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Neurology 2 Flashcards

1
Q

Shingles aetiology

A

VZV reactivation

Immunosuppression

  • Elderly
  • HIV
  • Steroids
  • Chemotherapy
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2
Q

Shingles presentation

A

Pre-eruptive

  • Itching and burning
  • Paraesthesia
  • B-symptoms

Painful rash - Dermatomal!
- Clusters of small vesicles

Herpes zoster ophthalmicus - Ophthalmic branch of trigeminal

  • Visual loss
  • Needs urgent referral
  • Hutchinson sign - Rash on nose
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3
Q

Shingles management

A

Acyclovir - Within 72 hours

Pain relief

  • Paracetamol
  • Ibuprofen
  • Gabapentin
  • Pregabalin
  • Amitriptyline

Housekeeping

  • Contagious - Chickenpox
  • Vaccine offered 70-79
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4
Q

Bell’s palsy aetiology

A

Facial nerve paralysis - Acute, unilateral
Ipsilateral LMNL

Infection - EBV / HSV 
SOL - Parotid tumour
GBS
Forceps delivery
Increased risk in pregnancy and DM

VZV - Ramsay Hunt syndrome

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5
Q

Bell’s palsy presentation

A

CN7 palsy

  • Speech disturbance
  • Eating disturbance
  • Dry eyes
  • Taste - Loss of anterior 2/3 tongue
  • Post-auricular pain/numbness
  • Hearing - Hyperacusis
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6
Q

Bell’s palsy investigations and management

A

Serology - VZV
CT/MRI

Management - Prednisolone + protect the eye
- Consider antivirals

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7
Q

GBS pathophysiology

A

Immune-mediated
Demyelination of PNS

Triggered by infection
Campylobacter jejuni

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8
Q

GBS presentation

A

AAAAA - Symmetrical

Ascending weakness - Proximal muscles
Absent reflexes 
Autonomic dysfunction 
- Urinary retention
- Tachycardia 
- Arrhythmias
Abnormal eyes - Diplopia
Ataxia

Paraesthesia
Respiratory depression

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9
Q

GBS investigations

A

Nerve conduction studies

Anti-ganglioside antibodies
Spirometry
LP - Protein ^
ECG - Arrhythmias

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10
Q

GBS management and complications

A

IV IG
ECG - Monitor arrhythmias
VTE prophylaxis

Severe - Plasmapheresis

Complications

  • Respiratory depression
  • Death
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11
Q

MS aetiology

+ Twins?

A

Cell-mediated AI disorder
Demyelination in CNS

3x more common in women
Aged 20-40

Monozygotic twin with MS = 30% risk
Dizygotic twin with MS = 2% risk

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12
Q

MS types

A

Relapsing-remitting - Most common

  • Acute attacks followed by periods of remission
  • 65% develop secondary progressive after 15 years

Secondary progressive

  • Relapsing-remitting patients who have deteriorated
  • Signs/symptoms present between relapses
  • Gait and bladder disorders

Primary progressive - 10%

  • Progressive deterioration from onset
  • More common in elderly
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13
Q

MS presentation

A

Visual
- Optic atrophy
- Uhthoff’s phenomenon - “Worse after a bath”
Internuclear ophthalmoplegia

Sensory

  • Numbness / paraesthesia
  • Trigeminal neuralgia
  • Lhermitte’s - Limb paraesthesia with neck flexion

Motor - Spastic weakness - Most common in legs
Cerebellar - Ataxia - Usually in acute relapse

Urinary incontinence
Sexual dysfunction
Intellectual deterioration

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14
Q

MS investigations

A

MRI - 2 lesions disseminated in time and space

LP - Oligoclonal bands

Anti-MOG antibodies

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15
Q

MS management

A

Acute - Methylprednisolone - 5 days

Chronic

  • Beta-interferon
  • Glatiramer acetate
  • Natalizumab
  • Fingolimod

Symptom control

  • Muscle relaxant - Baclofen
  • Tremor - BB
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16
Q

MG aetiology

A

AI disorder
Antibodies to acetylcholine receptors
More common in women

Exacerbations caused by…

  • Drugs - BB, opioids, gent, Li
  • Pregnancy
  • Infection
  • Change in environment
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17
Q

MG presentation

A

Weakness and fatigability!

Eyes

  • Diplopia
  • Ptosis
  • Peek sign - Gentle sustained lid closure, then separate

Bulbar - D

  • Dysphagia
  • Dysphasia
  • Difficulty chewing

Proximal weakness
Normal reflexes

“Can’t walk upstairs”
“Difficulty watching TV - Eyes get tired”

Ask them to count to 50 - Voice trails off!

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18
Q

MG investigations

A

Electromyography - Decreased evoked potentials

Anti-MuSK antibodies
Anti-AchR antibodies

CT - Thymoma
Spirometry

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19
Q

MG management and complications

A

Pyridostigmine
Prednisolone
Azathioprine

Complications - Respiratory

Lambert-Eaton syndrome - Associated with SCLC

  • Repeated muscle contraction
  • Increased strength
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20
Q

Myasthenic crisis

A

Known MG
Increasing generalised or bulbar weakness
Respiratory depression

Management

  • Intubation / ventilation
  • Plasma exchange - 2-3 sessions
  • IVIG - 4-5 days
  • Prednisolone
  • Eculizumab
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21
Q

MND aetiology

A

Apoptosis of motor neurons - SOD1 mutation

ALS - Most common - Mixed

  • UMN + LMN
  • Loss of neurons in motor cortex

Progressive muscular atrophy - LMN - Distal to proximal

Primary lateral sclerosis - UMN

Progressive bulbar palsy

  • Facial muscles, tongue, muscles of chewing/swallowing
  • Loss of function of brainstem motor nuclei
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22
Q

MND presentation

UMN + LMN

A

UMN

  • Upgoing plantars
  • Increased reflexes
  • Clonus
  • Spasticity

LMN

  • Fasciculations
  • Decreased reflexes
  • Wasting
  • Atrophy

Asymmetrical + Purely motor = ?MND

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23
Q

MND presentation

Bulbar + Limb

A

Bulbar - D

  • Dysphagia
  • Dysphasia
  • Dysarthria
  • Drooling
  • Emotionally labile

Limb

  • Foot drop
  • Asymmetrical weakness
  • Wasting - Thenar + Ant. tibialis

Asymmetrical + Purely motor = ?MND

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24
Q

MND complications

A

Speech difficulties
Aspiratory pneumonia
Respiratory failure

UTI
Constipation

Immobility complications - Skin ulcers

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25
MND investigations
Clinical diagnosis El Escorial diagnostic criteria EMG - Decreased action potential - Increased amplitude
26
MND management and prognosis
Symptom control Spasticity - Baclofen Feeding - NG/PEG NIV - BiPAP Respiratory failure - Opioids MDT - PT - OT - SALT Riluloze prolongs life by 3 months Prognosis - 2-4 years - 50% die within 3 years - Respiratory failure
27
Meningitis aetiology
Neonates - GBS / E.Coli Children / adults - NM / Strep P Viral - HSV - EBV - Mumps - Adenovirus
28
Meningitis presentation
1. Neck stiffness 2. Fever 3. Headache Photophobia Non-blanching purpuric rash Kernig's sign Brudzinski's sign Late presentation... - Seizures - FND - Coma
29
Meningitis investigations
Sepsis 6 ``` LP - CI if ICP ^ Blood cultures PCR virus FBC U&E CRP/ESR Glucose ABG ```
30
Meningitis CSF findings
Bacterial - Cloudy - PMNs ^ - Protein ^^^ - Glucose - LOW Viral - Clear - Lymphocytes - Protein ^ - Glucose - Normal / Low TB - Cloudy / Fibrin web - Monocytes - Protein ^^^ - Glucose - Very LOW
31
Meningitis management
Community - IM BENPEN IV Cef Listeria - Amox Household contact - Rifampicin ``` Paediatrics < 3 months - IV Amox + Cef > 3 months - IV Cef - Fluids - Cerebral monitoring ``` Notify PHE!
32
Meningitis complications
Sensorineural deafness Abscess Septicaemia
33
Encephalitis aetiology
Inflammation of cerebral cortex ``` HSV Enterovirus HIV Mumps Measles - Spontaneous sclerosing panencephalitis Lyme disease TB ```
34
Encephalitis presentation
1. Personality changes 2. Fever 3. Headache FND ICP ^ Seizures Coma FND + Personality changes = Encephalitis (vs Meningitis)
35
Encephalitis investigations and management
LP - Viral picture - Clear - Lymphocytes - Protein ^ - Glucose - Normal or LOW Bloods - Culture, PCR, clotting, ESR EEG MRI - Temporal lobe involvement? Management - IV acyclovir
36
Horner's syndrome aetiology
STC! Central - S - Stroke - MS Preganglionic - T - Tumour - Thyroidectomy - Trauma Post-ganglionic - C - Cluster headache - Cavernous sinus thrombosis - Carotid dissection
37
Horner's syndrome presentation
Ptosis Miosis - Small pupil Anhidrosis - Unilateral loss of sweating Enophthalmus - Sunken eye
38
Horner's syndrome investigations and management
Apraclonidine - Affected eye does not dilate CT - Suspected tumour CXR - Pancoast tumour Management - Treat cause
39
Anterior cord syndrome aetiology
Ischaemia of the anterior spinal artery - Branch of vertebral artery - Comes from aorta Most commonly due to aortic compromise - Dissection - Aneurysm - Vasculitis
40
Anterior cord syndrome presentation / investigations / management
Paralysis Loss of pain and temperature sensation Fine touch preserved - Dorsal column intact Areflexia Autonomic failure - Urinary/bowel - Sexual dysfunction Investigations - CT angiography Management - Treat cause
41
Cerebellar disorders aetiology
Vitamin D ``` Vascular - Stroke Infection - Meningitis, encephalitis, VZV, mumps Trauma AI Metabolic - B12, thiamine, hypothyroid, hypoPTH Idiopathic Neoplasm Degnerative Drugs - Li, phenytoin, isoniazid, Met. ```
42
Cerebellar disorders presentation
DANISHH - P ``` Dysdiadochokinesis Ataxia - Cerebellar vermis Nystagmus Intention tremor Slurred speech Heel-shin test Hypotonia ``` Pendular reflexes
43
Peripheral neuropathy aetiology
Motor - Infection - GBS Sensory - DM - B12 deficiency - Uraemia Alcohol SLE Thyroid disease Chemo/radio
44
Peripheral neuropathy investigations
Bloods - FBC - U&E - LFT - Toxicology - Cultures - Infection? - Anti-Ro / Anti-La - SLE? Nerve conduction studies - GBS?
45
Neurofibromatosis
Type 1 - Ch17 - AD - SKIN LESIONS - CAFE AU LAIT SPOTS - Axillary freckles - Optic lesions - Scoliosis - Phaemochromocytoma Type 2 - Ch20 - AD - TUMOURS - B/L ACOUSTIC NEUROMAS - Ependymomas - Schwannomas - Meningiomas
46
Brain tumours aetiology
Metastatic - Most common - Non-surgical - Lung - Most common - Breast - Bowel - Skin - Melanoma - Kidney
47
Glioblastoma multiforme
Most common primary tumour Imaging - Solid tumour - Central necrosis - Rim enhances contrast - BBB disruption - Vasogenic oedema Histology - Pleomorphic with necrotic areas Management - Surgical excision - Chemo/Radio - Dex - Reduce oedema Prognosis - Poor - 1 year
48
Meningioma
Second most common primary tumour Benign extrinsic Arise from dura mater Cause symptoms by compression rather than invasion Typical locations - Falx cerebri - Superior sagittal sinus - Convexity - Skull base Histology - Spindle cells in concentric whorls - Calcified psammoma bodies Investigations - CT/MRI Management - Surgery ± Chemo/Radio
49
Vestibular schwannoma
Benign Arises from CN8 - Vestibulocochlear Associated with NF2 Clinical features - Hearing loss - Facial nerve palsy (compression) - Tinnitus Histology - Antoni A or B patterns - Verocay bodies - Acellular areas surrounded by nuclear palisades Management - Surgery ± Chemo/Radio
50
Pliocytic astrocytoma
Most common primary brain tumour in children | Histology - Rosenthal fibres Corkscrew eosinophilic bundle
51
Pituitary adenoma
Benign tumour of pituitary gland Secretory or non-secretory Microadenomas < 1cm Macroadenomas > 1cm Clinical features - ACTH - Cushing's - GH - Acromegaly - Bitemporal hemianopia Investigations - CT/MRI - Pituitary blood profile Management - Hormonal / surgical
52
Brain abscess aetiology
VITAMIN DC ``` V - CHD - R-L shunting Infection - OM, dental, meningitis, endocarditis, mastoiditis, HIV, IVDU Trauma/surgery AI - DM, chronic granulomatous disease M Iatrogenic - Haemodialysis N ``` D C - Prematurity
53
Brain abscess clinical features
Depends on site ``` Headache - Dull and persistent Meningism CN palsy - 3 or 6 Kernig / Brudzinski +ve Fever ``` Neonates - Increasing head circumference / bulging fontanelle
54
Brain abscess investigations
Sepsis 6 FBC - WCC ^ ESR / CRP ^ Blood cultures Leucocytosis! CT / MRI - Halo around lesion Neonates - USS head
55
Brain abscess management
Surgery - Craniotomy + Debridement IV abx - Cef + Met ICP management - Dex
56
Myopathies aetiology
Inflammatory - Polymyositis Inherited - Duchenne's / Becker's - Myotonic dystrophy Endocrine - Cushing's - Thyrotoxicosis Alcohol
57
Myopathies clinical features
Symmetrical weakness - Proximal to distal Difficulty standing from sitting Difficulty getting out of bath Normal sensation Normal reflexes No fasciculations
58
Duchenne's aetiology
Progressive generalised muscle disease X-linked Becker muscular dystrophy is a milder form!
59
Duchenne's clinical features
Lower limbs - Flexion > Extension Delayed motor milestones - Ambulation > 18 months Gower's sign - Use of arms to stand from squatting Contractures Decreased tone/reflexes Toe walking Normal sensation Urinary and bowel incontinence Intellectual impairment Associated with dilated cardiomyopathy
60
Duchenne's investigations
Serum CK - 50-100x normal level Genetic testing - Xp21 mutation
61
Duchenne's management and prognosis
Prednisolone PT Surgery for contractures LVEF < 40-50% - Cardioprotective drugs - Carvedilol - Perindopril - Lisinopril - LVAD Prognosis - 40 year survival - 10-40% - Progressive respiratory weakness - Treated with NIV

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