Neurology Flashcards
(310 cards)
1
Q
What are cerebrovascular accidents?
A
Transient ischemic attack
Stroke
2
Q
What is a transient ischemic attack?
A
Sudden onset neurological deficit , lasting <24hr without infarction.
3
Q
What are the causes of a TIA?
A
Carotid thrombosis-emboli
- thrombosis
emboli from AF
- 90% ICA
-10% Vertebral
4
Q
What are the risk factors of a TIA?
A
- smoking
-T2DM
-HTN
-AF
-Obesity
-VSD
5
Q
What is the presentation of a TIA?
A
Focal neurology:
-Anterior cerebral artery =weak numb contralateral leg
-Middle cerebral artery= weak numb contralateral side of the body, face drooping w/ forehead spared, dysphasia ,(temporal)
-Amaurosis fugal
-Posterior CA= vision loss
-Vertebral artery = cerebellar syndrome; ataxia, nystagmus , tremor with the Romberg test (sensory +ataxia)
CN lesions 3-12
6
Q
What is Amaurosis Fugax?
A
Emboli passes into retinal, ophthalmic or ciliary artery, low blood flow to retina due to occlusion
7
Q
What is the vision loss seen seen in posterior cerebral artery ichemia?
A
contralateral homonymous hemianopia with macular sparing - occipital affected
8
Q
What is the diagnosis of TIA?
A
Clinically made - use scoring systems:
FAST- face arms speech time
ABCD2 scoring
-Diffusion weighted MRI?CT
-Carotid imaging - doppler USS
9
Q
What is the acute treatment for a TIA?
A
Aspirin 300mg
10
Q
What is prophylaxis treatment for a TIA?
A
Clopidogrel 75mg + atorvastatin 80mg
11
Q
What is hemiparesis?
A
weakness of an entire side of the body
12
Q
What is affected if a patients is unable to understand speech or is having trouble speaking?
A
inability to understand - (Wernickes)
or speech (Broca’s)
13
Q
What is a stroke?
A
Focal neurological deficit lasting 24hr< with infarction
14
Q
What are the types of stroke?
A
Ischemic -85%
Haemorrhagic-15%
15
Q
What is an ischemic stroke?
A
Essentially long TIA
- carotid throbs-emboli
-thrombosis
-AF embolism
16
Q
What is a haemorrhage stroke?
A
Brain bleeds - trauma , HTN, Berry aneurysm rupture
17
Q
What are the risk factors of a stroke?
A
HTN, smoking, obesity, T2DM, AF, TIA
18
Q
Why is atrial fibrillation a risk factor for stroke?
A
Due to stasis ob blood in atria which thromboses and can embolise to carotids
19
Q
What is the presentation of a stroke?
A
Focal neurology like TIA!!
- raise ICP t
-pronator drift -stroke sign
20
Q
How can a haemorrhage stroke cause an increase in ICP?
A
Bleeding/ cerebral oedema causes increase in pressure on the brain structures and causes a midline shift
21
Q
What are the signs of increased ICP?
A
Ipsilateral pupillary dilation - down and out
Headache, vomiting
Papilloedema
cushings reflex
midline shift
CN6 palsy
LOC
22
Q
What are the complications of ICP?
A
Tentorial herniation + coning
23
Q
What is the body’s repsonse/reflex to raised ICP?
A
Cushings reflex
24
Q
What is cushings reflex?
A
Hypertension
Bradycardia
Irregular breathing
25
What causes Cushing reflex?
Increase in ICP , ICP exceeds arterial blood pressure pushes on arterioles and they start to compress leading to reduced cerebral blood flow--> activates sympathetic system-> alpha 1 adrenergic receptors activated causing vasoconstriction + HTN
HTN detected by barroreceptors -->activation of para-sympathetic and therefore muscarinic 2 receptors to lower heart rate (bradycardia)
Irregular breathing caused by ICP and HTN pressing on respiratory centre
26
What is Lacunar stroke?
common type of ischemis stroke of lenticulostraite arteries (supply deep brain structures)--> ischemia to BG ,internal capsule + thalamus
27
What is pronator drift?
Ask patient to lift arms to ceiling ; pronators take over , arm on affected side will pronate + palm faces down
28
What is the diagnosis of a stroke?
non contrast CT head = ischemic- mostly normal
Haemorrhage - hyper dense blood
Needed to distinguish
29
What is the treatment for ischemic stroke?
1. presents within 4.5 hours = clot buster (thrombolysis) ? IV alteplase
2. Aspirin 300mg for 2 weeks
+ lifelong clopidogrel 75mg
30
What is the treatment for a haemorrhagic stroke?
Neurosurgery referral
IV mannitol for increased ICP
31
What is an intracerebral haemorrhage?
Sudden bleeding into brain tissue due to a rupture of a blood vessel within the brain
This can lead to infarction and raised ICP.
32
What are the types of intracerebral haemorrhages?
-subarachnoid
-subdural
-extradural
33
What is a subarachnoid haemorrhage?
spontaneous bleeding into the subarachnoid space usually due to a berry aneurysm circle of willis rupture
34
Where is the subarachnoid space?
Between the arachnoid and Pia mater
35
What are the risk factors of a subarachnoid haemorrhage?
HTN, Traumua, increasing age, FHX, known aneurysm
36
What is the presentation of a subarachnoid haemorrhage?
- occipital thunderclap headache
-sudden onset
-may have had sentinel headache - warning symptom that precedes the rupture of aneurysms
- worst headache of your life
-mennigism -mimics meningitis kernig + Brudzinksi signs
-Low GCS score
-CN3 palsy - fixed dilated pupi
-CN6 palsy- signs go increased ICP
37
What is Kernig sign?
can't extend leg when knee is flexed
38
What is Brudzinski sign?
when neck elevated knees automatically flex
39
What is GCS?
Glasgow coma scale - measures consciousness
15 - normal
8- comatose
3-unresponsive
40
What is the diagnosis of subarachnoid haemorrhage ?
Diagnostic CT head - a star shape
Positive = Do a CT angiogram to see extent
Negative = lumbar puncture - wait 12hr as results are most sensitive then
Positive sign is that you will see xanthochromia (yellowish CSF due to RBC haemolysis)
41
What is the treatment of subarachnoid haemorrhage?
1st line - neurosurgery ; end-vascular coiling
Nimodipine - CCB so reduces vasospasm and BP
42
What is a subdural haemorrhage?
Bleeding into subdural space due to a rupture of a bridging vein from shearing and deceleration injuries
43
What is the subdural space?
the space between dura mater and arachnid mater
44
What are the risk factors of subdural haemorrhage ?
- trauma
-child abuse
-cortical atrophy - dementia
45
What is the presentation of subdural haemorrhage?
Gradual onset with latent period
- bleeding is small ; accumulation + autolysis of blood - haematoma grows gradually - Sx after days/weeks/months
-Sx of raised ICP; Cushing triad + fluctuating GCS + papillodema
-focal neurology later
46
What is the diagnosis of subdural haemorrhage?
NCCT Head = banana or crescent shaped haematoma ,
crosses suture lines, unilateral, midline shift
47
What is the treatment for subdural haemorrhage?
Surgery; Burr hole + craniotomy
IV mannitol to lower ICP
48
What is the extradural space?
space between dura mater and skull bone
49
What is an extradural haemorrhage?
Bleeding into extradural space usually after trauma to middle meningeal artery / temporal bone
50
What is the epidemiology of extradural haemorrhage?
typically young adults 20-30
As you age the risk decreases as dura mate more firmly adhered to skull
51
What is a risk factor of extradural haemorrhage?
head trauma
52
What is the pathology of extra dural haemorrhage ?
Initial event --> lucid interval 'I feel fine' --> after weeks rapid deterioration due to raised ICP as the clot becomes haemolysed and takes up water therefore increases volume of skull; rises ICP
53
What is the presentation of extra dural haemorrhage?
Low GCS - confusion
Raised ICP signs - cushings triad, papillodema
54
What is the diagnosis pf extradural haemorrhage?
NCCT head - Lens shaped hyper dense bleed
-confined to suture lines
-midline shift
-unilateral
55
What is the treatment of extradural haemorrhage?
- urgent surgery - clot evacuation
-IV mannitol for raised ICP
56
What is a complication of extradural haemorrhage ?
Death from respiratory arrest
- tonsillar herniation + coning of brain= compressed respiratory centres
- due to untreated raised ICP
57
What are primary headaches?
-migraine
-cluster
-tension
-drug overdose
-Trigeminal neuralgia)
58
What are secondary causes of headaches?
Due to an underlying condition:
-GCA
-Infection
-SAH
-Trauma
-Cerebrovascular disease
-Eye, ear, sinus pathology
59
What is a migraine?
Episodes of recurrent throbbing headache +/- aura , often with vision change
60
What is the epidemiology of migraines?
- most common cause of episodic headache
-F>M
61
What are the triggers of a migraine?
- chocolate
-hangovers
-orgasms
-cheese
-oral contraceptives
-alcohol
-exercise
62
What is the pathology of migraines?
Prodome (days before attack)
- mood change
Aura (part of attack, minutes before headache)
- visual phenomena; zig zag lines
Throbbing headache lasting 4-72hr - migraine
63
What is the presentation of a migraine?
2< of:
- unilateral pain
-throbbing
-motion-sicknss
-mod-severely intense +
1< of:
- N+V
-Photophobia/ phonophobia
64
What is the diagnosis of a migraine?
clinical - unless other pathology suspected
65
What is the treatment of Migraine?
Acute - oral triptan (Sumatriptan) or Aspirin (900mg)
Prophylaxis- Bb - propanolol
or TCA- amitriptyline
66
What is a cluster headache?
Unilateral periorbital pain with autonomic features. 15-60mins
67
What is the epidemiology of a cluster headache?
- most disabling primary headache
-rare-ish
-many headaches clustered in a small amount of time
68
What are the risk factors of cluster headaches?
male
smoking
genetics (auto dom link)
69
What is the presentation of a cluster headache?
Crescendo (rising in severity) unilateral periorybital excruciating pain, may affect temples too
Autonomic features:
-conjunctival infection + lacrimation
-Ptosis (droopy eyelids)
-miosis (dilated unilateral pupil)
-rhinorrhoea
70
What is the diagnosis of cluster headaches?
clinically 5< similar attacks confirms diagnosis
71
What is the treatment of cluster headaches?
Acute - triptans (sumatriptan)
Prophylaxis - CCB- verapamil
72
What is a tension headache?
Bilateral generalised headache, radiated to neck
73
What is the epidemiology of tension headaches?
- most common primary headache
- triggered by stress
74
What is the presentation of tension headaches?
Rubber band, tight around head. Bilateral pain, feel it in trapezius too
- mild to mod severely
-no motion sickness, photophobia, aura
75
What is the diagnosis of tension headaches?
Clinical from Hx
76
What is the treatment for tension headaches?
Simple analgesia - Aspirin or paracetamol
77
Why would a patient avoid opiates?
Risk of dependence
78
What is trigeminal neuralgia ?
Unilateral pain in 1< trigeminal branches
79
What are the risk factors of trigeminal neuralgia ?
MS (20x more likely)
Increasing age
Female
80
What are the triggers of trigeminal neuralgia ?
eating, shaving, talking, brushing teeth
81
What is the presentation of trigeminal neuralgia?
Electric shock pain (secs -2min) in V1/2/3
82
What is the diagnosis of trigeminal neuralgia?
Clinical 3< attacks with symptoms
83
What is the treatment of trigeminal neuralgia?
Carbamazepine - anticonvulsant
84
What is giant cell arteritis?
Large vessel vasculitis
85
What is the pathology of giant cell arteritis?
50 year old - caucasian women - presents with unilateral tender scalp, intermittent jaw claudication
- worst case Amaurosis Fugax
86
What is the diagnosis of giant cell arteritis?
Temporal artery biopsy -> big sample as many skip lesions
- granulomatosis non caseating inflammation of intimal + media with skip lesions
- Raised ESR/CRP
-nomocytic nomochromic anemia (of chronic disease)
87
What is the treatment of giant cell arteritis?
Corticosteroids - prednisolone
- if signs of amaurosis fugax - high dose IV methylprednisolone
88
What is Parkinson's disease?
Progressive movement disorder due to degeneration of dopamine - producing neurons in the substantia nigra
89
What is the epidemiology of Parkinson's disease?
- 2nd most common neurodegenerative disorder after dementia
-more common in males, peak onset 55-65
90
What are the risk factors of Parkinson's disease?
FHx, males, increasing age, smoking seems to be protective ?
91
What is the pathology of Parkinson's disease?
To initiate movement - nigrostriatal pathway signals striatum to stop firing to substantia niagra pars reticularis therefore stop movement inhibition
Degenrated substantia Niagara pars compacta, less dopamine to striatum - harder to initiate movement
92
What is the presentation of Parkinson's disease?
Cardinal Sx = Bradykinesia , resting tremor , Rigidity, postural instability
- anosmia, constipation
-shuffling gait , pill rolling thumb
- typically asymmetrical
93
What is the diagnosis of Parkinson's disease?
Clinical - Bradykinesia + 1< other cardinal Sx
DaTSCAN - reduced dopamine supply
Head CT - SN atrophy
94
What is the treatment of Parkinson's?
Levodopa - increase amount of dopamine in CNS + carbidopa
95
What is the problem with L-DOPA?
L-DOPA usually works very well but soon the body becomes resistant to it, effects wear off therefore don't give LDOPA to mild Sx
96
What is Ddx of Parkinson's ?
Lewy body dementia - associated with Parkinson's
Parkinson Sx then dementia= Parkinson dementia
Parkinson Sx after dementia = Lewy body dementia with Parkinsonism
97
What is Dementia?
Neurodegenerative disorder; reduced cognition (memory, judgement, language) over time
98
What are the risk factors of dementia?
-Depression
-reduced activity
-Downs
99
What are the causes of dementia?
Alzheimer's - 60%
Vascular -20%
Lewy body- 10%
Fronto temporal -5%
100
What is Alzheimers disease?
Accumulation of beta amyloid plaques (breakdown product of amyloid precursor protein) and neurofibrillary tangles in cerebral cortex. This increases cortical scarring and brain atrophy and reduces Ach transmitters
101
What is the risk factors of Alzheimer's disease?
Downs - inevitable ; APP gene mutation
-ApoE4 allele in familial alzheimers late onset
102
What are amyloid plaques?
clusters that form in the space between nerve cells
103
What are neurofibrillary tangles?
Knots of the brain cells
104
What is the presentation of Alzheimers disease?
Agnosia - can't recognise things
Apraxia -cant do basic motor skills
Aphasia - can't talk as well as normal
-amnesia
- gradual onset / steady decline
105
What is vascular dementia?
Cerebrovascular damage - stroke,TIA
106
What is the presentation of vascular dementia?
UMN signs + general decline in cognition
Stepwise decline with short periods of stability
107
What is Lewy body dementia?
Lewy bodies (alpha synuclein + ubiquitin aggregates) accumulate in cortex. Associated with parkinons
108
What is the presentation of Lewy body?
Fluctuating cognitive function
Parkinsonism
109
What is front-temporal dementia?
Specific degeneration of frontal and temporal lobes of the brain
110
What are the risk factors of fronto temporal dementia ?
FHx-Autosomal dominant change in Tau protein , chromosome 17
- Motor neurone disease
111
What is the presentation of fronto-temporal dementia?
speech; language mostly = temporal more so affected
Thinking+memory affected= frontal more so
112
What is the diagnosis of dementia?
Mini mental state exam
>25 - normal
18-25 - impaired
<17 -severely impaired
Brain MRI - cortical atrophy
113
What is the treatment of dementia?
Conservative ; social stimulation, exercise
For alzheimers - Rivastigmine (Acetylcholinesterase inhibitor- stops the enzyme breaking down Ach)
Vascular - antihypertensives - ramipril
114
What is Huntington's disease?
Huntington's disease is an autosomal dominant neurodegenertive disorder with full penetrance characterised by the lack of inhibitor neurotransmitter GABA. The cause of chorea
115
What is the aetiology of HD?
CAG repeats on chromosome 4, affecting gene HTT
The more trinucleotide repeats, the earlier + more severe Sx present ; Anticipation.
116
What is the presentation of Huntington's disease?
Chorea, dementia, psychiatric issues, depression
117
What is Chorea?
A continuos flow of involuntary jerky movements
118
What is the diagnosis of Huntington's disease?
Clinical
FHx of earlier + more severe Huntington's
Genetic test if over 35 repeats
119
What is the treatment for HC?
Extensive counselling
DA antagonist - Tetrabenazine
120
What is Multiple Sclerosis?
Chronic autoimmune , T cell mediated inflammatory disorder against myelin basic protein of oligodendrocytes leading to multiple plaques of demyelination, occurring sporadically over years
121
What are the risk factors of MS?
females
20-40
Autoimmune disease- FHx
EBV
122
What are the types of MS?
Relapsing/ remitting
Primary Progressive
Secondary Progressive
123
What is relapsing-remitting?
Most common
- clearly defined disease relapses with full or partial
recovery with residual deficits
-periods between disease relapses have no increase in disability between bouts
- incomplete recovery
124
What is primary progressive?
Gradual deterioration without recovery
125
What is secondary progressive ?
Relapsing-remitting -> primary progressive - 75% R-R causes evolve to this
126
What are the symptoms of Multiple sclerosis ?
Parasthesia - tingling and numbness
Blurred vission
Uhtoffs phenomenon - Sx exacerbated with heat, after a shower
127
What are the signs of MS?
Optic Neuritis- inflamed optic nerve, can't see red properly
Internuclear opthalmoplegia - lateral gaze impaired - damaged medial longitudinal fasciculus
Brainstem signs(displopia, dysarthria , vertigo), Sensory signs ( impaired proprioception, Paraesthesia)
UMN signs = Lhermitte Phenomenon , Charcot neurological triad
128
What is Lhermitte phenomena ?
UMN sign
- electric shock sensation with neck flexion
129
What is Charcot neurological triad?
- dysarthria - struggle soaking due to muscles
-Nystagmus - miscommunication between eye and brain
-Intention tremor
130
What is the diagnosis of Multiple sclerosis?
Mcdonald Criteria = 2< attacks disseminated in time and space - separate events + different part of CNS affected
Diagnostic = MRI brain + cord- shows dissemination in space (where there is white demyelination)
- delayed conduction speed
-LP may show oligoclonal IgG bonds - CNS inflammation
131
What is the treatment for multiple sclerosis ?
Acutely - IV Methylprednisolone
Prophylaxis - Beta interferon
DMARD
132
What is motor neurone disease?
Progressive degeneration of motor neurones in the brain and spinal cord, causing UMN and LMN signs
133
What is the main motor spinal tract?
Corticospinal - UMN from precentral gyrus which has - Decussation (lateral , 90% fibres) and no decussation (anterior, 10% fibres)
134
What is the organisation of movement?
1. Idea of movement - association cortexes, pre motor cortex
2.Activation of UMNs - in motor cortex
3. Impulse via corticospinal tract to LMN
4.Modulation by
-cerebellum - fine tuning
-Basal ganglia - green signal to move
5. Movement + somatosensory info obtained by sensory tracts
135
What is a UMN lesion?
Lesion from precentral gyrus to anterior spinal cord
-everything goes up
136
What are the signs of a UMN lesion?
1. Hypertonia; rigidity, spasticity
2. Hyperreflexia
3.No fasciculations
4.Babinski Positive -occurs when stimulation of the lateral plantar aspect of the foot leads to extension (dorsiflexion or upward movement) of the big toe
5. Arms: Flexor muscles stronger> than extensors
Legs: Extensor> flexers
137
What is a LMN lesion?
Lesions from anterior spinal cord to the muscles innervated
-everything goes down
138
What are the signs of a LMN lesion?
1. Hypotonia ;flaccid +muscle wasting
2. Hypoflexia
3. Fasciculations
4.Babinski negative
5.Generally low power
139
What are the risk factors of motor neurone disease?
Male
FHx -SOD-1 mutation
Increasing age
140
What does motor neurone disease never affect?
Eye muscles --> MS+MG do
Sensory function --> MS+ polyneuropathies do
141
What are the classification of MND?
1. Amyotrophic lateral sclerosis
2.Progressive lateral sclerosis
3.Progressive muscular atrophy
4.Progressive bulbar palsy
142
What is Amyotrophic lateral sclerosis?
- most common
-UMN +LMN signs
-Can progress to bulbar palsy
143
What is primary lateral sclerosis?
UMN signs only
144
What is progressive muscular atrophy?
LMN signs only
145
What is progressive bulbar palsy?
-Cn 9-12 affected
-weak prognosis - increases risk of respiratory failure
- causes dysarthria, dysphagia , chocking
146
What are the Sx of MND?
mixed UMN +LMN signs
- no eye, sensory, cerebellar or parkinson signs
147
What is the diagnosis of MND?
Mainly clinical - LMN +UMN signs in 3 regions
Electromyography - shows fibrillation potentials - abnormal pattern
148
What is the treatment of MND?
MDT management
Rituzole - blocks glutamergic transmission
Supportive - breathing support
149
What are the primary brain tumours?
-Gliomas
-Meningioma
-Acoustic neuroma
150
What are Meningiomas?
Tumour growing from the cells of the meninges in the brain + spinal cord
151
What is acoustic neuroma?
Tumour of the Schwann cells surrounding the auditory nerve
152
What are gliomas and what are the types?
Tumour of the glial cells in the brain or spinal cord.
- Astrocytoma -mc especially in kids
-oligodendroglioma
-ependymoma
153
What are the secondary brain tumours?
NSCLC- mc +SCLC
Breast
Melanoma
Renal cell carcinoma
Gastric cancer
154
What is the grading system of astrocytomas?
WHO classification 1-4
1- benign
2- low grade astrocytoma
3- Anaplastic astrocytoma
4- Gliobastoma multiforme - bad prognosis
155
What is the presentation of brain tumours?
Raised ICP; couching triad (increased PP/ HTN, bradycardia, irregular breathing) ,Papillodema, CN6 palsy
-Focal neuroogy
-Epileptic seizures
-Lethargy and weight loss
156
What is the diagnosis of brain tumours ?
MRI head= locate tumour, then biopsy (determine grade)
- no LP as raised ICP - massive CI
157
What is the treatment of brain tumours?
Surgery - remove tumour if possible and low ICP
+ chemo
Steroids - dexamethasone
158
Where does the spinal cord extend from and to?
C1 to L1/2
159
At what level is the conus medullar is and Cause Equine ?
L3
160
What is Cauda Equine?
Lumbar and sacral nerve roots group together to form cauda equine
161
What is Hemiplegia?
Paralysis of one side of body - brain lesion
162
What is paraplegia?
paralysis of both legs - cord lesion
163
What is the DCML?
Dorsal column medial lemniscus - ascending
Dorsal root - medulla then decussates
-fine touch, 2 point discrimination , proprioception
164
What is spinothalamic tract?
Ascending
-Decussates 1-2 spinal levels above entry
- pain + temperature
165
What is the corticospinal tract?
Descending UMN; decussates at medulla - ventral root
- motor
166
What does a spinal cord lesion cause?
Ipsilateral Sensory signs
Contralateral Motor signs
167
What reflex is at L3/4?
Knee reflex
168
What reflex is at L5?
Big toe jerk
169
What reflex is at S1?
Ankle jerk
170
What are the causes of spinal cord compression/ myelopathy?
- Vertebral body neoplasms ! mc- mets from lung, breast , RCC, melanoma
-Spinal pathology - disc prolapse/ herniation
171
What is the presentation of spinal cord compression?
-Progressive leg weakness with UMN signs
-Sensory loss BELOW lesion as ascending send info up
172
What is the diagnosis of spinal cord compression?
If suspect; MRI cord ASAP
CXR if malignancy suspected
173
What is the treatment of spinal cord compression?
Neurosurgery + laminectomy / microdisectomy
174
What is Cauda Equina syndrome?
Compression of cauda equina
175
What are the causes of cauda equina syndrome?
Lumbar herniation
176
What is the presentation of Cauda Equina syndrome?
- Leg weakness with LMN signs
-Saddle anaesthesia - perioneal numbness
- Bladder/ bowel dysfunction + sphincter involvement common
177
What is the diagnosis of Cauda equina syndrome?
MRI cord - diagnostic + testing nerve roots/ reflexes
178
What is the treatment for Cauda equina syndrome?
Neurosurgery - microdisectomy
179
What is the Brown sequard syndrome?
Condition associated with hemisection (damage) to half of the spinal cord
180
What is the presentation of Brown sequard syndrome?
- ipsilateral motor weakness (UMN)
-ipsilateral DCML dysfunction - proprioception , 2point discrimination
-Contralateral spinothalamic dysfunction - paint + temp sensation
181
What are the types of peripheral neuropathy?
Mononeuropathy = affects single nerve
Polyneuropathy= multi systemic
Mononeuritis multiplex= several individual nerves
182
What is peripheral neuropathy?
Peripheral neuropathy is a type of nerve damage that can cause pain, numbness or weakness.
183
What are the causes of peripheral neuropathy?
T2DM
Surgery
B12 deficiency
Infection
chronic disease
Gullen Barre syndrome
184
What are the mechanisms of peripheral neuropathy?
- Demyelintaion- Schwann cell damage , slower conduction
-Axonal damage
-Nerve compression - focal demyelination at point of compression
-Wallerian degeneration - nerve cut distally dies
-Vasa nervorum infraction
185
What are the causes of mononeuritis multiplex?
- wegeners
-AIDs
-RA
-T2DM
-Sarcoidosis
-leprosy
-carcinomas
186
What are the types of mononeuropathy?
Carpal tunnel syndrome
Peroneal neuropathy
Ulnar neuropathy
187
What are the types of polyneuropathy?
MS
Guillen Barre
188
What is carpal tunnel syndrome?
Pressure on median nerve passing through carpal tunnel
- nerve roots C6-T1
189
What are the RF/Causes of carpal tunnel syndrome?
F>M
Hypothyroidism; acromegaly ; pregnancy
RA
Obesity
190
What is the presentation of carpal tunnel syndrome?
Gradual onset
- weakness of grip + aching hand/forearm
-pain worse at night
-parasthesia of hand
-Wasting of thenar eminence
191
What is the diagnosis of carpal tunnel syndrome?
Phalen test - flex fist for 1 minute at wrist +ve = parasthesia and pain
Tinel test = tapping wrist causes tingling
Electromyography diagnostic if above tests uncertain
192
What is the treatment of carpal tunnel syndrome?
Wrist splint at night + steroid injection
Last resort - surgical decompression
193
What is radial nerve palsy?
Roots C5 - T1
- Presents with classic wrist drop
- radial nerve mostly innervates extensor arm muscles
194
What is the treatment for radial nerve palsy?
Splint + simple analgesia
195
What is ulnar nerve palsy ?
Roots C8-T1
Presents with classic claw hand
196
What is the treatment for ulnar nerve palsy ?
Splint
Simple analgesia
197
What is sciatica?
L5/S1lesion
198
What are the causes of sciatica?
- spinal : Intervertebral disc herniation / prolapse
-Non spinal : piriformis syndrome, tumours, pregnancy
199
What is the presentation of sciatica?
Pain from buttock down lateral leg --> pinky toe
Weak plantar flexion + absent ankle jerk
200
What is the diagnosis of sciatica?
Exam ; can't do straight leg raise test without pain
MRI cord to confirm
201
What is the treatment for sciatica?
Analgesia + physiotherpay
Neurosurgery
202
What is polyneuropathy?
'Glove and stocking' distribution ; mostly peripheries affected
203
What are the causes of polyneuropathy?
Guillain barre - motor mostly
Diabetic neuropathy- sensory mostly
- vasculitis
-malignancy
-RA
-B-12 deficiency
204
What is the diagnosis of polyneuropathy?
Find underlying cause - bloods, serology, ESR/CRP
205
What is the treatment of polyneuropathy?
Analgesia + treat underlying cause
206
What is perineal neuropathy?
common perineal nerve compressed
- foot drop - ankle dorsiflexion deficit
-sensory deficit over dorsal foot
207
What are the causes of cranial nerve lesions?
Tumour
MS
Trauma
208
What is the presentation of CN3 nerve lesion?
Ptosis
Down and out eye
Fixed dilated pupil
209
What is the presentation of CN4 nerve lesion?
Diplopia looking down
- rare, always due to trauma
210
What is the presentation of CN 5 lesion?
Jaw deviates towards affected side
- loss of corneal reflex
-sensory pain/ motor jaw pain V1/2/3
211
What is the presentation of CN 6 lesion?
Adducted eye - signs of raised ICP
212
What cranial nerve lesions leads to a non functioning eye?
CN 3/4/6
213
What is the presentation of a CN 7 lesion?
Facial droop with no forehead sparing
- bell's palsy , parotid inflammation
214
What is the presentation of a CN8 lesion?
Hearing loss
Loss of balance
- skull change, compression, middle ear disease
215
What is the presentation of a CN 9+10 lesion?
Impaired gag reflex + swallowing, respiratory, vocal issues
216
What is the presentation of a CN11 lesion?
Cant shrug shoulder/ turn heard vs resistance
217
What is CN12 lesion presentation?
tongue deviation towards side of lesion
218
What is Myasthenia Gravis?
Autoimmune disease against neuromuscular junction post synaptic receptors , nicotinic acetylcholine receptors and muscle specific Kinase
219
What is MG mediated by?
Nicotinic acetylcholine receptor antibody- Anti- AchR and muscle specific receptor tyrosine kinase - anti-Musk
220
What is the epidemiology of MG?
Females = 40y/o- related to autoimmune disease
Males- 60y/o - related to thymoma - thymes tumour
221
What is the pathology of MG?
85% - AntiAchR ; bind to post synaptic receptor + inhibit competitively Act binding. More binding with exertion therefore worse Sx later on
15% AntiMusk; Musk helps synthesise Ach-R therefore anti-musk asks against Musk and therefore there is a low Ach-R expression on post synaptic membrane
222
What is the presentation of MG?
-Muscle weakness; worse later on with exertion
-Starts at head and neck--> lower body
-Better with rest
Weak eye muscles = diplopia
Ptosis
Myasthenic snarl
Jaw fatiguability
Swallowing difficulty
Speech fatiguability
223
What is the diagnosis of MG?
Serology- Anti AchR +AntiMusk raised
-Tensilon/edrotropium test - administer edrotropium (rapid acting Acetylcholinesterase inhibitor) - positive if results in muscle power in few seconds
224
What is the treatment of MG?
1st line - Achase inhibitor ; neostigmine
2nd line - Immunosuppression - steroids
225
What is a complication of MG?
Myasthenic crisis- Acute Sx worsening with severe resp weakness
226
What is the treatment for myasthenia crisis?
Plasma exchange + IVIg +BiPaP for respiratory failure
227
What is a Ddx of MG?
Lambert eaton syndrome
228
What is Lambert eaton syndrome?
Paraneoplastic (SCLC) or autoimmune antibodies against pre synaptic Ca++ channels
229
What is the presentation of LES?
Sx improve with exertion
Sx( weakness of muscles )start at extremities then move to head and neck + there is autonomic involvement - dry eyes/ mouth
230
What is the treatment of LES?
Steroids - prednisolone
+ immunosuppression - IV Ig
231
What is Guillain Barre syndrome?
An acute inflammatory demyelinating polyneuropathy affecting the PNS (targets Schwann cells) following an upper respiratory or GIT infection
232
What is the epidemiology of GBS?
males 15-30, 50-70 - mc
Acute polyneuropathy - 85% recover - good prognosis
233
What are the causes of GBS?
Camylobacter Jejuni -mc + viruses ;CMV,EBV,HZV
234
What is the pathology of GBS?
Molecular mimicry - organism antigens are similar to those on the schwann cells
- results in antibody production against schwann cells= leading to demyelination and acute polyneuropathy
235
What is the presentation of GBS?
Post infection presents with :
- ascending symmetrical muscle weakness + paralysis
-Loss of deep tendon reflexes
- autonomic involvement - 50%
-Resp failure - 35%
236
What is the diagnosis of GBS?
Nerve conduction studies (low conduction)
- Lumbar puncture at L3/4 = raised protein + normal WCC = inflammation and no infection
237
What is the treatment of GBS?
IVIg for 5 days + plasma exchange
(CI in IgA deficient patients - allergic reaction)
- also if FVC<0.8 consider ITU
238
What is Wernicke's encephalopathy?
Reversible acute emrgency; severe B1(thiamine) deficiency
239
What is the cause of wernickes encephalopathy?
mostly alcohol
240
What is the presentation of WE?
Ataxia, confusion, ophthalmoplegia
241
What is the diagnosis of WE?
Clinically recognised , supported with macrocytic anemia + deranged LFTs
242
What is the treatment of WE?
Pabrinex (Vit B1) for 5 days acutely
Oral thiamine prophylactically
243
What is the complication of WE?
Korsakoff syndrome
244
What is korsakoff syndrome?
When wernickes is left too long without TX; severe thiamine deficiency
Same Sx with increased memory loss
- irreversible damage
245
What is Duchenne muscular dystrophy?
X linked autosomal recessive disorder due to a mutation of the dystrophin gene leading to progressive muscle degeneration and weakness
Muscle replaced with adipose
246
What is the role of dystrophin?
protein that helps keep muscles intact
247
What sex is more affected by DMD?
males
248
What is the presentation of DMD?
Difficulty getting up from lying down - Gower's sign
Skeletal deformities- scoliosis
249
What is the diagnosis of DMD?
Prenatal tests+ DNA genetic test
250
What is the treatment for DMD?
purely supportive
251
What is Charcot Mary tooth ?
Autosomal dominant condition affecting the PMP22 gene on chromosome 17 causing sensory and motor PNS polyneuropathy
252
What is the presentation of CMT?
foot drop - common perineal palsy
Stork legs
Hammer toes
Feet - pes planus - flat feet
-pes cavus - high arched feet
253
What is the diagnosis of CMT?
Nerve biopsy, genetic testing
254
What is the treatment of CMT?
supportive - physio
255
What is Tetanus?
Inoculation through skin with clostridium tetani (gram positive bacillus)
256
What is the pathology of tetanus?
tetanospasmin toxin produced - travels along axon and causes involuntary muscle spasms
257
What is the treatment for tetanus?
Vaccine
258
What is Herpes Zoster (chicken pox/ shingles)?
Varicella zoster virus :90% under 16 have this --> reactivation = shingles
- peripheral nerves attacked via dorsal root (sensory)
Painful rash - confined to a dermatome
259
What is the treatment for Herpes zoster ?
Oral aciclovir - anti-viral
260
What is Prion (creutzfield - Jakub disease)?
Idiopathic misfolder protein deposited in cerebrum + especially cerebellum
- severe cerebellum dysfunction - sponge like appearance - ataxia, poor memory, behaviour changes
- no Tx
261
What is epilepsy ?
Idiopathic recurrent tendency of spontaneous , intermittent abnormal electrical activity in parts of the brain manifesting in seizures. 2< episodes more than 24hr apart
262
What are the components of an epileptic seizure?
Prodrome - mood change days/hours before
Aura- minutes before= deja vu, strange feelings , strange smells, lip smacking (not always seen - mostly seen in temporal lobe epilepsy)
Ictal event = seizure
Post octal period
263
What is the presentation of a post ictal period?
- headache
-confusion
-Todd's paralysis - if motor cortex affected , may have temporary paralysis + muscle weakness
-dyspahsia
-amnesia
-sore tongue
264
What are the types of seizures?
Generalised
Focal
265
What is a generalised seizure?
Electrical charge throughout whole cortex
Bilateral
always associate with loss of consciousness + awareness
266
What are the types of generalised seizures?
Tonic-rigidity
Tonic clonic- rigidity + jerking of limbs
clonic - muscle jerking
Atonic- floppy muscles
Absence -childhood - pale +stare blankly for seconds then carryon
Myoclonic - isolated jerk of a limb
267
What are focal seizure?
Focal onset that can be referred to a single lobe may progress to generalised
268
What are the types of focal seizures?
simple focal
Complex focal
269
What is a simple focal seizure?
- no affect on conscious
-patient awake + aware
270
What is a complex focal seizure?
- loss of consciousness , patient unaware , post octal period positive
271
What is the presentation of a temporal lobe specific seizure?
Aura, dysphasia , post ictal period
272
What is the presentation of. frontal lobe specific seizure ?
Jacksonian March (seizures march up and down motor hornuculus + Todd's palsy
273
What is the presentation of a parietal lobe specific seizure?
paraesthesia - tingling/numbness
274
What is the presentation of an occipital lobe specific seizure?
Vision change - spots, lines
275
What is the difference between an epileptic seizure and a non epileptic seizure?
Epilepsy - eyes open , can occur at night, situational (what they were doing)
Non- eyes closed, can't happen at night, can be related to syncope , metabolic disturbances
276
What is syncope?
A loss of consciousness for a short period of time due to an insufficient blood supply/02 to brain
277
What is the presentation of syncope?
dizzy, light head, from sitting or standing, hypoglycaemia , anemia
278
What investigations would be done for syncope?
- bloods
-ECG
-Echocardiogram
279
What is the diagnosis for epilepsy?
- Must have had >2 seizures 24hr part to consider epilepsy
-CT head +MRI (check bleeds, tumours)
Electroencephalogram
-Bloods- rule out metabolic cause
280
What is the treatment for Epilepsy?
Sodium valproate Except for women at child bearing age = Lamotrigine
Except Myoclonic = levetiracetom
Absence = ethosuximide
Focal = carbamazepine
281
What are the side effects of carbamazepine?
reduce risk of contraception
leukopenia
thrombocytopenia
If pregnant keep using - risk of epileptic damage worse risk than risk of foetus
282
What is a complication of Epilepsy?
Status epilepticus
283
What is status epilepticus?
epileptic seizures back to back without a break
or seizure lasting over >5mins
284
What is the treatment for a status epilepticus?
Benzodiazepines ; Lorazepam IV
285
What is Encephalitis?
Viral infection of brain parenchyma
286
What is the epidemiology of Encephalitis?
95% cases ; HSV-1 (herpes simplex virus) others CMV,EBV,HIV
287
What are the risk factors of encephalitis?
Immunocompromised
Extremes of age
288
What is the presentation of encephalitis?
Fever, headache, encephalopathy, Focal neurology - mc place affected is temporal lobe
289
What are the investigations for Encephalitis?
CSF- raised lymphocytes, consider PCR
MRI head - unilateral usually temporal encephalitis - midline shift
290
What is the treatment of encephalitis?
Aciclovir
291
What is Meningitis?
Inflammation of the meninges
Notifiable to PHE
292
What are the main bacterial causes of meningitis?
S.pneumonia
N.menningitis
Group B or haem strep - in neonates
Listeria - mc in elderly
293
What are the main viral causes in meningitis?
Viral causes -mc - less severe
Entervoiruses
Herpes simplex virus
VZV
294
What are the risk factors of meningitis?
-Extremities of age
-Immunocompromised
-Students
-non vaccination
295
What is Neisseria Meningitis?
- gram negative diplococcus
-vaccines available ; menB+C, men ACWY
-10% mortality
-Non blanching purpuric rash
296
What is Streptococcus pneumonia ?
-Gram positive diplococcus in chains
-PCV vaccine
-25% mortality
297
What is group B strep?
- gram postive coccus in chains
- mc cause of neonatal meningitis
- colonises maternal vagina
298
What is listeria monocytogenes?
-Gram positive bacillus
-affects extreme os age , and maternal ladies
-found in cheese
299
What is the presentation of Meningitis?
Meningism; Headache , neck stiffness, photophobia
Signs : Kernig (cant extend knee when hip is flexed)
Brudzinski (when neck flexed, knees + hips automatically flex)
Pyrexia
300
What is the diagnosis of Meningitis?
LP+CSF analysis from L3/4
CI in raises ICP due to tectorial herniation and coning risk
301
What is a bacterial result of an LP?
1. High opening pressure
2. Cloudy yellow
3.Raised neutrophilic
4. Raised protein
5. Low plasma glucose
302
What is a viral results of an LP?
1. normal pressure
2. normal/clear colour
3. raised lymphocytes
4. normal protein
5. Normla serum glucose
303
What is a fungal / TB result of an LP?
1. raised opening pressure
2.Cloudy colour
3.Raised lymphocytes
4.Raised protein
5.Normal serum glucose
304
What is the treatment of bacterial meningitis?
Ceftriaxone/ cefotaxime + steroids -Dexamethasone
- amoxicillin covers listeria
305
What is the treatment for viral meningitis?
Nothing if enteroviruses
Aciclovir if HSV,VZV
306
What is the prophylaxis treatment for Meningitis?
contact tracing - ciprofloxacin one of dose
307
What is a complication of meningitis?
DIC (meningococcal septicaemia)
Waterhouse friderichsen syndrome - adrenal insufficiency caused by intradrenal haemorrhage as a result of meningococcal DIC -disseminated intravascular coagulation)
308
What is the treatment for depression?
Selective serotonin reuptake inhibitors - fluoxetine
- prevent the presynaptic neurone from reabsorbing the serotonin so more remains in the synaptic cleft and can stimulate receptors on post synaptic neurone
TCA- Tricyclic Antidepressants - amitriptyline
309
What are the baby checks given ?
1- Within first 72hr + heel prick test- check sickle cell/CF/congenital hypothyroid
2 -6+8 weeks later (check arms , eyes, heart, hips
310
What vaccines are given at 8 weeks?
5 in 1 IM injection against
-diptheria
tetanus
whooping cough
H.inluenza
poliovirus
