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Logan Clinical > Neurology > Flashcards

Neurology Flashcards

1
Q

Symptoms of MS

A
  • Hemisensory loss
  • Hemiparesis
  • Impaired VA
  • Ataxia, dysarthria
  • Fatigue
  • Bulbar symptoms
  • Sexual dysfunction
  • Vertigo
  • Band sensation trunk
  • Bilateral limb paraesthesia / UMN signs secondary to spinal cord involvement
  • Cognitive dysfunction

No cortical signs such as aphasia and neglect

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2
Q

MRI MS Regions

A
  • Juxtacortical
  • Corpus callosum
  • Periventricular
  • Spinal cord
  • Infratentorial (brainstem / cerebellar)
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3
Q

CSF findings

A
  • Oligoclonal bands
  • <50 weight cells
  • Increased protein
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4
Q

Macdonald criteria

A
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5
Q

MS prognosis

A

50% with RRMS will progress to secondary progressive MS within 10 years

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6
Q

Management MS

A

Supportive:
- treatment of bladder dysfunction
- Botox or baclofen for spasticity
- Physiotherapy
- Occupational therapy for gait aids
- Vitamin D supplementation
- Treat sexual dysfunction
- Psychotherapy for mood

Immunosuppresive:
- IRT: Cladrabine, Alemtuzumab
- Natalizumab
- Sphingolomod
- Glataramer acetate
- Interferon

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7
Q

Management Acute Relapse of MS

A
  • Prednisolone
  • Methylprednisolone if severe or involving vision
  • Plasmapharesis / IVIG if failing steroids
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8
Q

MS in Pregnancy

A

Glataramer acetate safe to continue

Safe to continue IRT (alemtuzumab and Natalizumab)

Most patients disease will improve during pregnancy

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9
Q

Myasthenia Clinical Features

A
  • Occular symptoms (diplopia)
  • Limb weakness
  • Bulbar: dysarthria, dysphagia, choking
  • Neck weakness
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10
Q

Most common acute polyneuropathy

A

Gullian Barre Syndrome

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11
Q

Gullian Barre Features

A
  • Ascending motor sensory paralysis
  • Acute onset
  • Associated autonomic instability
  • Preceding infective aetiology (gastro or Resp)
  • Bulbar involvement
  • Associated dysautonomia

*Nadir within 2-4 weeks

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12
Q

Investigations GBS

A
  • Lumbar puncture raised protein no WCC
  • Immune stimulus: monospot, stool MCS, HIV
  • FEV1 / Vital capacity
  • Nerve conduction: conduction block, increased distal latencies
  • Antibodies: GQ1B in Miller fisher
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13
Q

Differential diagnosis for ascending paralysis

A
  • GBS
  • CIDP (Chronic mainly sensory symptoms)
  • Botulism
  • Diphtheria
  • PAN
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14
Q

Seizure driving restrictions

A
  • Commercial licence require 10 year seizure free period
  • Recreational: 6-12 months seizure free period
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15
Q

Myasthenia Facies

A
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16
Q

Cranial Nerve Exam tips

A

-Diplopia : if present test whether monocular or binocular.
- Saccades: delay or slow movement, overshooting / undershooting, dysconjugate movements
- Nystagmus: fast fase is name of nystagmus, slow phase is side of pathology
- Examining 9&10: 9 is sensory 10 is motor. Test palatal movement, sensation with spatula, character voice and cough.

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16
Q

Cranial Nerve Exam tips

A

-Diplopia : if present test whether monocular or binocular.
- Saccades:

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17
Q

Gaze evoked nystagmus

A

Nystagmus present in fast fase of direction of gaze. Typically cerebellar in origin.

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18
Q

Monocular nystagmus

A

Indicated likely weakness of opposite eye ie. cranial nerve III, IV, VI palsy

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19
Q

Peripheral nystagmus

A
  • Generally horizontal
  • May be torsional
  • Associated with corrective saccade with head impulse test
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20
Q

Central Nystagmus

A
  • Vertical nystagmus
  • Torsional nystagmus
  • Associated with skew
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21
Q

Multidirectional nystagmus

A
  • In a Gaze evoked pattern in suggestive of cerebellar disorder
  • Ddx drug toxicity i.e. anticonvulsants
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22
Q

Upbeat Nystagmus

A

Central cause
- Cerebellar / medullary lesion
- Wernickes encephalopathy
- Drug intoxication

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23
Q

Uvula deviation

A

Away from lesion

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24
Tongue deviation
Towards side of lesion
25
Eye Exam Proforma
26
Strabismus
27
One and half syndrome
Caused by dorsal pontine lesion. Horizontal gaze palsy (inability to look left or right) + INO
28
Aetiology Horners syndrome
- Carcinoma lung apex - Thyroid malignancy - Neck trauma - Lateral medullary syndrome - Carotid artery dissection / aneurysm - Retro-orbital lesions
29
Causes of anosmia
- Upper respiratory tract infection - Meningioma olfactory groove - Head trauma fracture cribriform plate - Meningitis - Kallmanns syndrome
30
Causes of accomodation without light reflex
- Midbrain lesion (argyll robertson pupil) - Ciliary ganglion lesion (Adies pupil) - Parinauds syndrome
31
Causes of absent accomodation but intact light reflex
Cortical lesion (cortical blindness)
32
Causes of pupil constriction
- Horners syndrome - Argyll Robertson pupil - Narcotics - Old age
33
Causes of pupil dilatation
- Drugs: amphetamines, cholinergic (atropine) - CN III palsy - Adies pupil - Trauma / cerebral death - Congenital
34
Adies pupil
Dilated pupils that demonstrate light-near dissociation (i.e. constrict with accommodation but not light) aetiology: damage to postganglionic parasympathetic nerve fibers secondary to viral infection
35
Common visual field deficits
36
Argyll. robertson pupil
Constricted pupils Light-near dissociation aetiology: - Syphilis - Diabetes - alcohol Damage to pre-tectal nuclei in midbrain
37
Causes of Papilloedema
- Space occupying lesion - Meningitis - Idiopathic intracranial hypertension (OCP, Hypertension) - Venous sinus thrombosis
38
Causes of optic neuropathy
- Multiple sclerosis - Toxic: ethambutol, alcohol, chloroquines - Metabolic: B12 deficiency - Ischaemia: DM, Temporal arteritis - Familial: lebers
39
Causes of cataract
- Senile cataracts - Diabetes Mellitus - Myotonic dystrophy - Steroids - Trauma
40
Causes of ptosis
Without pupil dilatation: - Senile ptosis - Myasthenia gravis - Fascioscapuhumeral dystrophy - Myotonic dystrophy - Thyrotoxic myopathy Constricted pupil: - Horners syndrome - Tabes dorsalis Dilated pupil: - III nerve palsy
41
Occulomotor nerve palsy aetiology
Central: - Brainstem infarction - Tumour - Demyelination - Trauma Peripheral: - PCA aneurysm - Raised intracranial hypertension - Cavernous sinus lesions
42
VII Palsy (facial)
Uppermotor - Vascular - Tumour Lower motor neurone lesion: - Idiopathic (bells) - Ramsay Hung (VSV) - Parotid tumour - CPA tumour compression - Pontine stroke - Multiple sclerosis - Otitis media - Temporal bone fracture
43
Bilateral lower motor neurone facial weakness
- Gullian barre syndrome - Sarcoidosis parotid disease - Mono-neuritis multiplex
44
Causes of sensoroneurial hearing loss
- Presbycusis - SSNHL - Trauma - Toxic (Etoh, streptomycin) - Infection: congenital rubella/ syphilis - Acoustic neuroma
45
Causes of conductive hearing loss
- Wax - Otitis media - Otosclerosis - Pagets disease
46
Pseudobulbar Palsy
Bilateral upper motor neurone lesions of CN 9, 10 and 12 Aetiology: - Stroke - MND - Mass - Multiple sclerosis
47
Bulbar vs pseudo bulbar palsy
48
Aetiology Bulbar palsy
- Brainstem stroke - MS - Myasthenia Gravis - Syringobulbia - Brainstem mass - Gullian barre
49
Arnold Chiari Malformation
Protrusion of the cerebellar tonsils through the Forman magnum. Features: - Lower CN Palsies 9-12 - Cerebellar symptoms: gait ataxia - Headache - Myelopathy
50
Differential for multiple cranial nerve palsies
- Chronic meningitis - Gullian Barre syndrome - Brainstem lesions - Arnold-Chiari malformations - Trauma - Pagets
51
Higher Centers Examination
52
Examination of dysphasia
53
Gertsmanns Syndrome
Damage to angular gyrus on dominant parietal lobe. Features: - Acalculia - Agraphia - Left/Right disorientation - Finger agnosia
54
Primitive reflexes
-Palmomental - Grasp - Pout
55
Gait apraxia
Cortical sign / particularly frontal lobe. Patients act as if glued to floor. Seen in Dementia, Frontal lobe CVA
56
Dressing apraxia
Non-dominant parietal lobe
57
Types of aphasia
58
Dysarthria Differential
- Cerebellar dysfunction - Pseudobulbar palsy (speech sounds hollow, and slow) - Bulbar palsy (nasal high pitched speech, imprecise articulation) - Myopathies
59
Causes of pronator drift
1) Downward drift: typically UMN weakness 2) Upward drift: hypotonia associated with cerebellar lesion 3) DCMLT loss: impaired proprioception may result in drift in either direciton
60
Hoffmans reflex
Sign of hypereflexia Scrape DIP of middle finger and observe for flexion of the thumb
61
Causes of upper limb weakness
Upper motor neuron: - Stroke -MND - Cervical myelopathy Lower motor neurone: - Peripheral neuropathy - Polyneuropathy - Radiculopathy - Plexopathy - MND - NMJ disorder
62
Fascioscapulohumeral mucular dystrophy
- Autosomal dominant - Onset 15-30 yoa Features: - Asymmetric muscle weakness of face, shoulder girl and distal leg (particularly foot drop) - Associated hearing loss
63
High Steppage Gait
- Cerebellar problem - Proprioceptive problem
64
Lower limb Dermatomes
65
Upper limb dermatomes
66
Upper motor neuron weakness
- Weakness predominately pyramidal pattern ie. UL extensors and LL flexors - Hypereflexia - Increased tone - Clonus - Spasticity
67
Peripheral neuropathy Causes
- Drugs: isoniazid, vincristine, cisplatin, amiodarone - Toxins: Alcohol - Amyloidosis - Metaboli: DM, Uraemia, Hypothyroidism - Immune: GBS / CIDP - Vitamin B12 deficiency - Connective tissue disease: SLE, Vasculitis, PAN - Hereditary: CMT
68
Motor dominant Peripheral Neuropathy
- CMT - Guillian Barre / CIDP - DM - Multifocal motor neuropathy
69
Sensory predominant peripheral neuropathy
- Diabetes - Paraneoplastic asco with lung / breast Ca - Paraproteinaemia assoc with MM - Sjogrens - B12 deficiency - idiopathic
70
Painful peripheral neuropathy
- Diabetes - Alcohol - B12 deficiency
71
Nerve Conduction tests for peripheral neuropathy
Demyelinating: - Aet: CIDP, MM, Diabetes - Prolonged distal latencies, reduced conduction velocity Axonal: - Aet: Diabetic, ischaemic, metabolic, paraneoplastic - Reduced velocity and amplitude
72
Causes of mono neuritis multiplex
- Diabetes Mellitus - Vascilitis (PAN) - CTD: SLE / RA - Sarcoidosis - Acromegaly - HNPPP
73
Causes of thickened nerves
- HMSP - Acromegaly - CIDP - Amyloidosis - Sarcoidosis - Neurofibromatosis
74
Causes of fasiculations
- Benign idiopathic fasiculation - Motor neurone disease - Spinal muscular atrophy - Any motor neuropathy - Motor root compression
75
Hereditary Sensory Motor Neuropathy
Aka Charcot Marie Tooth Autosomal dominant Features: - Pes Cavus - Hammer toes - Motor predominant weakness affecting lower limbs and lower arms (rarely proximal to elbow or knee) - Absent reflexes - Slight to no sensory loss in the limbs
76
Brachial Plexus finding
Complete: - LMN weakness whole arm - Absent sensation whole arm - May be Horners syndrome Upper trunk (Erb) C5-6: - Waiters tip - unable to flex elbow, lack of shoulder movement - Loss sensation lateral arm Lower trunk (Klumpkes) C8-T1: - Claw hand with paralysis of intrinsic hand muscles - Horners syndrome - Sensation loss medial hand and forearm
77
Median Nerve Palsy
Findings: - Weakness of LOAF - Hand of benediction - Sensory lose lateral hand - * Test using Pen touch or Ok sign or Oschners clasping test Aet (Carpal Tunnel Syndrome) - Idiopathic - Rheumatoid arthritis - Amyloidosis - Hypothyroidism / Acromegaly - Pregnancy - Trauma
78
Ulnar Nerve Palsy
Findings: - Weakness of intrinsic hand muscles (particularly finger Ab/Adductors) - Weakness thumb adduction - Partial Claw hand - Sensory loss medial hand
79
Intrinsic Hand Muscle Wasting Differential
Nerve lesion: - Median / ulnar neuropathy - Brachial plexopathy - HMSN (CMT) Anterior horn cell: - Motor neurone disease - Spinomuscular atrophy Myopathy: - Myotonic dystrophy Spinal cord lesions: - Syrinogmyelia
80
Femoral nerve lesion
Nerve roots L2,3,4 - Weakness of knee extension - Loss of knee jerk - Sensory loss to inner thigh and leg
81
Sciatic Nerve lesion
L4-S2 - Weakness knee flexion - Weakness to all muscle below knee -> foot drop impaired eversion/inversion - Loss off ankle jerks - Intact knee jerks
82
Common peroneal nerve palsy
- Foot drop with impaired eversion - Sensory loss to dorsum of foot - Intact reflexes
83
Causes of foot drop
- Common peroneal palsy - L4/5 radiculopathy - Sciatica - HMSN - Motor neurone disease *will have hyperreflexic ankle jerk*
84
Causes of paraplegia
- Spinal cord compression ***Make sure you look for spinal sensory level*** - Transverse myelitis - Anterior spinal artery occlusion (dorsal column spared) - Multiple sclerosis - Intrinsic cord lesion ie. syringomyelia - Motor neuron disease - Hereditary spastic paraplegia
85
Spinal Cord Lesion Signs depending on level
Above C5: - UMN in arms and Legs - Above C4 results in diaphragm paralysis C5-8: - Lower motor neurone proximal arms not hands - UMN in lower limbs C8-L3 - Lower motor in arms - UMN in Limbs - May have sensory level on trunk Below L3: LMN in lower limbs
86
Subacute combined degeneration of the cord
Features: - Symmetrical loss of vibration and proprioception - Sensory ataxic gait - Upper motor neuron signs in lower limbs - Absent ankle reflexes but extensor plantar response*** unique - Optic atrophy - Dementia
87
Brown-Sequard Syndrome
Features: - Ipsilateral UMN weakness below level - Ipsilateral LMN weakness at level - Ipsilateral DCMLT loss - Contralateral STT loss Aetiology: - Multiple sclerosis - Trauma - Glioma
88
Causes of spinothalamic loss only
- Central cord syndrome secondary to syringomyelia *at late stages may involve Corticospinal or DCMLT - Anterior cord syndrome secondary to anterior spinal artery thrombosis however will also involve corticospinal tract - Lateral medullary syndrome
89
Dorsal column only
- subacute combined degeneration - MS - Tabes dorsalis - Peripheral neuropathy ie. diabetes
90
Syringomyelia features
Triad of: 1) Loss of STT in band / cape like distribution 2) LMN weakness in upper limbs 3) Upper motor neurone weakness lower limbs
91
Causes of proximal muscle weakness
- Myopathy - Neuromuscular junction: MG - Neurogenic: motor neuron disease, polyradiculopathy
92
Causes of Myopathy
- Muscular dystrophy - Myotonic dystrophy - Inflammatory myopathies - Osteomalacia - Alcohol - Endocrine: Hypothyroidism, bushings, acromegaly) - Drugs: Steroids
93
Muscular Dystrophies
Duchenne - XLR - Males only (Female with turners) - Severe early proximal weakness rapidly progressive - Associated with dilated CM Beckers: - Same as Duchenne but less rapidly progressive Fascioscapulohumeral Dystrophy: - Proximal shoulder girdle and muscles of fascial expression first - Also associated foot drop
94
Tests for Myopathy
- CK - EMG - ECG -> exclude DCM - Muscle biopsy - Echocardiogram
95
Myotonic Dystrophy
Features: - Hatchet Facies - Wasting of muscles of facial expression, ptosis - Fronting balding - Weakness and myotonia (inability to relax) - Check hand grip inability to relax - Persussion myotonia (percuss thenar muscles watch for thumb abduction) ** - Associated Cardiomyopathy - Cataracts - Diabetes mellitus
96
Patterns of Gait Abnormality
- Hemiparetic Gait (foot is plantar flexed and leg swung in a lateral arc) - Paraparetic Gair (Scissor Gait) - Parkinsonian Gait > Shuffling > Freezing > Festination - Cerebella / ataxic gait: wide based staggering to affected side - Apraxic gait: feet glued to the floor - High Steppage gait: indicates distal weakness - Waddling gait: indicates proximal weakness
97
Causes of Cerebellar disease
Unilateral: - Stroke - MS - SOL: tumour / abscess - Trauma Bilateral: - Drugs: phenytoin - Alcohol - Multiple sclerosis - Arnold-chiari malformation - Fredrichs ataxia - Hypothyroidism
98
Cerebellar signs
- Intention tremor - Hypotonia - Upper limb drift - Nystagmus - Dysarthria - Dysmetria - Dysdiadochokinesis - Ataxic gait - Pendular knee jerks
99
Causes of Pes Cavus
- CMT - Fredrichs Ataxia
100
Features of Freidrichs ataxia
- Bilateral cerebellar sings - Posterior column loss in limbs - UMN signs in the limbs - Peripheral neuropathy - Optic atrophy - Pes cavus foot deformity - Cardiomyopathy - Diabetes Mellitus * Autosomal Recessive*
101
Causes of spastic ataxia and ataxic paraparesis (upper motor and cerebellar signs combined)
Young patients: - Spinocerebellar degeneration (Freidrichs Ataxia) Adults: - Multiple sclerosis - Spinocerebellar ataxia - Arnold chiari malformation
102
Differential of tremor
Resting tremor - Parkinsons Action tremor - Thyrotoxicosis - Anxiety - Drugs - Familial - Idiopathic Intention tremor *Increases at end of movement* - Cerebellar disease
103
Causes of Parkinsonism
- Idiopathic Parkinsons - Vascular parkinsonism - Parkinsons plus > MSA > PSP > CBD > Lewy body - Drugs: Antipsychotics, methyldopa
104
Chorea
Involuntary movements Hemiballismus: - Unilateral - Lesion to subthalamic nucleus on opposite side Athetosis: - Slow distal writing movements. - Lesion to putamen
105
Causes of Chorea
- Huntingtons disease - Syndenhams chorea (Rheumatic Fever) - Senility - Wilsons - Drugs: phenytoin, Levodopa - SLE
106
Patterns of small muscle wasting of hand
Abductor polices brevis -> Median Nerve First dorsal interossei and Abductor digiti minimi -> Ulnar nerve
107
Median neuropathy at carpal tunnel vs elbow.
Entrapment at wrist: mainly weakness of APB Entrapment at elbow: also weakness of lateral two deep finger flexors (Hand of Benediction)
108
Investigations for Peripheral Neuropathy
- NCS / EMG to clarify axonal vs demyelinating pattern - Nerve biopsy - CSF to exclude CIDP - SPEP (MM) - ANA, ESR, CRP , ANCA - B12 / Folate - HbA1c
109
Hereditary spastic paraparesis findings
- Bilateral lower limb spasticity, clonus, hypereflexia without motor weakness or sensory loss
110
Types of sacaddes
Hypometric / bunny hopping → Parkinson's disease Corrective soccades → cerebella I vestibular disorder.
111
Vertical diplopia vs. Horizontal diplopia
Vertical→ cn 3 or 5 Horizontal - C N7
112
Describing aphasia
• Fluent vs. Non-fluent. Repetition Comprehension

Logan Clinical (9 decks)

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