Neurology Flashcards
1
Q
Name 3 signs of an ACA stroke?
A
- Leg weakness and sensory disturbance
- Gait apraxia
Akinetic mutism (decrease in spontaneous speech)
2
Q
Name 3 signs of an MCA stroke?
A
- Contralateral arm and leg weakness
- Contralateral sensory loss
- Hemianopia
- Midline shift on CT
- Facial droop
3
Q
Name 3 signs of an PCA stroke?
A
- Contralateral homonymous hemianopia
- Visual agonisa
- Prosopagnosia (inability to recognise faces)
- Unilateral headache
4
Q
Name 3 signs of an posterior circulation stroke?
A
- Locked in syndrome
- Altered consciousness
- Vertigo, nausea and vomitting
5
Q
What is the first line investigation in a stroke before any treatment?
A
CT to distinguish whether it is haemorrhagic is ischaemic
6
Q
When can you offer prophylaxis for stroke?
A
Less than 4.5 hours post onset of symptoms
7
Q
What treatment is used for prophylaxis of stroke?
A
- Tissue plasminogen acttivator - IV alteplase
2. Anti-platelet - clopidogrel
8
Q
What are 4 of the contraindications of prophylaxis?
A
- Recent surgery (3 months)
- Active malignancy
- patient on anti-coagulation
- severe liver disease
- acute pancreatitis
- clotting disorders
- evidence of brain aneurism
- recent arterial puncture
9
Q
Name 3 clinical presentations of Subarachnoid haemorrhage?
A
Thunderclap headache Neck stiffness Kernigs and Brudunski's sign Papilloedema Vomitting, colapse
10
Q
What is Kernigs Sign?
A
Unable to extend leg at knee when the thigh is flexed
11
Q
What is Brudzinki’s sign?
A
When patient neck is flexed, patient will flex knees and hips
12
Q
Name a treatment method for Subarachnoid haemorrhage?
A
CCB - IV Nimodipine
Surgery
13
Q
What is the epidemiology of subdural haemorrhage?
A
Alcoholics, dementia, shaken baby syndrome
brains are more atrophic
14
Q
What is the pathology of subdural haemorrhage?
A
Bleeding from bridging veins -> forms haematoma-> haematoma autolyses - increase osmotic /oncotic pressure
15
Q
What is the clinical presentation of subdural haemorrhage?
A
Headache, personality change, unsteadiness, signs of increase ICP, focal neurology
16
Q
What is seen on a CT of a patient with a) subdural haemorrhage b) extradural haemorrhage?
A
a) Crescent shaped +/- midline shift
b) Convex shaped
17
Q
What investigation is contraindicated in extradural haemorrhage and why?
A
Lumbar puncture - can cause herniation and coning through foramen magnum
18
Q
Name a cause of extradural haemorrhage?
A
Fractured temporal or parietal bone -> lacerate middle meningeal artery
19
Q
How long does
a) Epileptic seizure
b) Non-epilpetic seizure
c) Syncope - typically last?
A
a) 30-120 seconds
b) 1-20 mins
c) 5-30 seconds
20
Q
What are the three different types of partial/focal seizures?
A
a) Partial seizure (simple) without impairment of consciousness
b) Partial seizure (complex) with impairment of consciousness
c) secondary generalised seizure
21
Q
What are the 5 different types of generalised seizure?
A
- Tonic-clonic
- Absence
- Myoclonic
- Tonic
- Atonic
22
Q
What is first line treatment for generalised seizure?
A
Valproate
23
Q
What is first line treatment for partial/focal seizure?
A
Carmazepine
24
Q
What is the clinical presentation of a tonic-clonic seizure?
A
Tonic - rigidity and limbs stiffen
Clonic- rythmic muscular contraction and relaxation
25
Name 4 of the differences of the clinical presentations of epilepsy and syncope?
Syncope there is tongue biting and head turning
Syncope rarely arises from sleep - epilepsy often does
Cyanosis in syncope
Muscle pain in syncope
26
Name 4 of the clinical presentations of non-epileptic seizures?
Eyes are typically closed
Itcal crying and speaking
History of psychiatric illness
Dramatic motor phenomena or prolonged atonia
27
How does carmazepine work?
Inhibits neuronal Na+ channels so reduces neuronal excitability
28
Name 2 pathological findings of parkinson's disease?
1. Presence of lewy bodies (composed of alpha synuclein)
| 2. Loss of dopaminergic receptors in substantia nigra
29
What are the three characteristic symptoms of parkinson's?
1. Rigidity
2. Bradykinesia - slow to initiate movement
3. Resting tremor - "pill rolling"
(Depression, sleep disorders, anosmia)
30
How do you diagnose parkinson's?
Clinical examination, by confirming response to Levodopa
31
What is the 1st, 2nd and 3rd line drug treatment for parkinson's?
1. L-Dopa given alongside a dopamine decarboxylase inhibitor eg cocaroldopa (to cross BBB)
2. Dopamine agonist eg roprinirole
3. Mono-oxidase inhibitors eg oral selegilline
32
When would you give dopamine agonists and mono-oxidase inhibitors in parkinson's?
To delay starting L-dopa in the early stages
33
What is the mechanism of action of L-dopa?
l-dopa can be taken up by dopaminergic receptors and converted into dopamine
34
What are the side effects of L-dopa?
Nausea, vomitting, arrhythmia, psychosis and visual hallucinations, dyskinesia
35
Why is a decarboxylase inhibitor given alongside L-dopa?
The decarboxylase inhibitor (cocaroldopa) prevents peripheral conversion of L-dopa to dopamine and therefore reduces peripheral side effects, and maximising dose crossing BBB
36
Name 4 long term complications of L-dopa use?
1. Reduced efficacy over time
2. On- dyskinesia
3. Off-dykinesia
4. Freezing - unpredictable loss of mobility
37
What is the mechanism of action of mono-oxidase inhibitors?
Inhibit enzyme which breaks down dopamine so domaine remains for longer
38
What are the symptoms of tremor in Parkinsons?
Worst at rest, often asymmetrical - pill-rolling of thumb and fingers
39
What are the symptoms of bradykinesia in Parkinsons?
Slow to initiate movement, decrease blink rate, monotonous hypo phonic speech, low amplitude movements
40
What are the symptoms of rigidity in Parkinsons?
Increase tone, limbs resist passive extension, cogwheel rigidity felt during rapid pronation/supination
41
Name 3 findings in the parkinsonism gait?
Reduced asymmetrical arm swing, stooped posture, small steps, shuffling, dragging foot
42
How would you distinguish motor neurone disease from multiple sclerosis?
No sensory loss or spinchter disturbance in motor neurone disease
43
How would you distinguish motor neurone disease from myasthenia gravis?
No affect on eyes movement in MND
44
What are the 3 main signs of UMN lesions?
1. Spascitiy (increased muscle tone - hypertonia)
2. Brisk reflexes (tendon and jaw reflexes)
3. Plantars upturned on stimulation (positive babinki's sign)
45
What are the 3 characteristic patterns of limb muscle weakness in UMN?
1. Upper limb extensors weaker than flexors
2. Lower limb flexors are weaker than extensors
3. Finer more skilled movement impaired
46
What are the 4 main signs of LMN lesions?
1. Muscle tone reduced (hypotonia)
2. Muscle wasting
3. Fasiculations - spontaneous contraction of motor units
4. Reflexes depressed or absent
47
What are the 5 types of multiple sclerosis?
a) Relapsing remitting
b) Primary progressive
c) Secondary progressive
d) Progressive relapsing
48
What is Uhtoff's phenomenon?
Symptoms worse in heat as new myelin is heat insufficient in MS
49
What is Lhermites phenomom?
Electric like sensation on flexion of the neck in MS
50
Name 4 symptoms of MS?
```
Unilateral optic neuritis
Bladder incontinence
Spascitiy and weakness (legs)
Sexual dysfunction
Intention tremor
```
51
What would you see on LP - CSF fluid of patient with MS?
Oligioclonal IgG bands
52
What is the GOLD standard diagnosis for MS?
MRI- periventricular lesions and white matter abnormalities (plaques)
53
Name 3 treatment options for MS?
Acute - IV methylprednisolone
| Precention - beta interferon, azathriorprine
54
Name some infective causes of GBS?
Campylobacter jejuni, EBV, HIV, CMV
55
What is the pathophysiology of GBS?
Infection -> autoantibody mediated nerve cell damage formation -> damage to schwann cells -> demyelination -> decreased peripheral nerve conduction
56
Name 4 clinical presentations of GBS?
Parasthesia in the hands and feet
Absent deep tendon reflexes
Symptoms are symmetrical
Proximal muscles are more affected - no wasting
57
How do you diagnose GBS?
CSF shows elevated protein and low WBC
Clinical examination
Look at stool sample for infective cause
58
What type of peripheral neuropathy is GBS?
Acute symmetrical polyneuropathy - present as axonal or demyelinating
59
What are the causes of peripheral neuropathy?
Diabetes, Alcohol, Vitamin deficiency, Infection, drugs
60
What are the 3 presentations of peripheral neuropathy?
1. Symmetrical
2. Asymmetrical sensory - patchy distribution
3. Asymmetrical sensorimotor (mononeuritis multiplex)
61
What is the best way to diagnose peripheral neuropathy?
Nerve conduction studies, reduced conduction velocities and or conduction block in sensory or motor nerve
62
Give an example of a mononeuropathy?
Carpal tunnel syndrome
63
In carpal tunnel syndrome where would you experience parasthsia?
Thumb, index and middle finger (median nerve distribution)
64
What is the pathology of the IDH mutation?
causes excessive 2-hydoxyglutarate, genetic instability in glial cells, inapproropiate mitosis, cancer
65
Which 2 genetic mutations do all olgiodendrogliomas posses?
IDH-1 mutation
| 1p19q
66
Name 4 things you would see in a patient with motor neurone disease?
Stumbling spastic gait, proximal myopathy, weak grip, shoulder abduction, aspiration pneumonia
67
What is the characteristic rash in meningitis?
Non-blanching petechial/purpuric rash
68
What is the triad of clinical presentation in meningitis?
Headache, neck stiffness and fever
69
If a) cytomegalovirus b) Bacterial was the cause of meningitis,what would the CSF results show?
a) Normal protein and normal glucose, clear fluid
| b) Turbid appearance, raised protein and low glucose
70
What would be the CSF results in a subarachnoid haemorrhage?
Blood stained (xanthochromoa), normal glucose and high protein
71
Which form of meningitis presents without a rash?
Viral meningitis - no specific treatment - less severe disease
72
What are the signs of meningococcal sepsis?
Shock
| Prolonged capillary refill time, cold hands and feet, decreased BP and evolving rash
73
Which antibiotic do you give in prophylaxis of contacts in meningitis?
Ciprfloxacin
74
What is the first line management in meningococcal sepsis?
Take blood cultures, IV antibiotics - don't need to LP as know likely cause
75
Give 4 differential diagnosis for encephalitis?
Encephalopathy, hypoglycaemia, hepatic encephalopathy, diabetic ketoacidosis, SLE, Wernickes
76
Name 4 signs and symptoms of encephalitis?
Decreased GCS, fever, headache, focal neurological signs, seizures, history of travel, photophobia
77
Name a) 3 viral and b) 3 non-viral causes of encephalitis?
a) Herpes simplex, coxsackie, EBV
| b) Bacterial, malaria, TB, Lyme disease
78
How would you confirm the diagnosis of encephalitis?
CSF - send for Viral PCR (common herpes simplex)
79
Name 4 investigations you would do in a patient with encephalitis?
1. Bloods
2. Contrast enhanced CT
3. LP
4. EEG- periodic sharp and slow wave complexes
80
What are the two treatment methods in encephalitis?
IV acyclovir and IV dextrose
81
When would you add amoxicillin in meningitis treatment?
>50, immunocompromised or pregnant to cover listeria or alcohol excess
82
What would you add to Cefotaxmine if meningitis has been caused by strep pneumoniae?
Dexamethasone to decrease cerebral oedema
83
Name 3 red flag signs for a patient with a suspected brain tumour?
1. New headache with history of cancer
2. Cluster headache
3. Seizure
4. Papiloedema
5. Altered conciousness
84
What complication does a lateral tectorial herniation in the brain cause?
3rd Nerve palsy and Contralateral hemiparesis
| Forces uncut of temporal lobe out of the tentorium cerebelli
85
Name the 4 most common locations of metastases to the brain causing secondary brain tumours? (lucy,ben,marry, really magnificent)
1. NSC Lung (25%) and SC Lung (39%)
2. Breast
3. Melanoma
4. Renal cell
5. Melanoma
86
Which drug is used to decrease cerebral oedema?
Dexamethasone
87
Name a pharmacological treatment method for glioblastoma?
Temolozomide
88
Which two genetic mutations are found in oligiodendrogliomas?
1p19q
| IDH
89
How does IDH mutation cause genetic instability in glial cells?
Mutation of isocitrate dehydrogenase, results in excessive build up on 2-hydroglutarate
90
Name the 3 presentations of brain tumour?
1. Symptoms of raised ICP (headache, papilloedema)
2. Progressive neurologica deficit
3. Epilepsy
91
When is Babinki's reflex positive?
Upper Motor Neurone lesions
92
Name 3 causes of spinal cord compression?
1. Vertebral body neoplasm
2. Disc Herniation
3. Disc Prolapse
93
What is the clinical presentation of spinal cord compression?
Progressive weakness or legs with UMN symptoms
Bladder incompetence
Tone and reflexes reduced
94
In spinal cord compression where is the sensory loss felt?
1-2 cord segments below the level of compression
95
What is the GOLD standard diagnosis for spinal cord compression?
MRI
96
Name 3 differences between huntigndons and parkinson's?
PD - Increase muscle tone, Decrease in HD
PD - reduced movement, HD, overshooting movement
PD not enough dopamine, HD- too much dopamine
97
What is the genetic mutation in Huntigdon's?
Mutation on chromosome 4 resulting in repeated expression of CAG sequence
Autosomal dominant
98
What is the definition of ataxia?
Wild movements which are clumsy, ill directional and poorly controlled
99
What is the definition of apraxia?
Disorders of consciously organised patterns or movement or impaired ability to recall acquired motor skill
100
What is Babinki's Sign?
Plantars are upturned on stimulation suggests MND
101
Name 3 tests to assess memory in dementia?
1. 6 CIT
2. Montreal cognitive assessment (MOCA) - sensitive
3. Mini-mental state examination (MMSE) <25 suggestive
102
Name 3 specialised diagnostic tests in dementia?
1. Structural MRI - can show brain atrophy
2. Amyloid imaging - look for neurofibrillary tangles (tau)
3. Brain function PET
103
Name 3 differences between dementia and depression?
1. Depression onset and decline rapid, AD vague insidious onset
2. Depression is subjective complaints of memory loss, AD = confusion
3. Depression patient is distressed and unhappy with variability in cognitive performance, AD mood may be labile and cognitive performance is consistant
104
Name the signs of cerebellar disease?
```
Dysiadokinesia
Ataxia
Nystagmus
Intention tremor
Slurred speech
Hypotonia
```
105
Name 3 causes of cerebellar disease?
Toxic eg alcohol or phenytoin, Post-infectious cerebellitis, multi-system atrophy
106
Give an example of an asymmetrical sensorimotor polyneuropathy?
Vasculitis
107
What is the first line treatment for a migraine?
Sumatriptin (5HT agonist)
Selective serotonin receptor agonists,
(remove triggers and NSAIDS)
108
What are the triggers for a migraine?
CHOCOLATE
| Chocolate, hangovers, orgasms, caffeiene, oral contraceptive, lie-ins, alcohol, travel, exercise
109
How long does a migraine typically last?
4-72 hours
110
Give 4 characteristics of a migraine?
Unilateral, pulsing, aggregate by exercise, moderate/sever,photophobia/ photophobia
111
Name 4 risk factors for a tension headache?
Stress, sleep deprivation, hunger, anxiety, noise
112
How long does a tension headache typically last?
30 minutes to 7 days
113
How long does trigeminal neuralgia typically last?
Fraction of a second to 2 mins
114
What is the main risk factor for trigeminal neuralgia?
Hypertension
115
What is the first line treatment for cluster headache?
Acute treatment = 100% oxygen
| Calcium channel blocker - vermapril (prevention)
116
How long does a cluster headache typically last?
15-180 mins
117
Whats first line and second line treatment for temporal arteritis?
```
1st = high dose oral corticosteroid
2nd = IV TIS methylprednisoline
```
118
Give three high risk factors of early stroke?
Atrial fibrillation, more than one TIA in a week, TIA whilst on anti-coagulant
119
What is the clinical presentation of Huntingdon's?
Chorea (involuntary, rapid, jerky movements)
Psychiatric/behavioural (irritability, aggression, impulsivity)
Dementia and fits
120
When is ICP made worse?
Worse on walking, lying down, bending forward
121
What are the clinical features of dementia with Lewy bodies?
Visual hallucinations, fluctuating cognition, parkinsonism
122
Give 3 causes of haemorrhagic stroke?
Hypertension. migraine, coagulation diorder, drugs (cocaine), tumours
123
What is the treatment for motor neurone disease?
Riluzole (increases survival 2-4 months)
124
How do you treat GBS?
IV Ig plasmapheresis
| Supportive (resp)
125
Give 4 situations where you would delay lumbar puncture?
1. Severe sepsis or rapidly evolving rash
2. Severe respiratory or cardiac compromise
3. Significant bleeding risk
4. Signs of raised intracranial pressure
126
Which 3 autonomic features are seen in cluster headaches?
Unilateral lacrimation, nasal congestion, conjunctival injection
Transit ipsilateral Horner's syndrome
127
What are the triggers for epilepsy?
Sleep deprivation, alcohol and drugs, intercurrent illness, missed doses of treated patients
128
Which neurological drug lowers the effectivity of the contraceptive pill?
Carbamazepine
129
Other than atherscleroris or emboli give 2 other causes of TIA?
- Vasculitis, sickle cell anaemia
| - Polycythaemia
130
What ABCD2 score requires urgent referral in the risk of developing a stroke?
>6
131
If you suspected atherosclerosis as the cause of TIA, what specific investigation would you carry out and what treatment would you consider?
```
Carotid Doppler and carotid endarterectomy
Consider warfarin (vitamin K antagonist)
```
132
Which 2 medications would you consider using in extradural haemorrhage to reduce the symptoms?
Dexamethasone – reduces cerebral oedema, stabilises blood-brain barrier, glucocorticoid
Nimodipine – calcium channel blocker, reduces vasospasm
133
Name 3 non-neurological symptoms of parkinsons?
Dementia, hallucinations, dribbling, constipation
134
What is the treatment for acute cluster headache and prophylaxis?
```
Acute = sumatriptan
Prolphylaxis = CCB - veramapril
```
135
Give 3 features a patient with aura may experience preceding their migraine?
Zig-zag lines, tingling and weakness down one side, visual distrurbance
136
Other than imaging, what physical examination would you do in Cauda Equine?
PR examination - checking anal and sphincter tone
137
What is the classical presentation of myasthenia gravis?
Slow/increasing muscular fatigue
| Signs = diplopia, ptosis, on costing voice fades, normal tendon reflex
138
How would you treat this condition?
Anticholinesterade eg pyridostigmine
139
Which antibodies may be present in myasthenia graves?
Anti-AChR and Anti-MUSK
140
Give 3 mechanisms by which you can develop peripheral neuropathy?
Demylination- schwann cell damage
| Axonal degeneration, infarction, infiltration of inflammatory cells
141
What are Tilen's and Phalen's Sign?
Tinel’s – lightly tap over a nerve to induce irritation in it, eg over the wrist
Phalen’s – ask patient to hold wrists in full flexion (reverse prayer position) for 30-60 seconds, press on the wrist if need be, should get a tingling sensation/pain
Diagnostic for carpal tunnel syndrome
142
Give 3 diseases carpal tunnel is associated with?
Diabetes mellitus, hypothryoidism, acromegaly and amyloidosis
