Neurology Flashcards
1
Q
What is Multiple Sclerosis?
A
An inflammatory demyelinating disorder of the CNS characterised by plaques disseminated in time and space
2
Q
What mediates the demyelination in MS?
A
T cells
3
Q
How does pyramidal dysfunction in MS present?
A
Increased tone, spasticity, weakness
4
Q
Where is the weakness in MS?
A
Extensors of upper limbs, flexors of lower limbs
5
Q
What sensory symptoms may be present in MS?
A
Pins & needles/numbness
Pain
Trigeminal neuralgia
6
Q
What is Lhermitte’s syndrome?
A
Paraesthesia of the limbs on neck flexion
7
Q
What cerebellar symptoms may be present in MS?
A
Ataxia, intention tremor, nystagmus, past pointing, pendular reflexes, dysdiadochokinesia, dysarthria
8
Q
What visual symptoms may be present in MS?
A
Optic neuritis, optic atrophy, internuclear ophthalmoplegia, Uhtoffs phenomenon
9
Q
What is Uhtoff’s phenomenon?
A
Worsening of vision due to increased body temperature
10
Q
What other symptoms may be present in MS?
A
Fatigue, urinary incontinence, sexual dysfunction, intellectual deterioration
11
Q
What are the types of MS?
A
Relapsing remitting
Relapsing progressive
Primary progressive
Secondary Progressive
12
Q
What is the commonest type of MS?
A
Relapsing remitting
13
Q
What investigations should be done if you suspect MS?
A
Bloods (FBC, PV, CRP, autoantibodies, B12, folate - all negative)
MRI
CSF
14
Q
What does an MRI in MS show?
A
T2 weighted MRI shows plaques disseminated in time and space
15
Q
What does electrophoresis of CSF show in MS?
A
Oligoclonal bands of IgG
16
Q
What does neurophysiology show in MS?
A
Delayed evoked potentials
17
Q
What criteria is used to diagnose MS?
A
McDonald Criteria
18
Q
How should an acute exacerbation of MS be treated?
A
Methylprednisolone (oral or IV)
19
Q
What are some first line disease modifying therapies for MS?
A
Beta-interferon
Copaxone
Tecfidera
20
Q
How is fatigue managed in MS?
A
Amantadine
21
Q
How is spasticity managed in MS?
A
Baclofen/gabapentin
22
Q
How is oscillopsia managed in MS?
A
Gabapentin/memantine
23
Q
How is emotional lability managed in MS?
A
Amitriptyline
24
Q
What is motor neurone disease?
A
An untreatable and rapidly progressive neurodegenerative condition characterised by selective loss of motor neurones
25
What symptoms do you get in MND?
UMN and LMN signs
| No sensory loss, no sphincter disturbance, no eye movements affected
26
What is the commonest type of MND?
Amyotrophic lateral scleorsis
27
What nerves do pseudobulbar palsy/bulbar palsy affect?
CN IX-XII
28
What investigations should be done for MND?
MRI (normal)
Nerve conduction studies (normal)
EMG
29
What does EMG show in MND?
Fasciculations and fibrillations
30
What drug prolongs life in MND and for how long?
Riluzole - anitglutaminergic drug prolongs life by 3 months
31
What drugs can be used for symptomatic relief in MND?
Quinine/baclofen for cramps
Baclofen/gabapentin for spasticity
Propantheline/botox for drooling
Supplements/gastronomy for nutrition
32
What does curare poisoning cause?
Blockage of acetylcholine receptors at NMJ leading to no muscle contraction (can mean no respiration)
33
What is botulism?
Caused by botilinum toxin, which blocks release of acetylcholine, causing flaccid paralysis
34
What is Lambert-Eaton Myaesthenic syndrome?
Antibodies against pre-synaptic calcium channels
35
What is LEMS associated with?
Small cell lung cancer
36
What are the symptoms of LEMS?
Weakness of limbs (improves with exercise), autonomic involvement, hyporeflexia
37
What investigations would you do for LEMS?
Bloods (increased autoantibodies)
| EMG (shows improvement of potentials after use)
38
How is LEMS treated?
TREAT UNDERLYING CANCER. Steroids, azaithioprine, pyridostigmine, immunoglobulins
39
What is Myaesthenia Gravis?
Autoimmune condition against post-synaptic acetylcholine receptors
40
Who commonly gets Myaesthenia Gravis?
Commonly females in 3rd decade of life or Males in 6th/7th decade
41
What are symptoms of Myaesthenia Gravis?
Muscular fatigue, eye signs (e.g. ptosis, diplopia), gets worse throughout day. Voice deterioration as they speak.
42
What can exacerbate symptoms of Myaesthenia Gravis?
Pregnancy, change of climate, emotion, exercise, certain medications
43
What investigations can be done for Myaesthenia Gravis?
Bloods (autoantibodies)
Tensilon test
Neurophysiology (decreased response to nerve stimulation over time)
44
How is Myaesthenia Gravis treated?
Pyridostigmine for symptom control
Steroids/azaithioprine/methotrexate for immunosuppression
Thymectomy may be needed if disease not well controlled by anticholinesterases
45
What is Myaesthenic crisis?
Weakness of respiratory muscles during a relapse which can be life threatening
46
How is a myaesthenic crisis treated?
Plasmapheresis or IV Immunoglobulins
47
What makes up the triad of meningism?
Fever, headache and neck stiffness
48
What are the key symptoms of meningitis?
Meningism, photophobia, confusion, agitation, seizure, non-blanching purpuric rash
49
What is Kernig's sign?
Pain and resistance on passive extension of the knee with flexed hip
50
What are some viral causes of meningitis?
ECHO virus, coxsackie virus, herpes simplex
51
What are the common bacterial causes of meningitis in neonates?
Listeria, Group B strep, E coli
52
What is the commonest bacterial cause of meningitis in children?
Haemophilus influenzae
53
What is the commonest bacterial cause of meningitis in those aged 10-21?
Neisseria Meningitidis
54
What are the common bacterial causes of meningitis in those over 21?
Strep pneumoniae and neisseria meningitidis
55
What are the common bacterial causes of meningitis in the elderly?
Strep pneumoniae, Listeria
56
What is aseptic meningitis?
Inflammation of the meninges with no pus
57
What are some causes of an aseptic meningitis?
TB, HIV, syphilis, vasculitis, drug induced
58
What investigations should you consider in someone with suspected meningitis?
Bloods (FBC, U&Es, coag screen, glucose, cultures), throat swab, CXR if suspect TB, LP is diagnostic
59
When is a lumbar puncture contraindicated?
Immunocompromised
Papilloedema
Focal neurological signs
60
On LP, which organisms show neutrophilia?
Bacterial
61
On LP, which organisms show lymphocytes?
Viral and TB
62
What are protein and glucose like in viral meningitis?
Normal
63
What are protein and glucose like in bacterial meningitis?
High protein, low glucose
64
What is the empirical antibiotic treatment for bacterial meningitis?
IV ceftriaxone 2g BD + Dexamethasone 10mg IV QDS
65
What antibiotic should be added if you suspect listeria as a cause of bacterial meningitis?
Amoxicillin IV 2g 4hrly (Chloramphenicol if allergic)
66
Who should be contacted if there is a case of bacterial meningitis?
Public Health
67
What is the contact prophylaxis for bacterial meningitis?
500mg ciprofloxacin orally
68
What is encephalitis?
Inflammation of the brain parenchyma
69
What are the common causes of encephalitis?
Herpes simplex, varicella zoster, CMV/HIV
70
How does encephalitis present?
Similar to meningitis but may also be odd behaviours or aphasia (if temporal lobe affected)
71
What investigations should be done for encephalitis?
LP - CSF shows lymphocytosis. Do PCR for HSV
| MRI - may show 'temporal lobe enhancement'
72
What is temporal lobe enhancement on MRI a sign of?
Herpes Simplex Encephalitis
73
How is Herpes Simplex Encephalitis treated?
IV Aciclovir
74
How does a brain abscess present?
Raised ICP, focal neurological signs, fever
75
How is a brain abscess diagnosed?
CT head
76
How is a brain abscess treated?
Surgically - crainiotomy and debridement
77
What is progressive multifocal leukoencephalopathy caused by?
JC virus which causes widespread demyelination
78
What are some risk factors for PML?
Immunosuppression, autoimmune disease, MS drugs
79
How is PML investigated?
LP shows JC virus DNA
| MRI shows focal white matter lesions
80
What is Parkinsons disease?
Progressive neurodegenerative condition caused by degeneration of dopaminergic neurons in the substantia nigra
81
What is the biggest risk factor for Parkinson's Disease?
Age
82
What are the 3 main motor symptoms of Parkinson's Disease (Parkinsonism)?
Bradykinesia
Tremor
Rigidity
83
How does bradykinesia present in Parkinsons?
Slowness of movement with progressive loss of amplitude, decreased facial expression (mask like expression), soft speech, micrographia, shuffling gait, decreased arm swing
84
What is the tremor like in Parkinsons?
4-7hZ pill rolling resting tremor, worse when stressed/tired. Usually disappears when doing something
85
How does the rigidity present in Parkinsons?
Increased tone
86
What is cogwheel rigidity?
Felt at the wrist, the result of the tremor imposed on hypertonia
87
What are some non-motor symptoms of Parkinsons?
Anosmia, visual hallucinations, REM sleep disorder, depression, drooling, constipation
88
What is the first line treatment for Parkinsons if QOL is severely affected by motor symptoms?
Levodopa
89
What is the first line treatment for Parkinsons if QOL not severely affected by motor symptoms?
Dopamine agonist, levodopa or MAO-B inhibitor
90
What is a risk if a medication is missed in Parkinsons disease?
Neuroleptic Malignant Syndrome
91
How does neuroleptic malignant syndrome present?
Pyrexia, rigidity, tachycardia, increased CK, leucocytosis
92
How is neuroleptic malignant syndrome treated?
IV fluids and dantrolene
93
What are some side effects of levodopa?
Nausea and vomiting, dyskinesia, sudden off days, psychosis
94
What is an example of a dopamine agonist?
Ropinorole (non-ergo_
| Bromocriptine (ergo)
95
What are some side effects of dopamine agonists?
Daytime somnomelence, impulse disorders, pulmonary fibrosis
96
What is an example of an MAO-B inhibitor and how does it work?
Selegiline - inhibits dopamine breakdown
97
What is an example of a COMT inhibitor and when is it used?
Entacapone. Used in conjunction with levodopa to increase its effect (e.g. synimet)
98
How is psychosis treated in Parkinsons?
Quetiapine
99
How is an REM sleep disorder in Parkinsons treated?
Clonazepam/Melatonin
100
What is the presentation of essential tremor?
Symmetrical, postural tremor with a higher frequency than PD. Intensifies with use. Autosomal dominant
101
How does Multiple System Atrophy present?
Jerky, postural tremor, cerebellar signs, parkinsonism, pyramidal signs, urinary retention/incontinence, postural hypotension, impotence
102
How is MSA differed from PD?
Autonomic involvement
103
'MRI shows hot cross bin sign'
MSA - due to cerebellar and pontine atrophy
104
How does progressive supranuclear palsy present?
Parkinsonism plus psuedobulbar palsy, neck dystonia, supranuclear ophthalmoplegia, gait and balance issues
105
How does corticobasal degeneration present?
Rigidity and weakness of one limb, apraxia, loss of powerful movement, sensory disturbance
106
What is fragile X tremor ataxia syndrome and how does it present?
Late onset neurodegenerative disorder. Causes cerebellar ataxia, postural/intention tremor, dysautonomia and cognitive decline
107
What drugs may cause parkinsonism?
Antipsychotics, prochloperazine, metoclopramide, methyldopa
108
What is Wilson's disease?
Autosomal recessive disease of copper accumulation in liver and CNS
109
What neurological symptoms does Wilsons disease cause?
Psychiatric issues, decreased IQ, decreased memory, tremor, akinesia, ataxia, movement disorders
110
What is epilepsy?
Common neurological condition characterised by recurrent seizures
111
What conditions are associated with epilepsy?
Cerebral palsy, tuberous sclerosis, mitochondrial diseases
112
What are the two classifications of epilepsy onset?
Focal
| Generalised
113
Where does a focal seizure occur in the brain?
Starts in an area on one side of the brain (can spread though)
114
Where does a generalised seizure occur in the brain?
Both sides of the brain at onset
115
What can focal seizures further be classified by?
Awareness retained or impaired
116
What motor symptoms may be seen in focal seizures?
Jerking, twitching, stiffening etc
117
What non-motor symptoms may be seen in focal seizures?
Changes in sensation, emotions, smells, thinking, experiences
118
What motor symptoms may be seen in generalised seizures?
Tonic-clonic, myoclonic etc
119
What non-motor symptoms may be seen in generalised seizures?
Absence seizures - staring, changes in awareness, lip smacking
120
What may patients experience following a seizure?
Post-ictal phase - flaccid, unresponsiveness, drowsiness, headache
121
What investigations should be done following a patients first seizure?
ECG, EEG, MRI
122
When is drug treatment for epilepsy introduced?
After the patients second seizure
123
What is the first line treatment for generalised seizures?
Sodium valproate
124
What is the first line treatment for focal seizures?
Carbemazepine or lamotrigine
125
What is the other drug option for absence seizures?
Ethosuximide
126
How does sodium valproate work?
Increases GABA activity
127
What are side effects of sodium valproate?
Weight gain, alopecia, ataxia, tremor, hepatitis, teratogenicity, p450 inhibitor
128
How does carbamazepine work?
Binds to sodium channels
129
What are side effects of carbamazepine?
p450 enzyme inducer, dizziness, drowsiness, agranulocytosis, diplopia, SIADH
130
How does lamotrigine work?
Sodium channel blocker
131
What are side effects of lamotrigine?
Steven-Johnson-Syndrome
132
What are side effects of phenytoin?
P450 enzyme inducer, facial coursening, anaemia, neuropathy
133
What medication should be used in the community for status epilepticus? (>5mins)
Buccal midazolam or rectal diazepam
134
What medication should be used in hospital for status epilepticus?
IV lorazepam repeated if necessary
| IV phenobarbitol/phenytoin if ongoing
135
How long are you not allowed to drive for after first seizure?
Car - 6 months
| HGV - 5 years
136
How long are you not allowed to drive for once you have a diagnosis of epilepsy?
Car - 5 years
| HGV - 10 years
137
What should be done in patients who are wanting to concieve with epilepsy?
Swap from valproate to lamotrigine
| 5mg folic acid from trying to concieve until 12 weeks
138
What are red flag symptoms in headache?
```
New onset aged over 55
Known/previous malignancies
Immunosuppression
Early morning headache
Exacerbation by coughing (raised ICP)
```
139
What is a migraine caused by?
Neural and vascular influences cause changes in the brain, activating trigeminovascular dilatation. Chemicals released irritate blood vessels and nerves causing pain
140
What are the features of migraine without aura?
Unilateral, pulsatile, moderate/severe pain, nausea, vomiting, photophobia, phonophobia
Need 5 separate attacks of duration 4-72hrs
141
What are features of migraine with aura?
Recurrent attacks lasting minutes of unilateral fully reversible visual, sensory or other CNS symptoms then headache
142
What can trigger migraines?
Stress, sleep (too much or too little), trauma, sensory stimulation, certain foods, exercise, heat, dehydration
143
What is non-pharmacological management of migraine?
Avoid triggers, stress techniques, accupuncture
144
What is the acute management of migraine?
Simple analgesia first (aspirin/ibuprofen), triptan +/- antiemetic
145
When is prophylactic treatment for migraine considered?
If more than 3 attacks per month/severe
146
What is the prophylactic treatment of migraine?
Propranolol, amitriptyline
| 2nd line - topiramate
147
Who is cluster headache common in?
Young men, smokers
148
How does a cluster headache present?
Severe, unilateral headache, bloodshot red eyes, rhinorrhoea, lid swelling, lacrimation
149
How often and for how long to cluster headaches occur?
30mins-3hrs, 1-8 times a day
150
How are cluster headaches managed acutely?
Oxygen for 15-20 mins and subcut sumitriptan
151
What is given prophylactically for cluster headaches?
Verapamil
152
How does paroxysmal hemicrania present?
In elderly women. Unilateral headache and autonomic features
153
How often and for how long does paroxysmal hemicrania occur?
Lasts 2-45mins , 1-40 times a day
154
How is paroxysmal hemicrania treated?
Absolute response to indomethacin
155
What is a SUNCT?
Short lived (15-120s), unilateral, neuralgiform headache with conjunctival injections and tearing
156
How is SUNCT treated?
Lamotrigine, gabapentin
157
How does trigeminal neuralgia present?
Severe stabbing unilateral pain in V2/3 triggered by touch
158
How long and how often does trigemnial neuralgia occur?
1-90 seconds 10-100times a day
159
How is trigeminal neuralgia managed?
Carbemazepine
160
How does a tension headache present?
Recurrent, non-disabling, bilateral headache, described as a tight band, non pulsatile
161
How is a tension headache managed?
stress relief
162
What are features of a medication overuse headache?
Present for 15+ days of the month, developed or worsened by medication, psychiatric comorbidity common
163
How is medication overuse headache managed?
Remove cause, advise patients to take OTC pain relief no more than 6 days a month
164
How does temporal arteritis present?
Rapid onset unilateral headache, jaw claudication, tender, palpable pulseless temporal artery. Raised ESR
165
How is temporal arteritis managed?
Steroids
166
What is a stroke?
Acute onset focal neurology due to a disruption of blood supply to the brain
167
What are the two main types of stroke?
Ischaemic and haemorrhagic
168
What are risk factors for stroke?
Age, hypertension, smoking, hyperlipidaemia, DM, atrial fibrillation
169
What which type of stroke is more common?
Ischaemic (85%)
170
What are the two causes of ischaemic strokes?
Thrombotic and embolic
171
If symptoms of stroke last less than 24hrs what is it defined as?
TIA
172
What are the symptoms of a TACS?
Hemiparesis+/- hemisensory loss AND
homonymous hemianopia AND
higher cognitive dysfunction
173
What arteries does a TACS affect?
Anterior circulation - middle and anterior cerebral
174
What are symptoms of a PACS?
2 from
Hemiparesis +/- hemisensory loss
homonymous hemianopia
higher cognitive dysfunction
175
What arteries does a PACS affect?
Middle/anterior cerebral arteries
176
What are symptoms of a LACS?
One from
Hemiparesis
Purely sensory loss
Ataxic hemiparesis
177
What arteries does LACS affect?
Perforating arteries (e.g. thalamus, basal ganglia etc)
178
What are symptoms of POCS?
One from
Cerebellar/brainstem syndromes
LOC
Isolated homonymous hemianopia
179
What symptoms does lateral medullary syndrome cause?
Ipsilateral ataxia, nystagmus, nerve palsies
| Contralateral limb sensory loss
180
What symptoms does Webers syndrome cause?
Ipsilateral CNIII palsy
| Contralateral weakness
181
What does a basilar artery stroke cause?
Locked in syndrome
182
What score is used to assess stroke?
Rosier
183
What score is used to assess TIAs?
ABCD2
184
What is the initial investigation of stroke?
CT head to rule in/out haemorrhagic stroke
185
What other investigations should be done in suspected stroke?
Bloods (FBC, glucose, U&Es, LFTs, coag, lipids)
ECG, echo
Carotid doppler
186
What is the initial management of ischaemic stroke?
Thrombolysis - Alteplase
187
What is the time frame for thrombolysis?
4.5hrs
188
What antiplatelet should initially be started for ischaemic stroke and for how long?
Aspirin 300mg for 14 days
189
How is haemorrhagic stroke managed?
Clot evacuation, treat underlying cause, stop anticoagulants
190
What are the post-stroke preventative medications?
Clopidogrel 75mg lifelong
Statin lifelong
ACEi/ARB + diuretic to control blood pressure
191
If a stroke patient is found to have AF, what should they be put on and with what target?
Warfarin with target INR 2-3
192
What are some common stroke mimics?
Hypoglycaemia, migraine, SOL, post-ictal, demyelination, intracranial haemorrhage, functional
193
Where does a subarachoid haemorrhage occur?
Bleed in circle of willis with blood accumulating in the subarachnoid space
194
What are causes of SAH?
AVM, ruptured berry aneurysm (EDS, PCKD)
195
How does SAH present?
Thunderclap headache, collapse, LOC, meningism, focal neurology
196
What does CT show in SAH?
Grey areas with dark ventricles
197
If the CT is negative in suspected SAH what should you do?
LP
198
How is SAH managed?
Fluids, nimodipine to prevent vasospasm, endovascular clipping/coiling of artery
199
What vessels cause and where does a subdural haemorrhage occur?
Bridging vessels
| Between dura and arachnoid
200
What are risk factors for subdural haemorrhage?
Increased age, alcoholics, epilepsy, anti-coagulants
201
What is the cause of a subdural?
Trauma or commonly unable to recall an incident of trauma
202
What is the presentation of a subdural haemorrhage?
Fluctuating consciousness, mental slowing, sleepiness, dull headache, focal neurology
203
What does a subdural look like on CT?
Creset shaped haematoma
204
How is a subdural haemorrhage treated?
Burr hole craniotomy
205
What vessels and where does an extradural haemorrhage occur?
Middle meningeal artery, blood accumulates between the bone and the dura
206
What are causes of extradural haemorrhage?
Temporal bone fracture, history of head injury
207
How does extradural haemorrhage present?
Head injury then lucid period. Increasing headache and then sudden decline in conscioussness, confusion, seizures, vomiting, hemiparesis, focal neurology
208
What does a CT head show in extradural haemorrhage?
Biconvex haematoma (rugby ball shaped)
209
How is an extradural haematoma managed?
Clot evacuation and ligation of middle meningeal artery
210
What are common side effects of triptans?
Tightness of chest, feeling of heaviness, pressure
211
What diet may be helpful in epilepsy?
Ketogenic diet
212
What is the commonest psychiatric problem in PD?
Depression
213
What is cataplexy?
Sudden and transient loss of muscle tone in response to emotion
214
What is the classic triad of Wernickes encephalopathy?
Nystagmus, ataxia and confusion
215
What is the triad of normal pressure hydrocephalus?
Ataxia, urinary incontinence, dementia
216
Obese young female with headache and blurred vision
Idiopathic intracranial hypertension
217
What are features of syringomelia?
Wasting and weakness of arms
Loss of pain and temperature sensation
Loss of reflexes, upgoing plantars
218
How does degenerative cervical myelopathy present?
Loss of fine motor function of upper and lower limbs
219
'Unilateral tinnitus and deafness'
Acoustic neuroma
220
How is cervical myelopathy investigated?
MRI
221
What drug is used to manage Bells palsy?
Prednisolone
222
What is chronic inflammatory demyelinating polyneuropathy?
Antibody mediated demyelination of peripheral nerves
223
What is the commonest long term complication of meningitis?
Sensorineural hearing loss
