Neurology Flashcards
1
Q
What is appropriate next line after seizure resolves jn possible status epilepticus?
A
Capillary blood glucose- Rule out hypoglycaemia
2
Q
Best antiemetic in parkinson?
A
Domperidone
3
Q
Features in normal pressure hydrocephalus?
A
urinary incontinence
dementia and bradyphrenia
gait abnormality (may be similar to Parkinson’s disease)
4
Q
Drugs associated with SJS?
A
Phenytoin
Salicylates
Sertraline
Imidazole antifungal agents
Nevirapine
Carbamazepine
5
Q
Dorsal column involvement in subacute combined degeneration of the spinal cord?
A
distal tingling/burning/sensory loss is symmetrical and tends to affect the legs more than the arms
impaired proprioception and vibration sense
6
Q
Features in lateral corticospinal involvement in subacute combined degeneration of the spinal cord?
A
muscle weakness, hyperreflexia, and spasticity
upper motor neuron signs typically develop in the legs first
brisk knee reflexes
absent ankle jerks
extensor plantars
7
Q
Features in spinocerebellar tract involvement in subacute combined degeneration of the spinal cord?
A
sensory ataxia → gait abnormalities
positive Romberg’s sign
8
Q
What is gullain barre classically caused by?
A
Campylobacter jejuni
9
Q
What is the Brathdel index?
A
scale that measures disability or dependence in activities of daily living in stroke patients
10
Q
Features of a vestibular schwanoma (acoustic neuroma)
A
The classical history of vestibular schwannoma includes a combination of vertigo, hearing loss, tinnitus and an absent corneal reflex. Features can be predicted by the affected cranial nerves:
cranial nerve VIII: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
cranial nerve V: absent corneal reflex
cranial nerve VII: facial palsy
11
Q
Characteristic features of guillane barre syndrome?
A
progressive, symmetrical weakness of all the limbs.
the weakness is classically ascending i.e. the legs are affected first
reflexes are reduced or absent
sensory symptoms tend to be mild (e.g. distal paraesthesia) with very few sensory signs
12
Q
Management of trigeminal neuralgia?
A
Carbamazepine
13
Q
Drugs that exacerbate myasthenia gravis?
A
penicillamine
quinidine, procainamide
beta-blockers
lithium
phenytoin
antibiotics: gentamicin, macrolides, quinolones, tetracyclines
14
Q
What does an upper motor neuron lesion of the facial nerve do?
A
Spares upper face
15
Q
WHat to give in stroke if clopidogrel not tolerated?
A
aspirin plus MR dipyridamole
16
Q
Risk factors for idiopathic intracranial hypertension?
A
obesity
female sex
pregnancy
drugs- combined oral contraceptive pill, steroids, tetracyclines, retinoids (isotretinoin, tretinoin) / vitamin A and lithium
17
Q
Investigations for encephalitis?
A
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
18
Q
What is a subdural haemorrhage caused by?
A
caused by damage to bridging veins between cortex and venous sinuses
19
Q
Treatment for focal seizures?
A
Lamotrigine or levetricaetam
Secon line is carbazepine, ocarbazepine or zonisamide
20
Q
Features of intracranial hypertension?
A
headache
blurred vision
papilloedema (usually present)
enlarged blind spot
sixth nerve palsy may be present
21
Q
Adverse effect of lamotrigine?
A
SJS
22
Q
First line for absent seizures?
A
Ethosuximide
23
Q
How are acousitc neuromas best visualised?
A
MRI of the cerebellopontine angle
24
Q
Triad of symptoms in normal pressure hydrocepahlus
A
Urinary incontinence
Gait distrubance
Dementia
25
Where is a lesion in Wernicke's aphasia?
Superior temporal guris. Typicall supplied by inferior division of the left MCA
26
Where is a lesion in brocas?
Due to a lesion of the inferior frontal gyrus. It is typically supplied by the superior division of the left MCA
27
What is conduction aphasia?
Classically due to a stroke affecting the arcuate fasiculus - the connection between Wernicke's and Broca's area
Speech is fluent but repetition is poor. Aware of the errors they are making
Comprehension is normal
28
Affects of anterior cerebral artery lesion?
Contralateral hemiparesis and sensory loss, lower extremity > upper
29
Effects of a middle cerebral artery lesion?
Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral homonymous hemianopia
Aphasia
30
Effects of a lesion affecting postgerior cerebral artery?
Contralateral homonymous hemianopia with macular sparing
Visual agnosia
31
Effects of a posterior inferior cerebellar artery lesion?
Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus
32
Effects of an anterior inferior cerebrellar artery lesion?
Symptoms are similar to Wallenberg's (see above), but:
Ipsilateral: facial paralysis and deafness
33
Symptoms of a retinal/opthamlic artery lesion?
Amaurosis fugax
34
Best imaging for demyelinating lesions?
MRI with contrast
35
What i pituitary apoplexy?
Sudden enlargement of a pituitary tumour (usually non-functioning macroadenoma) secondary to haemorrhage or infarction.
36
Features of pituitary apoplexy?
sudden onset headache similar to that seen in subarachnoid haemorrhage
vomiting
neck stiffness
visual field defects: classically bitemporal superior quadrantic defect
extraocular nerve palsies
features of pituitary insufficiency
e.g. hypotension/hyponatraemia secondary to hypoadrenalism
37
Management of pitutiary apoplexy?
urgent steroid replacement due to loss of ACTH
careful fluid balance
surgery
38
Management of pitutiary apoplexy?
urgent steroid replacement due to loss of ACTH
careful fluid balance
surgery
39
What is clonus?
bilateral upper and lower limbs contracting and relaxing
40
Females treatment for myoclonic seizures?
levetiracetam
41
When can stipping anti epileptic drugs be considered?
Can be considered if seizures free for more than 2 years, Stop over 2-3 months
42
The following drugs may exacerbate myasthenia:
penicillamine
quinidine, procainamide
beta-blockers
lithium
phenytoin
antibiotics: gentamicin, macrolides, quinolones, tetracyclines
43
First line for spacicity features in MS?
baclofen and gabapentin are first-line
Other options include diazepam, dantrolene and tizanidine
44
Degenerative cervical myelopathy leads to what?
loss of fine motor function in both upper limbs. There is a delay in diagnosis of degenerative cervical myelopathy, which is estimated to be >2 years in some studies
45
Medication that reduces relapses in MS?
Monoclonal antiboies like natalizumab
46
What is autonomic dysreflexia?
This clinical syndrome occurs in patients who have had a spinal cord injury at, or above T6 spinal level. Briefly, afferent signals, most commonly triggered by faecal impaction or urinary retention (but many other triggers have been reported) cause a sympathetic spinal reflex via thoracolumbar outflow. The usual, centrally mediated, parasympathetic response however is prevented by the cord lesion. The result is an unbalanced physiological response, characterised by extreme hypertension, flushing and sweating above the level of the cord lesion, agitation, and in untreated cases severe consequences of extreme hypertension have been reported, e.g. haemorrhagic stroke.
47
Management of acute cluster headaches?
100% oxygen (80% response rate within 15 minutes)
subcutaneous triptan (75% response rate within 15 minutes)
48
First line for trigeminal neuralgia?
Carbamazepine
49
Hoover's sign differentiates between what?
organic and non-organic lower leg weakness
50
What does a temporal seizure look like?
May occur with or without impairment of consciousness or awareness
An aura occurs in most patients
* typically a rising epigastric sensation
* also psychic or experiential phenomena, such as déjà vu, jamais vu
* less commonly hallucinations (auditory/gustatory/olfactory)
Seizures typically last around one minute
* automatisms (e.g. lip smacking/grabbing/plucking) are commo
51
First line for acute management of headaches?
* an oral triptan and an NSAID, or
* an oral triptan and paracetamol
52
Migraine prophylaxis treatment?
* propranolol
* topiramate: should be avoided in women of childbearing age as it may be teratogenic and it can reduce the effectiveness of hormonal contraceptives
* amitriptyline
53
Thrombolysis with alteplase should only be given if:
* administered within 4.5 hours of onset of stroke symptoms (unless as part of a clinical trial)
* haemorrhage has been definitively excluded (i.e. Imaging has been performed
54
When should a thromboectomy be done?
thrombectomy as soon as possible to people who were last known to be well between 6 hours and 24 hours previously (including wake-up strokes):
* confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA and
* if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
55
The macula sparing suggests the lesion is most likely to be in the occipital cortex rather than what?
The optic tract
56
Effects of lesion at anterior cerebral artery?
Contralateral hemiparesis and sensory loss, lower extremity > upper
57
Clinical pattern seen in MND?
Amytrophic latwral sclerosis
58
What are focal awareness seizures?
* previously termed partial seizures
* these start in a specific area, on one side of the brain
* the level of awareness can vary in focal seizures. The terms focal aware (previously termed 'simple partial'), focal impaired awareness (previously termed 'complex partial') and awareness unknown are used to further describe focal seizures
* further to this, focal seizures can be classified as being motor (e.g. Jacksonian march), non-motor (e.g. déjà vu, jamais vu; ) or having other features such as aura
59
homonymous quadrantanopias mnuemonic?
PITS
Parietal inferior
Temporal superior
60
Features in posterior cerebella’s artery?
Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmu
61
What is intranuclear opthamoplegia?
* a cause of horizontal disconjugate eye movement
* due to a lesion in the medial longitudinal fasciculus (MLF)
* controls horizontal eye movements by interconnecting the IIIrd, IVth and VIth cranial nuclei
* located in the paramedian area of the midbrain and pons
62
GCS that requires intubation?
Less than 8
63
Features of neurofibromatosis 1?
Café-au-lait spots (>= 6, 15 mm in diameter)
Axillary/groin freckles
Peripheral neurofibromas
Iris hamatomas (Lisch nodules) in > 90%
Scoliosis
Pheochromocytoma
64
Features of neurofibromatosis 2?
Bilateral vestibular schwannomas
Multiple intracranial schwannomas, mengiomas and ependymoma
65
Minimum length seizure free before can drive a car?
12 months
66
What is progressive supranuclear palsy?
* 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
67
Cutaneous features of tuberous sclerosis?
* depigmented 'ash-leaf' spots which fluoresce under UV light
* roughened patches of skin over lumbar spine (Shagreen patches)
* adenoma sebaceum (angiofibromas): butterfly distribution over nose
* fibromata beneath nails (subungual fibromata)
* café-au-lait spots* may be seen
68
Management of raised ICP?
* IV mannitol may be used as an osmotic diuretic
* controlled hyperventilation
* aim is to reduce pCO2 → vasoconstriction of the cerebral arteries → reduced ICP
* leads to rapid, temporary lowering of ICP. However, caution needed as may reduce blood flow to already ischaemic parts of the brain
* removal of CSF, different techniques include:
* drain from intraventricular monitor (see above)
* repeated lumbar puncture (e.g. idiopathic intracranial hypertension)
* ventriculoperitoneal shunt (for hydrocephalus)
69
EEG finding in absent seizures
3HZ spike and wave
70
Mneymonic for cerebella’s disease?
DANISH
* D - Dysdiadochokinesia, Dysmetria (past-pointing), patients may appear 'Drunk'
* A - Ataxia (limb, truncal)
* N - Nystamus (horizontal = ipsilateral hemisphere)
* I - Intention tremour
* S - Slurred staccato speech, Scanning dysarthria
* H - Hypotonia
71
Features of an acoustic neuroma?
* cranial nerve VIII: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
* cranial nerve V: absent corneal reflex
* cranial nerve VII: facial palsy
72
What is cataplexy?
sudden and transient loss of muscular tone caused by strong emotion (e.g. laughter, being frightened). Around two-thirds of patients with narcolepsy have cataplexy.
73
Presentation of anterior inferior cerebellar artery stroke (lateral pontine syndrome)
Symptoms are similar to Wallenberg's (see above), but:
Ipsilateral: facial paralysis and deafnes
74
Wallenberg is
Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmu
75
Features of occult motor nerve palsy?
* ptosis
* 'down and out' eye
* dilated, fixed pupil
76
CSF findings of MS patients?
normal cell counts and protein levels
Oligoclonal bands are found in the CSF of 80% of MS patients. Elevated IgG levels is another common finding.
77
Features of dorsal column involvement in subacute combined degenration of the spinal cord?
distal tingling/burning/sensory loss is symmetrical and tends to affect the legs more than the arms
impaired proprioception and vibration sense
78
Features of alteral corticospinal tract involvement in subacute combined degeneration of the spinal cord?
muscle weakness, hyperreflexia, and spasticity
upper motor neuron signs typically develop in the legs first
brisk knee reflexes
absent ankle jerks
extensor plantars
79
Features of spinocerebellar tract involevement in subacute combined degertion of the spinal cord?
sensory ataxia → gait abnormalities
positive Romberg's sign
80
What are potine arteries?
Radiate out from the basilar arteries and supply the pons
81
Classic sign of potine haemorrhage?
Pinpoint pupils
82
How to tell difference betwen posterior inferior cerebellar artery stroke and anterior inferior cerebellar artery stroke
Anterior inferior also has ipsilateral facial paralysis and deafness
83
Managememt of idiopathic intracranial hypertension?
weight loss
diuretics e.g. acetazolamide
topiramate is also used, and has the added benefit of causing weight loss in most patients
repeated lumbar puncture may be used as a temporary measure but is not suitable for longer-term management
surgery: optic nerve sheath decompression and fenestration may be needed to prevent damage to the optic nerve. A lumboperitoneal or ventriculoperitoneal shunt may also be performed to reduce intracranial pressure
84
What is syringomyelia?
neurological disorder in which a fluid-filled cyst (syrinx) forms within the spinal cord. The syrinx can get big enough to damage the spinal cord and compress and injure the nerve fibers that carry information to and from the brain to the body.
85
Syringomyelia classically presents with what?
cape-like loss of pain and temperature sensation due to compression of the spinothalamic tract fibres decussating in the anterior white commissure of the spine
86
Investigations in GBS?
lumbar puncture
rise in protein with a normal white blood cell count (albuminocytologic dissociation) - found in 66%
nerve condution studies may be performed
decreased motor nerve conduction velocity (due to demyelination)
prolonged distal motor latency
increased F wave latency
87
Acute management of cluster headaches?
100% oxygen (80% response rate within 15 minutes)
subcutaneous triptan (75% response rate within 15 minutes)
88
What is pituitary apoplexy?
Sudden enlargement of a pituitary tumour (usually non-functioning macroadenoma) secondary to haemorrhage or infarction.
89
Management of status epilepticus?
ABC
airway adjunct
oxygen
check blood glucose
First-line drugs are IV benzodiazepines such as diazepam or lorazepam
in the prehospital setting PR diazepam or buccal midazolam may be given
in hospital IV lorazepam is generally used. This may be repeated once after 10-20 minutes
If ongoing (or 'established') status it is appropriate to start a second-line agent such as phenytoin or phenobarbital infusion
If no response ('refractory status') within 45 minutes from onset, then the best way to achieve rapid control of seizure activity is induction of general anaesthesia.
90
Roots of the brachial plexus?
Located in the posterior triangle
Pass between scalenus anterior and medius
91
trunks in brachial plexus?
Located posterior to middle third of clavicle
Upper and middle trunks related superiorly to the subclavian artery
Lower trunk passes over 1st rib posterior to the subclavian artery
92
Nerve at risk during surgical fracture of the humerus?
Axillary nerve
93
What is Klumpke's paralysis?
involving brachial trunks C8-T1. Classically there is weakness of the hand intrinsic muscles. Involvement of T1 may cause a Horner's syndrome. It occurs as a result of traction injuries or during delivery.
94
What nerves does erb's palsy involve?
C5-6
95
Features of neurofibromatosis 2
Bilateral vestibular schwannomas
Multiple intracranial schwannomas, mengiomas and ependymomas
96
What does a subdural haemorrhage result from?
bleeding of damaged bridging veins between the cortex and venous sinuses
97
I remember webers and wallenburg with this:
weaky weber (weakness in the muscles)
and wobbly wallenburg (ataxia, and altered sensation)
and that for both of them it is ipsilateral in the head, contralateral in the body - Its not perfect but it helps me a bit :)
98
Acute relapse management in MS?
High-dose steroids (e.g. oral or IV methylprednisolone) may be given for 5 days to shorten the length of an acute relapse
99
What is thoracic outlet syndrome?
disorder involving compression of brachial plexus, subclavian artery or vein at the site of the thoracic outlet.
100
What is multi system atrophy?
rare condition of the nervous system that causes gradual damage to nerve cells in the brain. This affects balance, movement and the autonomic nervous system, which controls several basic functions, such as breathing, digestion and bladder control.
101
DCM symptoms can include any combination of [1]:
Pain (affecting the neck, upper or lower limbs)
Loss of motor function (loss of digital dexterity, preventing simple tasks such as holding a fork or doing up their shirt buttons, arm or leg weakness/stiffness leading to impaired gait and imbalance
Loss of sensory function causing numbness
Loss of autonomic function (urinary or faecal incontinence and/or impotence) - these can occur and do not necessarily suggest cauda equina syndrome in the absence of other hallmarks of that condition
Hoffman's sign: is a reflex test to assess for cervical myelopathy. It is performed by gently flicking one finger on a patient's hand. A positive test results in reflex twitching of the other fingers on the same hand in response to the flick.
102
Triad in Creutzfeldt Jakob disease?
dementia, myoclonus, and rigidity.
103
What is neuroeptic malginant syndrome?
rare but dangerous condition seen in patients taking antipsychotic medication. It carries a mortality of up to 10% and can also occur with atypical antipsychotics. It may also occur with dopaminergic drugs (such as levodopa) for Parkinson's disease, usually when the drug is suddenly stopped or the dose reduced.
104
Management of neuroleptic malignant syndrome?
stop antipsychotic
patients should be transferred to a medical ward if they are on a psychiatric ward and often they are nursed in intensive care units
IV fluids to prevent renal failure
dantrolene may be useful in selected cases
thought to work by decreasing excitation-contraction coupling in skeletal muscle by binding to the ryanodine receptor, and decreasing the release of calcium from the sarcoplasmic reticulum
bromocriptine, dopamine agonist, may also be used
105
preferred way to support nutrition in patents with motor neuron disease
Percutaneous gastrostomy tube (PEG)
106
How does controlled ventilation work in raised ICP?
controlled hyperventilation
* aim is to reduce pCO2 → vasoconstriction of the cerebral arteries → reduced ICP
* leads to rapid, temporary lowering of ICP. However, caution needed as may reduce blood flow to already ischaemic parts of the brain
107
Motor actions of ulnar nerve?
medial two lumbricals
aDductor pollicis
interossei
hypothenar muscles: abductor digiti minimi, flexor digiti minimi
flexor carpi ulnaris
108
Median nerve hand motor innervation?
LOAF
L ateral two lumbricals
O pponens pollicis
A bductor pollicis brevis
F lexor pollicis brevis
109
Inheritance of charcot marie tooth disease?
Autosomal dominant
110
Investigation for nacrolepsy?
multiple sleep latency EEG
111
Valporate side effects?
V - VALPROATE:
A - Appetite increase --> weight gain
L - Liver failure
P - Pancreatitis
R - Reversible hair loss (alopecia)
O - Oedema
A - Ataxia
T - Teratogenic, tremor, thrombocytopaenia
E - Enzyme ihibitor (p450), encephalopathy (due to high ammoni
112
Where do 5HT3 receptors act?
5-HT3 antagonists are antiemetics used mainly in the management of chemotherapy-related nausea. They mainly act in the chemoreceptor trigger zone area of the medulla oblongata.
113
Temporal lesions cause what visual defects?
Right superior quadranopia
PITS
114
Parietal lesions cause what visual defect?
Right inferior quadranopia
PITS
115
What can be used to differentiate between a true seizure and a pseudoseizure
Prolactin
116
Blood suppy to medulla?
Vertebral arteries
PICA
117
wHAT IS PONS SUPPLIED BY?
AICA
Pontine arteries
Superior cerebellar arteries
118
What supplies the midbrain?
Posterior cerebral arteries
119
What does damage to the corticospinal tract cause?
Muscle weakness or paralysis
120
What does damage to the spinothalamic tract result in?
Loss of pain and temperature sensation
121
whAT CRANIAL NERVES LIE IN THE BRAINSTEM?
3-12
122
What is wallen berg's syndrome affect?
Spinothalamic tract Contralateral loss of pain and temperature sensation
spinocerebellar tract Ipsilateral ataxia
Hypothalamospinal tract Ipsilateral horners syndrome
123
How to remebr clinical features of wallenberg's syndrome?
DANVAH syndrome
Dysphagia
Ataxia
Nystagmus
Vertigo
Anaesthesia
Horner's syndrome
124
What is weber's syndrome cause in terms of tracts?
Corticospinal tract- Contralateral weakness
| C
125
Tracts affected ion locked in syndrome?
Corticospinal tract- Quadiplegia
Corticobulbar- Anarhria
126
First line investigation for myasthenia gravis?
antibodies against acetylcholine receptors
127
if the motor symptoms are affecting the patient's quality of life for parkinsons. First line?
Levodopa
128
if the motor symptoms are not affecting the patient's quality of life. First line for parkinsons?
dopamine agonist (non-ergot derived), levodopa or monoamine oxidase B (MAO‑B) inhibitor
129
Why is levodopa nearly always combined with a decarboxylase inhibitor?
this prevents the peripheral metabolism of levodopa to dopamine outside of the brain and hence can reduce side effects
130
What is used to treat drug induced parkinsons?
Anti muscarinics- Procyclidine, benzotropine, trihexyphenidyl
131
Features in a temporal lobe seziure?
Aura and then seizure which has automatisms- Lip smacking/ grabbbing/plucking
132
Features of juvenile myoclonic epilepsy?
infrequent generalized seizures, often in morning//following sleep deprivation
daytime absences
sudden, shock-like myoclonic seizure (these may develop before seizures)
133
What is a surgical third nerve palsy?
Third nerve palsy features with pupil dilated (due to something comrpessing parasympathetic fibres)
134
What is autonomic dysreflexia?
This clinical syndrome occurs in patients who have had a spinal cord injury at, or above T6 spinal level. Briefly, afferent signals, most commonly triggered by faecal impaction or urinary retention (but many other triggers have been reported) cause a sympathetic spinal reflex via thoracolumbar outflow. The usual, centrally mediated, parasympathetic response however is prevented by the cord lesion. The result is an unbalanced physiological response, characterised by extreme hypertension, flushing and sweating above the level of the cord lesion, agitation, and in untreated cases severe consequences of extreme hypertension have been reported, e.g. haemorrhagic stroke.
135
What is an essential tremor?
common movement disorder that involves a tremor (unwanted and uncontrolled shaking) in both hands and arms during action and when standing still. It also may affect your head and voice and how you walk.
136
What should. beconsidered if a flapping tremor and COPD?
Carbon dioxide retenetion
137
Features of. aatotal anterior circulation stroke
all 3 of the following: higher cognitive dysfunction (e.g. dysphasia or decreased consciousness), homonymous hemianopia, and unilateral hemiparesis and/or sensory loss
138
Features of. a posterior circulation syndrome?
This involves the vertebrobasilar arteries and presents cranial nerve palsy and contralateral motor and/or sensory deficits, nystagmus, cerebellar dysfunction, vertigo, or isolated homonymous hemianopia.
139
Pontine haemorrhages are a form of what?
Intracerebral haemorrhages
140
Features of a pontine haemorrhage?
reduced GCS, paralysis and bilateral pin point pupils
141
What is spontaneous intracranial hypotension?
rare cause of headaches that results from a CSF leak. The leak is typically from the thoracic nerve root sleeves.
Key features:
strong postural relationship with the headache generally much worse when upright. Patients may, therefore, be bed-bound
142
Frontal lobe seizure features
Head/leg movements, posturing, post-ictal weakness, Jacksonian march
143
DCM symptoms can include any combination of [1]:
Pain (affecting the neck, upper or lower limbs)
Loss of motor function (loss of digital dexterity, preventing simple tasks such as holding a fork or doing up their shirt buttons, arm or leg weakness/stiffness leading to impaired gait and imbalance
Loss of sensory function causing numbness
Loss of autonomic function (urinary or faecal incontinence and/or impotence) - these can occur and do not necessarily suggest cauda equina syndrome in the absence of other hallmarks of that condition
Hoffman's sign: is a reflex test to assess for cervical myelopathy. It is performed by gently flicking one finger on a patient's hand. A positive test results in reflex twitching of the other fingers on the same hand in response to the flick.
144
Conditions MS is associated with?
thymomas in 15%
autoimmune disorders: pernicious anaemia, autoimmune thyroid disorders, rheumatoid, SLE
thymic hyperplasia in 50-70%
145
What does UMN lesion spare?
Upper face
146
Lab features of pseudomonas aerguinosa?
Gram-negative rod
non-lactose fermenting
oxidase positive
147
e commonest protozoal cause of diarrhoea in the UK?
Cryptosporidosis
148
Features of cryptosporidiosis?
watery diarrhoea
abdominal cramps
fever
in immunocompromised patients, the entire gastrointestinal tract may be affected resulting in complications such as sclerosing cholangitis and pancreatitis
149
The following antibiotics are commonly used in the treatment of MRSA infections:
vancomycin
teicoplanin
linezolid
150
What is the Jarisch-Herxheimer reaction?
sometimes seen following syphilis treatment
fever, rash, tachycardia after the first dose of antibiotic
in contrast to anaphylaxis, there is no wheeze or hypotension
it is thought to be due to the release of endotoxins following bacterial death and typically occurs within a few hours of treatment
no treatment is needed other than antipyretics if required
151
Management of whooping cough?
an oral macrolide (e.g. clarithromycin, azithromycin or erythromycin) is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread
152
Memory aid for finger sensations?
You can make an M with your thumb-index-middle for median nerve and a U with your little-ring for ulnar nerve
153
Management of acute MS relapses?
High dose steroids
154
PCA anaeurysm vs cavernous sinus thrombosis?
PCA= Think: 3rd nerve palsy = ptosis + dilated pupil
Cavernous sinus thrombosis= Absent corneal reflex and proptosis
155
What is a cavernous sinus thrombosis?
Cavernous sinus thrombosis is a rare blood clot that can form in response to an infection in your face or head. It's fatal in about 1 in 3 cases. Early symptoms include a severe headache, followed by swelling or bulging in one or both eyes. This condition requires immediate treatmen
156
Examples of dopamine receptor agonists?
bromocriptine, ropinirole, cabergoline, apomorphine
157
Drugs that cause raised ICP?
combined oral contraceptive pill
steroids
tetracyclines
retinoids (isotretinoin, tretinoin) / vitamin A
lithium
158
Transient global amnesia is percipiated by what?
strenuous activity, high-stress events, or coitus, but it can be seen with migraines
159
Causes of a third nerve palsy?
diabetes mellitus
vasculitis e.g. temporal arteritis, SLE
false localizing sign* due to uncal herniation through tentorium if raised ICP
posterior communicating artery aneurysm
pupil dilated
often associated pain
cavernous sinus thrombosis
Weber's syndrome: ipsilateral third nerve palsy with contralateral hemiplegia -caused by midbrain strokes
other possible causes: amyloid, multiple sclerosis
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First line treatment for neuropathic pain?
Amitryptiline, duloxetine, gabapentin or pregabalin
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Management of trigeminal neuralgia?
carbamazepine is first-line
failure to respond to treatment or atypical features (e.g. < 50 years old) should prompt referral to neurology
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Cerebellar hemisphere lesions cause what?
peripheral ('finger-nose ataxia')
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Cerebellar vermis lesions cause what?
Gait ataxia
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Drygs that cause compensatory tachycardia
The '4Ds' can be useful in remembering causes of postural hypotension with compensatory tachycardia.
Deconditioning.
Dysfunctional heart: aortic stenosis.
Dehydration: disease (acute illness, adrenal insufficiency), dialysis, drugs (diuretics, narcotics).
Drugs: anti-anginals, anti-parkinsonian medications (levodopa), antidepressants, antipsychotics, anti–benign prostatic hyperplasia drugs (tamsulosin).
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Adverse effects of lveodopa?
dyskinesia
'on-off' effect
postural hypotension
cardiac arrhythmias
nausea & vomiting
psychosis
reddish discolouration of urine upon standing
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Management of myasthenia gravis?
long-acting acetylcholinesterase inhibitors- pyridostigmine is first-line
immunosuppression is usually not started at diagnosis, but the majority of patients eventually require it in addition to long-acting acetylcholinesterase inhibitors:
prednisolone initially
azathioprine, cyclosporine, mycophenolate mofetil may also be used
thymectomy
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What is brown sequard syndrome?
lateral hemisection of the spinal cord
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Features of brown sequard syndrome
ipsilateral weakness below lesion
ipsilateral loss of proprioception and vibration sensation
contralateral loss of pain and temperature sensation
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Features of conduction aphasoa?
Classically due to a stroke affecting the arcuate fasiculus - the connection between Wernicke's and Broca's area
Speech is fluent but repetition is poor. Aware of the errors they are making
Comprehension is normal
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Features of global aphasia?
Large lesion affecting all 3 of the above areas resulting in severe expressive and receptive aphasia
May still be able to communicate using gestures
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Features of a pontine haemorrhage?
reduces Glasgow coma score, quadriplegia, miosis, and absent horizontal eye movements.
Pinpoint pupils point to pons
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Features of progressive supranuclear palsy?
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
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Routes for midazolam, lorazepam and diazepam
Midazolam - Mouth
Lorazepam - l looks like i - IV
Diazepam - up the derriere
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Painful third nerve palsy = what?
posterior communicating artery aneurysm
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What is paroxysmal hemicrania?
attacks of severe, unilateral headache, usually in the orbital, supraorbital or temporal region. These attacks are often associated with autonomic features, usually last less than 30 minutes and can occur multiple times a day.
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Features of mononeuritis multiplex?
simultaneous or sequential involvement of individual non-contiguous nerve trunks. It typically presents with acute or subacute loss of sensory and motor function of individual nerves. The pattern of involvement is asymmetric, however, as the disease progresses, deficit(s) becomes more confluent and symmetrical, making it difficult to differentiate from polyneuropathy.
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What is Arnold-Chiari malformation?
Downward displacement, or herniation, of the cerebellar tonsils through the foramen magnum. Malformations may be congenital or acquired through trauma.
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Superior oblique muscle action?
Abducts, depresses and internally rotates the eye
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Fourth cranial nerve poalsy results in what?
defective downward gaze → vertical diplopia
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6th cranial nerve palsy results in what?
Palsy results in defective abduction → horizontal diplopia
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Cranial nerve 9 lesions result in what?
hypersensitive carotid sinus reflex
loss of gag reflex (afferent)
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Cranial nerve 10 lesion results in?
uvula deviates away from site of lesion
loss of gag reflex (efferent)
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Management of restless leg syndrome?
simple measures: walking, stretching, massaging affected limbs
treat any iron deficiency
dopamine agonists are first-line treatment (e.g. Pramipexole, ropinirole)
benzodiazepines
gabapentin
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In a right haned male what hemisphere is dominant?
Left
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anagement of ocular myasthenia gravis
Pyridostigmine
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Cutaneous features of tuberous sclerosis?
depigmented 'ash-leaf' spots which fluoresce under UV light
roughened patches of skin over lumbar spine (Shagreen patches)
adenoma sebaceum (angiofibromas): butterfly distribution over nose
fibromata beneath nails (subungual fibromata)
café-au-lait spots* may be seen
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Common fratures of intracranial venous thrombosis?
headache (may be sudden onset)
nausea & vomiting
reduced consciousness
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What is klumpes paralysis?
damage to T1
loss of intrinsic hand muscles
due to traction
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Memory aid for epilepsy medication?
FocaL give Lamo/Leve (Ends in L)
Absent -> Ethosuximide
If not either of the above, then... check gender.
Females:
The letter V is a line away from the letter Y so mYoclonic you give leVetriacetam. tOnic/atOnic there is an O so give lamotrigine.
If it isn't any of the above, then its Sodium Valproate.
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Tracts affected in brown sequard syndrome?
1. Lateral corticospinal tract
2. Dorsal columns
3. Lateral spinothalamic tract
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Tracts affected in subacute combined degeneration of the spinal cord and friedrish ataxia?
1. Lateral corticospinal tracts
2. Dorsal columns
3. Spinocerebellar tracts
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Tracts affected in anterior s[inal artery occlusion?
1. Lateral corticospinal tracts
2. Lateral spinothalamic tracts
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Tracts affected in syringomyelia?
1. Ventral horns
2. Lateral spinothalamic tract
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Tracts affected in neurosphilis?
1. Dorsal columns
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The following drugs may exacerbate myasthenia:
penicillamine
quinidine, procainamide
beta-blockers
lithium
phenytoin
antibiotics: gentamicin, macrolides, quinolones, tetracyclines
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Investigations in GBS?
lumbar puncture
rise in protein with a normal white blood cell count (albuminocytologic dissociation) - found in 66%
nerve condution studies may be performed
decreased motor nerve conduction velocity (due to demyelination)
prolonged distal motor latency
increased F wave latency
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Where does herpes simplex encephalitis often affect?
Temporal lobes
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What is syringobulbia?
similar phenomenon in which there is a fluid-filled cavity within the medulla of the brainstem. This is often an extension of the syringomyelia but in rare cases can be an isolated finding.
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Investigations for intracranial venous thrombosis?
MRI venography is the gold standard
CT venography is an alternative
non-contrast CT head is normal in around 70% of patients
D-dimer levels may be elevated
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Lamotrigine side effect?
SJS
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Uhthoff's phenomenon:
worsening of vision following rise in body temperature
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commonest neurological manifestation of sarcoid
Facial nerve palsy
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Migrane and menstration treatment?
SIGN recommends that women are treated with mefanamic acid or a combination of aspirin, paracetamol and caffeine. Triptans are also recommended in the acute situation
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What is degenerative cervical myelopathy?
most common form of spinal cord dysfunction in adults. It occurs when age-related osteoarthritic changes cause narrowing of the cervical spinal canal, leading to chronic spinal cord compression and neurologic disability.
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`Features of a fourth nerve palsy
vertical diplopia
classically noticed when reading a book or going downstairs
subjective tilting of objects (torsional diplopia)
the patient may develop a head tilt, which they may or may not be aware of
when looking straight ahead, the affected eye appears to deviate upwards and is rotated outwards
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First line management of myasthenia gravis?
Pyridostigmine
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Features of Sagittital sinus thrombosis?
* may present with seizures and hemiplegia
* parasagittal biparietal or bifrontal haemorrhagic infarctions are sometimes seen
* 'empty delta sign' seen on venography
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Features of cavernous sinus thrombosis?
periorbital oedema
* ophthalmoplegia: 6th nerve damage typically occurs before 3rd & 4th
* trigeminal nerve involvement may lead to hyperaesthesia of upper face and eye pain
* central retinal vein thrombosis
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Chronic adverse effects of phenytonin?
* common: gingival hyperplasia (secondary to increased expression of platelet derived growth factor, PDGF), hirsutism, coarsening of facial features, drowsiness
* megaloblastic anaemia (secondary to altered folate metabolism)
* peripheral neuropathy
* enhanced vitamin D metabolism causing osteomalacia
* lymphadenopathy
* dyskinesia
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Contraindications of triptans?
patients with a history of, or significant risk factors for, ischaemic heart disease or cerebrovascular disease
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Features of CJD?
dementia (rapid onset)
myoclonus
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Where is the C6 dermatome?
Thumb and index finger
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Mneumonic for L4?
Down on aLL fours
L4
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Mneumonic for L5?
Largest of the 5 toes
Big toe
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A positive Hoffman sign indicates what?
indicates an upper motor neuron lesion and corticospinal pathway dysfunction likely due to cervical cord compression.
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Parkinson-plus syndromes are characterized by what?
primary features of Parkinson's disease, including bradykinesia, ataxia, resting tremor, and rigidity but also include additional features such as dementia, cognitive deficits, and cranial nerve impairment
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Lambert-Eaton myasthenic syndrome is caused by what?
antibody directed against presynaptic voltage-gated calcium channel in the peripheral nervous system.
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wHAT IS Lhermitte's syndrome:
paraesthesiae in limbs on neck flexion
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wHAT TO DO If seizure longer than 5 minutes and al;lready given the 2 doses of IV lorazepam?
phenytoin or phenobarbital infusion
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What can dfifferentiate between a real and psyedoseizure?
Prolactin
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Features of cavernous inus thrombosis?
unilateral facial oedema, photophobia, proptosis and palsies of the cranial nerves which pass through it (III, IV, V, VI).
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Features of Bells palsy?
lower motor neuron facial nerve palsy → forehead affected
in contrast, an upper motor neuron lesion 'spares' the upper face
patients may also notice
post-auricular pain (may precede paralysis)
altered taste
dry eyes
hyperacusis
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mANAGEMENT OF STROKE if less than 6 hours?
Offer thrombectomy as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if within 4.5 hours), to people who have:
acute ischaemic stroke and
confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA)
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Management of stroke if more than 6 hours?
Offer thrombectomy as soon as possible to people who were last known to be well between 6 hours and 24 hours previously (including wake-up strokes):
confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA and
if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
