Neurology Flashcards
(358 cards)
1
Q
What do if CT negative for SAH
A
If within 6 hours then no need to rescan
If was done after 6 hours do an LP after 12 hours post sx
2
Q
What is done if SAH confirmed
A
CT angio
3
Q
Management of aneurysmal SAH
A
Analgesia
Stop any anti-thrombotics
Nimodipine to prevent vasospasm
Interventional radiologist will treat it with a coil or it can be treated by neurosurgeon with clipping on craniotomy
4
Q
Complications of SAH
A
Re-bleeding
Hydrocephalus
Vasospasm
Hyponatraemia
5
Q
What does sudden worsening of symptoms post SAH suggest
A
Rebleeding
Do CT again
6
Q
What would cause a intracerebral haemorrhage patient to deteriorate
A
Hydrocephalus
7
Q
Presentation of acute sinusitis
A
Facial pain worse on leaning forward
Nasal obstruction and discharge
8
Q
Causes of acute sinusitis
A
Commonly rhinovirus
If bacterial then strep pneumoniae or HIB
9
Q
What can be used for anticoagulation post stroke if AF
A
Warfarin
Dabigatran
Apixaban
10
Q
Difference in when start long term anticoagulation for AF post TIA vs stroke
A
TIA= immediately
Stroke= 2 weeks later
11
Q
What antiplatelets are given for stroke and then long term
A
Aspirin 300mg for 2 weeks
Clopidogrel long term
12
Q
If in stroke and TIA, clopidogrel is contraindicated, what use instead
A
Aspirin and dipyridamole lifelong
13
Q
How differentiate LBD and parkinsons disease with dementia
A
Parkinsons dementia occurs after a long parkinsons like history
Dementia starts same time as extrapyramidal symptoms in LBD
14
Q
How investigate neoplastic chord compression
A
MRI whole spine within 24 hours and give high dose dexamethasone in meantine
15
Q
What medication want to stop in dementia
A
TCAs as risk of worsening cognitive function
16
Q
Management of migraines
A
1st line- NSAID ideally or paracetamol
2nd line- oral triptan
17
Q
When is prophylaxis indcated for migraines
A
Having significant effect on life due to frequency or severity
18
Q
First line for migraine prophylaxis
A
Propranolol
19
Q
Second line prophylaxis for migraine
A
Topiramate
20
Q
What can lead to idiopathic intracranial HTN
A
Obesity
Pregnacny
COCP
Tetracyclines
Steroids
21
Q
Presentation of idiopathic intracranial HTN
A
Headache
Blurred vision
Papilloedema
Enlarged blind spot
Sixth nerve palsy
22
Q
Signs on examination of IIH
A
6th nerve palsy
Enlarged blind spot
Papilloedema
23
Q
Management of IIH
A
Lose weight
Start medications
1st line - acetazolamide (carbonic anydrase inhibitors)
2nd topiramate
24
Q
Which anti-epileptic causes macrocytic anaemia
A
Phenytoin due to reduced folate metabolism
25
What are rare severe adverse effects of phenytoin
TEN
Hepatitis
Aplastic anaemia
26
Presentation of GBS
Preceding gastroenteritis
Initial leg or back pain
Ascending symmetrical weakness of limbs
Can also include
- swallowing difficulty
- cranial nerve defects
- mild sensory defects
- resp effort affected
27
What is GBS
Immune mediated demyelination of the PNS triggered by an infection
28
Investigations for GBS and their findings
LP
- isolated raised protein
Nerve conduction
- decreased motor nerve conduction
29
What is most common cause of GBS
Campylobacter jejuni infection
30
Causes of trigeminal neuralgia
Idiopathic but can be causes by compression from tumours or vascular problems
Commonly seen in MS
31
Presentation of trigeminal neuralgia
Unilateral disorder where get electric shock like sensation
Evoked by shaving, smoking, talking or brishing teeth
32
Management of trigeminal neuralgia
First line carbamazepine
If fails to respond or red flag features refer to neuro
33
Red flag signs of trigeminal neuralgia
Under 40
Deafness or ear problems
Sensory problems
Optic neuritis
FHx of MS
34
Presentation of charcot marie tooth disease
Mainly motor loss
- foot drop
- high arched feet
- muscle weakness if hands and feet
- hyporeflexia
- stork leg deformity
- lots of ankle sprains
35
Management of Charcot marie tooth disease
There is no cure, and management is focused on physical and occupational therapy
36
Believed aetiology of bells palsy
HSV
37
Who is bells palsy commonly seen in
Young people aged 20-40
Pregnant women
38
Management of bells palsy
If within 72 hours give prednisolone
Eye care important to prevent keratopathy- aritifical tears and lubricants
39
Eye care for bells palsy
Artifical tears and lubricants
May have to tape eyes closed if unable to shut at night
40
When refer bells palsy to ENT
If after 3 weeks is no real improvement
41
On top of facial paralysis what may also encounter in bells palsy
Post auricular pain preceding paralysis
Altered taste
Dry eyes
Hyperacusis
42
Cutaneous features of tuberous sclerosis
Ash leaf spots
Cafe au lait spots
Subungal fibromata
Adenoma sebaceum
Shagreens patch
43
What is adenoma sebaceum
Angiofibromas seen in butterfly distribution over nose
Seen in tuberous sclerosis
44
MOA of triptans
Serotonin (5-HT) agonists
45
When take a triptan
At outset of headache not aura
46
Side effects of triptans
Triptan sensations- tingling, chest and throat tightness, heaviness
47
Contraindications of triptans
SSRI, SNRI
IHD
48
First time seizure assessment
CT and BM
Refer to outpatient clinic where have EEG and anti-epileptic may be started
49
First line for tonic-clonic seizures
Sodium valproate if male
Lamotrigine or levetiracetam if female
50
First line for focal seizures
Lamotrigine or levetiracetam
51
Second line for focal seizures
Carbamazepine
52
First line for absence seizures
Ethosuximide
53
Second line for absence seizures
Sodium valproate if male
Lamotrigine or levetiracetam if female
54
Myoclonic seizures management
Sodium valproate if male
Levetiracetam if female
55
In ALS, what are mutations often seen in
Superoxide dismutase
56
Presentation of progressive bulbar palsy
Palsy of the tongue, chewing muscles, swallowing and facial muscles
57
Which MND has worst prognosis
Progressive bulbar palsy
58
What are the types of MND
Amyotropic lateral sclerosis
Progressive muscular dystrophy
Progressive bulbar palsy
Primary lateral sclerosis
59
Types of motor neurone signs seen in the different MNDs
ALS
- LMN in arms
- UMN in legs
PLS
- UMN only
Progressive muscular atrophy
- LMN only
- affects distal then proximal muscle groups
60
Which medications most commonly associated with medication overuse headaches
Opioids
Triptans
61
Management of medication overuse headaches
Principally need to stop analgesia even though will worsen headache
- slowly withdraw opioids
- simple analgesia and triptans stop abruptly
62
Management of acute MS relapse
High dose oral or IV methylprednisolone for 5 days
63
Main drug used for preventing relapse of MS
Natalizumab
64
Management of fatigue in MS
Rule out anaemia etc
Give amantadine first line then trial CBT or mindfulness
65
Management of spasticity in MS
Baclofen and gabapentin given first line
2nd line options- diazepam and physio
66
Management of bladder dysfunction in MS
Do USS first to determine if significant residual volume
If residual volume- intermittent self-catheterisation
If no residual volume- anticholinergics
67
What is it when visual fields oscillate in MS
Oscillopsia
68
How manage oscillopsia in MS
Gabapentin
69
Which anti-emetic give in migraines
Metoclopramide or prochlorperazine
70
What type of seizure if twitching and jerks in legs and arms in AM where maintain consciousness
Myoclonic
71
Long term mangement of TIA
Long term clopidogrel
Aspirin and dipyrimadole if can't tolerate clopidogrel
72
What can cause subacute degeneration of the spinal chord
Vit B12 deficency
Inhaled nitrous oxide
73
Which parkinsons medication most linked to impulse disorders
Dopamine receptor agonists
74
If there is macula sparing in vision, where is lesion
Occipital cortex
75
If a young man develops tunnel vision, what is diagnosis
Retinitis pigmentosa
76
Where is lesion if developing tunnel vision
Peripheral retina
77
How does retinitis pigmentosa present
Early blindness
Nighttime blindness first symptom often
Tunnel vision as peripheral vision lost
78
Management of brain abscess
IV ceftriaxone and metronidazole
Dexamethasone
Surgery to debride abscess
79
What test use to differentiate functional from organic weakness
Hoover sign
80
What is hoover sign
If someone was genuinely trying to lift up their leg they would feel the other leg pressing down against bed
81
What are pseudoseizures
Seen in patients with mental illness where they fake having a seizrue
82
Signs someone has had a pseudoseizure
pelvic thrusting
family member with epilepsy
much more common in females
crying after seizure
don't occur when alone
gradual onset
83
How differentiate between a seizure and pseudoseizure biochemically
Serum prolactin
84
What is hoffmans sign
If flick distal phalynx then with UMN lesion there will be flexion in the index and thumb
85
What is sign seen on examination typically in uncal herniation
6th nerve palsy
86
NF1 presentation
Café-au-lait spots
Axillary/groin freckles
Peripheral neurofibromas
Iris hamatomas
Scoliosis
Pheochromocytomas
Gastrointestinal stromal tumour
87
NF2 presentation
Bilateral vestibular schwannomas
Multiple intracranial schwannomas, mengiomas and ependymomas
88
Myasthenic crises management
IVIG
Plasmapharesis
Monitor FVC with spirometry (less than 1.5L= contact ITU)- BiPAP or mechanical ventilation may be required
89
Long term management for myasthenia
Long acting acetylcholinesterase inhibitor- pyridostigmine
May require immunosuppression with steroids or azathioprine
90
Most common primary tumour for brain mets
Lung
91
What is an antalgic gait
Limp caused by weight on the affected limb
92
What is an ataxic gait
Wide based gait
Struggle to do toe to heel walk
93
How to rememeber causes of cerebellar disease
PASTRIES
Posterior fossa tumour
Alcohol
MS
Trauma
Rarer causes
Inherited
Epilepsy tx
Stroke
94
What is a chiari formation
Where a part of brain herniates through a malformation in skull leading to compression of the spinal chord
95
Sensory loss in syringomyelia
Cape distribution
Neck, shoulders and arms
Pain and temperature
96
Autonomic dysfunction in syringiomyelia
Horners
Bladder and bowel problems
97
Presentation of syringiomyelia
Cape distribution pain and temp sensory loss
Spastic weakness in leegs
Upgoing plantars
Neuropathic pain
98
Investigations for syringiomyelia
MRI brain to look for chiari formation
MRI spine to look for tethered chord
99
Management of syringiomyelia
Treat cause like surgery
Drain if permenant or symptomatic
100
NPH MRI finding
Ventriculomegaly with an absence of sulcal enlargement
101
Triad of NPH
Incontinence
Dementia
Gait abnormality
102
Pathophysiology of NPH
Reduced absorption secondary to prior meningitis, trauma or bleed
103
Management of NPH
Ventriculoperitoneal shunt but very risky as high risk of bleeing, seizures and infection
104
Pathophysiology of cervical degenerative myelopathy
Compression of spinal chord in cervical area due to degenerative changes in the area
Typically smoking is main risk factor for it
105
Presentation of cervical degenerative myelopathy
Pain
- in neck directly
- in arms
Motor problems
- loss of dexterity in hands
- weakness
Sensory problems
Autonomic dysfunction
106
What is good indicator on examination for degenerative cervical myelopathy
Positive hoffmans sign
107
What is uthoffs phenomena
Worsening vision when temperature rises
MS
108
What is L'hermittes sign
Limb parasthesia when flex neck
109
Classical parkinsons triad
Tremor
Bradykinesia
Rigidity
110
Bradykinesia parkinsons presentation
Slow, shuffling gait
Difficulty initiating movements
Povert of movement
111
Characteristics of parkinsons tremor
Worse at rest
Helped by voluntary movements
Worse when tired or stressed
112
What is pill rolling tremor seen in
Parkinsons
113
What is rigidity described as in parkinsons
Leadpipe
Can be cogwheel superimposed from tremor
114
Extra features of parkinsons
Micrographia
Drooling
Autonomic dysfunction- postural drop
Depression
Loss of REM sleep
115
Drug induced parkinsons vs idiopathic
Drug induced
- bilateral
- rapid onset
- rest tremor and rigidity rare
116
If clinical diagnosis uncertain for parkinsons, what can use
123I‑FP‑CIT single photon emission computed tomography (SPECT)
117
Cluster headache presentation
Intense headache behind the eye, stabbing
Occur in clusters lasting 15-120 mins
Get over a period of time then remit for a bit
Associated with stuffy nose, red face and lacrimation
118
If someone presents to GP with cluster headache what do
Refer to neurology
119
What investigation will be done by neurology for cluster headaches
MRI with gadolinium contrast- may show underlying tumour
120
Acute management of cluster headache
High flow O2
Subcut triptan
121
What can be given for cluster headache prophylaxis
Verapamil
122
What often triggers autonomic dysfunction
Faecal impaction or urinary retention
123
What type of hallucination is smelling roses
Focal olfactory
124
How manage neuropathic pain
1 of amitryptylline, duloxetine, pregabalin or gabapentin
If fail to work switch
If resistant refer to pain clinic
125
What can use for localised neuropathic pain
Caspaicin
126
Which anti-emetic can cause prolonged QT
Ondensatron
127
Difference in appearance of ischaemic vs haemorrhagic stroke on CT
Haemorrhagic= hyperdense
Hypodense area and hyperdense artery = ischaemic
128
What is the hyperdense artery sign
Here the affected artery appears hyperdense due to accumulation
129
Presentation of sporadic creutzfield jacobs disease
Older patient
Rapid onset dementia
Myoclonus
Mutism
Psychiatric symptoms
130
Presentation of variant CJD
Younger patient
Psychiatric problems early
131
Investigations for CJD
CSF is usually normal
EEG: biphasic, high amplitude sharp waves (only in sporadic CJD)
MRI: hyperintense signals in the basal ganglia and thalamus
132
Antibodies in lambert eaton
voltage-gated calcium channel in the peripheral nervous system
133
Presentation of lambert eaton syndrome
Proximal myopathy of lower limbs
Autonomic dysfunction- dry mouth
Improves with exercise
Tenderness in muscles
Hyporeflexia which improves after exercise
134
Investigations for lambert eaton syndrome
EMG- shows incremental response to repetitive electrical stimulation
135
What is roughened skin over the lumbar spine in association with seizures
Shagreens patches seen in tuberous sclerosis
136
If not responded to 2 rounds of IV lorazepam what are options to start
Phenytoin
Sodium valproate
Levetiracetam
137
What is impaired in dorsal column disorders
Proprioception
Vibration
Light touch
138
Presentation of subacute degeneration of the spinal chord
Dorsal column involvement
- distal tingling/burning/sensory loss
- impaired vibration and proprioception
Corticospinal tracts
- weakness
- UMN signs
Spinocerebellar involvement
- gait abnormalities
139
What does positive rombergs indicate
B12 deficiency due to spinocerebellar tract involvement
140
What is the spinocerebellar tracts function
Sensory pathway relaying information about balance and proprioception to cerebellum
141
An aneurysm or aneurysm rupture in what vessel can lead to third nerve palsy
Posterior communicating artery
142
If have unprovoked seizure with normal imaging, when can drive next
6 months
Must notify DVLA
143
What is inheritance of essential tremor
Autosomal dominant
144
What are features of an essential tremor
Worse when arms outstretched
Can affect head, vocal chords and jaw
Improved by alcohol and rest
145
Where can essential tremor also affect
Vocal chords- can get change in voice
Head and jaw can be affected
146
Management of essential tremor
Propanolol
147
What is new definition of a TIA
Transient episode of neurologic dysfunction caused by ischaemia without acute infarction visible on imaging
NOT BASED ON TIME BUT IMAGING
148
Sensory predominant peripheral neuropathy causes
Alcohol
Vit B12
DM
Amyloid
Uraemia
Leprosy
149
Motor predominant peripheral neuropathy causes
Guillain-Barre syndrome
porphyria
lead poisoning
hereditary sensorimotor neuropathies (HSMN) - Charcot-Marie-Tooth
chronic inflammatory demyelinating polyneuropathy (CIDP)
diphtheria
150
What malignancy most likely to cause myasthenia gravis
Thymoma
151
What is presentation if pontine artery stroke
Low GCS
Bilateral pinpoint pupils
Paralysis
152
What does high stepping gait indicate
Foot drop- is walking technique used to accommodate
153
Causes of high stepping gait
Peripheral neuropathy
154
What is nature of parkinsons referral to neuro
Urgent
155
What diet advised for epilepsy
Ketogenic
156
Management of low pressure headache post LP
Fluids, coffee and rest
2nd line- blood patch, IV caffeine
157
Which drugs exacerbate myasthenia
Beta blockers
Lithium
Phenytoin
Abx
Stress
158
Causes of facial nerve palsy
Sarcoid
Petrous temporal fracture
Cholesteatoma
Parotid tumours
HIV
MS
DM
159
If seize with whole body but consciousness intact, what is it
Pseudoseizure
160
What use to image demyelinating lesions in MS
MRI with contrast
161
What is jacksonian march
Seizure will initially start with affecting a peripheral body part then spread over whole limb and can become generalised
162
Most common complication of meningitis
Sensorineural hearing loss
163
How is nutrition give in MND
Percutaneous gastrostomy tube (PEG)
164
What resp care is given for MND
BiPAP at night
165
What is management of MND
Riluzole if ALS
Resp care- BiPAP
Nutrition- PEG tube
166
What is riluzole
Drug used in MND which blocks glutamate receptors
167
If first line for focal seizures does not work, what do
Give either lamotrigine or levetiracetam depending on what trialled first
Second line is carbamazepine
168
LP finding in MS
Raised oligoclonal bands
169
How remember what visual defect a parietal or temporal lesion will cause
PITS
Parietal- inferior
Temporal- superior
170
Difference in bitemp hemianopia caused by pituitary tumour vs craniopharyngioma
Pituitary tumour- upper defect
Craniopharyngioma- lower defect
171
Which focal seizures often present with an aura
Temporal
172
Examples of temporal focal seizure auras
Rising epigastric sensation
Deja vu
Hallucinations- rare
173
If want to test CSF that is leaking out of nose or ear, what is quick bedside test can do
Check for glucose which will be present if CSF
174
What is further classification of focal temporal seizures
Impaired awareness or aware
175
Atonic seizure management
Sodium valproate if male
Lamotrigine if female (lAmotri for atonic and not levetiracetam)
176
TIA management if taking an anticoagulant
Refer for immediate assessment and imaging
177
Management of TIA immediately
Give 300mg aspirin unless
- on anticoagulant then refer for imaging
- taking low dose aspirin- continue dose until review
- aspirin CI
178
Best imaging for intracranial venous thrombosis
MRI venography
179
Management of intracranial thrombosis
LMWH
180
What are the types of intracranial venous thrombosis
Sagittal sinus
Cavernous sinus
Lateral sinus
181
What does empty delta sign on venography suggest
Sagittal sinus thrombosis
182
How manage neuroleptic malignant syndrome
Stop antipsychotic- transfer to medical ward
IV fluids
Dopamine agonists- bromocriptine
183
Presentation of neuroleptic malignant syndrome
Side effect of antipsychotics
- pyrexia
- muscle rigidity
- agitation and confusion
- autonomic instability- HTN, tachycardia
184
Blood findings of neuroleptic malignant syndrome
Leukocytosis
Raised CK
Can get AKI secondary to rhabdo
185
How position head if raised ICP
Head elevation to 30 degrees
186
Management of raised ICP
Head elevation to 30 degrees
Controlled hyperventilation
Put in shunt if from raised ICP
187
Cushings triad
Widened pulse pressure
Bradycardia
Irregular breathing
188
Investigation for narcolepsy
Multiple sleep latency EEG
189
How manage narcolepsy
Daytime stimulants
Nighttime sodium oxybate
190
What is sodium oxybate
A strong sedative
191
What is an example of daytime stimulant used in narcolepsy
Modafinil
192
Narcolepsy presentation
Excessive sleepiness
Cataplexy
Vivid hallucinations when falling asleep
Sleep paralysis
193
Where refer for degenerative cervical myelopathy
Spinal surgery
194
What Hz is parkinsons tremor typically
3-5
Essential tremor is 6-12
195
When can drive after a TIA
Can drive after a month if no symptoms
No need to inform DVLA
196
Are subdural bleeds limited by suture lines
No
197
What is klumpkes syndrome
C8 and T1 nerve root injury
198
What tends to causes klumpkes syndrome
Birth injury
Falling from tree and trying to grab a branch
199
Presntation of klumpkes syndrome
Claw grip from loss of intrinsic muscles in hand
Sensory loss in dermatomes C8 and T1
200
If someone with parkinsons presents to hospital and does not have a safe swallow for dopamine, what give
Dopamine patch agonist
201
What is mononeuritis multiplex
Simultaneous involvement at least 2 different areas of the peripheral nervous system
202
What is a polyneuropathy
a general symmetrical degeneration of peripheral nerves that spreads towards the centre of the body.
203
Differentiating mononeuritis multiplex from polyneuropathy
Mononeuritis multiplex asymmetrical
204
When can AEDs be withdrawn
If 2 years no seizures
Must be stopped over 2-3 months
205
In parkinsons what is it really important to do when patient admitted
They continue to have dopamine agonists as will go into acute dystonia
If unable to swallow then give patch
206
What anaesthetic would MG patients be resistant to
Suxamethonium
207
What dementia is associated with MND
Frontotemoral dementia
208
Where is seizure if post ictal dysphasia
Temporal
209
What is classic features of parietal lobe seizures
Parasthesia
210
What is classical feature of frontal seizures
Motor symptoms
Head/leg movements
Post-ictal weakness
Jacksonian march
211
What is contained within the cavernous sinus
3-6
Oculomotor nerve
Trochlear nerve
Opthalmic nerve (CNV1)
Maxillary nerve (CNV2)
Abducens
212
What causes cavernous sinus syndrome
Cavernous sinus tumours typically tumours that invade the cavernous sinus such as nasopharyngeal tumours
213
Patient with nasopharyngeal tumour develops; proptosis, absent coreal reflex, horners syndrome and pain on eye movements
Cavernous sinus syndrome
214
Presentation of cavernous sinus syndrome
Proptosis
Trigeminal nerve lesions
- absent corneal reflex
Horners
Third nerve palsy
215
If have painful third nerve palsy, what need to rule out
Posterior communicating artery
216
Sudden onset headache with isolate hypotension
Pituitary apoplexy from pituitary insufficiency
If bleed then HR up
217
What is pituitary apoplexy
Sudden enlargement of pituitary tumour from infarction or haemorrhage
218
Presentation of pituitary apoplexy
Sudden onset headache
Vomiting
Neck stiffness
Visual defects (bitemp superior quadrantopia)
Hypotension from pituitary insufficiency
219
How investigate pituitary apoplexy
MRI
220
Management of pituitary apoplexy
Urgent steroid replacement
Surgery
221
What is an arnold chiari malformation
Herniation of cerebellar tonsils through foramen magnum
222
Features of arnold chiari malformation
Non-communicating hydrocephalus
Headache
Syringomyelia
223
Multiple system atrophy presentation
Parkinsons
Early autonomic disturbance
- postural drop
- impotence
Cerebellar signs
224
What questionnaire measures impairment from stroke
NIHSS
225
What scale is used to differentiate stroke from stroke mimics in the acute setting
ROSIER
226
Management of chronic subdurals
If symptomatic or very large
- burr hole evacuation
Asymptomatic and found incidentally
- conservative
227
Management of acute subdural
Small
- conservative
Large
- depressive craniectomy or monitor intracranial pressure
228
If starting a phenytoin infusion for status epilepticus what need to do
Place on a cardiac monitor
229
If patient has locked in syndrome, what is location of stroke
Basilar
230
Presentation of middle cerebral artery stroke
Arm and facial hemiparesis plus sensory loss
231
Presentation of posterior cerebral artery
Contralateral homonymous hemianopia with macula sparing
Visual agnosia
232
What is visual agnosia
Impairment in recognising objects visually but would be able to identify via touch or smell
233
What is the basilar artery
Artery leading up to the circle of willis
234
What are the pontine arteries
Arteries branching off the basilar artery
235
What is the regional blood supply to the brain
236
What is blood supply to the midbrain
Branches of the posterior cerebral artery
237
What is presentation of midbrain stroke
Ipsilateral CN III palsy
Contralateral upper and lower limb weakness
238
What is weber syndrome
Get stroke in branch of posterior cerebral artery supplying the midbrain. Presents with ipsilateral CN III palsy and contralateral limb problems
239
What is other name for lateral medullary syndrome
Wallenberg
240
What causes lateral medullary syndrome
Stroke in the posterior inferior cerebellar artery
241
Presentation of lateral medullary syndrome
Ataxia and nystagmus
Horners
Ipsilateral pain or loss of pain in face
Contralateral pain in trunk or limbs
242
What causes lateral pontine syndrome
Anterior inferior cerebellar artery
243
Presentation of lateral pontine syndrome
Same as wallenbergs- Ataxia and nystagmus, horners, ipsilateral pain or loss of pain in face, contralateral pain in trunk or limbs
PLUS
Hearing loss and facial paralysis (CN7+8) involvement
244
Lacunar stroke presentation
Isolated hemiparesis or sensory loss
Or plus ataxia
245
Sites of lacunar infarcts
Mainly caused by HTN
- Thalamus
- Basal ganglia
- Internal capsule
246
Other than managing the infarct itself what 5 things need to be considered post stroke
Fluid balance
Glycaemic control
BP control
Feeding assessment
Assessing disability
247
Fluid balance important points post stroke
Review daily as hypovolaemia leads to poor perfusion and hypervolaemia leads to oedema
Oral hydration recommended but may need IV saline if swallow not intact
248
Glycaemia management post stroke
Important to keep between 4-11
Hyperglycaemia associated with poor mortality
249
Management post stroke if diabetic
Intense management
If diabetic optimise with IV glucose and insulin
250
How manage hypertension post stroke
Should avoid antihypertensives unless HTN emergency like dissection, nephropathy, encephalopathy or MI/HF
251
What must all stroke patients be screened for in 24 hours after event
Swallow
252
What do if is any concern about swallow after stroke
Withold all oral intake including food/drugs/fluids
Get specialist assessment within 24 hours
253
Management of impaired swallow post stroke
NG tube feed within 24 hours unless had thrombolytic therapy
If NG not tolerated arrange nasal bridle tube or gastrostomy
254
What is a nasal bridle tube
Nasal loop used to stop NG tube from being pulled out
255
What score is used to determine disability post stroke and requirement for rehab team
Barthel index
256
When start statin post stroke
If cholesterol over 3.5
Do after 48 hours
257
If swallow impaired post stroke how administer aspirin
Rectally
258
According to the bamford/oxford stroke classification, what are the main types
Total anterior
Partial anterior
Lacunar infarcts
Posterior circulation
Extra syndromes- lateral medullary, weber
259
What are 3 things assess in bamford stroke classification
Unilateral hemiparesis or sensory loss
Homonymous hemianopia
HIgher cognitive dysfunction
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In bamford stroke classification, what are examples of higher cognitive dysfunction
Aphasia
Apraxia
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What is difference between PACI and TACI
PACI= 2 of
TACI= 3 of
- Unilateral hemiparesis or sensory loss
- Homonymous hemianopia
- Higher cognitive dysfunction
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Difference in pathology of PACI and TACI
TACI= middle and anterior cerebral arteries involved
PACI= smaller vessels of these involved
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Ipsilateral CN III lesion with contralateral limb weakness
Midbrain stroke
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Where is brocas area
Frontal lobe
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Where is wernickes area
Superior temporal gyrus
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What is function of wernickes area
Area that comprehends speech
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What is function of brocas area
Expressive area that generates speech
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What is difference in arterial supply of brocas and wernickes area
Brocas- superior division of left MCA
Wernickes- inferior division of left MCA
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Post TIA when are carotid dopplers recommended
ASAP unless not candidate for endarterectomy
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What is preferred investigation for TIA
MRI diffusion weighted as best identifies area of ischaemia
Ideally do on same day as specialist assessment
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Difference in drug used to reduce ICP in different pathologies
Infection or malignancy= dexamethasone
Traumatic brain injuries= IV mannitol
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If brain bleed or traumatic injury, what drug use to reduce ICP
IV mannitol
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What cranial nerves affected by acoustic neuromas
5, 7, 8
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A 69-year-old woman presents with a 3 week history of a headache which is worse on the right side. She is generally unwell and feels 'weak', noting particular difficulty in getting up from a chair
GCA from PMR
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LP finding of IIH
Very high opening pressure
Normal CSF
276
What is restless leg syndrome
Syndrome of spontaneous continuous leg movements assoc with parasthesia
Very common- 2-10%
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Presentation of restless leg syndrome
Uncontrollable urge to move legs (akathisia)- worse at rest and at night
Parasthesias- weird sensations in legs
Movements of legs in sleep
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Causes of restless leg syndrome
Idiopathic with strong family history
DM
IDA
Pregnancy
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Investigations for restless leg syndrome
Rule out possible causes
- Iron studies
- HbA1c
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First line treatment for restless leg syndrome
Dopamine agonists- ropinirole
Walking, stretching, massaging
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Second line options for restless leg syndrome
Benzos
Gabapentin
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When do patients need specialist review by for TIA
In last 7 days= within 24 hours
Over 7 days ago= within 7 days
Need for admission under stroke physician if
- crescendo TIA
- suspected cardioembolic source
- carotid artery stenosis
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When may admit patient with TIA for observation
Crescendo TIA
Cardioembolic source
Suspected carotid artery stenosis aetiology
284
What is a cresecendo TIA
If have multiple in short space of time
285
If a patient under 55 presents with a stroke what investigations must be done
Thrombophilia screen
- ANA
- antiphospholipid syndrome
- lupus anticoagulant
- ESR
- syphilis serology
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Management of GBS
First line= IVIG
Can do plasmapharesis
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Rfs for MS
Vit D deficiency
Female
Aged 20-40
288
What use for nausea in parkinsons
Domperidone- blocks dopamine receptors but does not cross BBB
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What is type of seizure if becomes upset the unresponsive and wanders the house
Focal seizures with impaired awareness- automatisms evident
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DANISH
Dysdiadochokinesia
Ataxia
Nystagmus
Intention tremor
Slurred speech
Hypotonia
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If have hyperdense area in the centre of brain what could be
Basilar artery thrombus
292
What % of right handed people have speech centre on right side
10%
293
What % of left handed people have speech centre on left
60-70%
294
What is cut off INR for thrombolysis
1.7 and below
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Absolute CIs to thrombolysis
- Previous intracranial haemorrhage
- Seizure at onset of stroke
- Intracranial neoplasm
- Suspected subarachnoid haemorrhage
- Stroke or traumatic brain injury in preceding 3 months
- Lumbar puncture in preceding 7 days
- Gastrointestinal haemorrhage in preceding 3 weeks
- Active bleeding
- Pregnancy
- Oesophageal varices
- Uncontrolled hypertension >185/110
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If doing head CT scan and identify proximal infarction what do next
Convert to CT angio
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When can offer thrombectomy up to 24 hours post symptoms
If proximal anterior circulation stroke and is area of salvageable brain tissue identified on diffusion weighted MRI
Consider if posterior circulation stroke
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Management of DCM
Decompressive surgery
Can observe if very mild
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Corneal reflex nerve
CN V1
300
Progressive supranuclear palsy presentation
Parkinsons+ dysarthria and difficulty looking upwards
301
Internuclear opthalmoplegia presentation
Ipsilateral impaired eye adduction
Horizontal nystagmus in abucting eye on other side
302
Causes of internuclear opthalmoplegia
MS
Vascular cause
303
What is affected in internuclear opthalmoplegia
Medial longitudinal fasciculus
304
When give aspirin in stroke
If thrombolysis or thrombectomy not possible
305
If a patient is not aphasic where is stroke most likely to have occured
Anterior cerebral arteries
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In exacerbations of neuropathic pain what can be used
Tramadol
307
What is the cerebellar vermis
Central part of cerebellum which separates the hemispheres
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Where in cerebellum is lesion if develop ataxic gait
Cerebellar vermis
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What is an example of peripheral ataxia
Finger nose ataxia
310
If develop finger nose ataxia where is lesion
Cerebellar hemisphere
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What is todds paresis
After a focal motor seizure can develop weakness
312
If undergo haemorrhagic transformation of ischaemic stroke how manage
Stop aspirin/alteplase
Control BP to under 140 systolic
CT and neurosurgery referral
313
If patient undergoes surgery for DCM then later develop neuro problems what is likely cause
Recurrent DCM
314
Difference in supply of internal vs external carotid arteries
Internal- circle of willis
External- mainly facial arteries eg lingual, maxillary etc
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What investigation do for LBD
SPECT/DAT scan
316
How manage spasticity in MND
Baclofen
317
NCS and EMG findings in MND
NCS is normal
EMG is reduced number of action potentials and increased amplitude
318
Investigations for MND
MRI
NCS and EMG
CLINICAL DIAGNOSIS
319
Types of MS
Relapsing remitting- most common
Primary progressive-Progressive deterioration from the onset of the disease course
Secondary progressive- initial relapsing remitting then progresses
Clinically isolated syndrome- 1 demyelinating event which may progress to MS or remain isolated
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Definitive management options for SAH
IR will place platinum coil
Neurosurgeons can do craniotomy and clip
321
How manage hydrocephalus from SAH
Short term= ventricular drain
Long term= can put in ventriculoperitoneal drain
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CT scan of extradural
Limited by suture lines
Crescent shaped
323
Extradural haematoma management
If no focal neurology can do radiological monitoring
Otherwise need to do decompressive craniectomy and fix artery
324
Intracerebral haemorrhage investigation finding and management
Area of hyperdensity in cortex
Conservative under care of strokes, if LOC and massive clot then can do surgical management
325
Suspected brain tumour referral guidelines
MRI within 2 weeks for adults
MRI within 48 hours if young person with new onset cerebellar or neurological dysfunction
326
Investigations for brain tumour
Fundoscopy to look for papilloedema
MRI first line
Biopsy is gold standard
327
What must worry about if new onset personality
Brain tumour in frontal lobe- do MRI
328
What is most common tumour in brain
Metastases are most common
Most common primary is meningioma but if malignant then glioblastoma is most common
329
MRI meningioma vs glioblastoma
Meningioma- well circumscribed with dural tail where attatched to dura
Gliobastoma- ring enhancing lesion with lots of vasogenic oedema
330
If have diagnosed MG what need to do next as an investigation
CT/MRI thorax to check for thymoma
331
Investigations for MG
Antibodies- anti ACHr and MUSK
NCS- reduced after repeated stimulation
MRI/CT thorax- to look for thymoma
Tensilon test with edrophonium
332
What is tensilon test
Used if diagnostic uncertainty for MG
Give IV edrophonium which blocks acetylcholinesterase- if have MG will temporarily relieve weakness
333
What happens to reflexes in LEMS
Reduced/absent
If exercise can improve
334
Management of LEMS
Immunosuppression- steroids, azathioprine
335
Serious causes of tremor to rule out
Parkinson’s disease
Multiple sclerosis
Huntington’s chorea
Hyperthyroidism
Fever
Dopamine antagonists (e.g., antipsychotics)
336
Huntingtons inheritance details
AD
Anticipation as gets worse in future younger generations with earlier presentation
337
Hungtingtons features
Psych- depression and dementia first presentation
Then develop chorea, muscle rigidity, dysarthria, eye movement disorders and dysphagia
338
Investigation for huntingtons
Genetic testing
339
How manage chorea in huntingtons
Tetrabenzine
340
Management of parkinsons
First line depends if motor symptoms affecting daily life, if so then Levodopa
If not then choose between levodopa, dopamine agonist or MOA-B
341
Drug options for parkinsons
Levodopa
Dopamine agonists- ropinirole, cabergoline, bromocriptine
MAO-B inhibitors- raseligine, seligine
COMT inhibitors
342
What needs to be given with levodopa
Peripheral decarboxylase inhibitor (e.g., carbidopa and benserazide)
343
What is problem of leveodopa
Dyskinesia common
- athetosis
- acute dystonia
- chorea
Less effective over time
344
Main side effects of dopamine agonists
Impulse disorders
Pulmonary fibrosis
345
What are COMT inhibitors
Inhibit catechol-o-methyltransferase (COMT). The COMT enzyme metabolises levodopa in the brain. Entacapone is taken with levodopa (and a decarboxylase inhibitor) to slow the breakdown of the levodopa in the brain. It extends the effective duration of the levodopa
346
Principles of parkinsons management
Levodopa is the best treatment so only use if severe symptoms initially or if not that bad then want to delay its use as very severe SEs and becomes less effective
347
In controlled hyperventilation for raised ICP what attempting to do
Reduce Co2 leading to vasoconstriction and reduced ICP
348
If is 4th nerve palsy and at rest is issue where will eye be positioned
Deviated laterally upwards
349
Where do nerve roots leave spine in relation to the vertebra
Above except C8 which comes out below
350
What happens in conduction aphasia
Link between wernickes and brocas is affected
Arcuate fasiculus
351
Name for area of brain connecting brocas and wernickes
Arcuate fasiculus
352
Features of conductive aphasia
Speech fluent
Comprehension fine
Word finding difficulty
Hard to make repetitions
353
In aphasia what are causes of fluent speech
Receptive
Conductive
Determined by if comprehension impaired
354
In aphasia what are causes of non-fluent speech
Expressive
Global
Determined by if comprehension impaired
355
Difference in anatomy pseudobulbar vs bulbar palsy
Bulbar= LMN includes brainstem nuclei and cranial nerves
Pseudobulbar= UMN from lesions to corticobulbar tract in cortex
356
Difference in signs between pseudobulbar and bulbar palsy
Bulbar- LMN signs so fasiculations and atropy of tongue and pharyngeal muscles, absent or reduced jaw jerk and gag reflex
Pseudobulbar- UMN so spasticity of tongue, increased gag reflex
357
Which cranial nerves affected in pseudobulbar and bulbar palsy
5,7,10,11,12
358
Causes of bulbar vs pseudobulbar palsy
Bulbar- MND, GBS
Pseudobulbar- strokes, MS, tumours in high brainstem
