Neurology Flashcards
(241 cards)
1
Q
What is the treatment for trigeminal neuralgia?
A
carbamazepine 100 mg BD and uptitrate
2
Q
Capgras syndrome
A
the delusion that a friend or partner has been replaced by an identical-looking impostor
3
Q
Othello syndrome
A
irrational belief that one’s partner is having an affair with no objective evidence
4
Q
De clerambault syndrome
A
delusional idea that a person whom they consider to be of higher social and/or professional standing is in love with her.
5
Q
Cotard syndrome
A
delusional idea that one is dead.
6
Q
Fregoli syndrome
A
delusional idea that the various people that the patient meets are in fact the same person.
7
Q
Motor neuron disease features
A
-after 40
-asymmetric limb weakness
-lower motor neuron and upper motor neuron signs
-wasting of small hand muscles
-fasciculations
-absence of sensory signs
-no cerebellar
-no external ocular mm
-abdo reflexes preserved
-sphincter dysfunction is late
8
Q
C6 radiculopathy
A
-electric shock-like sensations
-exacerbation on head movement
-decreased sensation on the dorsal aspect of the thumb and index finger
9
Q
C4 radiculopathy
A
-sensory changes over the shoulder
-weakness in shoulder elevation
10
Q
C5 radiculopathy
A
-lateral arm and deltoid region sensory changes
-Weakness in shoulder abduction
11
Q
C7 radiculopathy
A
-sensory changes over the middle finger
-possibly triceps weakness
-pain radiates down the posterior arm to the dorsum of hand.
12
Q
T1 radiculopathy
A
-medial forearm and hand (the ulnar distribution)
-weakness in intrinsic hand muscles
13
Q
Focal seizure treatment
A
first line: lamotrigine or levetiracetam
second line: carbamazepine, oxcarbazepine or zonisamide
14
Q
Absence seizure treatment
A
first line: ethosuximide
second line:
male: sodium valproate
female: lamotrigine or levetiracetam
carbamazepine may exacerbate absence seizures
15
Q
Generalised tonic clonic seizure treatment
A
males: sodium valproate
females: lamotrigine or levetiracetam
girls aged under 10 years and who are unlikely to need treatment when they are old enough to have children or women who are unable to have children may be offered sodium valproate first-line
16
Q
Myoclonus seizure treatment
A
males: sodium valproate
females: levetiracetam
17
Q
Tonic or atomic seizure treatment
A
males: sodium valproate
females: lamotrigine
18
Q
Essential tremor features and management
A
-AD
Features
postural tremor: worse if arms outstretched
improved by alcohol and rest
most common cause of titubation (head tremor)
Management
propranolol is first-line
primidone is sometimes used
19
Q
Lacunae stroke features
A
-20-25% is he if strokes
-occlusion of a single penetrating branch of a large cerebral artery and affect the internal capsule, thalamus and basal ganglia.
-purely motor: most common lacunar syndrome
-purely sensory
-sensorimotor stroke
-ataxic hemiparesis: ipsilateral weakness and limb ataxia that is out of proportion to the motor deficit
-dysarthria-clumsy hand syndrome
-generally NO cortical findings such as aphasia, agnosia, neglect, apraxia, or hemianopsia
20
Q
Degenerative cervical myelopathy - symptoms
A
- Pain (affecting the neck, upper or lower limbs)
- Loss of motor function (loss of digital dexterity, preventing simple tasks such as holding a fork or doing up their shirt buttons, arm or leg weakness/stiffness leading to impaired gait and imbalance
-Loss of sensory function causing numbness
-Loss of autonomic function (urinary or faecal incontinence and/or impotence) - these can occur and do not necessarily suggest cauda equina syndrome in the absence of other hallmarks of that condition
-Hoffman’s sign: is a reflex test to assess for cervical myelopathy. It is performed by gently flicking one finger on a patient’s hand. A positive test results in reflex twitching of the other fingers on the same hand in response to the flick.
21
Q
DCM diagnosis gold standard
A
MRI cervical spine : disc degeneration and ligament hypertrophy, with accompanying cord signal change.
22
Q
DCM - management
A
- urgent referral to spinal for decompressive surgery
- close observation for mild stable disease - not if progressive
-specialist physio only
23
Q
GCS
A
654 MoVE
Motor response
6. Obeys commands
5. Localises to pain
4. Withdraws from pain
3. Abnormal flexion to pain (decorticate posture)
2. Extending to pain
1. None
Verbal response
5. Orientated
4. Confused
3. Words
2. Sounds
1. None
Eye opening
4. Spontaneous
3. To speech
2. To pain
1. None
24
Q
Carpal tunnel syndrome
A
- Median nerve compression
- Sensation; Thumb / Index / Middle Finger. This typically manifests as intermittent pain or parasthesiae.
- Motor; LOAF Muscles(lateral lumbricals, opponens pollicis, abductor pollicis brevis and flexor policis brevis). Motor signs are less commonly seen with presentations of CTS, but wasting of the thenar eminence may be present.
-Tinels and Phallens can be positive
25
DVLA: epilepsy
-all patient must not drive and must inform the DVLA
-first unprovoked/isolated seizure: 6 months off if there are no relevant structural abnormalities on brain imaging and no definite epileptiform activity on EEG.
- If these conditions are not met then this is increased to 12 months
-for patients with established epilepsy or those with multiple unprovoked seizures:
—>may qualify for a driving licence if they have been free from any seizure for 12 months
—>if there have been no seizures for 5 years (with medication if necessary) a 'til 70 licence is usually restored
- withdrawawl of epilepsy medication: should not drive whilst anti-epilepsy medication is being withdrawn and for 6 months after the last dose
26
Neuropathic pain - causes
diabetic neuropathy
post-herpetic neuralgia
trigeminal neuralgia
prolapsed intervertebral disc
27
Neuropathic pain treatment
- amitriptyline, duloxetine, gabapentin or pregabalin
- monotherapy
-tramadol as rescue
-topical capsain for local neuropathic (post-herpetic)
-trigeminal neuralgia: carbamazepine
28
Migraine: diagnostic criteria
Point Criteria
A: At least 5 attacks fulfilling criteria B-D
B: Headache attacks lasting 4-72 hours* (untreated or unsuccessfully treated)
C: Headache has at least two of the following characteristics:
1. unilateral location*
2. pulsating quality (i.e., varying with the heartbeat)
3. moderate or severe pain intensity
4. aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)
D: During headache at least one of the following:
1. nausea and/or vomiting*
2. photophobia and phonophobia
E: Not attributed to another disorder (history and examination do not suggest a secondary headache disorder or, if they do, it is ruled out by appropriate investigations or headache attacks do not occur for the first time in close temporal relation to the other disorder)
In children: attacks shorter-lasting, headache is more commonly bilateral, and gastrointestinal disturbance is more prominent.
29
Migraine aura: features and atypical(further investigation)
-progressive
-hours prior to headache
- transient hemianopia disturbance - spreading scintillating scotoma
-Auras may occur with or without headache and:
—>are fully reversible
—>develop over at least 5 minutes
—>last 5-60 minutes
Atypical and should be investigated further:
motor weakness
double vision
visual symptoms affecting only one eye
poor balance
decreased level of consciousness.
30
Psychogenic non-epileptic seizures : Paeudoseizure - factors
pelvic thrusting
family member with epilepsy
much more common in females
crying after seizure
don't occur when alone
gradual onset
31
True seizures features
tongue biting
raised serum prolactin*
32
Migraine management: acute vs prophylaxis
acute: triptan + NSAID
OR triptan + paracetamol
-consider non-oral metoclopramide or prochlorperazine and consider adding a non-oral NSAID or triptan
prophylaxis: -topiramate(teratogenic) or propranolol
-acupuncture
-riboflavin
-predictable menstrual migraine: fravotriptan and zolmotriptan
-off-licence: ezemumab and camdesartan
33
TIA clinical features
-unilateral weakness or sensory loss.
-aphasia or dysarthria
-ataxia, vertigo, or loss of balance
-visual problems
-sudden transient loss of vision in one eye (amaurosis fugax)
-diplopia
-homonymous hemianopia
34
management of patient on DOAC with suspected TIA
ED to rule out hemorrhage
35
what are guidelines on brain imaging in TIA
Only if advised by stroke specialist or if there is suspicion of alternate diagnosis (hemorrhage)
MRI preferred
36
TIA anti-thrombotic management
-patient with minor ischemic stroke or TIA should be given anti-plt if no contraindication
A) resolved TIA, awaiting specialist R/V in 24 hours: aspirin 300 mg
B) Reviewed by stroke; first 21 days: aspirin and clopidogrel
C) long-term secondary prevention after 21 days: clopidogrel
Doses: clopi and aspirin initial 300mg then 75 mg OD
-tica and clopi as alternative
-PPI
-clopi only if not for DUAPT
-atorvastatin
-DOAC if AF
37
TIA imaging / procedures
-carotid duplex USS, CT angio or MRI angio withing 24 hours
- if stenosis >50%; carotid endarterectomy if stroke or TIA in carotid territory and not disabled
38
secondary prevention in stroke
clopidogrel 75 mg after 14 days HD aspirin
39
management of acute stroke
-maintain blood glucose, hydration, O2 sats, temp
-BP: don't lower unless complications
-aspirin 300 mg
-DOAC for AF 14 days from onset of ischemic stroke
-statin if chol > 3.5mmol/L
40
When to control BP in stroke
-if present within 6 hours of acute ischemic stroke onset with BP>150
-BP should be <185/110 before thrombolysis
41
Thrombolysis for acute ischaemic stroke- criteria
-alteplase or tenecteplase
-exclude hemorrhage
-admin 4.5 and 9 hours of stroke onset or withing 9 hours of midpoint of sleep when woken up AND
-evidence of salvageable brain tissue
-even if large artery occulsion
-even if mechanical thrmbesctomy needed
-lower BP to 185/110
42
absolute contraindications to thrombolysis
Absolute Relative
- 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
- Oesophageal varices
- Uncontrolled hypertension >200/120mmHg
43
relative contraindication to thrombolysis
-pregnancy
-Concurrent anticoagulation (INR >1.7)
- Haemorrhagic diathesis
-Active diabetic haemorrhagic retinopathy
-Suspected intracardiac thrombus
-Major surgery / trauma in the preceding 2 weeks
44
Thrombectomy for acute ischaemic stroke - inclusion criteria
-modified Rankin score less than 3
-confirmed occlusion of the proximal anterior circulation on CTA or MRA
45
Offer Thrombectomy + thrombolysis
-within 6 hours of symptom onset and thrombolysis within 4.5 hours --> to people who have confirmed proximal anterior circulation occulusion on CTA or MRA
-offer thrombectomy
46
Offer thrombectomy..
offer ASAP to people last well between 6 and 24 hours previously if
-confirmed PAC occlusion
-salvageable brain tissue on CT perfusion or DWMRI with limited infarct core volume
47
Consider thrombectomy +thrombolysis
-for people last well up to 24 hours before
-confirmed proximal posterior circulation stroke on CTA or MRA
-AND salvagable brain tissue
48
complications associated with parotid surgery or pathology
Lower motor neurone facial palsy
49
What does facial nerve supply
'face, ear, taste, tear'
-face: muscles of facial expression
-ear: nerve to stapedius
-taste: supplies anterior two-thirds of tongue
-tear: parasympathetic fibres to lacrimal glands, also salivary glands
50
Causes of bilateral facial nerve palsy
-sarcoidosis
-Guillain-Barre syndrome
-Lyme disease
-bilateral acoustic neuromas (as in neurofibromatosis type 2)
-Bell's palsy
51
Causes of unilateral facial nerve palsy
-as with B/L plus
Upper motor neurone:
-Ramsay-Hunt syndrome (HZV)
-acoustic neuroma
-parotid tumours
-HIV
-multiple sclerosis*
-diabetes mellitus
Upper motor neuron: stroke
52
UMN vs LMN facial nerve
UMN: spares forehead
LMN: all facial muscles
53
Factors that increase risk of suicide
-male sex (hazard ratio (HR) approximately 2.0)
-history of deliberate self-harm (HR 1.7)
-alcohol or drug misuse (HR 1.6)
-history of mental illness
---depression
--schizophrenia: NICE estimates that 10% of people with schizophrenia will complete suicide
-history of chronic disease
-advancing age
-unemployment or social isolation/living alone
-being unmarried, divorced or widowed
54
factors associated with an increased risk of completed suicide at a future date
-efforts to avoid discovery
-planning
-leaving a written note
-final acts such as sorting out finances
-violent method
55
Multiple sclerosis features
-75% present with lethargy
Visual
-optic neuritis: common presenting feature
-optic atrophy
-Uhthoff's phenomenon: worsening of vision following rise in body temperature
-internuclear ophthalmoplegia
Sensory
-pins/needles
-numbness
-trigeminal neuralgia
-Lhermitte's syndrome: ---paraesthesiae in limbs on neck flexion
Motor: spastic weakness (common in legs)
Cerebellar:
-ataxia (relapse or presenting Sx)
-tremor
Others:
-urinary incontinence
-sexual dysfunction
-intellectual deterioration
56
Peripheral neuropathy - motor loss
-Guillain-Barre syndrome
-porphyria
-lead poisoning
-hereditary sensorimotor neuropathies (HSMN) - Charcot-Marie-Tooth
-chronic inflammatory demyelinating polyneuropathy (CIDP)
-diphtheria
57
Peripheral neuropathy - sensory loss
diabetes
uraemia
leprosy
alcoholism
vitamin B12 deficiency
amyloidosis
58
Alcoholic peripheral neuropathy
-secondary to both direct toxic effects and reduced absorption of B vitamins
-sensory symptoms typically present prior to motor symptoms
59
Vitamin B12 deficinecy
-subacute combined degeneration of spinal cord
-dorsal column usually affected first (joint position, vibration) prior to distal paraesthesia
60
Vitamin B6 (pyridoxine)
-needed for formation of Hb
-1.4mg men
-1.2 mg women
->200mg/day (overdose) --> peripheral neuropathy
61
GBS - causes
campylobacter jejuni
62
GBS pathogenesis
-anti-ganglioside antibody (e.g. anti-GM1)in 25% of patients
-affects peripheral nerves
63
Miller Fisher syndrome
-variant of GBS
-associated with ophthalmoplegia, areflexia and ataxia (eye muscles first)
-descending paralysis rather than ascending
-anti-GQ1b antibodies are present in 90% of cases
64
GBS symptoms
-progressive
-symmetrical weakness of the limbs, often in an ascending fashion.
65
Mid-shaft fracture clinical sign
wrist drop (radial nerve)
66
Radial nerve motor function
-triceps - to straighten elbow
-outer forearm - to supinate forearm
-extend wrist and fingers
67
radial nerve sensory function
-inner upper arm
-outer forearm
-back of wrist
-back of hand closest to thumb (thumb, 2,3, (1/2) of 4, NOT pinky)
68
Peroneal nerve lesion
-weakness of foot dorsiflexion and foot eversion
-loos sensation over dorsum and
-foot drop
-peroneal and anterior comp mm
-sensation to foot dorsum
-wraps around head of fibula
69
Brain abscess symptoms
-headache
-fever
-focal neurology (occulomotor nerve palsy or abducens nerve palsy)
-nausea, papilloedema, seizures
70
In a person with brain abscess and heart murmur what is the concern?
infective endocarditis
71
Causa equina symptoms
-leg weaknes
- saddle anaesthesia
-sphincter disturbance.
72
Transverse myelitis presentation
-acute
-sensory and upper motor neuron signs below level affected
-in MS or Devics disease
-optic neuritis
73
What is adjacent segment disease
DCM which re-occurs after laminectomy at an adjacent spinal level
74
Management of Bells's palsy if presents within 72 hours
Oral prednisolone 10 days +/- artificial tears
75
Features of Bells palsy
-more common in pregnant women
-lower motor neuron facial paralysis - forehead affected
-post-auricular pain
-altered taste
-dry eyes
-hyperacusis
76
Double vision + right eye fails to adduct and the left eye develops coarse nystagmus in abduction
Internuclear ophthalmoplegia
77
Internuclear ophthalmoplegia
-horizontal disconjugate eye movement
-lesion of medial longitudinal fasciculus
-interconnects 3rd, 4th, 6th N
-impaired adduction of the eye on the same side as the lesion
-horizontal nystagmus of the abducting eye on the contralateral side
-cause: MS, vascular
78
Parkinsons triad
bradykinesia
rigidity (lead pipe, cogwheel)
tremor (pill rolling)
-other:
mask-like facies
flexed posture
micrographia
drooling of saliva
depresion
impaired olfaction
REM sleep behaviour disorder
fatigue
autonomic dysfunction: PH
79
rapidly progressive symmetrical limb weakness following GI or rest infection; reflexes reduced
GBS
80
Part of the brain affected with lacunar stroke?
BG, thalamus, internal capsule
81
lacunar strokes
- isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
-association HTN
-common sites include the basal ganglia, thalamus and internal capsule
82
Anterior cerebral artery stroke
Contralateral hemiparesis and sensory loss, lower extremity > upper
83
Middle cerebral artery stroke
Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral homonymous hemianopia
Aphasia
84
Posterior cerebral artery stroke
Contralateral homonymous hemianopia with macular sparing
Visual agnosia
85
Weber's syndrome (branches of the posterior cerebral artery that supply the midbrain)
Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity
86
Posterior inferior cerebellar artery stroke (lateral medullary syndrome, Wallenberg syndrome)
-Ipsilateral: facial pain and temperature loss
-Contralateral: limb/torso pain and temperature loss
-Ataxia, nystagmus
87
Anterior inferior cerebellar artery stroke (lateral pontine syndrome)
Symptoms are similar to Wallenberg's, but:
Ipsilateral: facial paralysis and deafness
88
Retinal/ophthalmic artery stroke
Amaurosis fugax
89
basilar artery stroke
locked-in syndrome
90
Abducens 4 vs trochlear 6
4: inn. lateral rectus muscle
-allows lateral movement
6: superior oblique muscle
-allows down and inward movement
91
Third nerve palsy features
-occulomotor nerve ; lesions on same side as eye
-controls medial, sup, inf and inferior oblique muscles
-eye is deviated 'down and out'
-ptosis
-pupil may be dilated
92
absent corneal reflex?
acoustic neuroma (starts on 8th vestibulococchlear but compresses trigeminal 5th when grows)
93
Tremor and History of depression?
anxiety
94
Tremor with Weight loss, tachycardia, feeling hot
Thyrotoxicosis
95
Tremor and History of chronic liver disease?
Hepatic encephalopathy
96
Tremor and History of COPD?
Carbon dioxide retention
97
Tremor (Intention) and
Cerebellar signs e.g. Past-pointing, nystagmus
Cerebellar disease
98
Essential tremor features
-Postural tremor: worse if arms outstretched
-Improved by alcohol and rest
-Titubation
-Often strong family histor
99
Features of Parkinsonism
Resting, 'pill-rolling' tremor
Bradykinesia
Rigidity
Flexed posture, short, shuffling steps
Micrographia
'Mask-like' face
Depression & dementia are common
May be history of anti-psychotic use
100
GBS investigation findings
abnormal nerve conduction studies
-LP: albuminocytologic dissociation
101
MS: investigations
- lesions must be disseminated in time and space
-MRI: periventricular plaques, Dawson fingers, -CSF: oligoclonal bands, high IgG intrathecal
102
Cluster headache: long-term prophylaxis
Verapamil
103
Cluster headache: rescue therapy
sumatriptan + high flow O2
104
Cluster headache symptoms
red, swollen eye, ptosis, miosis, lacrimaton, sweating, coryza (unilateral)
105
relationship vs Wenicke's and Broca's
Spoken word is heard at the ear. This passes to Wernicke's area in the temporal lobe (near the ear) to comprehend what was said. Once understood, the signal passes along the arcuate fasciculus, before reaching Broca's area. The Broca's area in the frontal lobe (near the mouth) then generates a signal to coordinate the mouth to speak what is thought (fluent speech).
106
Wernicke's (receptive) aphasia
-lesion of the superior temporal gyrus
-supplied by the inferior division of the left MCA
-forms speech before sending it to Broca's
-lesions: senteces that make no sense
-comprehension impaired
107
Broca's (expressive) aphasia
-lesion inferior frontal gyrus
-supplied by the superior division of the left MCA
-repetition impaired
-comprehension normal
-speech: non-fluent, laboured, halting
108
Conduction aphasia
-arcuate fasiculus (connection btw Wernickes and Brocas)
-comprehension normal
-speech fluent
-repetition poor
-aware of errors
109
Global aphasia
-affects Wernickes, Brocas and arcuate fasciculus
-severe expresive and receptive aphasia
-may still communicat with gestures
110
B/L acoustic neuromas (vestibula schwannoma) associate with what?
Neurofobromatosis type 2
111
classical history of vestibular schwannoma is a combo of
-cranial nerve VIII: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
-cranial nerve V: absent corneal reflex
-cranial nerve VII: facial palsy
112
Contraindication to use of triptan (serotonin agonist) in migraine management?
-cardiovascular heart disease
- can cause vasospasms
113
How do triptans work
-serotonin agonists
- 5-HT1B and 5-HT1D agonists
-vasoconstricts of cranil blood vessels and inhibits release of vasoactive peptides
114
Triptan adverse effects
-triptan sensations
-tingling, heat, tightness (e.g. throat and chest), heaviness, pressure
115
Side-effects of phenytoin
acute: diziness, diplopia, nystagmus, slurred speech, ataxia, confusion
chornic: -peripheral neuropathy (glove and stocking
-lymphadenopathy
-bleeding gums / gingival hyperpasia
-megaloblastic anemia
-dyskenesiea
-increased vit D abs causing osteomalacia
idiosyncratic:
-rashed - toxic epidermal necrolysis
Dupuytrens
hepatitis
drug-induced lupus
aplastic anemia
teratogenic: cleft palate
116
Side effects carbamazepine
-dizziness
-ataxia
-diplopia
-some peripheral neuropathy
117
Side effects topiramate
weight loss
cognitive impairment
kidney stones
118
Sodium valproate side effects
(causes inhibition of the P450 system)
-gastrointestinal disturbances
-tremor
-hair loss
-teratogenic
-weight gain,nausea
-ataxia, tremor
-hepatotoxic, pancreatitis
-thrombocytopenia
-hypoNa
-hyperammonemic encephalopathy --> use L-carnitine
119
Lamotrigine
-skin rashes (including Stevens-Johnson syndrome)
-headache
-dizziness.
120
Phenytoin monitoring - when should this be done
-trough levels immediately before dose IF
-adjustment of phenytoin dose
-suspected toxicity
-detection of non-adherence to the prescribed medication
121
Epilepsy- when to start anti-epileptics after first seizure
-neurological deficit
-brain imaging shows a structural abnormality
-EEG -unequivocal epileptic activity
-Pt consider the risk of having a further seizure unacceptable
122
Trigeminal neuralgia
-severe unilateral pain
- evoked by light touch
-trigger areas: nasolabial fold or chin
123
124
Red flag symptoms in trigeminal neuralgia
-Sensory changes
-Deafness or other ear problems
-History of skin or oral lesions that could spread perineurally
-Pain only in the ophthalmic division of the trigeminal nerve (eye socket, forehead, and nose), or bilaterally
-Optic neuritis
-A family history of multiple sclerosis
-Age of onset before 40 years
125
ROSIER score
(one point for each) New, acute onset of:
-asymmetric facial weakness
-asymmetric arm weakness
--asymmetric leg weakness
-speech disturbance
-visual field defect
(One less point for each)
-LOC or syncope
-seizure activity
126
Motor neurone disease management
-Riluzole
-resp care (BIPAP)
-nutrition (PEG)
127
Motor neurone disease features
-UMN and/or LMN signs
-rarely presents before 40
-ALS, progressive muscular atrophy, bulbar palsy
128
Oxford Stroke classification - initial symptoms
1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
2. homonymous hemianopia
3. higher cognitive dysfunction e.g. dysphasia
129
TACI
total anterior circulation infarcts
-involves middle and anterior cerebral arteries
-all 3 criteria present
130
PACI
Partial anterior circulation infarcts
-involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
-2 of the criteria
131
Lacunar infarcts
-involves perforating arteries around the internal capsule, thalamus and basal ganglia
presents with 1 of the following:
1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
2. pure sensory stroke. e.g. complete one side sensory loss
3. ataxic hemiparesis
132
Posterior circulation infarcts
-involves vertebrobasilar arteries
presents with 1 of the following:
1. cerebellar or brainstem syndromes
2. loss of consciousness
3. isolated homonymous hemianopia
133
Lateral medullary syndrome (posterior inferior cerebellar artery)
-aka Wallenberg's syndrome
-ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner's
-contralateral: limb sensory loss
134
Weber's syndrome
ipsilateral III palsy
contralateral weakness
135
what nerve root does biceps reflex correspond to
C5-C6
136
Ankle reflex, knee, biceps, triceps
-S1-S2
-L3-L4
-C5-C6
-C7-C8
137
What to rule out first in status epilepticus
BM
hypoxia
138
Diagnostic criteria for migraine without aura
A At least 5 attacks fulfilling criteria B-D
B Headache attacks lasting 4-72 hours* (untreated or unsuccessfully treated)
C Headache has at least two of the following characteristics:
1. unilateral location*
2. pulsating quality (i.e., varying with the heartbeat)
3. moderate or severe pain intensity
4. aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)
D During headache at least one of the following:
1. nausea and/or vomiting*
2. photophobia and phonophobia
E Not attributed to another disorder
139
most common complication following meningitis?
Sensorineural hearing loss
140
Meningitis complications
Sensorineural hearing loss (most common)
seizures
focal neurological deficit
infective
sepsis
intracerebral abscess
pressure
brain herniation
hydrocephalus
Waterhouse-Friderichsen syndrome (adrenal insufficiency secondary to adrenal haemorrhage)
141
What is 'Saturday night palsy'
Compression of radial nerve
142
alternative to clopidogrel 75 mg in TIA patient?
aspirin 75 mg
143
most common side effect of sodium valproate
weight gain
144
Side effects ethosuximide
gastrointestinal disturbances,
dizziness
headache
145
Side effects levetiracetam
irritability, aggression, and mood swings
146
Side effects of carbamazepine
-dizziness, ataxia, hyponatremia, and rash (including the risk of Stevens-Johnson syndrome).
147
Side effects of lamotrigine
Stevens-Johnson syndrome
dizziness and headache.
148
GBS symptoms
-progressive, symmetrical weakness of all the limbs
-weakness is classically ascending
-reflexes are reduced or absent
-sensory symptoms tend to be mild
149
first-line for spasticity in multiple sclerosis
Baclofen and gabapentin
150
MS acute relapse management
high dose steroids (methypred) for 5 days to shorten relapse length
151
disease modifying drugs in MS
-natalizumab (1st line)
-ocrelizumab (1st line)
-less effective: fingolimod, beta-interferon, glatiramer acetate
152
MS - symptom relief drugs
-fatigue: amantadine, CBT
-spasticity: baclofen and gabapentin, physio , (diazepam, dantrolene and tizanidine)
-bladder dysfunction (res vol - intermittent self-cath vs no resiual volume - anticholinergics)
-oscillipsia - gabapentin
153
Neuropathic pain management
-first line: amitriptyline, duloxetine, gabapentin or pregabalin
-monotherapy
-tramadol as rescue therapy
-topical capsaicin for localized neuropathic pain
154
Temporal lobe seizure
-with or without impairment of consciousness
-An aura occurs in most patients- rising epigastric sensation
also psychic or experiential phenomena, such as dejà vu, jamais vu
less commonly hallucinations (auditory/gustatory/olfactory)
-Seizures typically last around one minute
automatisms (e.g. lip smacking/grabbing/plucking) are common
155
Frontal lobe (motor) seizure
-Head/leg movements, posturing
-post-ictal weakness
-Jacksonian march
156
Parietal lobe (sensory
Paraesthesia
157
Occipital lobe (visual)
Floaters/flashes
158
Parkinsons medication most likely to cause hallucinations
Ropinirole (dopamine agonists)
159
first line treatment Parkisons if motor symptoms affect QOL
levodopa
160
first line treatment Parkisons if motor symptoms not affect QOL
dopamine agonists, levodopa, MAO-B inhibitor
161
Side effects of levodopa
dry mouth
anorexia
palpitations
postural hypotension
psychosis
162
Dopamine receptor agonists side effects
-carbergoline, bromocriptine, ropinirole
-pulmonary, retroperitoneal and cardiac fibrosis
-impulse control disorders
-daytime somnolence
-hallucinations - more than levodopa
-postural hyotension and nasal congestion
163
Monoamine oxidase-B example
-selegiline
164
Amantadine side effects
-ataxia
-slurred speech
confusion
dizzines
liverdo reticularis
165
COMT (catechol-o-methyl transferase ) examples
-entacapone, tolcapone
166
Antimuscarinics in PD
-for drug-induced parkinsons
-help with tremor and rigidity
-procyclidine, benzotropine, trihexyphenidyl
167
effects of drug holiday in PD
-akinesia
-neuroleptic malignant syndrome
168
Hoffmans sign - what does it imply and what two conditions can it associate with
UMN sign
MS and DCM
169
global shoulder restriction especially when externally rotating ?
adhesive capsulitis
170
Kernig sign - what is it and what can it suggest
-painful knee extension, from a position of hip flexion and knee flexion
-SAH and meningitis
171
Straight leg raise - what can it suggest
radicular pathology
172
Tinels test
tapping over the volar surface of the wrist joint i.e. over the carpal tunnel can cause paraesthesia
173
clinical features of TIA
unilateral weakness or sensory loss.
aphasia or dysarthria
ataxia, vertigo, or loss of balance
visual problems
sudden transient loss of vision in one eye (amaurosis fugax)
diplopia
homonymous hemianopia
174
Difference between managing TIA in patient with and without DOAC
DOAC patient needs CT to rule out bleed
175
Migraine
-Recurrent
severe headache
-unilateral and throbbing i
-associated with aura, nausea and photosensitivity
-'going to bed'.
-associated with
-aggrated by routine activities
176
Tension headache features
recurrent
non-disabling
bilateral headache
'tight-band'
-Not aggravated by routine activities of daily living
177
Cluster headache
- once or twice a day
-episode lasting 15 mins - 2 hours
-every 4-12 weeks
-Intense pain around one eye (recurrent attacks 'always' affect same side)
-restless during an attack
-Accompanied by redness, lacrimation, lid swelling
-More common in men and smokers
178
Temporal arteritis
-t > 60 years old
-rapid onset (e.g. < 1 month)
-unilateral headache
-Jaw claudication (65%)
-Tender, palpable temporal artery
-Raised ESR
179
Medication overuse headache
-Present for 15 days or more per month
-Developed or worsened whilst taking regular symptomatic medication
-opioids and triptans
-May be psychiatric co-morbidity
180
Other causes of acute single episode headache
meningitis
encephalitis
subarachnoid haemorrhage
head injury
sinusitis
glaucoma (acute closed-angle)
tropical illness e.g. Malaria
181
causes of chronic headaches
chronically raised ICP
Paget's disease
psychological
182
MS subtypes from most common to least
Relapsing-remitting disease
Secondary progressive disease - gait and bladder disorders
Primary progressive disease- more common in older people
183
Wernickes features - acute thiamine deficiency
Confusion
gait ataxi
nystagmus
ophthalmoplegia
184
extradural hemorrhage features
head trauma
transient loss of consciousness, and a lucid interval.
signs of raised intracranial pressure (headache and vomiting) generalised neurology (acute confusion or seizures)
185
Focal aware seizure features
-hallucinations (auditory, gustatory, olfactory)
-epigastric rising
-automatisms sometimes
186
Epilepsy is based on which 3 things
1. Where seizures begin in the brain
2. Level of awareness during a seizure (important as can affect safety during seizure)
3. Other features of seizures
187
Focal seizures
-start in a specific area, on one side of the brain
-focal aware vs focal impaired awareness
-motor (Jacksonian march) vs non-motor (deja vu)
-may have aura
188
Generalized seizures
-networks on both sides of the brain at the onset
-immediate LOC
-motor (tonic-clonic) vs non-motor (absence)
189
Duchenne muscular dystrophy vs Becker muscular dystrophy
-progressive proximal muscle weakness from 5 years
calf pseudohypertrophy
Gower's sign: child uses arms to stand up from a squatted position
30% of patients have intellectual impairment
-develops after the age of 10 years
intellectual impairment much less common
190
Best imaging for de-myelinating diseases
MRI with contrast
191
CT with B/L temporal lobe ( and inferior frontal) changes and temp spikes - pathognomonic for..
herpes simplex encephalitis
-can cause aphasia
192
Where is the lesion? left homonymous hemianopia with some macula sparing.
occipital cortex
193
Where is the lesion? sweating, headaches and 'tunnel vision'.
optic chiasm
194
Where is the lesion? fam hx blindness and developing tunnel vision
retinitis pigmentosa
195
SPECT findings in PD
reduced dopaminergic activity in the substantia nigra
196
Alzheimers CT and MRI
atrophy of the medial temporal lobe and temporoparietal cortex.
197
Huntingtons imaging
-basal ganglia disorder but cell loss is predominantly in the striatum
-chorea
198
Syncope DVLA
simple faint: no restriction
single episode, explained and treated: 4 weeks off
single episode, unexplained: 6 months off
two or more episodes: 12 months off
199
DVLA: stroke
multiple TIAs over short period of time
craniotomy
narcolepsy/ cataplexy
MS and NMD
-stroke or TIA: 1 month off driving, may not need to inform DVLA if no residual neurological deficit
-multiple TIAs over short period of times: 3 months off driving and inform DVLA
-craniotomy e.g. For meningioma: 1 year off driving*
pituitary tumour: craniotomy: 6 months; trans-sphenoidal surgery 'can drive when there is no debarring residual impairment likely to affect safe driving'
-narcolepsy/cataplexy: cease driving on diagnosis, can restart once 'satisfactory control of symptoms'
chronic neurological disorders e.g. multiple sclerosis, motor neuron disease: DVLA should be informed, complete PK1 form (application for driving licence holders state of health)
200
Essential tremor - features
postural tremor: worse if arms outstretched
improved by alcohol and rest
most common cause of titubation (head tremor)
201
Essential tremor - management
Management
propranolol is first-line
primidone is sometimes used
202
what is required when starting a phenytoin infusion ?
cardiac monitoring due to pro-arrythmogenic effects
203
adverse effects are due to the difficulty in achieving a steady dose of levodopa
-end-of-dose wearing off
-'on-off' phenomenon
-dyskinesias at peak dose: dystonia, chorea and athetosis
-these effects may worsen over time
204
Laughter → fall/collapse?
Cataplexy
205
extra-pyramidal side effects of metaclopramide (dopamine antagonist)
acute dystonic reactions, akathisia, and parkinsonism
206
Cluster headache precipitants
alchohol
noctural sleep
207
degenerative cervical myelopathy (arm pain, stiffness and imbalance) misses follow up for 2 months due to ACS; what is the next most important step in his care?
urgent decompressive surgery to stop disease progression (spinal cord damage) within 6 months
208
fever, vomitting, headache, seizures, with findings of temporal lobe (&inferior frontal) prominent brain swelling and increased signal on MRI. LP: lymphocytosis, high Protein 92, normal glucose
aciclovir for encephalitis
209
60 year old male, progressive deteriorating clumsy hands over past months (loss of fine motor function)
Degenerative cervical myelopathy
210
Cushings triad for raised ICP
irregular breathing
wide pulse pressure
bradycardia
(suggests late sign of bran herniation)
211
cause of ICP
-idiopathic intracranial hypertension
-traumatic head injuries
-infection
-meningitis
-tumours
-hydrocephalus
212
features of ICP
headache
vomiting
reduced levels of consciousness
papilloedema
Cushings's triad (irregular breathing, bradycardia, wide pulpse pressure)
213
management of ICP
-CT/MRI
-may need invasive monitoring of ventricles
-cut of of >20 to determine if further tx needed
-elevate head to 30
-IV mannitol (osm diuretic)
-controlled hyperventilation - to dec CO2 which causes vasocontriction of arteries and dec ICP
-removal of CSF (drained, repeated LP, shunt)
214
Normal ICP
7-15 mmHg
215
Other features of tuberous sclerosis
-retinal hamartomas: dense white areas on retina (phakomata)
-rhabdomyomas of the heart
-gliomatous changes can occur in the brain lesions
-polycystic kidneys, renal
--angiomyolipomata
-lymphangioleiomyomatosis: multiple lung cysts
216
Peripheral neuropathy with predominantly motor loss
Guillain-Barre syndrome
porphyria
lead poisoning
hereditary sensorimotor neuropathies (HSMN) - Charcot-Marie-Tooth
chronic inflammatory demyelinating polyneuropathy (CIDP)
diphtheria
217
Peripheral neuropathy with predominantly sensory loss
diabetes
uraemia
leprosy
alcoholism
vitamin B12 deficiency
amyloidosis
218
Vitamin B12 deficiency
dorsal column usually affected first (joint position, vibration) prior to distal paraesthesia
219
Huntington's genetic
-autosomal dominant
-trinucleotide repeat disorder - presents early in successive generation
-degeneration of cholinergic and GABAergic neurons in the striatum of the basal ganglia
-defect in huntingtin gene on chromosome 4
220
Features of Huntingtons
-develop after 35 years
-chorea
-personality changes (e.g. irritability, apathy, depression) and intellectual impairment
-dystonia
-saccadic eye movements
221
first line for essential tremor
propranolol
blocking peripheral beta-adrenergic receptors.
222
Neuroleptic malignant syndrome features
-hours to days
pyrexia
muscle rigidity
autonomic lability: typical features include hypertension, tachycardia and tachypnoea
agitated delirium with confusion
223
Neuroleptic malignant syndrome
-IVF
-dantrolene (sometimes)
-bromocriptine, dopamine agonist
-high CK
224
Sciatic nerve damage
- weakness to all muscles groups below the knee, intact knee jerk but weak ankle jerk
225
sciatic nerve origin and what does it become
-L4-5, S1-3
-common peroneal and tibial nerves
226
what muscles does sciatic nerve suppy
hamstring
adductor muscles
227
causes of sciatic nerve damage
fracture neck of femur
posterior hip dislocation
trauma
228
drugs that exacerbate MS
penicillamine
quinidine, procainamide
beta-blockers
lithium
phenytoin
antibiotics: gentamicin, macrolides, quinolones, tetracyclines
229
Idiopathic intracranial HTN risk factors
obesity
female sex
pregnancy
drugs
combined oral contraceptive pill
steroids
tetracyclines
retinoids (isotretinoin, tretinoin) / vitamin A
lithium
230
Idiopathic intracranial HTN features
headache
blurred vision
papilloedema (usually present)
enlarged blind spot
sixth nerve palsy may be present
231
Idiopathic intracranial HTN
weight loss (semaglutide)
topiramate (weight loss
acetomolamide (carbonic anhydrase inhibitors)
shunts
fenetration
optic nerve sheath decompression
232
third nerve palsy causes
-diabetes mellitus
-vascululitis
-false localizing sign
-posterior communicating artery aneurysm
-Cavernous sinus thormbosis
-Weber's syndrome - same side 3rd nerve palsy with opposite side hemiplegia -due to midbrain stroke
-amyloid, MS
233
Cubital tunnel syndrome
-ulnar nerve neuropathy
-sensory innervation of palmar aspect, pinky and 1/2 ring finger
234
Ulnar nerve: origin
-medial cord of brachial plexus (C8, T1)
235
Ulnar nerve motor
- medial intrinsic hand muscles (except lateral two lumbricals)
- hypothenar muscles
236
Ulnar nerve damage - test
Froment's sign
237
ulnar nerve - damage at the wrist vs elbow
-claw hand
-wasting and paralysis of intrinsic hand muscles (except lateral two lumbricals)
-wasting and paralysis of hypothenar muscles
-sensory loss to the medial 1 1/2 fingers (palmar and dorsal aspects)
elbow:
-as above (however, ulnar paradox - clawing is more severe in distal lesions)
-radial deviation of wrist
238
status epilepticus management
-ABC(G)
- Iv lorazepam can repeat after 5-10 min
- if ongoing can add secod line phenytoin, levetiracetam or sodium valproate
- if ongoing after 45 minutes give general anesthesia or phenobarbiral
239
which disease presents with months of generalized weakness, fasciculations and weakness in arms with absent reflexes and increased tone and exaggerated reflexes in legs?
Amyotrophic lateral sclerosis (fasciculations - motor neuron disease)
240
In lady with migraines, Which is the most common presenting symptom of posterior circulation stroke?
Dizziness in 50% (double vision, disorientation, visual, confusion, memory loss). Consider if new vertigo, dizziness, or change in nature of migraine.
241
which anti-epileptic drug causes megaloblastic anemia and lethargy after 3 months?
P- cytochrome p450 induction; H- hirsutism
E-enlarged gums
N-nystagmus
Y-yellow-brown skin
T-teratogenic
O-osteopenia/osteomalacia
I-inhibits folate absorption
N-neuropathy
