Neurology Flashcards

Question

What are cluster headaches?

Answer 1

Severe unilateral headaches often periorbital that come in clusters of attack

Answer 2

A 0-50 year old male smoker. Attacks can be triggered by alcohol, strong smells and exercise

Answer 3

3-4 attacks a fay for weeks or months followed by a pain free period Attacks can last for 15 minuets to 3 hours

Answer 4

- Severe intolerable pain - Unilateral - Red swollen watering eye - Pupil constriction - Eyelid dropping - Nasal discharge - Facial swelling

Answer 5

- Triptans - High flow oxygen

Answer 6

- Verapamil - Lithium - Prednisolone

Answer 7

- Female - 50-60 - Increases with age - Unilateral - MS

Answer 8

Normally due to compression of the trigeminal nerve by a vascular loop often superior cerebellar artery

Answer 9

- Light touch - Washing - Shaving - Talking - Cold weather

Answer 10

Electric Shock Pain that lasts for seconds to minutes across the face 90% unilateral 10% bilateral

Answer 11

Clinical Dx 3 or more attacks with characteristic unilateral facial pain and symptoms MRI- exclude secondary causes/other pathology

Answer 12

- First line: carbamazepine - Second line: microvascular decompression

Answer 13

A benign tumour of the Schwann cells surrounding the auditory nerve that innervates the inner ear

Answer 14

Unilateral **Bilateral acoustic neuromas are almost always due to neurofibromatosis type II**

Answer 15

40-60 year old patient with gradual onset of: - Unilateral sensorineural hearing loss - Unilateral tinnitus - Dizziness - A sensation of **fullness** in the ear Can also be associated with a facial nerve palsy

Answer 16

Conservative management with monitoring may be used if there are no symptoms or treatment is inappropriate Surgery to remove the tumour (partial or total removal) Radiotherapy to reduce the growth

Answer 17

Audiometry Heating will be more affected with loud sounds

Answer 18

- Anterior tract is responsible for crude touch/or pressure - Lateral tract is responsible for pain and temperature

Answer 19

- These pathways decussate within the spinal cord and travel up to the brain So the lesion of the spinal cord will cause a of pain, crude touch, sensation As nerve entering the Anterior lateral pathways tend to travel up 1 or 2 vertebral levels before Decussating Spinothalamic and Dorsal Column medial lemniscal pathway synapses in the ventral posterio-lateral division (VPL) of the nucleus of thalamus.

Answer 20

- Fine touch and tactile sensation, vibration and proprioception - Signals from lower limbs travel up ** fasciculus gracillis** Signals from the upper limb (above T6) tend to travel in the **Fasciculus Cuneatus** *graciLis = L for Leg of Lower Limb*

Answer 21

- Afferent signals are carried along first order neurons to and up the dorsal columns then synapse in the medulla - 2nd order neurones **decussate at the medulla** and travel to the thalamus where they synapse again - 3rd order neurones the order neurones then travel through the internal capsule to the somatosensory cortex in the Parietal mode (postcentral gyrus) THESE TRACTS RUN IPSILATERALLY THROUGH THE SPINAL CORD AND DECUSSATE IN THE MEDULLA OF THE BRAINSTEM = so damage to spinal cord here would lead to loss of Ipsilateral fine touch, tactile sensation, proprioception etc.

Answer 22

Carry brain signals for voluntary movemnts

Answer 23

After originating from the cortex, the neurones converge, and descend through the internal capsule - this is particularly susceptible to compression from haemorrhagic bleeds The fibres within the lateral corticospinal tract decussate The anterior corticospinal tract remains ipsilateral, descending into the spinal cord. From the ventral horn, the lower motor neurones go on to supply the muscles of the body.

Answer 24

Corticospinal damage - UPPER MOTOR NEURONE SIGN, AS SPINAL NERVES ARE UMN Trauma MS Tumour/growth Vascular supply of the spinal cord/spinal cord stroke?? - ANTERIOR SPINAL ARTERY STROKE INFARCTS CAN AFFECT TRACTS, ---> can cause back pain as spine has pain receptors Acute spinal chord and strokes can cause lower MN signs (spinal shock) **Syringomyelia** - affects CRTS and STHAM - think this if see **cape like distribution** of weakness

Answer 25

It presents as a **unilateral lower motor neurone** facial nerve palsy. The majority of patients fully recover over several week but recovery may take up to 12 moths

Answer 26

prednisolone as treatment, either: 50mg for 10 days 60mg for 5 days followed by a 5-day reducing regime of 10mg a day Patients also require lubricating eye drops

Answer 27

A pus-filled pocket of infected material in the brain

Answer 28

Streptococcus pyogenes/Strep milleri Staph Aureus Klebsiella pneumoniae, Neisseria meningitides

Answer 29

Aspergillus fumigates, Candida albicans

Answer 30

Toxoplasma gondii,

Answer 31

Fever Headache Changes to mental state Focal neurological deficits Gradual mal seizures Nausea Vomiting Neck stifness

Answer 32

suddenly worsening headache, followed by emerging signs of meningism

Answer 33

FBC ESR and CRP raised Blood culture MRI CT scan: appears as a radiolucent space-occupying lesion

Answer 34

Vancomycin+ metronidazole+ Ceftriaxone drain intracranial collection administer effective antibiotic therapy (early treatment is essential) Steroids

Answer 35

Lung cancer, 48% Breast cancer, 15% Genitourinary tract cancers, 11% Osteosarcoma, 10% Melanoma, 9%

Answer 36

Refers to signs and symptoms linked to the impairment of the glossopharyngeal nerve (CN IX), the vagus nerve (CN X), the accessory nerve (CN XI), and the hypoglossal nerve (CN XII).

Answer 37

MND GBS Polio Brainstem tumours MG Myotonic dystrophy Toxic: Botulism

Answer 38

- Dysphagia - Chewing difficulty - Dysphonia - Nasal speech - Flaccid paralysis ***The ocular muscles are spared and this differentiates it from myasthenia gravis.***

Answer 39

electromagnetic articulography (EMA) electropalatography (EPG) pressure sensing EPG routine bloods, brain/brainstem imaging, electromyography

Answer 40

PSEUDO – affects the upper motor neurones BULBAR – affects the lower motor neurones (of CN 9,10,11,12) In contrast, pseudobulbar palsy is a clinical syndrome similar to bulbar palsy but in which the damage is located in upper motor neurons of the corticobulbar tracts in the mid-pons (i.e., in the cranial nerves IX-XII), that is the nerve cells coming down from the cerebral cortex innervating the motor nuclei in the medulla. This is usually caused by stroke.

Answer 41

D Dysdiadochokinesia A Ataxia (gait and posture) N Nystagmus I Intention tremor S Slurred, staccato speech H Hypotonia/heel-shin test

Answer 42

A neurological sign consisting of lack of voluntary coordination of muscle movements that can include gait abnormalities, speech changes and abnormalities in eye movements

Answer 43

- Cerebellar problems - Issues with proprioception

Answer 44

If they can walk normally with their eyes open but bad with their eyes closed then it is a proprioception problem If the problem is there all the time then it is a cerebellar cause

Answer 45

Wide based gait Falls Cannot walk hell-to-toe Often worse in the dark or with eyes closed Gait abnormalities nystagmus/ intention tremors Heart problems Decreased tone/reflexes

Answer 46

MS Posterior fossa tumour Alcohol Direct injury **Gluten ataxia** autoimmunity to purkinje cells or other neural cells CNS vasculitis, multiple sclerosis, infection, bleeding, infarction, tumors, direct injury, toxins (e.g., alcohol), genetic disorders and neurodegenerative diseases

Answer 47

Deficit is Ipsilateral If they are ataxic on the right, the problem is with the right side of the cerebellum) - ***UNLIKE IN CEREBAL LESIONS***

Answer 48

Sensory neuropathies- Low B12 Inner ear problems- affecting the vestibular system

Answer 49

Genetic, progressive, neurogenerative movement disorder which typically presents at age 10-15 years - Autosomal recessive on chromosome 9

Answer 50

It can lead to peripheral neuropathy, due to the atrophy of the dorsal root ganglia and thinning of the dorsal roots

Answer 51

* FBC, U&E, extended LFT’s * HbA1c, B12, folate, TSH * ESR, CRP * gluten related serology* (can only be requested in Sheffield)

Answer 52

- Permanent neurological problems resulting from damage to the brain around the time of birth - It is not a progressive conditions however problems may change over time during growth and development

Answer 53

Antenatal: Maternal infections Trauma during pregnancy Perinatal: Birth asphyxia Pre-term birth Postnatal: Meningitis Severe neonatal jaundice Head injury

Answer 54

Increased tone and reduced function resulting from damage to upper motor neurones

Answer 55

- Problems controlling muscle tone with **hypertonia and hypotonia** - It causes **athetoid movements** Twisting, turning, squirming, twitching, jerking, repeated motions, tremors, poor posture, unsteadiness, and grimacing - It also causes **oro-motor** problems Due to damage of the **BASAL GANGLIA**

Answer 56

Ataxic: problems with coordinated movement resulting from damage to the cerebellum Mixed: a mix of spastic, Dyskinetic and/or ataxic features

Answer 57

- Failure to meet milestones - Increased or decreased tone - **Hand preference below 18 months** - Problems with coordination - Feeding or swallowing problems - Learning difficulties

Answer 58

Monoplegia: one limb affected Hemiplegia: one side of the body affected Diplegia: four limbs are affects, but mostly the legs Quadriplegia: four limbs are affected more severely, often with seizures, speech disturbance and other impairments

Answer 59

- Hemiplegic gait: it is caused by increased muscle tone and spasticity in the legs - The leg will be extended with plantar flexion of the feet and toes - This means they have to swing the leg around in a large semicircle when moving their leg from behind them to in front. There is not enough space to swing the extended leg in a straight line below them.

Answer 60

Learning disability Epilepsy Kyphoscoliosis Muscle contractures Hearing and visual impairment Gastro-oesophageal reflux

Answer 61

Physiotherapy is used to stretch and strengthen muscles, maximise function and prevent muscle contractures. Occupational therapy is used to help patients manage their everyday activities, such as getting dressed and using the bathroom. That can involve techniques to perform tasks despite disability. They can also make adaptations and supply equipment, such as rails for assistance or fitting a hoist for a patient who is entirely wheelchair bound. Speech and language therapy can help with speech and swallowing. When swallowing difficultly prevents them meeting their nutritional requirements they may require an NG tube or PEG tube to be fitted. Dieticians can help ensure they meet nutritional requirements. Some children may require PEG feeding through a port on their abdomen that gives direct access to the stomach. **Orthopaedic surgeons can perform procedures to release contractures or lengthen tendons (tenotomy).**

Answer 62

Muscle relaxants (e.g. baclofen) for muscle spasticity and contractures and Botox Anti-epileptic drugs for seizures Glycopyrronium bromide for excessive drooling

Answer 63

A complex, chronic medical condition affecting multiple body systems and of unknown cause which has many different presentations Known as myalgic encephalomyelitis

Answer 64

- 50-80% of people start suddenly with a flu-like illness - Often found after infection - Strong genetic disposition - Life stressors

Answer 65

Onset is usually abrupt, often following a stressful event viral-like illness with swollen lymph nodes, extreme fatigue, fever, and upper respiratory symptoms Debilitating fatigue Post-exertional malaise Unrefreshing sleep or sleep disturbance ‘Brain fog’ Generalized pain Significantly reduced ability to engage in occupational, educational, social or personal activities

Answer 66

The diagnosis of CFS is made by the characteristic history combined with a normal physical examination and normal laboratory test results normal FBC, U+Es, Creatine, ESR, TFTs

Answer 67

Lifestyle advice - pace yourself, rest as needed, maintain health diet, work adjustments CBT No medicine treatment

Answer 68

peripheral nerve damage as a result of diabetes mellitus Commonly results in weakness; sensory symptoms such as numbness, tingling, or pain; or autonomic changes such as urinary symptoms. These changes are thought to result from a microvascular injury involving small blood vessels that supply nerves (vasa nervorum).

Answer 69

- A fine tremor affecting all the voluntary muscles it is most common in the hands - Can also affect the head, jaw and vocal cords

Answer 70

- Fine tremor - Symmetrical - More prominent with **voluntary movement** - Worse when tired, stressed or after caffeine - Improved by alcohol - Absent during sleep

Answer 71

Parkinson’s disease Multiple sclerosis Huntington’s chorea Hyperthyroidism Fever Dopamine antagonists

Answer 72

Propranolol (a non-selective beta blocker) Primidone (a barbiturate anti-epileptic medication)

Answer 73

A neurodegenerative disorder characterised by the loss of dopaminergic neurons within the **substantia nigra pars compacta** of the basal ganglia

Answer 74

Age Gender: more common in men Family history

Answer 75

- There is a progressive loss of dopamine-producing neurons meaning there is a reduction in the amount produced - This leads to a reduction in action of the **direct pathway** and an increase in the **antagonistic indirect pathway** which restricts movements - This leads to the symptoms of **bradykinesia and rigidity** - - There is also formation of protein clumps **Lewy bodies**

Answer 76

- Bradykinesia - Tremor - Rigidity Symptoms usually start unilateral and then become bilateral later in the disease course

Answer 77

- Incontinence - Dementia - Falls - Symmetry Can be a sign of normal pressure hydrocephalus

Answer 78

- Small handwriting - Shuffling gait - Difficulty initiating movement - Difficulty turning around when standing - Reduced facial movements and expressions

Answer 79

- Unilateral **resting tremor** - Described as a pill rolling tremor - Worse when resting and distracted using other hand Frequency of 4-6 times a second

Answer 80

- If you take their hand and passively flex and extend their arm at the elbow you will feel tension in their arm that gives way to movement in small increments (little jerks) - Described as **cogwheel**

Answer 81

- Depression - Sleep disturbance - Loss of smell - Postural instability - Cognitive impairment

Answer 82

- PD= asymmetrical BET= symmetrical - PD= frequency= 4-6 BET= 5-8 - PD= worse at rest BET= better at rest - PD= improves with intentional movement BET= worse - PD= no change with alcohol/worse BET= better with alcohol

Answer 83

a clinical diagnosis that showed be suspected in a patient with **bradykinesia** and at leas tone of: - Tremor - Rigidity - Postural instability

Answer 84

Motor symptoms not affecting quality of life: A choice of one of the following: **Dopamine agonist** (non-ergot derived) - Pramipexole, ropinirole **Monoamine oxidase B inhibitor** (MOA-B) - Selegiline, rasagiline - Stop breakdown of circulating dopamine Motor symptoms affecting the quality of life: - Synthetic dopamine **levodopa** given with a drug that stops it being broken down - **Peripheral decarboxylase inhibitors** Co-benyldopa (levodopa and benserazide) Co-careldopa (levodopa and carbidopa)

Answer 85

An **Autosomal dominant** condition that is neurodegenerative and causes a deterioration in the nervous system

Answer 86

- It is a **trinucleotide repeat disorder** - There is a repeat of CAG which codes for glutamine **36 times in a row** so patients have 6 glutamine in a row on the Huntington protein - These mutated proteins aggregate within neuronal cells of the caudate. This leads to decreased ACh and GABA synthesis - This leads to an increase in **dopamine production**

Answer 87

- A feature of trinucleotide repeat disorders. When coping the HTT gene DNA polymerase can lose track of which CAG it's on and add an extra CAG. - This leads to successive generations having more repeats in the gene resulting in: - Early age of onset - Increased severity of the disease

Answer 88

Patients asymptomatic until 30-50 - Begin with cognitive, psychiatric or mood problems - Chorea - Eye movement disorders - Dysarthria: speech difficulties - Dysphagia: swallowing difficulties - Dementia

Answer 89

- Life expectancy is 15-20 years after the onset of symptoms - Antipsychotics (e.g. olanzapine) - Benzodiazepines (e.g. diazepam) - Dopamine-depleting agents (e.g. tetrabenazine)

Answer 90

A vasculitis affecting the medium and large arteries it is the most common cause of systemic vasculitis It usually affects branches of the carotid artery

Answer 91

- Age usually over 50 - Female - Caucasians - **Polymyalgia rheumatica** associated in 50% of cases

Answer 92

It is a granulomatous vasculitis. Arteries become inflamed and thickened and there is a narrowed lumen which prevents blood flow Cerebral arteries are affected: **Superficial temporal**: headache and scalp tenderness **Mandibular**: Jaw claudication **Ophthalmic artery**: visual loss due to retinal ischaemia

Answer 93

- Superficial temporal artery tenderness - Absent temporal pulse - Reduced visual activity

Answer 94

- Main symptom is headache that us unilateral and around forehead and temple. - Irreversible painless complete sight loss - Jaw claudication - Scalp tenderness may be noticed when brushing hair

Answer 95

- **Fever** - **Muscle aches** - **Fatigue** - **Weight loss** - **Loss of appetite** - **Peripheral oedema**

Answer 96

- ESR a value of greater than 50 - A **temporal artery biopsy** is gold standard and will show **multinucleated giant cells** negative results don't rule out as there can be **skip lesions**

Answer 97

- Corticosteroids 40-60mg IV methylprednisolone - Oral aspirin to prevent ischaemic cranial complications

Answer 98

- Aortic aneurysms - Glucocorticoid toxicity - Vision loss - Cerebrovascular accident

Answer 99

Once the diagnosis is confirmed they will need to continue high dose steroids (40-60mg) until the symptoms have resolved. They then need to slowly wean off the steroids. This can take several years. This is a similar process to managing polymyalgia rheumatica.

Answer 100

- It is a autoimmune, rapidly progressing demyelinating condition of the peripheral nervous system

Answer 101

- Male - Age - Malignancies - Vaccines - Infecitons

Answer 102

- Campylobacter jejuni (most common) - Cytomegalovirus - EBV

Answer 103

- A pathogenic antigen resembles myelin gangliosides in the peripheral nervous system - The immune system targets the antigen and attacks the myelin sheath of sensory and motor neurones - it occurs in patches along the length of the axon so is called segmental demyelination

Answer 104

- Anti-ganglioside antibodies (anti-GMI)

Answer 105

Symptoms usually appear within 4 weeks of a preceding infection - Symmetrical ascending weakness - Reduced reflexes - Loss of sensation and pain - Cranial nerve involvement such as facial nerve weakness - Autonomic features (sweating, raised pulse) - Struggling to breathe

Answer 106

A clinical diagnosis that is evidenced by progressive weakness and hyporeflexia in the weaker limbs. The **Brighton criteria** is used for diagnosis.

Answer 107

- Myasthenia gravis - Transverse myelitis - Polymyositis

Answer 108

- IV immunoglobulins IV IG - Plasma exchange (alternative to IV IG) - **Venous thromboembolism prophylaxis (PE is the leading cause of death)**

Answer 109

80% will fully recover 15% will be left with some neurological disability 5% will die

Answer 110

also known as herpes zoster virus, shingles is a disease which triggers a painful skin rash in a dermatomal distribution

Answer 111

Human herpes virus-3 A primary infection usually occurs in childhood, producing chickenpox After that the virus lies dormant in the sensory nervous system and is prone to reactivation in patients over 50 years old and is associate with immunosuppressive illness, or psychological/physical trauma

Answer 112

An infectious disease caused by members of the plasmodium family of **protozoan parasites**

Answer 113

- The bite from the female anopheles mosquitoes

Answer 114

Plasmodium falciparum

Answer 115

Plasmodium vivax Plasmodium ovale Plasmodium malariae Plasmodium knowlesi

Answer 116

P. vivax and P. ovale For up to four years

Answer 117

The parasite lies dormant in the mosquitos gut producing sporozoites When someone is bitten by mosquito these are injected into blood sporozoites travel to the liver of the newly infected person They mature in the liver into merozoites which infect RBCs causing them to rupture releasing more into the blood stream causing haemolytic anaemia For P. vivax and P. ovale, this rupture and release of merozoites occurs every 48 hours, causing a fever spike every other day. A fever every 48 hours is referred to as tertian malaria. P. falciparum has more frequent (“subtertian“) or irregular fever spikes, and P. malariae has spikes every 72 hours (“quartan“).

Answer 118

Malaria should be suspected in someone that has travelled to an area where malaria is present. The incubation period is usually 1-4 weeks after exposure, although it can lie dormant for years. Many of the symptoms are non-specific: - Fever sweats and rigors - Fatigue - Myalgia - Headache - Nasuea - Vomiting

Answer 119

- Pallor due to anaemia - Hepatosplenomegaly - Jaundice

Answer 120

- Made using a malaria blood film Three negative samples taken over three consecutive days are required to exclude malaria due to the parasites being released from red blood cells into the blood every 48-72 hours

Answer 121

Artemether with lumefantrine (Riamet) is the usual first choice Quinine plus doxycycline Quinine plus clindamycin

Answer 122

Artesunate is the usual first choice (haemolysis is a common side effect) Quinine dihydrochloride

Answer 123

Cerebral malaria Seizures Reduced consciousness Acute kidney injury Pulmonary oedema Disseminated intravascular coagulopathy (DIC) Severe haemolytic anaemia Multi-organ failure and death

Answer 124

Proguanil with atovaquone (Malarone) Doxycycline Mefloquine (risk of psychiatric side effects) Chloroquine with proguanil (less often used due to high resistance)

Answer 125

A long term inner ear disorder that causes recurrent attacks of vertigo

Answer 126

e excessive build up of endolymph in the labyrinth of the inner ear, causing a higher pressure than normal and disrupting the sensory signals. This increased pressure of the endolymph is called endolymphatic hydrops.

Answer 127

- Hearing loss - Vertigo - Tinnitus It is sensorineural hearing loss, generally unilateral and affects low frequencies first.

Answer 128

A sensation of fullness in the ear Unexplained falls (“drop attacks”) without loss of consciousness Imbalance, which can persist after episodes of vertigo resolve Usually presents in 40-50 year olds There may also be spontaneous nystagmus during an attack

Answer 129

Managing symptoms during an acute attack Prophylactic medication to reduce the frequency of attacks

Answer 130

Prochlorperazine Antihistamines

Answer 131

Betahistine

Answer 132

A progressive neurodegenerative disease where both upper and lower motor neurones stop functioning but there is **no effect on sensory neurons**

Answer 133

Amyotrophic lateral sclerosis- **most common 50% of cases** Primary lateral sclerosis (PLS) UMN Progressive muscular atrophy LMN Progressive bulbar palsy

Answer 134

It is an anterior horn cell lesion so LMN signs only **affects distal muscle groups before proximal** In contrast ALS or PLS there is an absence of: - Brisk reflexes - Spasticity - Babinski's sign

Answer 135

UMN + LMN + Cranial Nerve IX, X, XI, XII signs Lower cranial nerve nuclei affected causing dysarthria, dysphagia, nasal regurgitation of fluids, choking

Answer 136

Degenerative condition affecting motor neurons – **mainly the anterior horn cells** There is relentless and UNEXPLAINED destruction of UMN and anterior horn cells in the brain and spinal cord Causes both UMN and LMN dysfunction UMN and LMN affected but no sensory or sphincter loss – distinguishes from MS Never affects eye movements – distinguishable from myasthenia gravis

Answer 137

- Family history - Smoking - Heavy metal - Pesticides - Excessive exercise

Answer 138

Insidious onset of weakness throughout the body Weakness is often first noticed in upper limbs and increasing fatigue when exercising They may complain of clumsiness, dropping things or tripping over and also slurred speech

Answer 139

- Muscle wasting - Reduced tone - Fasciculations - Reduced reflexes

Answer 140

- Increased tone - Brisk reflexes - Rigidity + spasticity - Babinski reflex positive

Answer 141

- Definite: LMN + UMN signs in 3 regions - Probable: LMN + UMN signs in 2 regions - Probable with lab support: LMN + UMN signs in 1 region, or UMN sign in more than 1 region + electromyography (EMG) shows acute denervation in more than 2 limbs

Answer 142

- **Electromyography:** in MND there will be evidence of fibrillation potentials - due to denervation of muscles due to LMN dysfunction - *( EMG is a technique for evaluating and recording the electrical activity produced by skeletal muscles.)* - **Nerve conduction studies:** may show modest reductions in amplitude - **MRI spine:** imaging can help exclude spinal pathology which may mimic MND, such as cervical cord compression and myelopathy - **Lumbar puncture:** to exclude inflammatory causes - **Pulmonary function tests:** patients with MND are at risk of respiratory failure Blood tests e.g. raised Creatinine Kinase (due to muscle destruction),

Answer 143

- **Multiple sclerosis** - **Polyneuropathies** - **Myasthenia gravis** - **Diabetic amyotrophy** - **Guillain-Barre syndrome** - **Spinal cord tumours**

Answer 144

- **Riluzole** prolongs survival by 2-4 months by protecting motor neuron damage form glutamate - **Respiratory support:** patients with reduced FVC can use non-invasive ventilation at home, usually BiPAP; prolongs survival by 7 months - **Supportive treatment:** - **Antispasmodics:** such as baclofen

Answer 145

- Eye movements - Sensory loss

Answer 146

A autoimmune cell-mediated demyelinating disease of the central nervous system

Answer 147

- Vitamin D deficiency - **Family history**: HLA-DR2 is implicated; 30% monozygotic twin concordance - EBV - Smoking - Obesity - Gender (more common in females)

Answer 148

- T-cells get through the blood brain barrier and are activated by myelin. The T-cell then changes the BBB to allow more immune cells in - MS is a **type IV hypersensitivity reaction**. T-cells release cytokines and these recruit more immune cells whilst also damaging the oligodendrocytes - B-cells will make antibodies that will destroy the myelin of the oligodendrocytes. leaving behind areas of **plaque/sclera**

Answer 149

In early disease, re-myelination can occur and symptoms can resolve. In the later stages of the disease, re-myelination is incomplete and symptoms gradually become more permanent. A characteristic feature of MS is that lesions vary in their location over time, meaning that different nerves are affected and symptoms change over time **MS lesions change location over time is that they are “disseminated in time and space”.**

Answer 150

- Relapsing-remitting: - Secondary progressive - Primary progressive - Progressive relapsing - Clinically isolated syndrome

Answer 151

- The most common pattern 85% of cases - Episodic flare-ups separated by periods of remission. There isn't full recovery after flare ups so disability increases over time. 60% will develop secondary within 15 years

Answer 152

Initially, the disease starts with a relapsing-remitting course, but then symptoms get progressively worse with no periods of remission

Answer 153

- Symptoms get progressively worse from disease onset with no periods of remission - Accounts for 10% of cases and is more common in older patients

Answer 154

- One constant attack but there are bouts superimposed during which the disability increases even faster

Answer 155

- This describes the first episode of demyelination and neurological signs and symptoms. MS cannot be diagnosed on one episode as the lesions have not been “disseminated in time and space”. - Patients with clinically isolated syndrome may never have another episode or develop MS. If lesions are seen on MRI scan then they are more likely to progress

Answer 156

Optic neuritis- demyelination of the optic nerve

Answer 157

Central scotoma (an enlarged central blind spot) Pain with eye movement Impaired colour vision Relative afferent pupillary defect- pupil constricts more when light is shined in contralateral eye than when in actual eye

Answer 158

Sarcoidosis Systemic lupus erythematosus Syphilis Measles or mumps Neuromyelitis optica Lyme disease

Answer 159

- Optic neuritis - Eye movement abnormalities- double vision - Focal weakness (incontinence, limb paralysis, Bell's palsy) - Focal sensory symptoms (numbness, pins and needles) - Ataxia

Answer 160

- **Lhermitte’s sign** is an electric shock sensation that travels down the spine and into the limbs when flexing the neck - **Uhthoff's phenomenon**: worsening of symptoms following a rise in temperature, such as a hot bath

Answer 161

MRI of the brain and spine **Active Lesions will take up contrasts, Old ones will not** ==> Can also see Demyelinated Plaques, known as Dawson's Fingers Lumbar puncture with CSF electrophoresis = inflammatory proteins found in the **CSF, not serum** - shows you that there's an inflammatory response in the CNS **eg Oligoclonal IgG bands** = CNS inflammation -

Answer 162

McDonald criteria

Answer 163

2 or more relapses and either: - Objective evidence of two or more lesions - Objective evidence of one and a reasonable history of a previous relapse ‘Objective evidence’ is defined as an abnormality on neurological exam, MRI or visual evoked potentials

Answer 164

- Oral or IV methylprednisolone - Plasma exchange

Answer 165

**Disease-modifying drugs** **Beta-interferon**: decreases the level of inflammatory cytokines - **Monoclonal antibodies** e.g. alemtuzumab (anti-CD52) and natalizumab (anti-α4𝛃1-integrin)

Answer 166

- GU: urinary tract infections due to retention and incontinence - Constipation - Depression - Visual impairment - Mobility impairment - Erectile dysfunction

Answer 167

A rare neurological condition caused by inflammation of the spinal cord. The swelling damages the nerves and can leave permanent scars of lesionr

Answer 168

- 60% of cases are idiopathic - Can be seen in MS and neuromyelitis optica Infections: TB, HIV, HSV, CMV, EBV

Answer 169

Muscle weakness in legs Mobility problems Unusual sensations and numbness Bladder problems Sexual problems back pain A lesion of the thoracic segment (T1–12) will produce upper motor neuron signs in the lower limbs, presenting as a spastic paraparesis. This is the most common location of the lesion, and therefore most individuals will have weakness in the lower limbs Lesions of the lower cervical region (C5–T1) will cause a combination of upper and lower motor neuron signs in the upper limbs, and exclusively upper motor neuron signs in the lower limbs.

Answer 170

A chronic autoimmune disorder of the **post synaptic membrane** at the neuromuscular junction of skeletal muscle

Answer 171

- Symptoms peak in women in 20/30s - Symptoms peak in men 50/60s

Answer 172

- Female 2x as common - Autoimmune: linked to rheumatoid and SLE -**Thymoma or thymic hyperplasia**: 10-15% have a thymoma and 70% have thymic hyperplasia

Answer 173

- Axons of motor nerves are situated across a synapse from the post-synaptic membrane on the muscle cell - The axons release a neurotransmitter from the pre-synaptic membrane - The neurotransmitter is **acetylcholine** which travels across the synapse and attaches to **nicotinic** receptors on the post-synaptic membrane stimulating muscle contraction

Answer 174

Acetylcholine receptor antibodies are found in patients with MG. These antibodies bind to **postsynaptic membrane acetylcholine receptors** blocking them and preventing stimulation by ACh. These antibodies also activate the **complement system** which damages cells further making the problem worse

Answer 175

- **Muscle specific kinase (MuSK)** - **low-density lipoprotein receptor-related protein 4 (LRP4).** They are both proteins that are important for making the acetylcholine receptor. These antibodies lead to inadequate acetylcholine receptors causing MG

Answer 176

The more the receptors are used during muscle activity, the more they become blocked. There is less effective stimulation of the muscle with increased activity. With rest, the receptors are cleared, and the symptoms improve. More movement=more symptoms

Answer 177

Symptoms affect proximal muscles of the limbs and small muscles of the head and neck with: - Difficulty climbing stairs - Extraocular muscle weakness causing double vision - Eyelid weakness causing drooping of the eyelids - Weakness in facial movements - Difficulty swallowing - Fatigue in jaw - Slurred speech

Answer 178

Repeated blinking will exacerbate ptosis Prolonged upward gazing will exacerbate diplopia on further testing Repeated abduction of one arm 20 times will result in unilateral weakness when comparing both sides

Answer 179

AChR antibodies (around 85%) MuSK antibodies (less than 10%) LRP4 antibodies (less than 5%) A CT or MRI of the thymus gland is used to look for a thymoma. The edrophonium test can be helpful where there is doubt about the diagnosis.

Answer 180

Patients are given IV neostigmine. Normally cholinesterase enzymes in the neuromuscular junction break down ACh. As a result, the level of acetylcholine at the neuromuscular junction rises, temporarily relieving the weakness. A positive result suggests a diagnosis of myasthenia gravis.

Answer 181

Pyridostigmine is a cholinesterase inhibitor that prolongs the action of acetylcholine and improves symptoms Immunosuppression (e.g., prednisolone or azathioprine) suppresses the production of antibodies Thymectomy can improve symptoms, even in patients without a thymoma Rituximab (a monoclonal antibody against B cells) is considered where other treatments fail

Answer 182

Myasthenic crisis where there is an acute worsening of symptoms, often triggered by another illness such as a respiratory tract infection. Respiratory muscle weakness can lead to respiratory failure.

Answer 183

Patients may require non-invasive ventilation or mechanical ventilation. Treatment is with IV immunoglobulins and plasmapheresis.

Answer 184

A genetic condition that causes nerve tumours to develop throughout the nervous system These tumours are benign but can cause neurological and structural problems Neurofibromatosis type 1 is more common than neurofibromatosis type 2.

Answer 185

Neurofibromatosis type 1 gene is found on **chromosome 17**. It codes for a protein called neurofibromin, which is a tumour suppressor protein **autosomal dominant pattern**

Answer 186

**CRABBING** C- Cafe-au-lait spots R- Relative with NF1 A- Axillary or inguinal freckling BB- Bony Bony dysplasia, such as Bowing of a long bone or sphenoid wing dysplasia I- Iris hamartomas (Lisch nodules), which are yellow-brown spots on the iris N- Neurofibromas G- Glioma of the optic pathway

Answer 187

Malignant peripheral nerve sheath tumours Gastrointestinal stromal tumours

Answer 188

A build up of CSF in the brain and spinal cord. It is usually caused by overproduction of CSF or a problem with the drainage or absorption of it

Answer 189

CSF is found in the ventricles and it provides a cushion for brain tissue

Answer 190

The choroid plexus in the ventricles and also the walls of the ventricles

Answer 191

It is absorbed into the venous system by the arachnoid granules in the subarachnoid space

Answer 192

Communicating: where there is communication between the ventricles and the subarachnoid space and the problem and the problem lies outside of the ventricular system **(e.g. due to reduced absorption or blockage of the venous drainage system)**, may also be due to increased CSF production Non-communicating/obstructive - the flow of CSF is obstructed within the ventricles or between the ventricles and the subarachnoid space Normal pressure hydrocephalus is a condition with low-grade hydrocephalus with intermittently raised ICP.

Answer 193

- Most common cause is **aqueduct stenosis** leading to insufficient drainage of CSF - The cerebral aqueduct that connects the third and fourth ventricle is stenosed (narrowed). This blocks the normal flow of CSF out of the third ventricle, causing CSF to build up in the lateral and third ventricles.

Answer 194

Arachnoid cysts can block the outflow of CSF if they are large enough Arnold-Chiari malformation is where the cerebellum herniates downwards through the foramen magnum, blocking the outflow of CSF Chromosomal abnormalities and congenital malformations can cause obstruction to CSF drainage.

Answer 195

Its a form of communicating hydrocephalus in which excess cerebrospinal fluid (CSF) builds up in the ventricles, leading to normal or slightly elevated cerebrospinal fluid pressure.

Answer 196

- Gait abnormality - Urinary incontinence - Dementia

Answer 197

- Neuroimaging: CT will show enlarged ventricles including temporal horns but with normal sulci. - High volume lumbar puncture with removal of 30-50ml of CSF. Gait and cognitive function are typically tested just before LP to asses for signs of symptomatic improvement

Answer 198

The most common type is a ventriculoperitoneal shunt. - It drains CSF to the peritoneal cavity. Adjustable valves allow fine-tuning of CSF drainage - Symptoms improve in 70-90% of patients

Answer 199

A chronic neurological disorder in which the brain loses its normal ability to regulate the sleep-wake cycle

Answer 200

Type 1: Involves cataplexy and patients have low levels or orexin (also known as hypocretin) in the CSF Type 2: does not involves cataplexy

Answer 201

It's a neuropeptide that regulates arousal, wakefulness and appetite It is thought in type 1 narcolepsy that mutations lead to the loss of the hypothalamic hypocretin-containing neurons, via autoimmune destruction.

Answer 202

A bilateral loss of tone in antigravity muscles provoked by emotions such as laughter startle, excitement or anger

Answer 203

- Severity can vary from barely susceptible slackening of the facial muscles, dropping of the jaw or the entire head, to weakness at the knees or collapse onto floor - Slurred speech and visual symptoms - Intact hearing, awareness and consciousness - Variable frequency

Answer 204

- Excessive daytime sleepiness - Disrupted night-time sleep and vivid dreams - Cataplexy - hypnopompic hallucinations - sleep paralysis

Answer 205

Sleep apnoea Sleep deprivation Automatism Sleep paralysis

Answer 206

Scheduled naps - CNS stimulants: modafinil, or Methylphenidate - Antidepressants: (for cataplexy) e.g. clomipramine, SSRIs, venlafaxine

Answer 207

- Damage to the cervical sympathetic chain by removing sympathetic innervation to the head and neck

Answer 208

- Stroke - MS - Swelling - Syringomyelia (cyst in the spinal cord) - Pancoast tumour (apex of the lung) - Trauma - Thyroidectomy - Carotid aneurysm - Carotid artery dissection - Cavernous sinus thrombosis - Cluster headache

Answer 209

- **Ptosis** (eyelid drooping) - **Miosis** (excessive constriction of the pupil) - **Anhidrosis** (Decreased sweating in half of the face)

Answer 210

- Normally light shone into either eye should constrict both pupils equally - In RAPD ( affecting either the retina or optic nerve) light directed into the affected eye will cause only **mild constriction of both pupils** (due to decreased response to light from the afferent defect) - Meanwhile, light in the unaffected eye will cause normal constriction of both pupils (due to an intact efferent path and an intact consensual pupillary reflex)

Answer 211

MS Glaucoma Severe retinal disease Optic nerve lesion

Answer 212

A consensual pupillary reflex is response of a pupil to light that enters the contralateral (opposite) eye.

Answer 213

- Pupil constriction is mediated via parasympathetic activation - Pupil dilation via sympathetic activation

Answer 214

A fixed dilated pupil

Answer 215

Fixed constricted pupil, as only parasympathetic innervation is received - think in horners syndrome

Answer 216

Any disorder that affects the spinal cord Can be caused by: - Trauma - Degenerative causes - Inflammation - Tumour - Vascular - Infectious diseases

Answer 217

Radiculopathy is the term used to describe pinching of the nerve roots as they exit the spinal cord or cross the intervertebral disc, rather than the compression of the cord itself (myelopathy).

Answer 218

!!The commonest cause of myelopathy is disc-osteophyte cord compression Infectious Diseases: Tuberculosis, HIV-associated myelopathy, or viral infections Degenerative Disorders: Cervical spondylosis (age-related changes in the spine), spinal stenosis (narrowing of the spinal canal), or herniated discs Inflammatory Disorders: multiple sclerosis, transverse myelitis,

Answer 219

Proximal muscle weakness Clumsy hands, struggling with keyboard, texting on mobile etc Also difficulty walking, legs feel 'not my own', 'like lead boots, not doing what I tell them' - *Similar to peripheral neuropathy* Bowel/bladder symptoms and sexual dysfunction

Answer 220

Upper motor neurone signs (Long tract signs) Babinski Clonus Cross-adductors sign Hoffman's sign Loss of fine finger movements - treacle hands

Answer 221

Because the term myelopathy describes a clinical syndrome that can be caused by many pathologies the differential diagnosis of myelopathy is extensive The best way to visualize the spinal cord is magnetic resonance imaging (MRI) CT and xrays

Answer 222

A pinched nerve that refers to a set of conditions in which one or more nerves are affected and do not work properly The problem occurs at or near the root of the nerve shortly after its exit from the spinal cord. But symptoms radiate to other parts of the body innervated by that nerve

Answer 223

Changes in tissue surrounding the nerve roots For example intravertebral disc herniation ( Most commonly at C7 and then C6 level) osteoarthritis, ligamentous hypertrophy, spondylolisthesis Cancer Infections like Shingles, HIV, Lyme Disease Proximal Diabetic neuropathy

Answer 224

99% patients have radiating limb pain, often in the pattern of the dermatome, sharp/shooting in character, - going down limbs

Answer 225

C6 and C7 C6 Thumb up - C6 nerve root - myotone - Biceps (6 letters Middle finger - C7 - mytone - Triceps (7 letters)

Answer 226

L5 and S1 L5: the dorsum or top of foot/big toe and dorsiflexion S1: all the S's: side of foot, sole of foot, small toe area Plantar flexion Ankle jerk

Answer 227

Medications, like nonsteroidal anti-inflammatory drugs, opioid medicines or muscle relaxants, to manage the symptoms Weight loss strategies to reduce pressure on the problem area Physical therapy to strengthen the muscles and prevent further damage Steroid injections to reduce inflammation and relieve pain Surgery to reduce pressure on nerve root

Answer 228

Compression of the spinal cord resulting in UMN signs and symptoms depending on where the compression is It is a medical emergency and can lead to paralysis

Answer 229

Vertebral body neoplasms (most common cause) - **Spinal pathology** - **Disc herniation** - When centre of disc (nucleus pulposus) has moved out through the annulus (outer part of disc) resulting in pressure on nerve root and pain - **Disc prolapse** - When nucleus pulposus moves and presses against the annulus - can cause a bulge in the disc - **Primary spinal cord tumour** e.g. glioma, neurofibroma - **Infection** e.g. epidural abscess - **Haematoma**

Answer 230

- Lung - Breast - Prostate - Kidney - Myeloma - Lymphoma

Answer 231

- **Sensory loss 1-2 cord segments below the level of lesion** - **UMN signs below the level of lesion** - Progressive symmetrical weakness of legs **LMN signs at level of lesion** Bladder sphincter involvement – hesitancy, frequency, painless retention

Answer 232

Hypertonia - an abnormally high level of muscle tone or tension Hyperreflexia - overactive or overresponsive bodily reflexes, twitching Spasticity Positive Babinski sign - extension of large toe when plantar surface of foot is stroked

Answer 233

Hyporeflexia/ areflexia - decreased or absent reflexes Hypotonia/ atonia - loss of muscle tone Flaccid muscle weakness or paralysis Fasciculations – small involuntary muscle twitches, Muscle atrophy

Answer 234

All motor and sensory function lost below the SCI level

Answer 235

This is a late and bad sign signalling a poorer prognosis

Answer 236

**Do not delay investigations** - **MRI:** gold standard; identifies cause and site of compression - **Biopsy/surgical exploration** may be required to identify the nature of any mass - **Screening blood tests**: FBC, ESR, B12, U&E’s, syphilis serology, LFT, PSA - **Chest x-ray:** to check for TB or lung malignancy

Answer 237

Neurosurgery to decompress cord Dexamethasone to reduce inflammation

Answer 238

It's a nerve bundle formed by the lumbar, sacral and coccygeal nerves, as they travel down the spinal canal together to reach their corresponding openings. Distal to level of termination of spinal cord at L1/L2. Cauda equina syndrome caused by damage to the peripheral nerves at the cauda equina

Answer 239

nerves in the cauda equina carry motor innervation for the genitals, both internal and external anal sphincter, detrusor vesicae, and muscles of the leg. They are also responsible for skin sensations in these regions.

Answer 240

Cauda equina syndrome (CES) is a neurosurgical emergency which occurs when the bundle of nerves below the end of the spinal cord are compressed.

Answer 241

Herniation of lumbar disc – most commonly at L4/L5 and L5/S1 Spondylolisthesis – most commonly anterolisthesis (vertebra moves forward) Trauma – car crash, gun shot, bleeding via haematomas Tumours Infection Post-op haematoma

Answer 242

Spondylolisthesis is where one of the bones in your spine, called a vertebra, slips forward most commonly anterolisthesis (vertebra moves forward) Slippage of one vertebra over the one below Nerve root comes out ABOVE the disc therefore root affected will be the one BELOW the disc herniation E.g. L4/L5 herniation 🡪 L5 nerve root compression

Answer 243

***Saddle anaesthesia*** Less bladder and bowel control – increased tone of anal sphincter and muscle wall of bladder Erectile dysfunction (or other sexual dysfunction) Lumbosacral pain Leg weakness – flaccid and areflexic Paraplegia Signs Areflexia Fasciculations Loss of bowel/bladder control Urinary retention **WILL SEE LOWER MOTOR NEURON SIGNS ONLY***

Answer 244

MRI spinal cord (diagnostic) PR exam - feel for any abnormalities, and check anal tone Testing nerve roots/reflexes Knee flexion – test L5-S1 Ankle plantar flexion – test S1-S2 Straight leg raising – L5, S1 Femoral stretch test – L4

Answer 245

Management Refer to neurosurgeon ASAP to relive pressure Surgical decompression High dose dexamethasone Corticosteroids

Answer 246

Spinal cord compression is more likely to be thoracic with neurology in the upper limbs with bladder & bowel changes being a very late sign. Whereas in cauda equina, the lower limbs are classically affected with earlier bladder & bowel dysfunction and saddle anaesthesia.

Answer 247

Anterior spinal artery syndrome (also known as cord) is caused by the ischaemia of the anterior spinal artery This results in loss of function of the anterior two thirds of the spinal cord It is usually the result of a flexion/compression injury

Answer 248

- It affects the descending corticospinal tract and the ascending spinothalamic tract as well as autonomic fibres - This results in loss of motor function, loss of pain and temperature sensation - Also causes hypotension

Answer 249

- Lower limbs more affected - Loss of pain and temperature - Loss of motor function Preserved the DC tract: proprioception and vibratory sensation

Answer 250

Nerve pathology outside of the CNS that affects the peripheral nerves Mononeuropathy: a process affecting a single nerve Polyneuropathy: many nerves involved. Usually describes a symmetrical disease, and it usually begins distally. Can be sensory, motor or mixed.

Answer 251

DAVIDE Diabetes Alcohol Vitamin B12 Infective: GBS Drugs: Isoniazid Every vasculitis **Multiple myeloma**

Answer 252

- Carpal tunnel syndrome - Wrist drop - Claw hand - Foot drop

Answer 253

A collection of symptoms caused by the compression of the **median nerve** in the carpal tunnel

Answer 254

- Mostly idiopathic HODPARAR - Hypothyroidism - Obesity - Diabetes - Pregnancy - Acromegaly - Rheumatoid Arthritis - Amyloidosis - Repetitive Strain Injury Females due to narrower wrists so more likely to have compression Over 30s *exam tip - if you see a patient with bilateral carpal tunnel syndrome, look for features that might suggest underlying rheumatoid arthritis, diabetes, acromegaly or hypothyroidism.*

Answer 255

Weakness of thumb movements Weakness of grip strength Difficulty with fine movements involving the thumb Wasting of the thenar muscles

Answer 256

Thenar muscles Flexor pollicis brevis Abductor pollicis Opponens Pollicis

Answer 257

Phalen Test Tinel Test Nerve conduction studies: small electrical current is applied by an electrode (nerve stimulator) to the median nerve on one side of the carpal tunnel - Recording electrodes over the median nerve on the other side of the carpal tunnel record the electrical current that reaches them

Answer 258

Phalen’s test - flex the wrists are far as possible and hold that position for a minute, this results in numbness in the areas of the hand innervated by the median nerve in people with carpal tunnel syndrome

Answer 259

tap the **transverse carpal ligament**, this reproduces the symptoms of tingling or feelings of pins and needles in areas of the hand served by the median nerve *TOM TIP: I think of tapping a tin can (Tinel’s) to remember the difference between Phalen’s and Tinel’s test.*

Answer 260

Rest and altered activities Wrist splints that maintain a neutral position of the wrist can be worn at night (for a minimum of 4 weeks) Steroid injections Surgery

Answer 261

Damage to the radial nerve Compression of the radial nerve at the humerus

Answer 262

Claw hand (4th/5th fingers claw up)

Answer 263

Splint Analgesia

Answer 264

L4-S1 (Branch off the Sciatic nerve)

Answer 265

Common peroneal nerve palsy!1 muscle or spinal cord trauma Toxins More commonly: Diseases, such as: Stroke, ALS,, Charcot Marie Tooth, MS, Cerebral Palsy, GBS

Answer 266

supplies motor and sensation to deltoid Check sensation to the deltoid with a neuro tip if they've broken/dislocated their shoulder, for axillary nerve damage

Answer 267

A type of peripheral neuropathy where there is damage to several individual nerves due to systemic causes.

Answer 268

Systemic necrotizing vasculitis * Polyarteritis nodosa * ANCA-associated (Churg–Strauss syndrome, Granulomatosis with polyangiitis) Vasculitis associated with connective tissue disorders * Rheumatoid arthritis. * Sjögren’s syndrome. * SLE. Hypersensitivity vasculitis * Drug-induced vasculitis. * Malignancy. Infections * Bacterial: Lyme disease, TB, syphilis. * Viral: HIV, herpes zoster, CMV

Answer 269

Autoimmune disorders where there is inflammation in the muscles. Polymyositis refers to chronic inflammation of the muscles. Dermatomyositis is a connective tissue disorder where there is chronic inflammation of the skin and muscles Leads to proximal muscle weakness and muscle pain

Answer 270

The creatine kinase blood test. It is an enzyme that is found inside muscle. Inflammation of the muscles can lead to the release of it. **It can also be raised in Acute kidney injury, Myocardial infarction, Statins Strenuous exercise**

Answer 271

Anti-Jo-1 antibodies: polymyositis (but often present in dermatomyositis)

Answer 272

Patients should be assessed for underlying cancer Corticosteroids are first line Then immunosuppressants Then infliximab - *(targets TNF-a )*

Answer 273

A neurological emergency resulting from thiamine deficiency

Answer 274

Hypothalamic damage & cerebral atrophy due to thiamine (vitamin B1) deficiency (eg in alcoholics). Wernicke's encephalopathy is the acute, reversible stage of the syndrome, and if left untreated it can later lead to Korsakoff syndrome, which is chronic and irreversible.

Answer 275

- **Alcohol abuse** - **Malnutrition** - **Anorexia** - **Malabsorption due to stomach cancer and IBD** - **Prolonged vomiting e.g. due to chemotherapy, hyperemesis**

Answer 276

- Thiamine deficiency impairs glucose metabolism and this leads to a decrease in cellular energy - The brain is particularly vulnerable to impaired glucose metabolism since it utilises so much energy

Answer 277

1. Confusion 2. Ataxia 3. *ophthalmoplegia** (nystagmus, lateral rectus or conjugate gaze palsies).

Answer 278

Mainly targets the limbic system, causing severe memory impairment: - **Anterograde amnesia:** inability to create new memories - **Retrograde amnesia:** inability to recall previous memories. - **Confabulation:** creating stories to fill in the gaps in their memory which they believe to be true. - **Behavioural changes**

Answer 279

- Give thiamine - Oral supplementation until no loner at risk - Correct magnesium deficiency - If there is coexisting hypoglycaemia, correct it

Answer 280

It is important to stabilise thiamine levels because without thiamine pyrophosphate, **most of the glucose will become lactic acid and that can lead to metabolic acidosis.** (often the case in this group of patients),

Answer 281

- Diagnosis is typically made **based on clinical presentation** - **Bloods including LFTs**: measure thiamine levels, measure blood alcohol levels, liver function may be deranged in alcoholism

Answer 282

Eyes: Eye-opening spontaneously 4 points Eye-opening to sound 3 points Eye-opening to pain 2 points No response 1 point Verbal response (V) Orientated 5 points Confused conversation 4 points Inappropriate words 3 points Incomprehensible sounds 2 points No response 1 point Motor response (M) - You should score the patient based on the highest scoring response you were able to elicit in any single limb Obeys command 6 points Localises to pain 5 points Withdraws to pain *(normal flexion)* 4 points Abnormal Flexion *(decorticate posture 3 points)* Abnormal extension *(decerebrate posture 2 points)* No response 1 point