Neurology Flashcards
1
Q
What is shingles also known as?
A
Herpes Zoster Infection
2
Q
What causes shingles?
A
reactivation of varicella zoster virus
3
Q
Key risk factors for shingles
A
increasing age, immunosuppressive conditions, HIV
4
Q
typical presentation of shingles
A
acute, unilateral, painful blistering rash
5
Q
Which dermatomes are commonly affected in shingles
A
T1- L2
6
Q
Features of shingles
A
prodromal period
- 2-3day hx of burning pain over the dermatomes affected
- may have fever, headache, lethargy
Rash
- erythematous, macular rash which becomes vesicular
- demarcated by dermatome and doesnt cross the midline
7
Q
How is shingles diagnosed?
A
clinical diagnosis
8
Q
What are the complications of shingles
A
- post- herpetic neuralgia
- herpes zoster ophthalmicus
- herpes zoster oticus (Ramsay Hunt syndrome):
9
Q
What is syncope?
A
transient loss of consciousness with spontaneous complete recovery
10
Q
What are the main causes of syncope?
A
- Reflex mediated (neurally mediated)
- Cardiac (arrhythmias and structural causes)
- Orthostatic (iatrogenic, dementia, volume depletion)
11
Q
Which investigations should be carried out in syncope?
A
- ECG (?prolonged QT)
- lying standing BP / tilt table test
- Glucose
- Electrolytes
- FBC
- Underlying illness (CXR, CT, LP, ECHO etc)
12
Q
Causes of cardiac syncope
A
arrhythmias - bradycardia / tachycardia structural - valvular - MI - HOCM
13
Q
What is vasovagal syncope?
A
triggered by emotion, pain or stress. Often referred to as ‘fainting’
14
Q
What is subarachnoid haemorrhage?
A
presence of blood in the subarachnoid space
15
Q
What are the causes of SAH?
A
head injury (traumatic SAH) is the most common cause
spontaneous SAH (non-traumatic)
16
Q
Causes of spontaneous SAH
A
- Intracranial aneurysm( ruptured ‘berry’ aneurysms)
- Arterial dissection
17
Q
Which conditions are associated with berry aneurysms?
A
- Adult Polycystic Kidney Disease
- coarctation of the aorta
18
Q
Classical presentation of SAH
A
- Thunderclap headache
- N&V
- Meningism (photophobia, stiff neck)
19
Q
How can a SAH be confirmed?
A
CT head
LP if CT Head if negative
Neuro referral
20
Q
Which findings on an LP are indicative of SAH
A
xanthochromia (result of RBC breakdown) and normal or raised opening pressure
21
Q
After SAH is confirmed, which investigations can be carried out to identify a causative pathology?
A
CT inter-cranial angiogram (vascular lesion e.g aneurysm)
22
Q
What is Multiple sclerosis?
A
autoimmune disorder characterised by demyelination in the central nervous system
23
Q
Who is at higher risk of MS
A
women ages 20-40 living at higher latitude
24
Q
How can MS be diagnosed
A
refer to neuro and bloods to exclude other causes
25
What are the most common initial presentations of MS
- optic neuritis
- transverse myelitis (inflammation within spinal cord)
- cerebellar sx ( dysmetria, ataxia, vertigo)
sx disseminated in time and space
26
Which investigations should be carried out for MS?
MRI
27
What is a venous sinus thrombosis?
occurs when a blood clot forms in the brain's venous sinuses. This prevents blood from draining out of the brain. As a result, blood cells may break and leak blood into the brain tissues, forming a hemorrhage.
28
What are the symptoms of venous sinus thrombosis?
- headaches
- n&v
- blurred vision
- LOC
- seizures
29
How is venous sinus thrombosis diagnosed?
MRI venography
CT venography
30
What is a Cavernous sinus thrombosis
the formation of a clot within the cavernous sinus
31
What is the most common cause of CST
infection
32
Common clinical features of CST
headache, unilateral periorbital oedema, proptosis (eye bulging), photophobia and cranial nerve palsies
33
Which nerve is most commonly affected in CST
abducens nerve (CN VI)
34
Complication of CST
Where the cause is infection, thrombosis of the cavernous sinus can rapidly progress to meningitis.
35
Investigations requested in suspected CST
CT Head/ MRI
FBC
Blood culture
?LP
36
Which seizures last a few seconds and are associated with a quick recovery
Absence
37
What may provoke an absence seizure
hyperventilation or stress
38
Who is most commonly affected by absence seizures?
3-10 years old and girls are affected twice as commonly as boys
39
Prognosis of absence seizures
good prognosis - most become seizure free in adolescence
40
Status epilepticus is defined as...
a single seizure lasting >5 minutes OR
| >= 2 seizures within a 5-minute period without the person returning to normal between them
41
Why is the priority in Status epilepticus to terminate seizure activity
can lead to irreversible brain damage
42
What is a febrile convulsion?
seizures provoked by fever in otherwise normal children
43
clinical features of febrile convulsion
usually occur early in a viral infection
usually lasting less than 5 minutes
most commonly tonic-clonic
44
How can a generalise seizure be further classified
Motor- e.g tonic-clonic
| Non-motor - e.g absence
45
Sx of epilepsy
bite their tongue
incontinence of urine
post-ictal phase
46
Which investigations are ordered following a patients first seizure?
EEG and MRI
47
What are the guidelines for driving post seizure?
- Generally patients cannot drive for 6 months following a seizure.
- For patients with established epilepsy they must be fit free for 12 months before being able to drive
48
What is the difference between a generalised and focal seizure?
Focal onset seizures start in one area and can spread across the brain and cause mild or severe symptoms, depending on how the electrical discharges spread. Generalized seizures can start as focal seizures that spread to both sides of the brain.
49
What happens in tonic-clonic seizure?
```
Tonic
- muscles stiffen
- LOC
- tongue biting
Clonic
- rhythmical jerking
```
50
What is Bell's palsy?
Acute, unilateral facial nerve (CN VII) paralysis
| - rapid onset ( < 72 hours)
51
Features of Bell's palsy
- Lower motor neuron facial nerve : forehead affected
- Post-auricular pain (preceding paralysis)
- Altered taste
- Dry eyes
Facial muscle weakness (unilateral):
- drooping of the eyebrows
- corner of the mouth
- loss of the nasolabial fold
52
What is the bell's phenomenon?
The eye can't be closed- eyeball rotates upwards and outwards
53
What is the follow-up for bell's palsy?
If paralysis shows no improvement after 3 week, refer to ENT urgently
54
What is the prognosis for bell's palsy?
Full recovery within 3-4 months
55
What are the two main ascending tracts of the spinal cord and what information do they carry?
Dorsal - fine touch, proprioception, vibration sense
| Spinothalamic - pain and temperature
56
What is the descending tract of the spinal cord called and what does it carry?
corticospinal tract carries motor information
57
Which signs indicate there is a problem with the spinal cord rather than with the other parts of the nervous system?
often bilateral and asymmetrical
mixed upper and lower motor neuron signs as the spinal cord is part of both the CNS and PNS
- upper signs : increased tone, clonus, hyperreflexia
- lower signs: muscle wasting, flaccid paralysis, reduced reflexes
sphincter involvement (e.g urinary retention/constipation)
autonomic dysfunction indicates lesion is above T6
58
How to tell where in the spinal cord the problem is
cervical if all 4 limbs affected
thoracic if only lower limbs affected
above C3 if resp difficulties and diaphragm affected
59
What is Amyotrophic lateral sclerosis
(motor neuron disease)
affects both upper (corticospinal tracts) and lower motor neurons
results in a combination of upper and lower motor neuron signs
60
What features are seen in neoplastic spinal cord decompression?
back pain, may be worse on coughing or lying down
- lower limb weakness
- sensory loss or numbness
- neuro signs dependent on level of lesion
- -above L1 usually UMN in legs and sensory
- - below L1 usually LMN in legs and perianal numbness
61
Which investigation should be requested following suspected neoplastic spinal cord decompression?
urgent whole MRI spine within 24hrs of presentation
62
What are the symptoms of diabetic peripheral neuropathy?
Sensory loss:
- Tingling
- Numbness - unable to feel light touch
- Cannot feel pain
- Unable to detect change in temperature
63
What are the presentations of diabetic foot disease?
1. neuropathy: loss of sensation
| 2. ischaemia: absent foot pulses, reduced ankle-brachial pressure index (ABPI), intermittent claudication
64
What is involved in annual diabetic foot check?
1. screening for ischaemia: done by palpating for both the dorsalis pedis pulse and posterial tibial artery pulse
2. screening for neuropathy: a 10 g monofilament is used on various parts of the sole of the foot
65
What is guillain-barre syndrome?
immune-mediated demyelination of the peripheral nervous system often triggered by an infection
66
What infection triggers guillain-barre syndrome?
campylobacter jejuni
67
What are the characteristic features of guillain-barre syndrome?
Progressive, symmetrical weakness of all limbs
- usually ascending (leg first)
- reflexes reduced or absent
- mild sensory symptoms
68
What are the other features for guillain-barre syndrome?
1. Weakness
- Maximum severity at 2 weeks after initial onset , stops progressing after 5 weeks
- Facial weakness, dysphasia, dysarthria
- May lead to resp failure
2. Pain – neuropathic pain esp in legs, possible back pain
3. Reflexes – may be reduced or absent
4. Sensory symptoms – paraesthesia & sensory loss starting in the lower extremities
5. Autonomic symptoms – reduced sweating, heat tolerance, urinary hesitancy
69
How do you diagnose GBS?
Clinical assessment
70
What investigations may be helpful in diagnosing GBS?
1. Nerve conduction studies – most useful confirmatory test, if initially normal should be repeated after 2 weeks.
2. Lumbar puncture – elevated level of CSF protein with normal white cell count, week 1 after symptom onset
71
What does Chronic IDP stand for?
chronic inflammatory demyelinating polyneuropathy
72
Symptoms of Chronic IDP
1. Initially present with some limb weakness which will slowly progress to symmetrical weakness in muscles of the hands, feet, shoulder and hip.
2. Symptoms may be progressive, episodic or monophasic (1-3 years).
3. Symptoms should last > 8 weeks
4. Loss of sensation, numbness, tingling, pins and needles
73
Clinical features of Chronic IDP
1. Muscle atrophy in hands, feet, shoulders and hips
2. Absent or diminished deep tendon reflexes
3. Impaired responses to sensory stimulation
4. Ataxic gait
5. Some cranial nerve involvement such as dysphagia or diplopia
74
Investigations of Chronic IDP
- NCS
- Lumbar Puncture
- Peripheral nerve biopsy
75
Features of migraine
1. a severe, unilateral, throbbing headache
- -> attacks may last up to 72 hours
2. associated with nausea, photophobia and phonophobia
3. patients characteristically go to a darkened, quiet room during an attack
4. 'classic' migraine attacks are precipitated by an aura.
5. typical aura are visual, progressive, last 5-60 minutes and are characterised by transient hemianopic disturbance or a spreading scintillating scotoma
76
What medication is contraindicated in migraine with aura?
COCP
77
Symptoms of tension headache
* often described as a 'tight band' around the head or a pressure sensation.
* bilateral
* tends to be of a lower intensity than migraine
* may be related to stress
78
Symptoms of cluster headache
1. Unilateral periorbital pain
2. Ipsilateral autonomic symptoms: eyelid oedema, facial sweating or flushing, nasal congestion, conjunctival injection, lacrimation
3. Brief attacks of < 3 hours duration
4. pain typical occurs once or twice a day, each episode lasting 15 mins - 2 hours
5. clusters typically last 4-12 weeks
79
What is essential tremor?
Autosomal dominant condition which usually affects both upper limbs
80
Features of essential tremor
- postural tremor: worse if arms outstretched
| - improved by alcohol and rest
81
What is parkinson's disease?
Progressive neurodegenerative condition caused by degeneration of dopaminergic neurons in the substantia nigra
82
What is the classic triad of features of parkinson's disease?
1. Bradykinesia
- short, shuffling steps
- difficulty initiating movement
2. Tremor
- worse when stessed or tired
- 'pill-rolling'
3. Rigidity
- lead pipe
83
How is parkinson's diagnosed?
usually clinical
84
What investigation can distinguish between essential tremor and parkinson's?
- Single-photon emission computed tomography
85
How do you differentiate between parkinson's disease and drug-induced parkinsonism?
In drug-induced parkisonism:
- motor symptoms are generally rapid onset and bilateral
- rigidity and rest tremor are uncommon
86
What is huntington's disease?
- inherited neurodegenerative condition.
| - progressive and incurable condition that typically results in death 20 years after the initial symptoms develop.
87
Features of huntington's disease
Typically develop after 35 years of age:
- chorea
- personality changes (e.g. irritability, apathy, depression) and intellectual impairment
- dystonia
- saccadic eye movements
88
What can peripheral neuropathy conditions be divided into?
1. Motor loss
| 2. Sensory loss
89
What conditions cause motor loss in peripheral. neuropathy?
1. Guillain-Barre syndrome
2. lead poisoning
3. chronic inflammatory demyelinating polyneuropathy (CIDP)
4. diphtheria
90
What conditions cause sensory loss in peripheral. neuropathy?
1. diabetes
2. uraemia
3. leprosy
4. alcoholism
5. vitamin B12 deficiency
6. amyloidosis
91
What nerve damage causes a foot drop?
Peroneal nerve (L4-L5, S1-S2)
92
What nerve damage causes a wrist drop?
Radial nerve
93
What is carpel tunnel syndrome?
When carpel tunnel is swollen/inflammed - the median nerve is affected
94
Symptoms of carpel tunnel syndrome
- Aching, tingling, pins & needles
- Symptoms can spread up the arm
- Worse on movement
- temporary relief by hanging had out of bed at night or shaking vigorously
95
What examination tests do you carry out for carpel tunnel syndrome?
Phalens
- hold wrist fully palmarflexed
- tap on wrist reproduces symtpoms
Tinel's sign
- tapping over dorsum of the wrist percipitates pain
96
What does wasting of the thenar eminence indicate?
Median nerve affected
97
What investigation can be carried out for carpel tunnel syndrome?
NCS
98
What do you not prescribe for carpel tunnel syndrome?
NSAIDs
99
What is myasthenia gravis?
Autoimmune disorder from insufficient functioning ACh receptors
Affect women > men
100
What is the key feature of myasthenia gravis?
muscle fatigability
- worsens with activity
- improves after rest
101
What other features can you get with myasthenia gravis?
- extraocular muscle weakness: diplopia
- proximal muscle weakness: face, neck, limb girdle
- ptosis
- dysphagia
102
What is the diagnostic test for myasthenia gravis?
- Serological testing for ACh receptor antibodies
| - Repetitive EMG
103
What is cerebral palsy?
disorder of movement and posture due to a non-progressive lesion of the motor pathways in the developing brain
104
What is the classification of cerebral palsy?
1. Spastic
2. dyskinetic
3. ataxic
4. mixed
105
What non-motor problems can children with cerebral palsy develop?
1. learning difficulties (60%)
2. epilepsy (30%)
3. squints (30%)
4. hearing impairment (20%)
106
What are the possible manifestations of cerebral palsy?
1. abnormal tone early infancy
2. delayed motor milestones
3. abnormal gait
4. feeding difficulties.
107
What is stroke?
sudden interruption in the vascular supply of the brain
108
What are the types of stoke?
1. Ischaemic
- subtype: TIA
- ' blockage in blood vessel'
2. Haemorrhagic
- blood vessel burst leading to reduction in blood
109
What are the symptoms of a stroke?
1. Motor weakness
2. speech problems (dysphasia)
3. swallowing problems
4. visual field defects
5. balance problems
110
What are some symptoms more common with haemorrhagic stroke than ischaemic?
- decrease in consciousness
- headache
- N & V
- Seizures
111
What is the FAST campaign?
1. Face - 'Has their face fallen on one side? Can they smile?'
2. Arms - 'Can they raise both arms and keep them there?'
3. Speech - 'Is their speech slurred?'
4, Time - 'Time to call 999 if you see any single one of these signs.'
112
What are the 2 types of imaging used in stroke?
CT
MRI
1st line = non-contrast CT head
113
What criteria needs to be met for immediate treatment of ischaemic stroke?
Criteria
1. patients present with 4.5 hours of onset of stroke symptoms
2. the patient has not had a previous intracranial haemorrhage, uncontrolled hypertension, pregnant etc
114
What is the surgical option for acute ischaemic stroke?
Thrombectomy
115
Secondary prevention for stroke
1st line = Clopidogrel
2nd line = aspirin + modified-release (MR) dipyridamole
116
What is TIA?
a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction. (<24 hours)
117
Clinical features of TIA
- unilateral weakness or sensory loss.
- aphasia or dysarthria
- ataxia, vertigo, or loss of balance
symptoms typically resolve within 1 hour
118
What is the advice on driving for TIA?
Do not drive until seen by specialist
119
What investigation should be carried out for TIA?
1. MRI - to detect territory of ischaemia
2. Urgent carotid doppler
CT should be done unless alternative diagnosis
120
What is raised intracranial pressure?
Additional volume in the brain + ventricles
121
Features of raised ICP
1. headache
2. vomiting
3. reduced levels of consciousness
4. papilloedema
5. Cushing's triad
- widening pulse pressure
- bradycardia
- irregular breathing
122
What investigations should be carried out for raised ICP?
1. Neuroimaging = underlying causes
| 2. Invasive ICP monitoring
123
What is temporal arteritis?
Large vessel vasculitis which overlaps with polymyalgia rheumatica (PMR).
124
Features of temporal arteritis
1. Jaw claudication
2. temporal headache
3. eventually leads to vision loss as optic nerve loses blood supply as large to medium vessels becomes narrowed.
4. Can be systemically unwell.
5. Hard, non-pulsating temporal artery (normal = pulsating, able to palpate and doesn’t feel hard)
125
What is the gold standard investigation for temporal arteritis?
USS and biopsy
- raised ESR > 50mm/hr
126
What is vasculitis?
Inflammation of small vessels
| - May be drug reaction
127
Symptoms of vasculitis
- Itching, burning purpuritic rash
| - 1-3mm lesions, often on legs
128
What is Alzheimers?
progressive degenerative disease of the brain
129
When should antipsychotics be given to patients with Alzheimers?
when pt is at risk of harming themselves or others or has delusions/hallucinations causing them severe distress
130
What is the most common causative pathogen in enchephalitis?
HSV-1
131
Symptoms of enchephalitis
```
confusion or disorientation.
seizures or fits.
changes in personality and behaviour.
difficulty speaking.
weakness or loss of movement in some parts of the body.
loss of consciousness.
```
132
Which investigations should be requested in ?encephalitis
CSF
PCR for HSV
MRI
EEG
133
What might you see in CSF of encephalitic patient
lymphocytosis, elevated protein
134
Life threatening complication of meningitis
septicaemia resulting in permanent damage of nerves or brain
135
Symptoms of meningitis
headache, neck stiffness, photophobia, confusion, fevers, non-blanching rash
136
Gold standard investigation for meningitis
lumbar puncture
137
Characteristic CSF findings in bacterial meningitis
cloudy, low glucose, high protein
138
What should be given to patients with suspected meningococcal disease in a pre-hospital setting?
IM benzylpenicillin
139
When should you suspect hiv ?
- unusually severe/prolonged symptoms that are recurrent or unexplained
- conditions related to immunosuppression (shingles/oral candidiasis)
- lymphadenopathy
- pyrexia
- weight loss
140
HIV risk factors
- coming from high prevalence area
- sex between men and men
- injecting drug use
141
When should asymptomatic patients with HIV be tested after possible exposure?
at 4 weeks
142
How is HIV monitored
HIV viral load and CD4 lymphocyte cell count
143
What are people with CD4 count <200 at a higher risk of?
HIV-related opportunistic infections and cancers
144
The causative pathogen of tuberculosis
Mycobacterium tuberculosis
145
Which vaccine offers protection against TB
BCG
146
What are the 2 types of TB
PRIMARY
infection occurring in previously uninfected host , usually asymptomatic
SECONDARY
If the host becomes immunocompromised the initial infection may become reactivated.
147
Gold standard investigation for active TB
Sputum culture
148
What investigations may be requested in ?active TB
Sputum culture -GOLD STANDARD
CXR
NAAT
149
What is a classical finding in CXRs in active TB
Upper lobe cavitation and hilar lymphadenopathy
150
Give key side effects for TB drugs
Rifampicin : red/orange secretions
Isoniazid: peripheral neuropathy
Pyrazinamide: hyperuricaemia=gout
Ethambutol : optic neuritis
151
Primary and secondary features of syphilis
Primary features
- chancre
- lymphadenopathy
Secondary features - occurs 6-10 weeks after primary infection
- systemic symptoms: fevers, lymphadenopathy
- rash on trunk, palms and soles
- condylomata lata (painless, warty lesions on the genitalia )
152
Investigations for ?syphilis
clinical diagnosis and GUM referral for serology and microscopic
153
How is lyme disease spread
ticks
154
key features of lyme disease
```
erythema migrans (bulls eye rash)
systemic features (headaches, lethargy, fever)
```
155
How is lyme disease diagnosed
clinical if erythema migrans is present
| ELISA antibodies to Borrelia burgdorferi
156
What is a prion disease and what is the most common
A prion is a type of protein that can trigger normal proteins in the brain to fold abnormally.
Creutzfeldt-Jakob disease
157
features of prion disease
rapid onset dementia and myoclonus
158
What is Whipples disease
Whipple disease is a rare bacterial infection that most often affects your joints and digestive system. Whipple disease interferes with normal digestion by impairing the breakdown of foods, and hampering your body's ability to absorb nutrients, such as fats and carbohydrates.
