch, epidural saline and intravenous caffeine

Answer 181

- Muscle wasting of the hands - Numbness and tingling - Possibly autonomic symptoms Subclavian vein compression leads to painful diffuse arm swelling with distended veins Subclavian artery compression leads to painful arm claudication and in severe cases, ulceration and gangrene

Answer 182

A disorder involving compression of brachial plexus, subclavian artery or vein at the site of the thoracic outlet

Answer 183

Typically young thin women possessing long neck and drooping shoulders

Answer 184

- Usually Hx of neck trauma (acute or repeated stress) - Anatomical abnormalities: - Osseous, e.g. CERVICAL RIB - Soft tissue, e.g. scalene muscle hypertrophy, anomalous bands

Answer 185

6th nerve palsy (abducens) Unable to abduct --> affected eye is adducted Can sometimes get a third nerve palsy (down and out if herniation)

Answer 186

- Hangover-like headache - Leg pain - Cold hands and feet - Abnormal skin colour - Meningism: neck stiffness, photophobia, Kernigs +ve - Low GCS - Papilloedema - Brudinski's sign - Petechial rash (NOT in viral)

Answer 187

KERNIG'S SIGN | - Hip at 90 degrees, can't straighten leg > 135 without pain

Answer 188

BRUDZINSKI'S SIGN | - Flex neck --> patient compromised by flexing hips and knees

Answer 189

- CT head - LP if not raised ICP - High opening pressure - Send CSF for gram stain - Fundoscopy for papilloedema

Answer 190

Bacterial: - High neutrophils - High protein - Low glucose Viral: - High lymphocytes - High/normal protein - Normal glucose

Answer 191

Community --> IM/IV benzylpenicillin - CEFOTAXIME + Amoxicillin if < 3 months, > 50 yrs or immunocompromised to cover for listeria + Dexamethasone - If viral --> Acylovir Do NOT give Dex if: - Septic shock - Meningococcal septicemia - Immunocompromised - Meningitis following surgery

Answer 192

- For close contacts within 7 DAYS before onset - First-line = Ciprofloxacin - 2nd line = Rifampicin (NOT pregnancy)

Answer 193

- HERPES SIMPLEX VIRUS 1 + 2 - VZV, HIV - Bacterial - Non-infectious prodrome: immunocompromised, hypoglycaemia, hepatic encephalopathy, DKA, drugs

Answer 194

- Odd behaviour - COnfusion - Fever - Lethargy - Headache - SEIZURES - History of animal/travel bite

Answer 195

- LP: raised protein and lymphocytes, low or normal glucose - Contrast CT - white areas of enhancement VIRAL HAS TEMPORAL CHANGES

Answer 196

ACYCLOVIR within 30 mins of admission for 2 weeks

Answer 197

- Cluster of major degenerative diseases - Degeneration of UPPER AND LOWER motor neurons - Sensory neurons are spared !! - Does NOT affect ocular muscles

Answer 198

- FASCICULATIONS - Absence of sensory signs - Does NOT affect ocular muscles - Mixture of LMN and UMN signs - Wasting of small hand muscles - No cerebellar signs - Abdominal reflexes are usually preserved - Sphincter dysfunction if present is a late feature

Answer 199

Clinical diagnosis usually - Nerve conduction studies would be NORMAL (help exclude neuropathy) - Electromyography: reduced number of action potentials with increased amplitude - MRI to exclude cervical cord compression and myelopathy

Answer 200

ALS (50%) - amyotrophic lateral sclerosis - LMN in arms and UMN in legs Primary lateral sclerosis: - UMN signs only - Loss of Betz cells in motor cortex Progressive muscular atrophy: - LMN signs only - Anterior horn cell lesion ONLY - Affects distal muscle before proximal - Best prognosis Progressive bulbar palsy: - Palsy of tongue, muscle of chewing/swallowing and facial muscles due to loss of function of brainstem motor nuclei - Cranial nerves IX - XII (9-12) - Worst prognosis

Answer 201

Chromosome 21 if familial (codes for superoxide dismutase)

Answer 202

- Palsy of tongue, muscle of chewing/swallowing and facial muscles due to loss of function of brainstem motor nuclei - Cranial nerves IX - XII (9-12) - Jaw jerk = normal or absent - Speech = quiet, hoarse, nasally - Worst prognosis

Answer 203

- Bulbar palsy or bulbar onset of ALS - Increased age - Low FVC

Answer 204

- Riluzole = anti glutaminergic --> prolongs life by about 3 months. Mainly used in ALS. - Resp: BIPAP at night, survival benefit of about 7 months

Answer 205

Acetylcholinesterase inhibitors - Donepezil - Galantamine - Rivastigmine

Answer 206

MEMANTINE - MoA: NMDA antagonist - binds to glutamate site on NMDA receptor to block glutamate action - Moderate Alzheimer's who are intolerant of, or have a contraindication to, acetylcholinesterase inhibitors - As an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer's - Monotherapy in severe Alzheimer's

Answer 207

- Relatively contraindicated in patients with bradycardia | - Adverse effects include insomnia

Answer 208

- Antipyschotics

Answer 209

- Urinary incontinence - Gait abnormality - Dementia/bradyphrenia (mental slowing)

Answer 210

Hydrocephalus with ventriculomegaly in the absence of, or out of proportion to, sulcal enlargement

Answer 211

- Ventriculoperitoneal shunting | - Complications = seizures, infection, intracerebral haemorrhages

Answer 212

- Headache (typically worse in the morning, when lying down and during valsalva) - Nausea and vomiting - Papilloedema - Coma (in severe cases)

Answer 213

- Excessive volume of CSF in ventricular system of brain | - Caused by imbalance between CSF production and absorption

Answer 214

- Failure of upward gaze - Sunsetting eyes - Due to compression of superior colliculus of midbrain

Answer 215

Obstructive: - Tumours - Acute haemorrhage (SAH/intraventricular) - Developmental abnormalities (e.g. aqueduct stenosis) Non-obstructive: - Increased production, e.g. choroid plexus tumour - Failure of resorption at arachnoid granulations (meningitis, post-haemorrhage)

Answer 216

- CT head - MRI if suspected underlying lesion - LP

Answer 217

- External ventricular drain (ECD) in acute, severe, typically in RIGHT lateral ventricle - VPS is a long-term CSF diversion that drains CSF into peritoneum - If obstructive may require surgery to remove obstruction

Answer 218

Do NOT do an LP

Answer 219

- Obesity - Female sex - Pregnancy - Drugs: - combined oral contraceptive pill - steroids - tetracyclines - vitamin A - lithium

Answer 220

- Headache - Blurred vision - Papilloedema - Enlarged blind spot - Sixth nerve palsy

Answer 221

- Weight loss - DIURETICS --> ACETAZOLAMIDE - Topiramate can be used and helps weight loss - Repeated LPs - Surgery: optic nerve sheath decompression and fenestration may be needed to prevent damage to the optic nerve. A lumboperitoneal or ventriculoperitoneal shunt may also be performed to reduce intracranial pressure

Answer 222

- Pain (neck, limbs) - Loss of motor function (holding fork, doing up buttons, arm/leg stiffness/weakness) - Loss of sensory function - numbness - Loss of autonomic function (urinary incontinence) - Hoffman's sign: reflex test for cervical myelopathy. Flick one finger of patients hand. Positive = reflex twitching of other fingers on same hand.

Answer 223

- MRI of cervical spine | - May show disc degeneration and ligament hypertrophy, with accompanying cord signal change

Answer 224

- Urgent referral to spinal surgery | - Decompressive surgery

Answer 225

- Most common = central disc prolapse, typically at L4/L5 or L5/S1 - Tumours - Infection: abscess, discitis - Trauma - Haematoma

Answer 226

- Low back pain - Bilateral sciatica - Reduced sensation/pins-and-needles in perianal area - Decreased anal tone - Urinary dysfunction

Answer 227

- Urgent MRI

Answer 228

Surgical decompression

Answer 229

0: No contraction 1: Flicker of trace of contraction 2: Active movement with gravity eliminated 3: Active movement against gravity 4: Active movement against gravity and resistance 5: Normal power

Answer 230

Eyes 4 1: No opening 2: Open to pain 3: Open on demand 4: Open spontaneously Verbal 5 1: No response 2: Incomprehensible sounds 3: Inappropriate words 4: Confused 5: Orientated Motor 6 1: No movement 2: Extension 3: Abnormal flexion 4: Flexion withdrawal from pain 5: Moves to localised pain 6: Obeys commands

Answer 231

- Sympathetic overdrive - Flushing - Sweating - HTN

Answer 232

Above T6 spinal level

Answer 233

- History of freq sprained ankles - Foot drop - High arched feet - Hammer toes - Distal muscle weakness - Distal muscle atrophy - Hyporeflexia - Stork leg deformity

Answer 234

- B12 deficiency - Replacing folate without vitamin B12 can precipitate subacute combined degeneration of the cord in a patient who is vitamin B12 deficient. - Always ensure vitamin B12 levels are checked (and replenished) before giving folate for a macrocytic anaemia - Dorsal columns and lateral corticospinal tracts due to vitamin B12 deficiency - joint position and vibration sense lost first then distal paraesthesia - UMN signs typically develop in the legs, classically extensor plantars, brisk knee reflexes, absent ankle jerks

Answer 235

- Flexion of head, trunk, limbs - Hypsarrhythmia on EEG - Progressive mental handicap - Poor prognosis

Answer 236

- Focal symptoms including paraesthesia on one side of child face or mouth - 'Fizzy' or 'buzzing' - Twitching - Usually on waking up

Answer 237

- Adolescence - Infrequent generalised seizures - Often in morning/following sleep deprivation - Daytime absences - Sodium valproaete

Answer 238

- Onset 4-8 yrs - Duration few-30 secs; no warning, quick recovery; often many per day - EEG: 3Hz generalized, symmetrical - Sodium valproate, ethosuximide - Good prognosis: 90-95% become seizure free in adolescence

Answer 239

- Elevated serum prolactin 10 to 20 minutes after an episode = true epileptic seizure - Tongue biting = true epileptic seizure

Answer 240

- May start as back/leg pain initially - Progressive peripheral polyneuropathy - Hyporeflexia - Ascending - Some mild sensory symptoms - Hx of gastroenteritis (classically Campylobacter jejuni) - Resp muscle weakness - Cranial nerve involvement: diplopia, bilateral facial nerve palsy, oropharyngeal weakness - Autonomic involvement

Answer 241

- LP: rise in protein, normal WCC - Nerve conduction studies: decreased motor nerve conduction velocity, also prolonged distal motor latency, increased F wave latency

Answer 242

- IV immunoglobulins - Plasma exchange (alternative to IV IG) - Supportive care - VTE prophylaxis (pulmonary embolism is a leading cause of death)

Answer 243

80% will fully recover 15% will be left with some neurological disability 5% will die

Answer 244

- Molecular mimicry - B cells of the immune system create antibodies against the antigens on the pathogen that causes the preceding infection - These antibodies also match proteins on the nerve cells - They may target proteins on the myelin sheath of the motor nerve cell or the nerve axon.

Answer 245

Autoimmune and thrombophilia screening!

Answer 246

- Oral triptan and an NSAID OR - Oral triptan and paracetamol Can use nasal triptan if 12-17 yrs``

Answer 247

- Topiramate | - Propanolol

Answer 248

If a patient with Parkinson's disease cannot take levodopa orally, they can be given a dopamine agonist patch as rescue medication to prevent acute dystonia

Answer 249

- Simple faint: no restriction - Single episode, explained and treated: 4 weeks off - Single episode, unexplained: 6 months off - Two or more episodes: 12 months off

Answer 250

- pyrexia - muscle rigidity - autonomic lability: typical features include hypertension, tachycardia and tachypnoea - agitated delirium with confusion

Answer 251

- Raised CK - AKI sometimes - 2ndry to rhabdomyolysis - Leukocytosis

Answer 252

- Stop antipsychotic - Transfer to medical ward - IV fluids - Dantrolene can sometimes be used

Answer 253

Cerebellar hemisphere lesions cause peripheral ('finger-nose ataxia') Cerebellar vermis lesions cause gait ataxia

Answer 254

- Dementia (rapid onset) - Myoclonus (spasmodic jerky contraction of groups of muscles) - Rigidity

Answer 255

- CSF = normal - EEH: biphasic high amplitude sharp waves - MRI: hyperintense signal in BASAL GANGLIA and THALAMUS

Answer 256

- Rapidly progressive neurological condition caused by prion proteins - These proteins induce the formation of amyloid folds resulting in tightly packed beta-pleated sheets resistant to proteases

Answer 257

Autosomal dominant - Defect in huntingtin gene on chromosome 4 - Trinucleotide repeat disorder: repeat expansion of CAG - Phenomenon of anticipation (disease presents earlier in successive generations)

Answer 258

Triad of motor, cognitive and psychiatric symptoms - Motor: impairment of involuntary (chorea) and voluntary movements, reduced manual dexterity, balance problems and falls - Cognitive: initially = loss of speed and flexibility in thinking but later develop into global dementia - Psychiatric: depression (most common), irritability, anxiety, agitation, and social withdrawal

Answer 259

- Chorea: tetrabenazine - Depression: SSRIs - Psychosis: Haloperidol - Aggression: Risperidone - Bilateral stimulation of globus pallidus - Counsel patiecnt and family

Answer 260

- Degeneration of cholinergic and GABAnergic neurons in the striatum of basal ganglia

Answer 261

- If seizure free for > 2 years | - Stopped over 2-3 months

Answer 262

- A physiological nervous system response to increased intracranial pressure that results in HYPERTENSION and BRADYCARDIA

Answer 263

1 Buccal midazolam/ IV lorazepam 2 IV lorazepam 3 IV phenytoin (phenobarbital if already on regular phenytoin) 4 Rapid sequence induction of anaesthesia using thiopental sodium

Answer 264

- Sensory changes - Deafness or other ear problems - History of skin or oral lesions that could spread perineurally - Pain only in the ophthalmic division of the trigeminal nerve (eye socket, forehead, and nose), or bilaterally - Optic neuritis - A family history of multiple sclerosis - Age of onset before 40 years

Answer 265

- Headache - N+V - Reduced consciousness

Answer 266

MRI venography (or CT venography) - D-dimer level may be elevated

Answer 267

- Anticoagulation (typically LMWH) | - Warfarin generally still used for long-term anticoag

Answer 268

- Causes: local infection, neoplasia, trauma - Periorbital oedema - Ophthalmoplegia (6th nerve damage before 3rd or 4th) - Trigeminal nerve involvement - may lead to hyperaesthesia of upper face/eye pain - Central retinal vein thrombosis

Answer 269

- May present with seizures and hemiplegia - Parasagittal biparietal or bifrontal haemorrhagic infarctions are sometimes seen - Empty delta sign on venography

Answer 270

- 6th and 7th cranial nerve palsies (abducens, facial)

Answer 271

Serum phosphate level <0.80 mmol/L: - Mild (∼0.64–0.80 mmol/L) - Moderate (∼0.32–0.64 mmol/L) - Severe (<0.32 mmol/L)

Answer 272

Mild to moderate: enteral replacement is required using Phosphate Sandoz® effervescent tablet Severe or symptomatic: IV phosphate replacement