Neurology Flashcards
(332 cards)
1
Q
What is the normal pressure hydrocephalus triad?
A
- Urinary incontinence
- Dementia and bradyphrenia
- Gait abnormality (similar to Parkinson’s)
2
Q
How does a pontine haemorrhage usually present?
A
Reduced GCS
Paralysis
Pinpoint pupils
3
Q
How does an anterior cerebral artery lesion present?
A
Contralateral hemiparesis and sensory loss, lower extremity > upper
4
Q
How does a middle cerebral artery lesion present?
A
Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral homonymous hemianopia
Aphasia
5
Q
How does a posterior cerebral artery lesion present?
A
Contralateral homonymous hemianopia with macular sparing
Visual agnosia
6
Q
How does Weber’s syndrome (lesion of branches of posterior cerebral artery that suppies the midbrain) present?
A
Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity
7
Q
Posterior inferior cerebellar artery (lateral medullary syndrome, Wallenberg syndrome) lesion symptoms?
A
Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus
8
Q
Anterior inferior cerebellar artery (lateral pontine syndrome) lesion symptoms?
A
Symptoms are similar to Wallenberg’s (see above), but:
Ipsilateral: facial paralysis and deafness
9
Q
Retinal/ophthalmic artery lesion symptoms?
A
Amaurosis fugax
10
Q
Basilar artery lesion symptoms?
A
‘Locked-in’ syndrome
11
Q
How do lacunar stroke present?
A
Present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
Strong association with hypertension
Common sites include the basal ganglia, thalamus and internal capsule
12
Q
Clinical signs CN3?
A
Palsy results in
ptosis
‘down and out’ eye
dilated, fixed pupil
13
Q
Clinical signs CN4?
A
Palsy results in defective downward gaze → vertical diplopia
14
Q
Clinical signs CN5?
A
Lesions may cause:
trigeminal neuralgia
loss of corneal reflex (afferent)
loss of facial sensation
paralysis of mastication muscles
deviation of jaw to weak side
15
Q
Clinical signs CN6?
A
Palsy results in defective abduction → horizontal diplopia
16
Q
Clinical signs CN7?
A
Lesions may result in:
flaccid paralysis of upper + lower face
loss of corneal reflex (efferent)
loss of taste
hyperacusis
17
Q
Clinical signs CN8?
A
Hearing loss
Vertigo, nystagmus
Acoustic neuromas are Schwann cell tumours of the cochlear nerve
18
Q
Clinical signs CN9?
A
Lesions may result in;
hypersensitive carotid sinus reflex
loss of gag reflex (afferent)
19
Q
Clinical signs CN10?
A
Lesions may result in;
uvula deviates away from site of lesion
loss of gag reflex (efferent)
20
Q
Clinical signs CN11?
A
Lesions may result in;
weakness turning head to contralateral side
21
Q
Clinical signs CN12?
A
Tongue deviates towards side of lesion
22
Q
What is the diagnostic test for MS?
A
MRI with contrast
23
Q
What are the three features of Wernicke’s (receptive) aphasia?
A
Speech Fluent
Comprehension abnormal
Repetition impaired
24
Q
What is the difference between aphasia and dysarthria?
A
Aphasia- language comprehension and production problems
Dysarthria- Motor speech disorder
25
Where is Wernicke's area located?
Superior temporal gyrus
26
Where is Broca's area located?
Inferior frontal gyrus
27
What are the features of Broca's (expressive) aphasia
Speech in non-fluent, laboured and halting
Repetition impaired
Comprehension normal
28
Is Bell's palsy upper or lower motor neurone
Lower motor neurone and meaning the forehead is affected (UMN spares upper face)
29
What are the symptoms of Bell's palsy
Lower motor neurone facial nerve palsy (forehead affected)
Post-auricular pain (may precede paralysis)
Altered taste
Dry eyes
Hyperacusis
30
Management of Bell's palsy
1. Corticosteroids- prednisolone
(Potentially antiviral aciclovir)
31
What are the key features of MND?
Asymmetric limb weakness
Mixtures of lower and upper motor neurone signs
Wasting of small muscles in hand
Fasciculations
Absence of sensory signs/symptoms
32
What is conduction dysphasia?
A stroke affecting the arcuate fasciculus in the dominant hemisphere (connection between Wernicke's and Broca's area)
33
What are the features of conduction dysphasia?
Speech fluent but repetition poor
Comprehension relatively intact
34
What is first line for spasticity in MS?
Baclofen or Gabapentin
35
What is first line in an acute relapse of MS?
High dose steroids (methylprednisolone)
36
What is the investigation for narcolepsy?
Multiple sleep latency EEG
37
What is a focal aware seizure?
Sudden short-lived change is senses (smell, taste, tactile, visual). No post ictal. Accompanied by sweating, twitching or gaze deviation.
38
What is a complex focal seizure?
A focal impaired awareness seizure
39
Do all patients lose conciousness in generalised seizures?
Yes
40
What are the types of generalised seizure?
Tonic-clonic
Tonic
Clonic
Atonic
Absence
41
What is a focal to bilateral seizure? (secondary generalised)
Starts in one side and area of the brain before spreading to both lobes
42
Difference between tibial nerve palsy and peroneal nerve palsy
TIPPED
Tibial- inversion, plantarflexion
Peroneal- eversion, dorsiflexion
Opposite one spared wheras in L5 radiculopathy all knocked out and weakness of hip abduction
43
How to manage bladder dysfunction in MS?
May be (urgency, incontinence, overflow)
Get ultrasound to assess bladder emptying (anticholinergics may worsen problem in some)
If significant residual volume → intermittent self-catheterisation
If no significant residual volume → anticholinergics may improve urinary frequency
44
What are the features of autonomic dysreflexia?
Hypertension, flushing and sweating above the level of the lesion
Paleness below region
45
What type of Parkinson's does asymmetrical tremor (symptoms) suggest?
Idiopathic Parkinson's
46
What is the triad of Parkinson's
Bradykinesia, tremor and rigidity
47
What type of tremor is seen in Parkinson's
Unilateral that improves with voluntary movement
48
What is the key investigation for encephalitis?
Cerebrospinal fluid PCR
49
What is the management of encephalitis?
Intravenous aciclovir in all cases of suspected encephalitis
50
What are the features of progressive supranuclear palsy?
Postural instability, impairment of vertical gaze, Parkinsonism and frontal lobe dysfunction
Parkinson's with visual problems and poor response to l-dopa
51
What is the acute management of a cluster headache?
100% oxygen
Subcutaneous triptan
52
What is the prophylactic treatment for a cluster headache?
Verapamil
(Tapering dose of prednisolone)
53
What condition is Lambert-Eaton syndrome also associated with?
Small cell lug caner
54
Myasthensia gravis and Lambert-Eaton difference?
MG worse with exercise, LE gets better with exercise
55
Features of Lambert-Eaton syndrome?
Repeated muscle contractions lead to increased muscle strength
Limb-girdle weakness (manifesting as a waddling gait)
Hyporeflexia
Autonomic symptoms: dry mouth, impotence, difficulty micturating
(No eye problems like in MG)
56
Lambert-Eaton syndrome management
Treat underlying cancer
Immunosupression (prednisolone and/or azathioprine)
Intravenous immunoglobulin therapy may be helpful
57
What is Guillain-Barre syndrome?
Immune mediated demyelination of the peripheral nervous system often triggered by an infection
58
What is often the initial symptom of GB
Back/leg pain
59
What are the characteristic features of GB?
Progressive, symmetrical weakness of all the limbs
Weakness typically ascending with legs affected first
Reflexes reduced or absent
Sensory symptoms mild
(History gastroenteritis common)
60
What are the GB investigations?
Lumbar puncture- High protein, normal WCC
Nerve conduction studies
61
Multiple sclerosis features
Lethargy
Visual:
Optic neuritis
Optic atrophy
Uhthoff's phenomenon: worsening of vision following rise in body temperature
Sensory:
Pins and needles
Numbness
Trigeminal neuralgia
Motor:
Spastic weakness
Cerebellar:
Ataxia
Tremor
Urinary incontinence
Sexual dysfunction
Intellectual deterioration
62
How to remember GCS?
Motor (6 points) Verbal (5 points) Eye opening (4 points). Can remember as '654...MoVE'
63
What are the break downs for GCS?
Motor response
6. Obeys commands
5. Localises to pain
4. Normal flexion
3. Abnormal flexion to pain (decorticate posture)
2. Extending to pain
1. None
Verbal response
5. Orientated
4. Confused
3. Words
2. Sounds
1. None
Eye opening
4. Spontaneous
3. To speech
2. To pain
1. None
64
What are the features of a stroke?
Motor weakness
Speech problems (dysphasia)
Swallowing problems
Visual field defects (homonymous hemianopia)
Balance problems
65
What are the criteria for offering thrombolysis?
Patient presents within 4.5 hours of onset of symptoms
Patient has not has a previous intracranial haemorrhage, uncontrolled hypertension, pregnant etc
66
What should be done as soon as haemorrhagic stroke excluded?
Given 300mg of aspirin and anti platelet therapy continued
67
TIA management?
Give 300mg aspirin immediately unless contraindicated
If TIA in last 7 days- assessment by stoke physician within 24 hours
If TIA over 1 week ago- refer to specialist within 7 days
68
What is the management for haemorrhagic strokes?
Supportive
Stop/reverse anticoagulation/ antithrombotic
69
CN Motor, Sensory or Both
Some Say Marry Money But My Brother Says Big Brains Matter Most
70
What does a defective CN IV cause?
Defective downward gaze- vertical diplopia
71
What are the three classifications of subdural hematoma?
Acute
Subacute
Chronic
72
What is the presentation of acute subdural hematoma on a CT?
Crescent shaped collection, not limited by suture lines
Hyperdense (bright)
If large may cause midline shift or herniation
73
Who is most at risk of subdural haematomas?
Elderly or alcoholic patients
74
What is the presentation of a chronic subdural haematoma?
Several weeks to month progressive confusion, reduced conciousness or neurological defecit
75
What is the difference between chronic and acute subdural on CT scans?
Acute- hyperdense (bright)
Chronic- hypodense (dark)
76
What is the treatment for an essential tremor?
Propanolol
77
What are the features of essential tremor?
Postural tremor- worse if arms outstretched
Improved by alcohol and rest
Most common cause of titubation (head tremor)
78
What are the common features of MND?
Asymmetric limb weakness most common presentation of ALS
Mixture of LMN and UMN signs
Wasting of small hand muscles/ tibialis anterior is common
Fasciculations
Absence of sensory signs
79
CN3 clinical presentation?
Palsy:
Ptosis
Down and out eye
Dilated, fixed pupil
80
CN4 clinical presentation?
Defective downwards gaze- vertical diplopia
81
CN5 clinical presentation?
Trigeminal neuralgia
Loss of corneal reflex
Loss of facial sensation
Paralysis of mastication muscles
Deviation of jaw to weak side
82
CN6 clinical presentation?
Defective abduction- horizontal diplopia
83
CN7 clinical presentation?
Flaccid paralysis of upper + lower face
Loss of conreal reflex (efferent)
Loss of taste
Hyperacusis
84
CN8 clinical presentation?
Hearing loss
Verigo, nystagmus
Acoustic neuromas are Schwann cell tumours of the cochlear nerve
85
CN9 clinical presentation?
Hypersensitive carotid sinus reflex
Loss of gag reflex (afferent)
86
CN10 clinical presentation?
Uvula deviates away from the site of lesion
Loss of gag reflex (efferent)
87
CN11 clinical presentation?
Weakness turning head to contralateral side
88
CN12 clinical presentation?
Tongue deviates towards side of lesion
89
What are the features of MS?
Lethargy
Visual- optic neuritis, optic atrophy, Uhthoff's phenomenon- worsening of vision following rise in body temperature, internuclear opthalmoplegia
Sensory- Pins/needles, numbness, trigeminal neuralgia, Lhermitte's syndrome- paraesthesiae in limbs on neck flexion
Motor- spastic weakness- most commonly seen in the legs
Cerebellar- ataxia- seen during acute relapse, tremor
Others:
Urinary incontinence
Sexual dysfuntion
Intellectual deterioration
90
Presentation of acute narrow angle glaucoma?
Severe pain around eye, nausea, redness, misty vision and semi dilated pupil
91
Anterior cerebral artery lesion?
Contralateral hemiparesis and sensory loss, lower extremity > upper
92
Middle cerebral artery lesion?
Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral homonymous hemianopia
Aphasia
93
Posterior cerebral artery lesion?
Contralateral homonymous hemianopia with macular sparing
Visual agnosia
94
Weber's syndrome (branches of the posterior cerebral artery that supply the midbrain) lesion?
Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity
95
Posterior inferior cerebellar artery (lateral medullary syndrome, Wallenberg syndrome) lesion?
Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus
96
Anterior inferior cerebellar artery (lateral pontine syndrome) lesion?
Symptoms are similar to Wallenberg's (see above), but:
Ipsilateral: facial paralysis and deafness
97
Retinal/ophthalmic artery lesion?
Amaurosis fugax
98
Basilar artery lesion?
'Locked-in' syndrome
99
Lacunar stroke presentation?
Isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
Strong association with hypertension
Common sites include basal ganglia, thalamus and internal capsule
100
Parietal lobe lesions presenation?
Sensory inattention
Apraxias
Astereognosis
Inferior homonymous quadrantanopia
Gerstmann's syndrome
101
Occipital lobe lesions?
Homonymous hemianopia (macular sparing)
Cortial blindness
Visual agnosia
102
Temporal lobe lesion?
Wernicke's aphasia- (forms speech)- speech remains fluent but word substitutions and neologisms
Superior homonymous quadrantanopia
Auditory agnosia
Prosopagnosia
103
Frontal lobe lesions?
Expressive Broca's aphasia- speech non-fluent, laboured and halting
Disinhibition
Perseveration
Anosmia
Inability to generate a list
104
Cerebellum lesions?
Midline lesions- gait and truncal ataxia
Hemisphere lesions- intention tremor, past pointing, dysdiadokinesis, nystagmus
105
Amygdala problem?
Kluver-Bucy syndrome (hypersexuality, hyperorality, hyperphagia, visual agnosia)
106
Substantia nigra of basal ganglia?
Parkinson's disease
107
Striatum (caudate nucleus) of the basal ganglia damage?
Huntington chorea
108
Subthalamic nucleus of basal ganglia?
Hemiballism
109
Medial thalamus and mammillary bodies of the hypothalamus?
Wernicke and Korsakoff syndrome
110
What is the presentation of a vestibular schwannoma (acoustic neuroma)?
Vertigo, hearing loss, tinnitus and an absent corneal reflex
Affected CN
8- vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
5- Absent corneal reflex
7- Facial palsy
111
Epilepsy treatment summary?
Generalised tonic clonic- M-sodium valproate
F- Lam/leve
F under 10 may get SV
Focal
1st- Lam/leve
2nd- Carbamazepine
Absence-
1st- Ethosuximide
2nd- M- SV, F- lam/leve
Carbamazepine makes them worse
Myoclonic seizures
M- SV
F- Leve
Tonic or atonic
M- SV
F- Lam
112
Tonic or atonic treatment in female?
Lamotrigine
113
Myoclonic treatment in female?
Levetiracetam
114
What are the adverse effects of sodium valproate?
Teratogenic
P450 inhibitor
GI- nausea
Increased appetite and weight gain
Alopecia
Ataxia
Tremor
Hepatotoxicity
Pancreatitis
Thrombocytopaenia
Hyponatraemia
Hyperammonemic encephalopathy
115
What is the treaetment for focal seizures?
Lamotrigine or levetiracetam
116
What is the aphasia classifications?
Speech non fluent
Comprehension intact- Broca's aphasia
Comprehension impaired- global aphasia
Speech fluent
Comprehension relatively intact- conduction aphasia
Comprehension impaired- Wernicke's aphasia
117
What are the side effects of levodopa?
Dry mouth
Anorexia
Palpitations
Postural hypotension
Psychosis
118
Migraine prophylaxis?
1st- Propanolol or topiramate M or F not of child bearing age
2nd- Amitriptyline
Topiramate is teratogenic so not in women of child bearing age
119
What is the acute treatment of a migraine
1st- combination therapy-
Oral triptan + NSAID or
Oral triptan + paracetamol
120
Classic triad in Parkinson's?
Bradykinesia, tremor and rigidity. Characteristically asymmetrical
121
Carbamazepine adverse effects?
P450 enzyme inducer
Dizziness and ataxia
Drowsiness
Headache
Visual disturbances
Steven-Johnson syndrome
Leucopenia and agranulocytosis
Hyponatreamia secondary to SIADH
122
What is given pre hospital for status epilepticus?
Rectal diazepam or buccal midazolam
123
What is first line in hospital for status epilepticus?
IV Lorazepam
124
What is the management of status epilepticus?
ABC
(Pre hospital rectal diazepam or buccal midazolam)
In hospital IV lorazepam (another after 5 mins)
If ongoing add levetiracetam, phenytoin or sodium valproate
If over 45 mins general anaesthesia or phenobarbital
125
Status management?
Oh My Lord Phone the Anaesthetist
Oxygen, midazolam, lorazepam, phenytoin, general anaesthetic
126
What is the wernicke's encephalopathy traid?
Opthalmoplegia/nystagmus
Ataxia
Encephalopathy
127
Features of wernicke's encephalopathy?
Oculomotor dysfunction- nystagmus, opthalmoplegia
Gait ataia
Encephalopathy- confusion, disorientation, indifference and inattentiveness
Peripheral sensory neuropathy
128
Treatment for wernicke's encephalopathy?
Urgent replacement of thiamine
129
When does wernicke's syndrome become wernicke-korsakoff's syndrome
When there is an onset of antero and retrograde amnesia and confabulation
130
Myasthenia gravis management?
1st- Pyridostigmine- long acting acetylcholinerase inhibitors
Add- prednisolone initally or azathioprine, cyclosporine
Thymectomy
131
What is Creutzfeldt-Jakob disease?
Rapidly progressing neurological condition-
Rapid onset demetntia
Myoclonus
132
Which hemisphere is usually dominant?
Left- 90% in RH, 60% in LH
133
What are the features of a common peroneal lesion?
Most characteristic feature is foot drop
Other features:
Weakness in dorsiflexion of the foot
Weakness of foot eversion
Wasting of the anterior tibial and peroneal muscles
134
What should you not do in headaches linked to Valsalva manoeuvere?
LP
Raised ICP until proven otherwise
135
What are the features of myasthenia gravis?
Muscle fatigue- progressive weakness improved with rest
Extraocular muscle weakness: diplopia
Proximal muscle weakness: face, neck, limb girdle
Ptosis
Dysphagia
136
What is the definition of status epilepticus?
A single seizure lasting over 5 mins
2 seizure within 5 mins without the person returning to normal between them
137
What is the management of status epilepticus?
ABC
Prehospital- PR diazepam or buccal midazolam
In hospital IV lorazepam. Repeat after 5-10 mins
Start second line such levetiracetam, phenytoin or sodium valproate
If no response within 45 mins from onset, induction of general anaesthesia or phenobarbital
138
What are the features of cluster headaches?
Intense sharp stabbing pain around one eye
Occurs once or twice a day, each episode 15mins to 2 hours
Patient agitated and restless during attack
Clusters typically last 4-12 weeks
Redness, lacrimation, lid swelling
Nasal stuffiness
Miosis and ptosis in minority
139
Investigations for cluster headaches?
Neuroimaging
MRI with gadolinium contrast is the investigation of choice
140
Management of cluster headaches?
Advice from specialist
Acute
100% oxygen
Subcut triptan
Prophylaxis
Verapamil
Some evidence for tapering dose of prednisolone
141
What is raised GGT a sign of?
Excessive alcohol consumption
142
Peripheral neuropathy causes that are motor loss?
Guillain-Barre syndrome
Porphyria
Lead poisoning
Hereditary sensorimotor neuropathies (HSMN) -
Charcot-Marie-Tooth
Chronic inflammatory demyelinating polyneuropathy (CIDP)
Diphtheria
143
Peripheral neuropathy causing mainly sensory loss?
Diabetes
Uraemia
Leprosy
Alcoholism
Vitamin B12 deficiency
Amyloidosis
144
What is alcoholic neuropathy?
Sensory loss prior to motor loss
From alcohol and the loss of B vitamins
145
Learn dermatomes
N
146
When is neuroleptic malignant syndrome most commonly seen?
In patients who have just started treatement with antipsychotics
Can also occur with levodopa if drug is suddenly stopped
147
What is a good way to remember neuroleptic malignant syndrome?
FEVER
Fever
Encephalopathy
Vitals dysregulation- increase in HR, RR, Fever
Enzyme- CK increase
Rigidity
148
What are the features of neuroleptic malignant syndrome?
Within hours to days of starting antipsychotics
Pyrexia
Muscle rigidity
Autonomic lability- hypertension, tachycardia and tachypnoea
Agitated delirium with cofusion
Raised creatine kinase present in most cases, AKI secondary to rhabdmyolysis may occur
Leukocytosis may also be seen
149
What is the management of neuroleptic malignant syndrome?
Stop antipsychotic
Patients transferred to medical ward if they on psychiatric ward
IV fluids to prevent renal failure
Dantrolene may be useful in some cases
Bromocriptine may also be used
150
What to do if GCS is below 8?
Review by an anaesthetist
Intubation and ventilation
151
What are the features of seizures in the temporal lobe?
With or without impairment of consciousness
Aura occurs in most patients- rising epigastric sensation
Pssychic phenomena such as deja vu
Less commonly hallucinations- olfactory, auditory
Seizures typically last around 1 minute- automatisms- lip smacking, grabbing, plucking
152
What are the features of seizures in the frontal lobe?
Head/leg movements, posturing, post-ictal weakness, Jacksonian march
153
What are the features of parietal lobe seizures?
Paraesthesia
154
What are the features of occipital lobe seizures?
Floaters/ flashes
155
Who is idiopathic intracranial hypertension seen in?
Classically young, overweight females
156
What are the risk factors for idiopathic intracranial hypertension?
Obesity
Female
Pregnancy
Drugs:
COCP
Steroids
Tetracyclines
Retinoids/Vit A
Lithium
157
What are the features of idiopathic intracranial hypertension?
Headache
Blurred vision
Papilloedema
Enlarged blind spot
CN6 nerve palsy may be present
158
What is the management of idiopathic intracranial hypertension?
Weight loss
Carbonic anhydrase inhibitors- acetazolamide
Topiramate also used, added benefit of causing weight loss
LP can be use as temporary measure
Surgery- optic nerve decompression may be needed
Lumboperitoneal shunt to reduce intracranial pressure
159
What are the features of trigeminal neuralgia
Unilateral brief electric shock pains, abrupt in onset and termination
Pain commonly evoked by light touch- washing, talking, brushing teeth etc
Pain remits for variable periods
160
What are the red flag symptoms of trigeminal neuralgia?
Sensory changes
Deafness
Skin or oral lesions
Only opthalmic pain
Optic neuritis
FH MS
Onset before 40
161
Trigeminal neuralgia management?
Carbamazepine
Failure to respond to treaetment or less than 50 should prompt referral to neurology
162
How to remember arm injuries?
A- Top of arm (humeral head dislocation)- axillary nerve injury
R- Middle of arm- radial nerve injury
M- Supracondylar- median nerve injury
163
What do the different nerve roots do?
C4 shoulder shrugs
C5 shoulder abduction and external rotation; elbow flexion
C6 wrist extension
C7 elbow extension and wrist flexion
C8 thumb extension and finger flexion
T1 finger abduction
L2 hip flexion
L3 knee extension
L4 ankle dorsiflexion
L5 great toe extension
S1 ankle plantarflexion
S4 bladder and rectum motor supply
C5,6 pick up sticks (biceps reflex)
C7,8 lay them straight (triceps reflex)
S1,S2 buckle my shoe (ankle reflex)
L3,L4 kick the door (patellar reflex)
164
What is palsy of the radial nerve associated with?
Wrist drop
165
What are the first line treatments for Parkinson's disease?
If motor symptoms affecting the patient's quality of life- Levodopa
If motor symptoms not affecting the patient's quality of life- dopamine agonist, levodopa or MAO-B inhibitor
166
Parkinson's management?
Levodopa
If not worked add in either a dopamine agonist (ropinirole, cabergoline), MAO-B inhibitor (selegiline), COMT inhibitor (entacapone), amantidine
167
When should thrombolysis with alteplase be done?
Within 4.5 hours of onset of stroke symptoms
A haemorrhage has definitely been excluded (imaging performed)
168
What can cause parkinsonism?
Parkinson's disease
Drug induced- antipsychotics, metoclopramide
Progressive supranuclear palsy
Multiple system atrophy
Wilson's disease
Post-encephalitis
Dementia pugilistica (secondary to chronic head trauma)
Toxins- carbon monoxide, MPTP
169
Which anti emetic to use in Parkinsonism?
Donperidone as does not cross blood brain barrier
170
What is degenerative cervical myelopathy?
Pain (neck, upper or lower limbs)
Loss of motor function (dexterity)
Loss of sensory function (numbness)
Loss of autonomic function (urinary, faecal incontinence, impotence)
Hoffman's sign (flicking one finger they all react)
171
What are the causes of raised intracranial pressure?
Idiopathic intracranial hypertension
Traumatic head injuries
Infection- meningitis
Tumours
Hydrocephalus
172
What are the features of raised intracranial pressure?
Headache
Vomiting
Reduced levels of consciousness
Papillodema
Cushing's triad- widening pulse pressure, bradycardia, irregular breathing
173
What investigations and monitoring for raised intracranial pressure?
Neuroimaging- CT/MRI- investigate underlying cause
Invasive ICP monitoring- catheter placed into lateral ventricles of brain to measure the pressure
174
What is the management of raised intracranial pressure?
Investigate and treat underlying cause
Head elevation to 30 degrees
IV mannitol may be used as osmotic diuretic
Controlled hyperventilation- aims to reduce pCO2, temporary lowering of ICP
Removal of CSF-
Drain from intraventricular monitor
Repeated LP
Ventriculoperitoneal shunt (for hydrocephalus)
175
Which conditions could have Hoffman's sign?
MS
Degenerative cervical myelopathy (DCM)
Flick one finger all twitch
176
Where is the damage for a subdural haemorrhage?
Bridging vein between cortex and venous sinuses
177
Where is the bleeding for an extradural haematoma?
Middle meningeal artery
178
Where is the bleeding for a subarachnoid haemorrhage?
Berry aneurysm
179
What are first line for spasticity in MS?
Baclofen and gabapentin
180
What is subacute degeneration of the spinal cord?
Vitamin B12 deficiency resulting in impairment of the dorsal columns, lateral corticospinal tracts and spinocerebellar tracts
181
What are the features of subacute degeneration of the spinal cord?
Dorsal column involvement- distal tingling/burning/sensory loss-impaired proprioception and vibration loss
Lateral corticospinal tract involvement- muscle weakness, hyperreflexia, spasticity, UMN signs in the legs, brisk knee jerk, absent ankle jerk, extensor plantars
Spinocerebellar tract involvement- sensory ataxia--> gait abnormalities
Positive Romberg's sign
182
What is a sudden onset headache reaching its maxiumum intensity within 5 minutes indicative of?
Subarachnoid haemorrhage
183
What is the investigation for SAH?
Non-contrast CT head as quicker
184
What is a rare but serious complication of carbamazepine?
Carbemazepine can be used for trigeminal neuralgia
Steven Johnson syndrome
185
What are the features of Steven-Johnson syndrome?
Rash typically maculopapular with target lesions being characteristic
may develop into vesicles or bullae
Nikolsky sign is positive in erythematous areas - blisters and erosions appear when the skin is rubbed gently
Mucosal involvement
Systemic symptoms: fever, arthralgia
186
What drugs can cause Steven-Johnson syndrome?
Penicillin
Sulphonamides
Lamotrigine, carbamazepine, phenytoin
Allopurinol
NSAIDs
Oral contraceptive pill
187
Hoffman's vs Hoover's sign?
HoFFman - Finger Flick (to see reflex of index finger Exaggerated or not- if exaggerated reflex then UMN lesion)
hOOver - Organic vs non Organic
188
What can Hoffman's sign differentiate between?
Organic and non-organic leg problems
If patient making an effort other leg presses down- organic
If patient not making effort other leg doesn't press down- conversion disorder
189
Which organism commonly causes Guillain-Barre syndrome?
Campylobacter jejuni
190
Absent corneal reflex think which condition?
Acoustic neuroma
191
Which cancers most commonly spread to the brain?
Metastatic most common type of brain tumour
Lung (most common)
Breast
Bowel
Skin
Kidney
192
Glioblastoma multiforme features?
Poor prognosis
Associated with oedema
Surgical treatment with post operative chemotherapy
Dexamethosone for oedema
193
Features of meningioma?
Second most common
Typically benign causing compression symptoms
Investigation- CT with contrast
Treatment- observation, radiotherapy or surgical resection
194
What is the treatment for atrophic vaginitis?
Older post menopausal women- vaginal dryness, dyspareunia and occasional spotting
Vagianal lubricants and moisturisers, topical oestrogen cream can be used
195
What happens when you give folate to a patient who is deficient in vitamin B12?
It can precipitate subacute degeneration of the spinal cord
Damage to the posterior columns - loss of proprioception, light touch and vibration sense (sensory ataxia and a positive Romberg's test).
Damage to lateral columns - spastic weakness and upgoing plantars (UMN signs).
Damage to peripheral nerves - absent ankle and knee jerks (LMN signs).
Dorsal column involvement
distal tingling/burning/sensory loss is symmetrical and tends to affect the legs more than the arms
impaired proprioception and vibration sense
Lateral corticospinal tract involvement
muscle weakness, hyperreflexia, and spasticity
upper motor neuron signs typically develop in the legs first
brisk knee reflexes
absent ankle jerks
extensor plantars
Spinocerebellar tract involvement
sensory ataxia → gait abnormalities
positive Romberg's sign
196
Learn spinal cord problems
NJDSAf
197
What does clozapine cause most dangerous?
Agranulocytosis, neutropaenia
198
Phenytoin adverse effects?
Acute- dizziness, diplopia, nystagmus, slurred speech, ataxia. Later: confusion, seizures
Chronic- Gingival hyperplasia, megaloblastic anaemia, peripheral neuropathy, dyskinesia, lymphadenopathy,
Idiosyncratic- fever, rashes, hepatitis, Dupytren's, aplastic anaemia, drug-induced lupus
Teratogenic- cleft palate and CHD
199
Do phenytoin levels need to be monitored?
No, although trough levels immediately before dose if-
Adjustment of phenytoin dose
Suspected toxicity
Detection of non-adherence to the prescribed medication
200
When should anti-D prophylaxis be given in termination of pregnancy?
Anti-D prophylaxis should be given to women who are rhesus D negative and are having an abortion after 10+0 weeks' gestation
201
What to do if gestation diabetes if diagnosed at over 7 when fasting?
Start insulin immediately
202
What type of insulin is used to treat gestational diabetes?
Short-acting
203
What is the management of endometrial hyperplasia?
Simple endometrial hyperplasia without atypia- high dose progestogens and repeat sampling in 3-4 months- levonorgestrel intra-uterine system may be useed
Atypia- hysterectomy usually advised
204
Nerve damages on fractures?
The nerves damaged in humeral fractures from proximal to distal
ARM- Axillary (neck), Radial (shaft), Median (supracondylar)
205
Do triptans increase the risk of serotonin syndrome?
Yes, sumatriptan so don't use SSRI and triptan together
Think migraine
206
What are the types of multiple sclerosis?
Relapsing-remitting- acute attacks followed by periods of remission
Secondary progressive disease- relapsing-remitting patients who have deteriorated and developed neurological signs and symptoms between relapses
Primary progressive disease- progressive deterioration from the onset
207
What is intracranial venous thrombosis (venous sinus thrombosis)?
Clot in veins of brain
Can cause cerebral infarction but much less common than arterial causes
(Get signs ICP from venous occlusion)
208
What are the features of intracranial venous thrombosis?
Headache (may be sudden onset but commonly gradual)
Nausea and vomiting
Reduced conciousness
Usually have some risk factors such as COCP, family history VTE
209
Investigations for intracranial venous thrombosis?
MRI venography is gold standard (MR venogram)
D-dimer may be elevated
210
What is the management of intracranial venous thrombosis?
Anticoagulation - LMWH
211
What is syringomelia?
Collection of cerebrospinal fluid in the spinal cord
212
What are the causes of syringomelia?
A Chiari malformation
Trauma
Tumours
Idiopathic
213
What are the features of syringomyelia?
Cape like (neck, shoulders and arms)- loss of sensation.. continue
214
Stoke management?
Within 4.5 hours: Thrombolysis with Alteplase, followed 24 hours later by aspirin 300mg
After 4.5 hours: No thrombolysis; just give Aspirin 300mg
215
Triad for normal pressure hydocephalus remember tool?
Wet, wobbly and weird
Urinary incontinence, gait ataxia and dementia
216
What is the definition of a TIA?
Now tissue based not time based
A transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction
217
What are the clinical features of a TIA?
The clinical features are similar to those of a stroke, i.e. sudden onset, focal neurological deficit but, rather than persisting, the features resolve, typically within 1 hour.
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
218
What is the assessment and referral criteria for TIAs?
ABCD2 no longer used
Immediate antithrombotic therapy:
Aspirin 300mg immediately unless:
1. Bleeding disorder or taking anticoagulant
2. Already taking aspirin- continue dose
3. Aspirin contraindicated
More than 1 TIA- discuss admission
Within last 7 days- 24 hour referral to specialist
Over 7 days ago- referral within a week to specialist
Don't drive until seen by specialist
219
What are the investigations of TIAs?
No CT unless clinical suspicion different diagnosis CT could detect
MRI- diffusion weighted- to assess territory of ischaemia
Carotid imaging- atherosclerosis in carotids can be source of emboli so- urgent carotid doppler- unless not elegible for carotid endarterectomy
220
What is the further management of TIAs?
Secondary prevention
Antiplatelet to follow on from aspirin therapy- 1st-Clopidogrel
2nd- aspirin and dipyridamole if clopidogrel not tolerated
Lipid modification- High intensity statin- atorvastatin
Carotid artery endarterectomy- stroke or TIA and not severely disabled
Only considered if- carotid stenosis >70%
221
What are the features of a brain abscess?
Mass effect in the brain- raised ICP common
Headache- dull
Fever
Focal neurology- oculomotor/abducens nerve palsy
Other features consistent with raised ICP- nausea, papilloedema, seizures
222
Investigations of brain abscess?
CT scan
223
Management of brain abscess?
Surgery- craniotomy performed
IV antibiotics- cephalosporin + metronidazole
Intracranial pressure management- dexamethasone
224
What is the minimum length of time seizure free before driving a car?
12 months completely
After 5 years normal licence restored
225
Driving rules if epilepsy?
All patients must not drive and must inform the DVLA
First unprovoked/isolated seizure: 6 months off if there are no relevant structural abnormalities on brain imaging and no definite epileptiform activity on EEG. If these conditions are not met then this is increased to 12 months
Established epilepsy- qualify if seizure free for 12 months
No seizures for 5 years means licence restored
Should not drive while anti-epilepsy medication being withdrawn and for 6 months after the last dose
226
Driving rules around syncope?
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
227
Driving rules miscellaneous conditions?
Stroke or TIA: 1 month off driving, may not need to inform DVLA if no residual neurological deficit
Multiple TIAs over short period of times: 3 months off driving and inform DVLA
Craniotomy e.g. For meningioma: 1 year off driving*
Pituitary tumour: craniotomy: 6 months; trans-sphenoidal surgery 'can drive when there is no debarring residual impairment likely to affect safe driving'
Narcolepsy/cataplexy: cease driving on diagnosis, can restart once 'satisfactory control of symptoms'
Chronic neurological disorders e.g. multiple sclerosis, motor neuron disease: DVLA should be informed, complete PK1 form (application for driving licence holders state of health)
228
Acute management of cluster headaches?
High flow oxygen and subcutaneous sumatriptan
229
What to do for a haemorrhagic transformation?
Stop anticoagulants such as aspirin and control BP
230
What is the Cushing's reflex?
Physiological nervous system response to increased intracranial pressure that results in hypertension and bradycardia
As the ICP raised to keep cerebral perfusion have to raise blood pressure but this causes counter reflex that lowers the heart rate- bradycardia
231
What might a fall in CPP indicate?
Cerebral perfusion pressure
A cerebral ischaemia
Calculated using:
CPP= mean arterial pressure- intracranial pressure
232
What is Lhermitte's sign?
Electric shock sensation that extends down your spine
233
What are the features of transient tachypnoea of the newborn?
Rapid breathing, grunting, mild intercostal recesssion
Caesarean is risk factor, maternal DM
O2 sats normal or mildly reduced
Resolves in 24-48 hours
234
Features of medication overuse headache?
Features
Present for 15 days or more per month
Developed or worsened while taking regular symptomatic medication
Patients using opioids and triptans are most at risk
May be psychiatric co-morbiditiy
Management
Simple analgesics and triptans can be withdrawn abruptly (may initially worsen headaches)
Opioid analgesics should be gradually withdrawn
Withdrawal symptoms such as vomiting, hypotension, tachycardia, restlessness, sleep disturbances and anxiety may occur when medication is stopped
235
What treatment can be helpful for severe eczema?
Wet wrapping
Management:
Avoid irritants
Simple emolients
Topical steroids
Wet wrapping
In severe cases, oral ciclosporin may be used
236
TempORAL seizures features?
Oral- lip smacking, grabbing, plucking
Post ictal dysphasia
Epigastric sensation
Deja vu
Hallucinations
237
What is thoracic outlet syndrome?
Thoracic outlet syndrome (TOS) is a disorder involving compression of brachial plexus, subclavian artery or vein at the site of the thoracic outlet
238
Features of thoracic outlet syndrome?
Painless wasting of hand muscles, patients complain of weakness
Sensory symptoms such as numbness
Cold hands, blanching or swelling
239
Is the forehead affected in Bell's palsy?
Yes as LMN signs
240
What are the mot common triggers of autonomic dysreflexia?
Urinary retention and faecal impaction
241
Why should topiramate be avoided in women of child bearing age?
Teratogenic and can reduce the effectiveness of hormonal contraceptives
242
When can pre eclampsia and gestational hypertension be diagnosed in pregnancy?
Only after 20 weeks
243
Meningitis complications?
Neurological sequalae
Sensorineural hearing loss (most common)
Seizures
Focal neurological deficit
infective
Sepsis
Intracerebral abscess
pressure
Brain herniation
Hydrocephalus
244
Brown-Sequard syndrome?
Caused by lateral hemisection of the spinal cord
Features:
Ipsilateral weakness below lesion
Ipsilateral loss of proprioception and vibration sensation
Contralateral loss of pain and temperature sensation
245
Management after a stoke?
300mg aspirin for first 14 days then clopidogrel long term
Any other secondary prevention measures (statins, BP)
246
Which Parkinson's medications can cause impulse control disorders?
Dopamine receptor agonists (bromocriptine, ropinirole, cabergoline, apomorphine)
247
What is the Barthel index?
Measures disability or dependence in ADLs after a stroke
248
Cerebellar lesion symptoms from which parts?
Cerebellar hemisphere- peripheral finger nose ataxia
Cerebellar vermis- gait ataxia
249
Which antibiotics raise the risk of idiopathic intracranial hypertension?
Tetracyclines- doxycycline
250
What is a classical history for multi system atrophy?
Poor response to levadopa, impotence, urinary retention and age group
Can have postural hypotension
251
Drugs to prevent relapse in MS patients?
Natalizumab
Beta-interferon
252
What is second line after clopidogrel for secondary stroke prevention?
Aspirin with modified release dipyridamole
253
What investigations should all TIA patients get after imaging?
Urgent carotid doppler if eligible for a carotid endocardectomy
254
Which lobes for quadrantanopias?
PITS
Parietal - Inferior quadrantanopia
Temporal - Superior quadrantanopia
255
Visual field defects summary?
Visual field defects:
left homonymous hemianopia means visual field defect to the left, i.e. lesion of right optic tract
homonymous quadrantanopias: PITS (Parietal-Inferior, Temporal-Superior)
incongruous defects = optic tract lesion; congruous defects= optic radiation lesion or occipital cortex
256
Remember propanolol
Not to be used in asthmatics- for migraine
In women on of child bearing age- past menopause- use topiramate
257
What do the power grades mean?
Grade 0 No muscle movement
Grade 1 Trace of contraction
Grade 2 Movement at the joint with gravity eliminated
Grade 3 Movement against gravity, but not against added resistance
Grade 4 Movement against an external resistance with reduced strength
Grade 5 Normal strength
258
Reflex routes?
S1-S2 buckle my shoe- ankle
L3-L4 kick the door- knee
C5-C6 pick up sticks- bicep
C7-C8 open the gate- tricep
259
Investigation for acoustic neuroma?
MRI of the cerebellopontine angle
260
MS investigation?
MRI with contrast
261
Subacute combined degeneration of the spinal cord (lack of vit B12) symptoms?
Loss of proprioception and vibration sense, muscle weakness and hyperrefelxia
262
Is the entire face affected in Bell's Palsy?
Yes, cannot move forehead all paralysed as LMN lesion
263
GCS?
Motor response
6. Obeys commands
5. Localises to pain
4. Withdraws from pain
3. Abnormal flexion to pain (decorticate posture)
2. Extending to pain
1. None
Verbal response 5. Orientated
4. Confused
3. Words
2. Sounds
1. None
Eye opening 4. Spontaneous
3. To speech
2. To pain
1. None
264
Neuro eye problems?
Homonymous quadrantopia
- PITS- parietal inferior, temporal superior
Bitemporal hemianopia
- lesion of optic chiasm
upper quadrant>lower= pituitary tumour
lower quadrant>upper= craniopharyngioma
265
Difference between vertical nystagmus and horizontal nystagmus when acute onset?
Vertical nystagmus- cerebellar stroke
Horizontal nystagmus- viral labyrinthitis
266
What are the features mentioned in the Oxford Stroke Classification?
The following criteria should be assessed:
1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
2. homonymous hemianopia
3. higher cognitive dysfunction e.g. dysphasia
267
Myasthenia gravis is associated with which type of malignancy?
Thymoma
268
Underlying pathology of myasthenia gravis?
Autoimmune disorder with antibodies to acetylcholine receptors
Extraocular muscle weakness: diplopia
Proximal muscle weakness: face, neck, limb girdle
Ptosis
Dysphagia
269
Investigations for myasthenia gravis?
Single fibre electromyography: high sensitivity (92-100%)
CT thorax to exclude thymoma
CK normal
Antibodies to acetylcholine receptors
positive in around 85-90% of patients
n the remaining patients, about about 40% are positive for anti-muscle-specific tyrosine kinase antibodies
Tensilon test: IV edrophonium reduces muscle weakness temporarily - not commonly used any more due to the risk of cardiac arrhythmia
270
Management of myasthenia gravis?
1st- long-acting acetylcholinesterase inhibitors- pyridostigmine
2nd- immunosuppression- prednisolone initially and then azathioprine
271
Management of myasthenic crisis?
Plasmapheresis
Intravenous immunoglobulin
272
What nerve may be damaged by a Colle's fracture (fall on outstretched hand)?
Median nerve
Inability to abduct thumb
273
Painful third nerve palsy?
Posterior communicating artery
274
What to do with ovarian cyst in pregnancy?
Nothing- they should go by themselves
275
HNPCC/Lynch syndrome is associated with which cancers?
Endometrial and ovarian
276
Is tamoxifen associated with endometrial cancer?
Yes
277
Temporal arteritis (GCA) features?
Overlap with polymyalgia rheumatica
Typically over 60 years old
Rapid onset
Headache
Jaw claudication
Vision testing a key investigation
Raised inflammatory markers- raised ESR
Temporal artery biopsy
Urgent high dose glucocorticoids before the temporal biopsy
High dose prednisolone if no visual loss
High dose methylprednisolone if visual loss
278
Trigeminal neuralgia features?
Electric shock like pain down side of face- unilateral
Caused by light touch
Red flags- sensory changes, deafness, optic neuritis, FH MS, onset before 40
Carbamazepine first line, atypical features refer to neurology
279
Tuberous sclerosis vs neurofibromatosis?
Look it up
Tuberous sclerosis- depigmented ash leaf spots
Neurofibromatosis- cafe au lait spots
280
What can raised ICP and brain herniation due to bleeding in the brain acuse?
Third nerve palsy
Down and out of the eye
281
What are the complications of meningitis?
Sensorineural hearing loss (most common)
Seizures
Focal neurological deficit
Infective
sepsis
intracerebral abscess
Pressure
brain herniation
hydrocephalus
282
Meningitis CSF analysis overview?
Bacterial
Cloudy
Glucose low
Protein high
White cells- 10-5000 polymorphs
Viral
Clear
Normal glucose
Protein- normal
White cells- 15-1000 lymphocytes
TB same as bacterial but lymphocytes
283
What are the features of encephalititis?
fever, headache, psychiatric symptoms, seizures, vomiting
focal features e.g. aphasia
peripheral lesions (e.g. cold sores) have no relation to the presence of HSV encephalitis
cerebrospinal fluid
lymphocytosis
elevated protein
PCR for HSV, VZV and enteroviruses
neuroimaging
medial temporal and inferior frontal changes (e.g. petechial haemorrhages)
normal in one-third of patients
MRI is better
EEG
lateralised periodic discharges at 2 Hz
IV aciclovir to all patients with suspected encephalitis
284
Seizure vs vasovagal post ictal?
Seizure post-ictal lasts around 15 mins
Vasovagal lasts 2-3 mins
285
Should beta blockers be avoided in MG?
Yes
286
Which Parkinson's medication is most associated with poor impulse control?
Dopamine receptor antagonists
287
Differentiate between total and partial anterior circulation infarcts?
Total involves all 3 criteria
Partial involves 2 criteria
The following criteria should be assessed:
1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
2. homonymous hemianopia
3. higher cognitive dysfunction e.g. dysphasia
288
Difference between 3rd nerve palsy and Horner's?
Ptosis and dilated pupil= third nerve palsy
Ptosis and constricted pupil= Horner's (and anhidrosis loss of sweating on one side)
289
Features of Charcot-Marie-Tooth
Features:
There may be a history of frequently sprained ankles
Foot drop
High-arched feet (pes cavus)
Hammer toes
Distal muscle weakness
Distal muscle atrophy
Hyporeflexia
Stork leg deformity
290
Arteries vs nerves on MRI?
Approximate
Arteries- CT without contrast
Nerves- CT with contrast
291
Four main features of neuroleptic malignant syndrome?
Rigidity, hyperthermia, autonomic instability (hypertension/tachycardia) and altered mental status (confusion)
Known cause of AKI so can cause deranged U+Es
292
Bacterial meningitis on LP?
Turbid, high polymorphs, high protein, low glucose
293
Migraine causes?
CHOCOLATE- Chocolate, hangover, orgasm, cheese, oral
contraceptive, lie in, alcohol, tumult, exercise
294
Benign rolandic epilepsy?
Seizures at night parasthesia affecting the face but can also go to generalised tonic clonic
Good prognosis- resolve by adolescence
295
Criteria for a CT head in under 1 hour head injury?
CT head within 1 hour
GCS < 13 on initial assessment
GCS < 15 at 2 hours post-injury
suspected open or depressed skull fracture
any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign).
post-traumatic seizure.
focal neurological deficit.
more than 1 episode of vomiting
296
Criteria for a CT head in under 8 hours head injury?
CT head scan within 8 hours of the head injury - for adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury:
age 65 years or older
any history of bleeding or clotting disorders including anticogulants
dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs)
more than 30 minutes' retrograde amnesia of events immediately before the head injury
297
Causes of spontaneous SAH
intracranial aneurysm (saccular ‘berry’ aneurysms)
accounts for around 85% of cases
conditions associated with berry aneurysms include hypertension,adult polycystic kidney disease, Ehlers-Danlos syndrome and coarctation of the aorta
arteriovenous malformation
pituitary apoplexy
mycotic (infective) aneurysms
298
Classic features of SAH?
Classical presenting features include:
Headache
Usually of sudden-onset (‘thunderclap’ or ‘hit with a baseball bat’)
severe (‘worst of my life’)
Occipital
typically peaking in intensity within 1 to 5 minutes
nausea and vomiting
meningism (photophobia, neck stiffness)
Coma
Seizures
ECG changes including ST elevation may be seen
299
SAH investigation?
non-contrast CT head is the first-line investigation of choice
if CT head is done within 6 hours of symptom onset and is normal
new guidelines suggest not doing a lumbar puncture
consider an alternative diagnosis
if CT head is done more than 6 hours after symptom onset and is normal
do a lumber puncture (LP)
timing wise the LP should be performed at least 12 hours following the onset of symptoms to allow the development of xanthochromia (the result of red blood cell breakdown).
xanthochromia helps to distinguish true SAH from a ‘traumatic tap’ (blood introduced by the LP procedure).
as well as xanthochromia, CSF findings consistent with subarachnoid haemorrhage include a normal or raised opening pressure
if the CT shows evidence of a SAH
referral to neurosurgery to be made as soon as SAH is confirmed
After spontaneous SAH is confirmed, the aim of investigation is to identify a causative pathology that needs urgent treatment:
CT intracranial angiogram (to identify a vascular lesion e.g. aneurysm or AVM)
+/- digital subtraction angiogram (catheter angiogram)
300
Management of confirmed SAH?
Management of a confirmed aneurysmal subarachnoid haemorrhage
supportive
vasospasm is prevented using a course of oral nimodipine
intracranial aneurysms are at risk of rebleeding and therefore require prompt intervention, preferably within 24 hours
most intracranial aneurysms are now treated with a coil by interventional neuroradiologists, but a minority require a craniotomy and clipping by a neurosurgeon
301
Complications of SAH?
Rebleeding
Hydrocephalus
Vasospasm
Hyponatraemia
Seizures
302
Presentation of hydrocephalus?
Headache (typically worse in the morning, when lying down and during valsalva)
Nausea and vomiting
Papilloedema
Coma (in severe cases)
Infants can have increase in head size, bulging fontanelles and failure of upward gaze
303
Neuropathic pain drugs?
Don't get pain again
Duloxetine
Gabapentin
Pregabalin
Amitriptyline
304
Can Parkinson's cause postural hypertension?
Yes
Causes autonomic dysfunction
305
What are the three things that occur in juvenile myoclonic epilepsy?
Absence seizures
Single limb jerking in the morning following sleep deprivation
Generalised tonic-clonic
306
If a Bell's palsy shows no signs of improvement, after how long should you refer urgently to ENT?
3 weeks
307
Parkinson's disease with more falls, ED, postural hypertension?
Potentially multiple system atrophy
308
DANISH?
DANISH: dysdiadochokinesia, ataxia, nystagmus, intention tremor, slurred speech, and hypotonia
309
Triptans?
Adverse effects
'triptan sensations' - tingling, heat, tightness (e.g. throat and chest), heaviness, pressure
Contraindications
patients with a history of, or significant risk factors for, ischaemic heart disease or cerebrovascular disease
310
LP findings in MS?
Oligoclonal bands in CSF
311
What score assesses stroke in an emergency setting?
ROSIER
312
Triad for brain abscess?
Fever, headaches, focal neurology
313
Should someone on warfarin/doac get a head CT after TIA?
Yes
314
What is pituitary apoplexy?
Sudden enlargement of pituitary tumour due to haemorrhage
Sudden onset headache
Visual field defects
Vomiting
Neck stiffness
Urgent steroid replacement
315
What triggers cluster headaches?
Smoking, alcohol, nocturnal sleep
316
Chronic subdural management?
Asymptomatic- conservative
Symptomatic- burr hole evacuation
317
Where does herpes simplex encephalitis affect?
The temporal lobes
318
Lesion of the optic chiasm?
Pituitary adenoma- bitemporal hemianopia upper quadrant>lower quadrant
Craniopharyngioma- bitemporal hemianopia lower quadrant>upper quadrant
319
Stopping antiepileptics?
Seizure free over 2 years, drugs stopped over 2-3 months
320
What scale used to measure disability after a stroke?
Barthel index
321
What antibody is involved in Lambert-Eaton syndrome?
An antibody directed against presynaptic voltage-gated calcium channel
Features of Lambert-Eaton
Features
repeated muscle contractions lead to increased muscle strength (in contrast to myasthenia gravis)
in reality, this is seen in only 50% of patients and following prolonged muscle use muscle strength will eventually decrease
limb-girdle weakness (affects lower limbs first)
hyporeflexia
autonomic symptoms: dry mouth, impotence, difficulty micturating
ophthalmoplegia and ptosis not commonly a feature (unlike in myasthenia gravis)
322
When to give aspirin after thrombectomy?
24 hours after
323
Remember symptoms of stroke on the other side
If left symptoms, need a right carotid endarterectomy
324
Todd's paresis?
Occurs after a frontal lobe seizure
Post-ictal weakness
325
Does multiple system atrophy present with significant cognitive dysfunction?
No, differentiates it from Lewy body dementia
326
Charcot-Marie-Tooth
Long term demyelinating
High arched feet- CMT
(Muscle weakness, power reduction in limbs, sprained ankle)
327
Difference between miosis and myadriasis?
Miosis- small pupil
Myadriasis- large pupil
328
Spasticity in MS?
Baclofen and gabapentin are first line
329
Differentiate between cavernous sinus syndrome or posterior communicating artery aneurysm?
Posterior communicating artery aneurysm (pupil dilated)
= Think: 3rd nerve palsy = ptosis + dilated pupil
Cavernous sinus thrombosis
= absent corneal reflex + proptosis
330
Check for asthma when prescribing propanolol?
YEES
331
Progressive supranuclear palsy?
PSP-Problems seeing planes
Features
postural instability and falls
patients tend to have a stiff, broad-based gait
impairment of vertical gaze (down gaze worse than up gaze - patients may complain of difficultly reading or descending stairs)
parkinsonism
bradykinesia is prominent
cognitive impairment
primarily frontal lobe dysfunction
Poor response to l-dopa
332
Multiple system atrophy?
Parkinson's with cerebellar signs and autonomic disturbance (ED, atonic bladder, postural hypotension)
