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Phase 2a > Neurology 4 > Flashcards

Neurology 4 Flashcards

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1
Q

What scan should you do for an acute neuro presentation (except for spine)? Why?

A

CT head. Takes 2-3 mins whereas an MRI takes about 40 mins and has more safety issues.

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2
Q

What scan should you do for anything to do with the spine or anything to do with MS?

A

MRI, even in acute presentations involving the spine e.g. cauda equina

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3
Q

Why is a CT of the spine not very useful?

A

Doesn’t show discs/nerves/nerve roots etc.

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4
Q

Where does the spinal cord end?

A

L1/2

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5
Q

What is at the bottom of the spinal cord?

A

Cauda equina - bundle of nerve roots from the lumbar/sacral levels that branch off the bottom of the spinal cord

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6
Q

What causes cauda equina?

A

Lumbar disc herniation = most common
Spinal stenosis e.g. degeneration from ankylosing spondylitis
Trauma, tumours, abscesses

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7
Q

How is cauda equina treated?

A

Surgical decompression ASAP

Treat underlying cause - antibiotics for abscess, chemo for malignancy etc.

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8
Q

How is cauda equina investigated?

A

MRI spine

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9
Q

How does cauda equina present?

A

Bowel + bladder dysfunction (incontinence/loss of sphincter control)
Saddle paraesthesia - feels strange sitting/wiping
Bilateral leg weakness/loss of reflexes
Aching back pain with sciatica (radiates down leg)
Sexual dysfunction

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10
Q

What are the 3 cardinal symptoms of brain tumours?

A

Signs of raised ICP
Progressive focal neurological deficits
Epileptic seizures

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11
Q

What are the less common symptoms of brain tumours?

A

Constant headache
N+V
Drowsiness
Change in personality/behaviour

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12
Q

Describe the headache seen in a brain tumour.

A

Often nocturnal, worse on waking, coughing, straining, bending forward and lying down

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13
Q

What are primary brain tumours?

A

Brain is original site of tumour

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14
Q

Where do primary tumours metastasise to?

A

Don’t metastasise outside of CNS

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15
Q

What are the types of primary brain tumours?

A

Gliomas
Meningiomas
Others - pituitary, CN, haematopoietic (lymph cells)

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16
Q

What is the most common primary brain tumour?

A

Glioma

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17
Q

What is a glioma?

A

Tumour of the glial cells in the brain/spinal cord e.g. astrocytoma, oligodendroglioma

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18
Q

What is a meningioma?

A

Tumour growing from cells of the meninges, usually benign

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19
Q

What are secondary brain tumours?

A

Sites the cancer has spread to i.e. metastases?

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20
Q

What are the most common cancers to metastasise to the brain?

A

Lung, breast, kidney, GI tract and skin

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21
Q

How do you investigate a brain tumour?

A

Brain imaging - CT/MRI

Brain biopsy/surgery

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22
Q

How is a brain tumour treated?

A

Often non-curative
Radio/chemotherapy - limited use
Consider palliative care

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23
Q

What can a glioma progress to?

A

Glioblastoma when it gets to grade 4 = really bad

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24
Q

When should you suspect a brain tumour when a patient presents with a headache?

A 
New onset headache + history of cancer
Cluster headache
Seizure
Significantly altered consciousness, memory, confusion
Papilloedema
Other abnormal neuro exam
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25
What are the signs of raised ICP?
Papilloedema Focal neurological signs Loss of consciousness New onset seizures
26
What are the symptoms of raised ICP?
Headache Drowsiness Vomiting
27
What nerves are affected in a polyneuropathy?
Lots of nerves affected all over body
28
What nerves are affected in a mononeuropathy?
Just one nerve
29
How does polyneuropathy present?
Slowly progressive Sensory symptoms Motor symptoms e.g. weakness Trophic changes
30
What are the sensory symptoms of a polyneuropathy?
Loss of touch/proprioception/pain/temp, paraesthesia
31
What are the trophic changes in a polyneuropathy?
Dry scaly pigmented skin with ulcers/callouses
32
What causes polyneuropathy?
Diabetes and CMT disease
33
How does mononeuropathy present?
Upper limb nerves mostly affected at compression points | Sensory/motor symptoms in dermatome and myotome supplied by nerve
34
What causes mononeuropathy?
Most common = median nerve entrapment at wrist (CTS)
35
What are the other peripheral nerve causes of weakness?
``` Metabolic - B12 deficiency Uraemia Thyroid Alcohol Toxins Drugs Paraneoplastic Guillain Barre ```
36
What pattern of neuropathy does vasculitis normally present with?
Asymmetrical sensorimotor, often patchy distribution
37
How do you investigate neuropathy?
Mostly clinical Bloods - FBC, U+Es, ESR, glucose, TFTs, LFTs, B12, folate Vasculitic antibodies if vasculitis suspected e.g. ANA, ANCA, anti-dsDNA, RhF etc. Nerve conduction studies
38
How is neuropathy managed?
Neuropathic analgesia options = gabapentin, pregablin, amitriptyline Treat underlying cause e.g. diabetes control, steroids if vasculitis/inflammatory
39
How does CTS present?
Pain and parasthesia in thumb, index and middle finger Wakes people from sleep in morning Can't open jars
40
What nerve is affected in CTS?
Median nerve = C6-T1
41
What causes CTS?
Entrapped at wrist e.g. sleeping position
42
How does an ulnar nerve mononeuropathy present?
Pain and parasthesia in little and ring fingers and forearm
43
What are the nerve roots of the ulnar nerve?
C8-T1
44
What causes an ulnar nerve mononeuropathy?
Entrapped at cubital tunnel at elbow - elbow fracture/arthritis
45
How does a common peroneal nerve mononeuropathy present?
Foot drop | Sensory deficit over dorsum of foot
46
What are the nerve roots of the common peroneal nerve?
L4-S2
47
What causes a common peroneal nerve mononeuropathy?
Compressed against head of fibula
48
How does a radial nerve mononeuropathy present?
Can't extend fingers or wrist > wrist drop
49
What causes a radial nerve mononeuropathy?
Falls - spiral fracture of humerus | Sitting/sleeping with arm on chair/underneath someone = 'Saturday night palsy'
50
What are the nerve roots of the radial nerve?
C5-T1
51
What is Guillain Barre Syndrome (GBS)?
Demyelinating disease of the PNS
52
What causes GBS?
Unknown
53
What triggers GBS?
Usually triggered by infections - bacteria, viruses
54
What bacteria commonly cause GBS?
Campylobacter jejuni, mycoplasma pneumoniae
55
What viruses commonly cause GBS?
Cytomegalovirus, EBV
56
What are the features of GBS?
Progressive onset limb weakness/paralysis (LMN signs) Numbness/tingling CN and autonomic nerves may be involved
57
How does GBS present?
Ascending pattern - starts distally and spreads proximally | Usually symmetrical
58
How are the CN involved in GBS?
Diplopia, difficulty speaking, bulbar palsy
59
How are the autonomic nerves involved in GBS?
Constipation, urinary incontinence etc.
60
How is GBS diagnosed?
Clinical - tests can be normal in early disease LP Nerve conduction tests and EMG studies - shows slowing of motor conduction
61
What does a LP show for GBS?
CSF shows increase in protein or albumin without raised white cells, normal glucose
62
What is a key complication of GBS?
Involvement of respiratory muscles > respiratory depression > risk of death
63
What must be monitored in GBS?
FVC serially (spirometry)
64
How is GBS treated?
Aimed at reducing symptoms Supportive therapy - physio, feeding tubes, heparin to prevent DVT Immunosuppressants - IV IG reduces duration and severity of paralysis Plasmapheresis
65
What is plasmapheresis?
Plasma filtered to eliminate bad antibodies
66
What is the prognosis for GBS?
Slowly recover over weeks-months as there is regrowth of myelin 20% have permanent neurological damage
67
What happens in a CNIII palsy?
Loss of motor function to extraocular muscles (except superior oblique and lateral rectus) + parasympathetic supply responsible for pupillary constriction
68
How does CNIII palsy present?
Down and out appearance Ptosis Mydriasis
69
What is Horner's syndrome?
Damage to sympathetic nerves of face
70
How does Horner's syndrome present?
Unilateral Miosis - constricted pupil Anhidrosis - loss of sweating Partial ptosis - dropping upper eyelid
71
How does Bell's palsy present?
Ipsilateral LMN facial weakness e.g. inability to wrinkle brow, close eye, asymmetrical smile, drooping mouth Hyperacusis (hypersensitivity to sound)
72
What nerve is affected in Bell's palsy?
CN VII
73
What does CNVII innervate?
Muscles of facial expression and stapedius muscle + taste to anterior 2/3 of tongue
74
How does a LMN facial nerve lesion present?
E.g. Bell's palsy | Upper and lower facial paralysis
75
How does a UMN facial nerve lesion present?
E.g. stroke | Lower facial paralysis only - forehead is spared
76
What does CNIV do?
Innervates superior oblique | Medial rotation, depression and abduction
77
What does CNVI do?
Lateral rectus | Abducts the eye (ABducens ABducts)
78
Why is the eye down and out in CNIII palsy?
Unopposed action of superior oblique and lateral rectus muscles
79
Why is there ptosis in CNIII palsy?
Loss of innervation to levator palpebrae superioris
80
Why is there mydriasis in in CNIII palsy?
Loss of parasympathetic fibres that innervate the sphincter pupillae muscle
81
What is the pathophysiology of myasthenia gravis?
Disorder of neuromuscular transmission due to binding of autoantibodies (anti-AChR and anti-MuSK) to the Ach receptor at NMJs.
82
What does myasthenia gravis have a strong link with?
Thymus is abnormal in majority - strong link with thymoma
83
How is myasthenia gravis investigated?
Bloods - serum anti-AChR/anti-MuSK CT thymus Crushed ice test EMG
84
What is the crushed ice test?
Ice applied to ptosis for few mins > if ptosis improves = indicative of MG
85
What does an EMG show for MG?
Decremental muscle response to repetitive stimulation
86
How does MG present?
Muscle weakness that get worse with use and improve with rest = fatigueability, especially with repetitive movements No sensory symptoms
87
What muscles are most affected in MG?
Proximal muscles + muscles of head/neck/eyes most affected
88
What are the symptoms of MG?
``` Diplopia Ptosis Myasthenic snarl on smiling (outer corners of lips don't elevate) Weakness in facial movements Difficulty swallowing Dysarthria ```
89
How is MG managed?
Acetylcholinesterase inhibitors e.g. pyridostigmine = 1st line Steroids/immunosuppressants Consider thymectomy
90
What is the main complication of MG?
Myasthenic crisis
91
What is myasthenic crisis?
Acute worsening of symptoms often triggered by another illness
92
What can myasthenic crisis lead to?
Can lead to respiratory failure due to weakness of respiratory muscles > do an FVC
93
How is myasthenic crisis treated?
May require ventilation/intubation | Treat with immunomodulatory therapies (IV Ig) and plasma exchange
94
What causes Lambert-Eaton syndrome?
Paraneoplastic - especially small cell lung cancer | Autoimmune - antibodies against voltage gated calcium channels in presynaptic membranes > defective Ach release
95
How does Lambert-Eaton syndrome present?
Weakness | Autonomic involvement e.g. dry mouth, incontinence
96
How do you investigate Lambert-Eaton syndrome?
Serum auto-antibodies | EMG - incremental muscle response to repetitive stimulation (differentiates from MG)
97
How is Lambert-Eaton syndrome treated?
Treat cancer if present IV Ig or immunosuppressants Symptomatic treatment - pyridostigmine
98
Where does weakness affect in LES?
Proximal muscles around pelvic girdle +/- shoulder
99
What does weakness in LES improve with?
Sustained/repeated exercise
100
What is LES similar to?
MG
101
Give examples of focal neurological deficit symptoms seen in brain tumours.
Sensory loss, ataxia, speech disturbances
102
What is pyridostigmine?
Acetylcholinesterase inhibitor
103
What improves pain in CTS?
Hanging arm over side of bed
104
Why do people with CTS struggle to open jars?
Wasting of thenar muscles
105
What part of the hand is not affected in CTS?
Palm
106
Where do polyneuropathies present?
'Glove and stocking' distribution | Often symmetrical, starts in legs
107
What is the non-medicated treatment for HD?
MDT - physio, OT, SALT

Phase 2a (25 decks)

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