Neurology Flashcards
1
Q
What is the most common CNS disorder of the young (80:100000)?
A
Multiple sclerosis
2
Q
what is MS?
A
Inflammation causing changes to the myelin sheath around the nerve axons connecting different parts of the brain
3
Q
Is MS a demyelinating or myelinating condition?
A
Demyelinating
4
Q
What group of individuals are likely to have the most severe onset of MS?
A
Women with 4th decade onset
5
Q
Which individuals have higher incidence of MS?
A
Identical twins and immediate family members
6
Q
The aetiology of MS remains a mystery. Nevertheless, what are the three suspected causes?
A
- Susceptibility acquired during childhood
- Altered host reactions to an infective agent
- Background genetic/immune factors
7
Q
What incidence has lead to the suggestion that lack of sunlight and vitamin D may be a factor involved in the aetiology of MS?
A
Incidence of MS increases the further away from the equator that a person lives
8
Q
What specific effects can MS have on the brain?
A
- fatigue
- cognitive changes
- depression
- dizziness and vertigo
9
Q
What specific effects can MS have on the eyes?
A
- Blurred vision
- temporary blindness
- seeing dark spots
10
Q
What specific effects can MS have on the bowl?
A
- constipation
- diarrhoea
11
Q
What specific effects can MS have on the bladder?
A
- frequent urination
- incontinence
12
Q
What specific effects can MS have on the muscles?
A
- weakness
- stiffness
- spasms
13
Q
How will demyelination appear on an MRI scan?
A
As areas of red (inflammatory change)
14
Q
What is muscle spasticity?
A
Abnormal muscle tightness due to prolonged muscle contraction
15
Q
What is muscle spasticity an indication of?
A
A motor neurone lesion
16
Q
What degenerative change, and in what nerve, can be easily measured? (Common test for assessing MS)
A
The decreased speed of conduction in the optic nerve
17
Q
What is protracted pain?
A
Pain that lasts longer than 3-6 months (chronic pain)
18
Q
What is dysarthria?
A
Difficulty speaking because muscles used for speech are weak
19
Q
What are the symptoms of MS?
A
- muscle weakness
- visual disturbances
- parasthesia
- autonomic dysfunction
- dysarthria
- pain
- balance/hearing loss
20
Q
what are the signs of MS?
A
- muscle weakness
- spasticity
- altered reflexes
- intention tremor
- optic atrophy
- Proprioceptive loss
- loss of touch
21
Q
What is intention tremor?
A
A tremor during a purposeful motor movement,which worsens before reaching the end point
22
Q
what is optic atrophy?
A
Optic nerve shrinkage
23
Q
what are the 4 main investigations for MS?
A
- History and examination
- MRI
- CSF analysis
- Visual evoked potentials
24
Q
What does CSF analysis show if MS is present?
A
- reduced lymphocytes
- increased IgG protein
25
What do visually evoked potentials measure?
“Measures the electrical signal generated at the visual cortex in response to visual stimulation”
26
What would reduced visual evoked potentials suggest?
Optic neuritis
27
what is optic neuritis?
When inflammation damages the optic nerve
28
Is MS curable?
No
29
What are the two types of MS?
1. Replacing and emitting type
2. Primary progressive type
30
What type of MS is characterised by acute exacerbations and periods of respite, where damage builds up with each episode?
Relapsing and emitting type
31
What type of MS is characterised by slow steady progressive deterioration from cumulative neurological damage?
Primary progressive type
32
What is the symptomatic Management for an acute MS attack?
- antibiotics, antispasmodics, analgesia
- physiotherapy and occupational therapy
33
What are the names of three drugs that are effective at slowing down the rate at which new lesions occur, making a significant difference to management of MS?
1. Cladribine
2. Siponomod
3. Ocrelizumab
34
What are the dental considerations of someone who has MS?
- patients may have limited mobility & psychological disorders
- always treat under LA if possible
- orofacial motor and sensory disturbances
- chronic orofacial pain
- enhanced risk of trigeminal neuralgia
35
Why should patients with MS ideally be treated under LA?
There is a suggestion that giving LA hastens the onset of damage within the brain
36
In the dental clinic, what is the most key indicator that a patient may have MS?
Orofacial motor and sensory disturbances
37
What is trigeminal neuralgia?
A type of chronic pain disorder that involves sudden, severe facial pain
38
What condition is characterised by degeneration of the motor nerves in the anterior horn of the corticospinal tracts, in the spinal cord, and the degeneration of bulbar motor nuclei in the brain?
Motor neurone disease (MND)
39
What age range is particularly affected by MND?
Patients aged 30-60 years old
40
What is the usual prognosis of life expectancy for individuals with MND?
Death within 3 years of diagnosis
41
what is the ratio of males to females with MND?
(M) 2.5:1 (F)
42
What are the symptoms of MND, which the patient may notice?
- weakness in the ankle or leg
- slurred speech
- a weak grip
- muscle cramps and twitches
- weight loss
- emotional lability (crying out laughing in inappropriate situations)
43
In MND, what does progressive loss of motor function in the diaphragm lead to?
Impairment of ventilation, which causes hypoxia
44
Which cranial nerves are most likely affected by MND, which can usually result in difficulties swallowing as well as maintaining facial expression?
CN VII- XII
45
What are the two consequences of the progressive loss of function from MND which lead to death?
- ventilation failure (type 2 respiratory failure)
- aspiration pneumonia
46
what medication is suggested to give some individuals with MND 6-9 months life extension?
Riluzole
47
What treatment measurement is often taken for individuals with MND who are at high risk of aspiration?
Stopping the patient taking food by mouth and directing it into the stomach via a PEG tube
48
Why do patients with MND need to control rate of salivation?
As saliva could be aspirated, carrying oral bacteria into the lungs
49
What are the difficulties associated with dental care for patients with MND?
- difficulty to maintain head and neck posture
- realistic treatment planning
- drooling and swallowing difficulties
50
What drugs are sometimes taken to stop excess salivation for individuals with MND?
- Anticholenergics
- sometimes Botox injections into salivary glands
51
What condition is characterised by lack of the neurotransmitter,dopamine, in the substantia nigra of the brain?
Parkinson’s disease
52
what are the three main clinical features of Parkinson’s disease?
1. bradykinesia
2. Rigidity
3. Tremor
53
what is meant by bradykinesia?
Slowness of movement and speed as movements are continued
54
When does tremor usually occur in an individual with Parkinson’s disease. At rest or when active?
At rest
- when patient makes intentional movement, tremor will go away
55
what are the 4 manifestations of Parkinson’s disease?
- impaired gait and falls
- impaired use of upper limbs
- mask-like face
- swallowing problems
56
What is meant by an impaired gait?
When an individuals walking is unsteady and unusual in its pattern
57
What is the first-line drug (dopamine precursor) used for the management of Parkinson’s motor symptoms?
Levodopa
58
What are the 3 forms of dopamine analogues that mimic dopamine in the treatment of Parkinson’s disease? Give examples.
1. Tablets (promipexole, selegiline)
2. Injections (apomorphine)
3. Infusion (duodopa- directly into gut)
59
what is the main negative side effect of taking dopaminergic drugs?
They can lead to impulsive behaviour such as gambling
60
what treatment helps individuals with Parkinson’s disease maintain function at a high level for as long as possible?
Physiotherapy and occupational therapy
61
What are the two potential surgical options for individuals with Parkinson’s disease?
1. Stereotactic surgery
2. Stem cell transplant (new findings- not implicated as major therapy)
62
what is stereotactic surgery?
Deep brain stimulation where there is use of 3D techniques to locate electrodes into part of the brain
63
What are the barriers and difficulties for patients with Parkinson’s disease in receiving dental care?
- difficulty accepting treatment
- access and movement difficulties
- Dry mouth due to anticholenergic drugs
- may be drug interactions as usually on many medications
64
Is it likely that a patient with Parkinson’s disease will not be able to receive intra-oral care from their dentist due to their tremor?
No. This tremor is at rest, when the patient opens their mouth they will loose the tremor and treatment can progress.
65
What is a stroke?
Death of brain tissue due to blockage of blood delivering oxygen to tissues in the brain leading to hypoxia
66
What are the three types of stroke?
1. Ischaemic stroke
2. Haemorrhagic stroke
3. Transient ischaemic attack
67
What happens during a transient ischaemic attack (TIA’s)?
Rapid loss of function but a rapid recovery of function. Within 24 hours the patient will have recovered all neurological issues.
68
What acronym is useful to use when there has been suspected stroke and what does it stand for?
FAST.
F- facial drooping?
A- arm weakness?
S- speech difficulty?
T- time?
69
Why do TIA’s occur?
Thought to occur due to platelet emboli from vessels in the neck. These emboli block the blood flow to the brain tissue causing ischaemia, but are then rapidly removed by the circulation and blood flow is restored before any permanent damage has occurred.
70
How long does it take most people to recover from a TIA?
30 minutes
71
What are the future consequences of a TIA?
Patient at higher risk of a ‘proper’ stroke over 5 years
72
what is an ischaemic stroke?
Blockage cuts off the blood supply to part of the brain causing death to tissue.
73
What is a Haemorrhagic stroke?
Bleeding in and around the brain (usually caused by aneurysm rupture)
74
What type of stroke is most common?
Infarctive/ ischaemic stroke (85%)
75
what is a subarachnoid haemorrhage?
Uncommon type of stroke (5%) caused by bleeding on the surface of the brain.
76
What is the lifetime risk of a stroke?
1 in 6
77
A stroke has increasing incidence with age.
True or false?
True
78
What is the main risk factor for haemorrhagic stroke?
Hypertension
79
If a patient has hypertension, and their diastolic measurement is >120 mm Hg, how many times greater is their risk for stroke compared to a
Patient who has <80mm Hg diastolic measurement?
15 times greater
80
what are the 6 main risk factors for a stroke?
- hypertension
- smoking
- alcohol
- ischaemic heart disease
- atrial fibrillation
- diabetes mellitus
81
how might atrial fibrillation be a risk factor for stroke?
It is associated with emboli from the abnormally contracting atria passing through the ventricle and up into the cerebral circulation, potentially causing ischaemia.
82
What causes an embolic stroke?
Usually a blood clot that forms elsewhere in the body (embolus) and travels through the bloodstream to the brain (e.g. embolism from left side of heart)
83
What is Atheroma of cerebral vessels?
Otherwise known as cerebral atherosclerosis, it is a build up of plaque in blood vessels if the brain (e.g. carotid bifurcation, internal carotid artery, vertebral artery)
84
On a CT scan, how would a Haemorrhagic stroke tend to appear?
As a radio-opaque mass
85
Digital subtraction angiogram can show small buds, what are these known as and why are they a cause for concern?
Berry aneurysms, these can be weak points and rupture leading to bleeding.
86
Which type of radiographic imaging is better at showing inflammatory change and infarctive lesions early after their onset? CT scan or MRI?
MRI
87
what are three less common, but still significant causes of stroke?
1. Venous thrombosis
2. ‘Border zone’ infarction
3. Vasculitis
88
What are three causes of venous thrombosis?
1. Contraceptive pill use
2. Polcytheamia/erythrocytosis
3. Thrombophilia
89
What is polycythemia/erythrocytosis?
Increased red blood cell mass
90
What is thrombophilia?
Abnormal tendency to develop blood clots
91
What are border zone infarctions?
Ischaemic lesions that occur in characteristic locations at the junction between two main arterial territories
92
What are the two main causes of borderzone infarction?
1. Severe hypotension
2. Cardiac arrest
93
What is vasculitis?
A disorder which narrows the blood vessels into the brain and causes limitations of oxygen delivery and therefore stroke
94
What risk factors need to be reduced in order to prevent stroke?
1. Smoking
2. Diabetes control
3. Control of hypertension
95
What group of medications can be used as secondary prevention for stroke? Give three examples of drugs.
Antiplatelets
- aspirin, dipyridamole and clopidogrel
96
What are the two surgical options for prevention of stroke?
1. Carotid endarterectomy
2. preventative neurosurgery
97
What are the indications for carotid endarterectomy?
- severe stenosis
- previous TIA’s
- <85 years of age
98
What is the mortality rate from carotid endarterectomy surgery?
7.5%
99
Is a CT scan good for visualising Haemorrhagic or ischaemic stroke?
Haemorrhagic
100
What type of radiographic imaging is better at visualise early changes of damage in brain that may lead to stroke?
MRI scan
101
what type of radiographic image is best for investigating and visualising the brain circulation?
MR angiography (MRA)
102
When MRA is not available, what type of imaging can be used to looks at blood flow in brain?
Digital subtraction angiography (DSA)
103
What anatomy can be visualised on an MR angiograph?
Blood vessels and and their location in three dimensions
104
What anatomy can be visualised by subtraction angiogram?
Only blood vessels
105
What are the 6 investigations of stroke to assess risk factors?
1. Carotid ultrasound
2. Cardiac ultrasound
3. ECG (arrhythmias)
4. Blood pressure
5. Diabetes screen
6. Thrombophilia screen
106
In what way does a carotid ultrasound investigate the risk factors for stroke?
It looks for atherosclerosis in the carotid artery
107
In what way does a cardiac ultrasound investigate the risk factors for stroke?
Investigates if there is a thrombus forming in the left ventricle
108
In what way does a ECG investigate the risk factors for stroke?
It looks for Cannes such as arrhythmias and typically atrial fibrillation
109
In what two ways can loss of functional brain tissue occur due to stroke?
1. Immediate nerve cell death
2. Nerve cell ischaemia in penumbra around infarction
110
What are the three main complications of a stroke?
1. Motor function loss
2. Sensory loss
3. Cognitive impairment
111
What is phantom limb?
A form of sensory loss where patients experience sensations, pain or otherwise, in a limb that does not exist.
112
In what way can cognitive function be impaired by stroke?
- processing difficulties
- memory impairment
- emotional lability and depression
113
How would you manage stroke in the acute phase?
- Limit damage to penumbra by use of calcium channel blockers
- improve blood flow/oxygenation
- improve glucose level (normoglyceamia)
- prevent future risk by use of medication (e.g. antiplatelet or anticoagulants)
114
How would you manage stroke in the chronic phase?
- nursing and rehabilitation
- reduce future risk
115
How would subarachnoid haemorrhage be managed in the acute phases?
By removal of haematoma
116
What are the three main aspects of nursing and rehabilitation treatment for stroke in the chronic phase?
1. Immobility support
2. Speech and language therapy
3. occupational therapy
117
what are the 6 main dental aspects/considerations of patients who have had a stroke?
1. Impaired mobility & dexterity
2. Communication difficulties
3. Risk of cardiac emergencies
4. Loss of protective reflexes (aspiration, managing saliva)
5. Loss of sensory information
6. Stroke pain (CNS generated pain)
118
What is ‘stroke pain’?
Also known as neuropathic pain, it is a type of pain that occurs when sensation is reduced after stroke. The brain is used to receiving normal sensory inputs, and when it doesn’t, the CNS produces painful sensations itself.
119
What is epilepsy?
A group of conditions which happens because of abnormal discharge of neurones within the brain. These bursts of electrical activity cause seizures and fits.
120
what is GABA and its role?
Important inhibitory neurotransmitter in the CNS, its role is to reduce neuronal excitability throughout the nervous system.
121
What inhibitory neurotransmitter is associated with epilepsy and why?
GABA.
level changes in GABA lead to abnormal cell-cell message propagations so that it takes less stimulation to fire and pass on a message to another cell.
122
What are febrile seizures?
Seizures that largely happen in children and usually when child has a fever.
123
What are the measures that should be taken to cool a child down to prevent a febrile seizure?
- paracetamol
- ibuprofen
- remove clothes
- cool sponging
- cool bath
124
What are the 5 signs and symptoms of a febrile seizure?
1. Fever
2. Face may turn blue or red
3. Eyes rolling upwards
4. Loss of consciousness
5. Muscles and limbs jerk in unnatural movements
125
What are the two forms of epilepsy?
1. Generalised
2. Partial
126
What are the three main types of generalised seizures?
1. Tonic/clonic
2. Absence/petit mal
3. Myoclonic/atonic
127
what are the three types of partial seizure?
1. Simple partial
2. Complex partial
3. Simple sensory
128
What is meant by idiopathic?
Any disease or condition which arises spontaneously or for which the cause is unknown
129
What are the 4 major suggested causes of epilepsy?
1. Idiopathic
2. Trauma
3. CNS disease
4. Social (alcohol, hypoglycaemia, flashing lights)
130
what CNS diseases can trigger epilepsy in susceptible patients?
1. Creutzfeldt-Jakob disease (CJD)
2. Meningitis
3. Encephalitis
131
What is CJD?
A rapidly worsening brain disorder that causes unique changes in brain tissue and affects muscle coordination, thinking and memory.
132
what is meningitis?
Inflammation of the lining around the brain and spinal cord
133
What is encephalitis?
Inflammation of the brain, usually caused by infection.
134
what is generalised epilepsy?
Where there is often a central focus in the brain which spreads the signal to all parts of the cortex, which means that all parts of the body are involved in the seizure
135
what is a partial seizure?
Where the epileptic focus is much closer to one particular part of the cortex in the brain, this will primarily be the area affected- effecting motor,perception and sensation.
136
What is prodromal aura?
Where you start to feel strange and early warning signs start, symptoms of this can be depression or irritability.
137
What are tonic-clonic seizures?
Involves stiffening (tonic) and twitching/jerking (clonic) phases of muscle activity
138
What are associated symptoms of tonic clonic seizure?
- prodromal aura
- loss of consciousness/continence
- initial tonic stiffness
- jerking/twitching
- post-ictal drowsiness
139
Define, the ability to control the bladder.
Continence
140
What is an initial tonic (stiff) reaction?
where all the voluntary muscles in the body contract together, this puts a tremendous strain on the skeleton, particularly on the spine and can lead to damage
141
What is the clonic phase of a seizure?
where there is intermittent contraction and relaxation of the muscles and this is where the patient seems to jerk or spasm
142
What is post-ictal drowsiness?
After seizure patient will remain drowsy until they gradually return to full consciousness
143
What is meant by status epilepticus?
Recurrent seizures
- ‘A seizure that lasts longer than 5 minutes, or having more than 1 seizure within a 5 minute period, without returning to a normal level of consciousness between episodes’
144
What is asphyxia?
When your body doesn’t get enough oxygen to keep you from passing out
145
how would you treat asphyxia?
- use supplemental oxygen through a guedel airway
146
what epilepsy drug can be particularly harmful during pregnancy?
Sodium valproate
147
What are the two main causes of death from tonic/clonic seizures?
1. Asphyxiation
2. Aspiration of gastric contents which leads to acute lung damage
148
Give two examples of epileptogenic drugs (can cause seizures)?
1. Alcohol
2. Some GA agents
149
What are the 5 main precipitators of epilepsy?
1. Withdrawal/poor medication compliance
2. Epileptogenic drugs
3. Fatigue/stress
4. Infection
5. Mesntruation
150
What are absence/petit mal seizures?
Very short lived seizures which most often happen to children
151
What are the common signs of an absence seizure?
- loss of awarenessof surroundings
- eyelashes will flutter
- vacant stare
- Failure to respond to communication
152
What type of partial seizure may move/spread to other motor areas of the brain?
Jacksonian seizure
153
What is a Jacksonian seizure?
Where the patient will start with a small tremor at the extremity of the upper limb and it will progressively move up towards the elbow, shoulder and then to the neck
154
what are complex partial seizures?
when different parts of the brain are affected, which produce connected movements (for example, grimacing and lip smacking). Associated with impairment in consciousness.
155
What is the primary preventative treatment for epilepsy?
Anticonvulsant drugs
156
what are the three most commonly used anticonvulsants for tonic/clonic seizures?
1. Valproate
2. Carbamazepine
3. phenytoin
157
What is the most commonly used anticonvulsant for absence seizures?
Levitiracetam
158
what is the emergency treatment for epilepsy?
- supplemental oxygen to prevent hypoxia
- airway support
- status epilepticus requires benzodiazepines
159
What indications are there for surgery for epilepsy?
- if there is a benign brain tumour, removal of neurological lesions
- if focal seizures which have an identifiable point of origin within brain and are not well controlled by medicine
160
What are the three most important questions to as a patient with epilepsy?
- what type of seizures do you have?
- do you take you medication/has there been a change in medication?
- when did your last three seizures take place?
161
What anticonvulsant can cause gingival hyperplasia?
Phenytoin
162
What anticonvulsant is associated with a bleeding tendency?
Sodium Valproate
163
What is cerebellar ataxia?
a broad‐based stance with truncal instability during walking, causing falls to either side. The steps are irregular, and the feet may be lifted too high.
164
what is intention tremor?
characterized by coarse, low frequency oscillation. Increases in amplitude as the extremity approaches endpoint of deliberate, visually‐guided movement.
165
what os resting tremor? What disease is it frequently seen in and describe?
a tremor not associated with voluntary muscle contraction and occurring in a body part supported against gravity.
Typically seen in Parkinson’s disease as a “pill‐rolling” action of the hand (slow oscillation at wrist with fingers curved into the palm)
166
What is essential tremor?
a tremor occurring during voluntary contraction of the muscles and not associated with any other neurological disorder. Tremor may occur maintaining a posture, moving a limb or in purposeful movement toward a target (i.e. essential tremor is in fact a disorder comprising one or more different tremors)
167
What is festination?
quickening and shortening of normal gait pattern seen in Parkinson’s. Makes patient appear to hurry but is a very inefficient way of moving.
168
what is bradykinesia? Give an example.
slowness of movement. A key feature of Parkinson’s which is responsible for the mask‐like face, loss of arm swing, festination and difficulty initiating and stopping an action (e.g. turning a corner or starting to walk)
169
what is paralysis?
loss of motor control in a part of the body. Sometimes associated with some sensory impairment. It may be flaccid (floppy) or spastic (rigid)
170
What is spasticity?
caused by hypertonia or stiffness of the muscles. A common finding in patients who recover from a stroke. Causes typical features of flexed adducted upper limb and extended lower limb with foot drop. If untreated spasticity can lead to contractures in the limb with resulting fixed deformity.
171
What is automatism? Give examples.
automatic, repetitive, involuntary behaviour e.g. lip smacking, chewing, swallowing, grasping, skin rubbing
172
What is the difference between complex partial seizures and absence seizures, in terms of duration?
Complex partial lasts longer than absence
173
What is the difference between complex partial seizures and absence seizures, in terms of automatisms?
Complex partial seizures have prominent automatisms, whereas absence seizures have subtle automatisms
174
What is the difference between complex partial seizures and absence seizures, in terms of return to consciousness?
Complex Partial is gradual, absence is sudden
175
What is the difference between complex partial seizures and absence seizures, in terms of post-ictal confusion?
Complex partial seizures have post ictal confusion whereas absence do not
