Neurology Flashcards
(97 cards)
0
Q
Upper motor neurone signs
A
Hypertonia, Spasticity Clonus Weakness- in pyramidal pattern Hyperreflexia Pathological reflexes (eg extensor plantars)
1
Q
Lower motor neurone signs
A
Muscle wasting Fasciculations Hypotonia Reduced power not in pyramidal pattern Reduced or absent reflexes
2
Q
Cerebellar dysfunction
“am i std please”
A
alcohol
ms (demyel)
inherited - friedrich (young)
stroke
tumour
drugs (isoniazid, henytoin)
paraneopastic
3
Q
cerebellar signs
A
DANISH dysdiadocokinesia ataxia nystagmus intention tremor slurred speech hypotonia
4
Q
peripheral neuropathy
A
Polyneuropathy I DAVID - can be sensory, motor or mixed S: dm, alcohol M: GB, polio MS: CMT, CIDP
Radiculopathy
- often w spondylosis
- pain, ting, sensory dist, motor dist
Mononeuropathy
- eg carpal (median), common peroneal (foot drop), radial (wrist drop), ulnar (hand)
- can get multiplex in DM, hypothyroid, vasculitis
5
Q
speech problems
A
cortical - dysphasia - expressive, receptive or mixed
cerebellar - staccato, loss of normal scanning
parkinsonian - hypophonic
pseudobulbar - spastic, hot potato
bulbar (palatal paralysis) - nasal
6
Q
leg myotomes
A
hip flex: L1/2
hip ext: L5 S1
knee flex: S1
knee ext: L3/4 (jerk)
ankle dorsi: L4
ankle plantar: S1/2 (jerk)
7
Q
arm myotomes
wrist extension (cocked)
A
shoulder: C5 axillary
bicep: C5/6
(reflex C5/6)
tricep: C7 radial
(reflex C7/8)
(supinator C6/7)
wrist ext: C7 radial nerve
wrist flex: C8 uln and med
fingers: T1 ulnar
thumb: C8 median
8
Q
stroke
A
sudden neurolog deficit of vascular origin
1/6 are hem; 5/6 are infarct
Assess w Rosier criteria
abc, source of embolus, assess swallow
do CT asap to rule out hem,
- thrombolysis (alteplase) if w/in 4.5 hrs
- if CI 300mg aspirin stat,
other: bloods (fbc, esr, clot), cxr, ecg, carotid ddoppler
mx: longterm CLOPIDOGREL
mdt rehab,
treat htn/chol/diab
?endarterectomy ?warfarin (if AF)
embolism - AF, valvular disease, recent MI
thrombosis - atheroma
9
Q
stroke prognosis
A
25% die in a year
50% dependant
25% independant
mdt rehab - phsyio, ot, salt stop: smoking, cocp, hrt manage bp, chol, diab clopidog (stroke) asp + dipyrid (tia) ?warfarin ?endarterectomy
10
Q
AC stroke
carotid circultaion
A
1) cortical deficit - Aphasia, visuospatial, attention
2) homonymous hemianopia
3) hemiparesis including face (+sensation)
all - TACS
or partial - PACS
highest mortality
11
Q
lacunar strokes
A
pure motor or sensory
cognitive impairment
12
Q
PC stroke
vertebrobasilar circulation
A
1) brainstem - cerebellar (ataxia), CN, bulbar (swallowing), dysphasia, horners,
2) hemiparesis on opposite sides to CN
3) hemianopia
13
Q
extradural haematoma
aka epidural
A
tearing of meningeal artery - often middle near pterion
history of trauma -> lucid period -> icp and gcs (coma)
ct: biconvex
not spread past falci
midline shift
14
Q
TIA
A
less than 24 hrs
Assess w ABCD
hemiparesis and aphasia - common
amaraurosis fugax, amnesia
Could do ecg, carotid duplex
30% stroke in 5 yrs
- start aspirin + dipyradamole daily
15
Q
sah
A
sudden (thunderclap) occipital
meningism - neck stiff, photophob
papilloedma ?focal neurology
ruptured berry aneurysm, avm
ct
lp (xanthochromia, blood on serial tap)
mx:
maintain bp
nimodipine (prev ischaemic damage)
surgical - coiling
16
Q
subdural haematoma
A
venous bleed in oldies
can be chronic + acute
gradual accum of neuro defecits - may be non specific (off legs, cogntiive)
ct: concave density (but old bleed are isodense)
can spread around brain
17
Q
Epilepsy history
A
Preceding factor
- head injury, infection
- stress, tiredness, alcohol, missed meals
Fh?
Pmh? - febrile seizures as child?
Seizure markers
- tongue biting
- incontinence
- confusion/tiredness afterwards
18
Q
Epilepsy management
A
Generalized
1) sodium valproate (avoid in reproductive female)
- se: wg, tremor, (tiredness, nausea at first)
2) lamotrigine
Focal
1) Lamotrigine
2) carbamazepine
19
Q
treatment for generalized vs focal epilepsy
A
Generalised (inc absence)
- sodium valproate
- (se: weight gain, temporary hair loss, ntd)
- lamotrigine if pregnancy risk
Partial: carbamezipine (se rash)
general se: drowsy, dizzy, nausea
sv: avoid alcohol
for absence - ethosuximide is second line
20
Q
Focal seizures
A
Start w strong aura Affect specific distribution Short duration Stereotyp pattern Altered consciousness
- must image brain (mri)
21
Q
Juvenile myoclonic epilepsy
A
Three features
- myoclonus - often in morning
- absense seizures
- gen tonic clonic
Do eeg if suspected
Start SV if man, lamotrigine if woman
22
Q
Status epilepticus
A
Pre hosp rescue therapy - buccal medazolam
Hosp
- iv lorazepam
- ?phenytoin
- ?aneasthetize
Identify/treat cause
ie hypoglycaemia?
23
Q
status epilepticus mx
A
recovery posit
avoid injury
call amb
buccal medaz or rectal diaz
in hosp
iv loraz
o2
check glucose
24
cluster headache
severe, quick onset, around eyes
runny noise, red eye
*come in clusters, daily 4-12 weeks
T: acute: O2, nasal triptan
proph: verapamil
25
tension headache
tightness, bilateral
recurrent/chronic, worse at end of day
precip: stress, noise, depression, analgesia overuse
tension, tenderness, stiff neck
m: simple analgesia
lifestyle - stress, alcoho, exercise, antidep
avoid analgesia overuse
physical massage/icepacks
26
treat migraine
attack: analgesia, metoclopramide, sleep/darkness, triptans
lifestyle - avoid triggers (sleep, eat well)
prophylaxis if severe, affecting life, frequent
- b block (avoid asthma, raynauds)
- topiramate (avoid if preg risk)
- acupuncture, gabapentin
27
migraine
unilateral, throbbing
pre: aura - visual, sensory
assoc: photo/phonophobia, nausea, vom
aggrav/triggered by choc, caffeine, alcohol, exercise
acute: analgesia, triptan
prevent: b block, or topiramate, or amitript
28
giant cell arteritis eg temporal
painful - rapid, unilat, v tender, erythema
jaw claudication
! risk visual loss
clinical diagnosis: give prednisolone
see rasied ESR, do biopsy
29
trigeminal neuralgia
unilateral face pain in trigem distrib - brief, severe, shock/stab, w/or w/out background ache
triggered by shaving/washing face/wind
treat: carbamezipine
check neuro signs - suggest tumour/lesion
(can be sign of MS)
pt typically > 50 yrs
may be idiopathic
due to compression of sensory root adjacent to brainstem
- eg tumour in cerebello pontine angle (v, vii, viii),
- also multiple sclerosis if younger patient
30
ms presentation
lethargy
ocular
- unilateral blurry/loss of vision
- pain - dull ache, worse w move
- colour desat
- RAPD, nystag (INO)
- late optic atrophy
worse with temperatrue - uhtoff's phenom
neck bend->paraesth - lhermitte's phenom
```
sensory and motor signs
trigem neuralgia
cerebellar signs - ataxia, tremor
urinary
cog/psych
```
31
investigations and treatment in ms
mri - visualise plaques
vep - slowed
csf - lymphocytes, protein, oligoclonal bands
steroids for relapses
?disease modifier: beta IFN, azathioprine
mdt support
treat symptoms (see card)
32
patterns of ms
relapsing remitting
primary progressive
- little or no recovery from episodes
secondary progressive
- starts as relapse/remit but recovery becomes less and less
aetiology: genetic and environmental, not fully understood
- certain parts of the world
33
specific treatmetns in ms
shooting pains, paraesthesia - gabapentin, carbamazepine
bladder - oxybutinin, self cath
constip - laxaives
muscle spasticity - baclofen
depression - ssri (fluox, cital)#
erectile - viagra
34
Acute spinal cord compression
- primarily MOTOR dysfunction below certain level - weakness, umn
- sensory level
may not be symmetrical
- tumour (slow appearance)
- prolapsed disc (more acute)
similar pic may be due to
- transverse myelitis
- ant spinal artery thrombosis
(no compression, weakness tends to be flaccid)
--> do urgent MRI
35
Progressive spastic paraparesis
Bilateral weakness and spasticity of legs
Differentials
- B12 deficiency (SACD)
- also copper deficiency (SACD)
- HEREDITARY spastic paraparesis
36
B12 deficiency - subacute combined degeneration of spinal cord (SACD)
May precede megaloblastic anaemia
1) Corticospinal tract
- prog spastic paraparesis
2) Dorsal columns
- proprioception, vibration, fine touch
- see high stepping gait, rhombergism, pseudoathetosis
3) Peripheral neuropathy
- sensory and motor
37
Cervical spondylotic myelopathy
Vertebral degen can cause
1) radiculopathy of local nerve roots
- pain, tingling, sensory dist, lmn signs
2) spinal cord syndrome
- spastic paraparesis
- gait and sphincter dysturb
38
Transverse myelitis
Localised inflammatory lesion across one level of SC
---> acute flaccid weakness w sensory level below this point
1) viral (recent flu-like) illness
2) MS
Do MRI to rule out SC compression
39
Transverse myelitis
Inflam on spinal cord across transverse plane
Often self limiting
Often viral - tends to be complete - paraplegia
Also w MS - tends to be partial - patchy motor sensory loss
40
Spinal shock
Sudden transaction of spinal cord (trauma)
Loss of autonomic control of vasoconstriction
- catastrophic hypotension - need fluid
41
Neuromuscular disease
1) MND
2) MG
3) Muscular disorders
42
mnd
upper and lower mn signs
no sensory signs
CLASSICALLY: >40, ataxia develops, weak grip
survival 2-5 yrs
TYPES:
50% amyotrophic lateral sclerosis
- UMN legs, LMN arms
primary lat sclerosis - only UMN
progressive muscular atrophy - only LMN, best prog
progressive bulbar palsy - swallowing/speech prob
- worst prog
43
myaethenia gravis
autoimmune vs ACh at nmj
fatiguable
particularly ocular (diplopia and ptosis) and facial muscle
- also bulbar, respiratory, limb
assoc w thymoma
80% succesfully managed with iv Ig (remission/improvement)
44
MG examine and invest
fatiguability
- eg counting and rep movem
impaired upward gaze
nb reflexes normal
Ix:
antibody to ACh
nerve conduction
tensilon test - improves with edrophonium
?thymoma
45
Muscle disorders
Distinguished by weakness with normal reflexes
Muscular Dystrophy
- inherited x linked - present in childhood - life exp ~ 20's
- duchennes and beckers
- prog wasting and weakness
Myotonic Dystrophy
- hered autosomal dom
- male pattern baldness
- dm, cataracts, cardiac, sleep
- successive generations more severe
- distal weakness and wasting
* * diff relaxing grip **
Also
- inflammatory (myositis)
- metaboilic (steroids, cushings, thyroid)
Ix: creatinine phosphokinase
EMG, biopsy
genetics
46
Peripheral neuropathy subtypes
```
Polyneuropathy I DAVID
- can be sensory, motor or mixed
S: dm, alcohol
M: GB, polio
MS: CMT, CIDP
```
Radiculopathy
- often w spondylosis
- pain, ting, sensory dist, motor dist
Mononeuropathy
- eg carpal (median), common peroneal (foot drop), radial (wrist drop), ulnar (hand)
- can get multiplex in DM, hypothyroid, vasculitis
47
polyneuropathy
- length dependant
I DAVID
```
inherited - charcot marie tooth
diabetes
alcohol
vitamin B12
inflammatory GB, CIPD, polio
drugs - isoniazid, vincristine
```
48
neuropathy w nutritional deficit
thiamine - beriberi
- peripheral neurop + WK (confusion, speech probs, nystagmus)
wernicke korsakoff
- seen w thiamine def
- W enceph: confusion, nystag, ataxia
- K psychosis: amnesia, halluc, confabulation
B12- subacute combined degen
- peripheral neurop
- prop and vib (dorsal column)
- umn signs (corticospinal)
49
Guillain barre
immune mediated demyel of PNS
- often triggered by infec
- classically campyobacter jejuni
prog weakness of 4 limbs (starts in legs)
reduced reflexes
?paraesthesia
?cranial nerve
Ix:
nerve conduction
monitor lung function
CSF: increased protein
T: IV Ig
50
charcot marie tooth
hered sensory motor polyneuropathy
weakness, wasting distally especially lower limbs
atrophic calf, prominent shin, champagne bottles
variable sensory loss
proprio loss - sensory ataxia, high step gate,
pes cavus and clawing of toes
51
mononeuropathies
carpal tunnel - median
saturday night - radial - wrist drop
common peroneal - foot drop
52
wrist drop
Mono or radiculo?
- from c7 nerve root lesion or radial nerve lesion
Test brachioradialis
- innervated by radial but not c7
- affected in radial lesion but not c7 lesion
Also mononeuritis multiplex
53
Foot drop
Mononeuropathy or radiculopathy?
Often L5 or common popliteal lesion
- get patient to invert foot - this uses median popliteal, L5
- - ability retained in comm perin lesion not L5
Also could be
- diabetic mononeuritis multiplex
If bilat: i david
54
T1 vs ulnar lesion
Mono or radiculo
T1 nerve root lesion
- takes out all the muscles of the hand - wasting and weakness
Ulnar nerve root lesion
- thenar eminence preserved
- causes claw hand (4th and 5th fingers drawn in)
55
carpal tunnel
Idiopathic or 2dry to ra, trauma, preg, hypothyroid, dm
Numb pain at night and on waking
- relieved by shaking
- thenar wasting if severe
T:
- splinting at nights
- corticosteroid temporary but effective relief
- surgical decompression
56
Parkinsonism exam
General around bed
- salbut, thyroid, ldopa
```
Facies - hypomymia
Eyes - blink rate, upgaze
Nose - anosmia
Greasy skin
Glabellar tap
Speech - hypophonic
```
Look: Tremor rest, amplify, essential, intention
Feel: Rigidity
Move: Brady (quack), handwriting
```
Posture (stooped)
Righting reflex
Gait
- shuffle festinant small steps
- no arm move
- difficult initiating, freezing, turning
- stooped
```
Follow up with
- lying standing bp
- righting reflex
- look at meds
Good Q - turning over in bed
Differentials
- PSP - up gaze
- MSA - cerebellar, post hypot, incontinence
- LBD - dementia
- Drug induced - haloperidol, prochlorpromazine
57
parkinsons management
Mdt etc
co-beneldopa - L dopa + periph inhibitor
- v effective (not vs tremor) but limited after 5 years
- dyskinesia, painful distonia, on/off
- se: halluc, post hypo
dopamine alternative/adjuncts:
* selegeline (MAOi),
* ropinirole (dop rec ag),
* amantadine (block dop reuptake),
give domperidone if drugs casue nausea
vs tremor - anti-muscarinics (orphenadine, benzhexol)
58
Parkinsons plus
MSA - autonomic, cerebellar
PSP - upgaze impaired
LBD - dementia
59
movement disorders
tremor - rhythmic oscillate
dystonic - invol contract
myoclonus - jerks
tic - can transiently suppress, relief post move
athetosis - slow writhing
choreoform - randome flowing dance-like
ballismus - high amplitude limb flail
60
essential tremor
exag by arms outstretch
dec with alcohol
T: propranolol
61
huntingtons
```
hereditary chorea (inviol writhing)
dementia/behavioural element - cerbreal atrophy
```
onset in 30's, progressive, usually die within 15yrs
autosomal dominant
62
causes of choreoform
huntingtons
wilsons
ataxic telangectasia
sle
antiphospholipid
drugs - L dopa, antipsych
63
meningitis
fever, headache, stiff neck, photophobia
```
bacterial
- may be sepetic - tachy, hypot, shock
-> purpuric rash, DIC
- neisseiria meningitidis (meningococcus), strep pneumonia
- risk neuro deficits - deaf, blind, cog
Ix: blood cluture, csf
T: high dose ceftriaxone
```
```
viral
- often sefl limiting
- less meningism (neck, photo)
- often enterovirus
T: treat as bacterial until ruled out,
rehydrate, analgesia, ?acyclovir
```
64
encephalitis
fever, headache, confusion/drosy/changed behaviour, seizures
CSF - lymphocytes
most treatable form in herpes - so give acyclovir
- affects temporal lobes (seen on eeg, mri)
- affects memory and speech
- poor prognosis
65
cerebral abscess
rare
headache, fever (swingin), focal neurology
signs of raised ICP - papilloed
spread from ears, sinuses, or embolic
do not perform LP - risk coning
T - prolonged abx and surgery
25% mortality
66
Brain tumours
Can be classified as supratentorial and infratentorial
50% secondary - look for primary
```
Generally present w
Headache - constant, at night, worse w cough/bend
Seizures
ICP - ha, vom, drowsy, papilloedema
Focal neurology
```
If suspected do contrast enhanced CT
Supratentorial
- more of a mass effect - ICP and focal neuro
- inc astrocytoma, oligodendroglioma, lymphoma, meningioma
Infratentorial
- often specific defects (CN) and early/dramatic ICP rise
- eg acoustic neuroma most common
67
tumours metastasising to brain
LUNG, breast, genitourinary, bone
68
acoustic neuroma
benign tumour (schwannoma) in cerebellopontine angle
Schwanoma of sheath of 8th cn
affects nerve 8 first:
unilateral sn hearing loss
then vertgo
then affects 5 and 7:
trigem neuralgia?
unila facial weakness
69
Neurocutaneous syndromes
assoc w phaeochromocytoma
Neurofibromatosis
- type 1 - skin nf's, cafe au lait, axillary freckles
- - brain/meningeal tumours
- type 2 central tumours common - eg bilateral acoustic neuroma, also cutaneous
Von hippel lindau
- brain, renal, adrenal tumours
70
Dementia types
Alzheimers
- senile (beta amyloid) plaques and neurofibrillary tangles
- also cerebral atrophy on mri
- gradual progressive decline
- memory, visuospatial, nocturnal wondering, verbal, intellect, personality, self care
Vascular
- stepwise cog decline, vascular risk factors/history
- characteristic gait: march a petit pas
- cerebral atrophy and vascular lesions on mri
Lewy body
- parkinsonism - tremor, rigid, brady, gait - non treatable w dopa
- fluctuating consciousness
- nocturnal visual halluc
71
normal pressure hydrocephalus
triad
gait disorder
dementia (reversible)
urinary incontinence
- see enlarge of 4th ventricle
72
hydrocephalus
infantile: arnold chiari malf
- cereb tonsils in f.m.
- assoc spina bifida, syringomyelia
adult: tumour, post SAH (clot blocks ventricles)
73
Visual field defects
homonymous hemi
- lesion in contralat optic tract
homonymous quadratanopia
-PITS
(parietal inferior, temporals superior)
macula sparing - occip cortex
temporal - optic chiasm eg pit tumour
74
Cranial nerves 1 and 2
1 - olfactory
```
2 - optic
- FARO(C)
- fields
- acuity
- reflexes: light, accom
- opthalmoscopy
(- colour - ishihara)
```
Fields
- 4 quadrants, inattention, blind spot
Acuity
- wearing correction, 1 eye at a time
Reflexes
- light: hand divider. direct, consensual, swing (rapd)
- accom
75
Cranial nerve 3, 4, 6
```
3 Oculomotor
4 trochlear (sup oblique)
6 abducens (lat rectus)
```
Look for ptosis, squint
Ask about diplopia
Do H ?nystag or diplopia
76
3rd nerve palsy
```
eye down and out
ptosis
pupil dilate (in aneurysm)
```
post comm artery aneurysm
- painful
- pupil dilate
DM
weber's syndrome - midbrain stroke
- w contralat hemiplegia
77
6th nerve palsy
failure of lateral rectus
may have strabismus (bad eye pulled in)
diplopia and strabismus maximal on lateral gaze
- eye may visibly fail to abduct
- patient reports double vision
- cover one eye at a time
- false image is fainter and more lateral
causes
- trauma
- diabetes, ms, tumour affecting 6th nerve
78
Cranial nerve 5, 7
5: trigeminal
- muscles of mastication
- sensation throughout face (opthalmic, maxillary, mandibular)
(corneal reflex)
7
- facial movements
79
bilateral facial weakness
primary muscle disease - muscular distrophy
nmj disease - myaeshenia gravis (bilat ptosis, opthalmopleia, fatiguable)
80
bells palsy
idiopathic unilateral lmn facial paralysis
? viral aetiology ?herpes simplex
onset over hours
assoc w pain in/behind ear
if caught early could start prednis and aciclovir
also eye drops to pretect cornea or tape down eyelid
90%self-limiting - few weeks
few have only partial recovery
81
7th facial nerve palsy
| Upper vs lower motor neurone
Forehead will be spared in upper motor neurone lesion
Lower motor neuron (Bell's) - whole side affected
82
Cranial nerves 8 - 12
8 - vestibulocochlear
- any hearing changes - rhinnes and webers
- any vertigo
9 glossopharyngeal
10 vagus
11 accessory
12 hypoglossal
83
causes pes cavus
Charcot Marie tooth disease
Hereditary spastic paraplegia
Cerebral palsy
84
causes of high stepping gait
sensory ataxia - sacd
peripheral neuropathy - bilat foot drop
85
Increased physiological blind spot
Pappiloedema
86
Level that spinal cord stops
L1/L2
87
post herpetic neuralgia treat
amitriptyline
pregabalin
88
Spinal cord tracts
Descending: Corticospinal
- decussation at medullar oblongata
- lateral and anterior cs tracts
- carry motor signals
-------------
Ascending
Dorsal column
- proprio, vibration, fine touch
Spinothalamic
- lateral and anterior tracts
- pain and temp; curde touch/pressure
89
neuro systems review
headache
fit faint funny turn
memory
eyes - diplopia
speech and swallow
weakness
tingling or loss of sensation
90
Approach to exam
Power- test normal side first
| Sensory- test abnormal side first
91
EXPLAN: MS
disease where body attacks nerves in cns (brain and sc)
- causes injury to the insulation/coating of nerves
- impairs function
Can occur at different sites and come and go (r+r, episodic)
- often eyes - blurry vision, pain, colour/loss, movements
- weakness - limbs (spasticity), face, speech
- sensation - tingling, numb
- bladder
- coordination
FATIGUE AND DEPRESSION
All can come and go, but may have left over problems: accumulate disability
- very variable - three main patterns - after ten year some will be disabled, wheelchair, some functioning ok
Ix to monitor (mri, ver, csf)
Tx: prednis for attack
beta IFN prevents relapses
physio and support
92
EXPLAN: temporal arteritis
body attacks and causes inflammation in artery in side of face
- not fully understood, genetic and environmental factors
pain, claudication, v tender
FATIGUE MALAISE
can be assoc PMR - mornign v stiff in muscles
prednisiolone for about 2 years, slowly reducing
aspirin (prevent thrombo-occlusion)
MUST LOOK OUT FOR VISUAL CHANGES
```
se steroids:
gastric
bones
infection
sleep
cushing
```
93
Signs of raised ICP
headache (progressive, worse w bending, coughing, on waking)
vomitting
visual disturbance, pupillary changes, papilloedema
reduced consciousness
94
rarer causes of dementia
Picks disease - Fronto Temporal dementia
- largely personality change - disinhibition, emotional unconcern
Normal pressure hydroceph
- gait, urinary, dementia
Pellagra
- niacin defic
- dementia, diarrrhoea, dermatitis
Prion disease
- dementia, myclonus, ataxia, blindness
- associated w CJD
95
infantile hydrocephaly features
```
big head
'sunset' appearance of eyes
mental impair
convulsions
diplegic spasticity
optic atrophy
```
96
causes of ptosis
congenital
- often w impaired upgaze (sup rectus)
acquired
- CN 3 palsy - eye down and out
- 2dry to PCA aneurysm; DM
- Horner's - w anhydrosis and miosis
- MG - fatiguable
- myotonic dystrophy - w catarract
Senile myogenic ptosis
* most common*
- degen of muscle w age
