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NEUROLOGY Flashcards

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1
Q

What is a migraine?

A

Primary brain disorder, resulting from altered modulation of normal sensory stimuli - neuronal hyperexcitability
Causes aura for 15-30 min followed by unilateral, throbbing headache

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2
Q

Mechanism of migraine?

A 
Neurogenic basis
Wave of neuronal depolarisation followed by depressed activity from the occipital region across the cerebral cortex
Activation of trigeminal pain neurones
Cerebral oedema
Dilatation of vessels
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3
Q

Causes/triggers of migraine?

A 
Chocolate
Hangovers
Orgasms
Cheese
Oral contraceptives
Lie-ins
Alcohol
Tumult
Exercise
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4
Q

Symptoms of migraine without aura?

A

Photo/phonophobia
Motion sensitivity
Nausea/vomiting
Disabling pain - unilateral, throbbing

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5
Q

Symptoms of migraine with aura (25%)?

A

Visual aura - shimmering, zig zag lines, image fragmentation, possible hemaniopia
Tingling, dysphasia
Loss of motor control
Dizziness, vertigo

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6
Q

What is a hemiplegic migraine?

A

Causes hemiparesis with possible coma with the headache, rare

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7
Q

Treatment of migraine? (4)

A

NSAIDs
Triptans (5HT agonists) e.g. sumatriptan
Ergotamine as headache starts
Botulinum toxin type A last resort injections

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8
Q

When are triptans contraindicated?

A

IHD, coronary spasm, uncontrolled hypertension

Recent lithium or SSRI use

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9
Q

Prevention of migraine?

A

Remove triggers
Propanalol or amitriptyline or topiramate or CCBs 1st line
Valproate, pregabalin, gabapentin 2nd line

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10
Q

How do triptans work?

A

5HT agonists
Constrict arteries
Inhibit release of pro-inflammatory neuropeptides

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11
Q

What are the characteristics of a tension type headache?

A

Bilateral, non pulsatile headache, tight band sensation
Possible scalp muscle tenderness
No nausea or sensitivity to movement

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12
Q

How are tension type headaches treated?

A

Simple analgesics

Massage, ice packs, relaxation

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13
Q

Treatment of chronic tension headaches?

A

Tricyclic antidepressants

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14
Q

What is a cluster headache?

A

Recurrent bouts of excruciating pain lasting 30-90 minutes

Unilateral, retro-orbital

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15
Q

Cause of cluster headaches?

A

Possible superficial temporal artery smooth muscle hyperreactivity to 5HT
Hypothalamic grey matter abnormalities

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16
Q

Symptoms of cluster headaches? (3)

A

Excruciating pain around 1 eye
Watery eye, swollen, bloodshot
Rhinorrhoea

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17
Q

Frequency of cluster headaches?

A

Can occur multiple times a day, often at night

Clusters last 1-3 months and are followed by pain free periods of months before the next cluster

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18
Q

Treatment of cluster headache?

A

Oxygen for 15 min
Sumatriptan at onset
Preventative - steroid injections, verapimil, lithium, melatonin

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19
Q

What would cause acute single episode headache? (5)

A 
Meningitis/encephalitis
Trauma - intracranial haemorrhage
Venous sinus thrombosis
Sinusitis
Acute glaucoma
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20
Q

What would cause recurrent acute attacks of headache? (3)

A

Migraine
Cluster headache
Trigeminal neuralgia

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21
Q

What would cause headache of subacute onset?

A

Giant cell arteritis

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22
Q

What causes chronic headaches?

A

Tension headache
Raised ICP
Medication overuse headache

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23
Q

Features of raised intracranial pressure?

A

Worse on waking, lying, bending forward or coughing
Vomiting, papilloedema present
Exclude SOL
Consider idiopathic intercranial hypertension

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24
Q

What is trigeminal neuralgia?

A

Paroxysms of intense stabbing pain in the trigeminal nerve distribution

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25
Cause of trigeminal neuralgia?
Commonly starts in older age, hypertension main risk factor | Compression of the trigeminal nerve by intracranial vessels or a tumour, or inflammation
26
Symptoms of trigeminal neuralgia? (3)
Sudden attacks of knife like/electric shock pain lasting a few seconds Unilateral Commonly mandibular or maxillary divisions
27
Triggers of trigeminal neuralgia?
Washing face, shaving, eating, talking
28
Treatment of trigeminal neuralgia? (3)
Carbamazepine Or lamotrigine, phenytoin, gabapentin Surgery - microvascular decompression where vessels are separated from nerve root
29
What is giant cell (temporal) arteritis?
Systemic granulomatous arteritis that usually affects large and medium sized vessels Common in elderly, associated with polymyalgia rheumatica
30
Symptoms of GCA? (4)
Headache Temporal artery/scalp tenderness Jaw claudication Amaurosis fugax or sudden blindness in on eye
31
Treatment of GCA?
Start high dose prednisolone immediately to avoid irreversible vision loss
32
Investigations of GCA?
ESR and CRP high Platelets and alkaline phosphatase high, Hb low Temporal artery biopsy
33
What is a stroke?
Rapid onset of focal CNS signs and symptoms due to infarction or bleeding into part of the brain
34
Causes of stroke?
Ischaemic stroke - thrombosis of cerebral vessel, embolism | Haemorrhagic - intracerebral haemorrhage, subarachnoid haemorrhage
35
Risk factors for stroke? (10)
``` Age Male Family history Hypertension Smoking Diabetes Heart disease Peripheral vascular disease COCP Alcohol ```
36
What symptoms would more indicate a haemorrhagic stroke? (3)
Meningism Severe headache Coma
37
What symptoms would more indicate an ischaemic stroke? (4)
Carotid bruit Atrial fibrillation Past TIA IHD
38
Mechanism of an ischaemic stroke?
Embolus or thrombus cuts off the blood supply so oxygen can't reach the neurons, so they infarct causing symptoms dependent on site
39
Mechanism of a haemorrhagic stroke?
Bleed due to aneurysm or trauma or BP, accumulates and compresses surrounding tissue so loss of function but neurons still receive oxygen
40
Anatomical locations of stroke?
Cerebral Lacunar Brainstem
41
General symptoms of cerebral infarcts? (3)
Contralateral sensory loss or hemiplegia (initially flaccid then spastic - UMN) Dysphasia Homonymous hemianopia
42
General symptoms of brainstem infarcts? (3)
Quadriplegia Disturbances of vision Locked in syndrome
43
General symptoms of lacunar infarcts? (5)
``` Ataxic hemiparesis Pure motor Pure sensory Sensorimotor Dysarthria ```
44
Site of lacunar infarcts? (4)
Basal ganglia Internal capsule Thalamus Pons
45
Immediate management of stroke?
``` Protect airway Do pulse, BP, ECG - careful about treating BP as may cause fall in cerebral pressure Glucose CT/MRI urgent if thrombolysis considered Thrombolysis within 4.5hrs if ischaemic Aspirin 300mg when haemorrhagic excluded ```
46
What is used for thrombolysis in non-haemorrhagic stroke?
Alteplase - tissue plasminogen activator
47
Contraindications for thrombolysis? (7)
``` Past intracranial haemorrhage Seizures Major infarct or haemorrhage Recent surgery/trauma On anticoagulants or INR >1.7 Low platelets Very high BP ```
48
Primary prevention of stroke?
Control risk factors - hypertension, DM, high lipids (statins), cardiac disease Exercise Quit smoking Lifelong anticoagulation if left sided prosthetic valves, or if AF (warfarin)
49
Secondary prevention of stroke?
Control risk factors Clopidogrel (antiplatelet) after a stroke if no haemorrhage Warfarin (or NOAC) after stroke if AF - use antiplatelet until anticoagulated Aspirin instead of warfarin if lower risk
50
What is carotid endarterectomy?
Surgery to remove atherosclerotic plaque causing narrowing of the carotid artery Done when carotid Doppler ultrasound shows >70% stenosis
51
MDT management after a stroke? (5)
``` Stroke unit Feeding techniques Physiotherapy Home adaptations - occupational therapy Speech and language therapy ```
52
What is the CHA2DS2-VASc score?
``` Risk of stroke in patients with AF Congestive heart failure Hypertension Age >75 (2) Diabetes Stroke, TIA, VTE previously (2) Vascular disease Age >65 Sex - female ```
53
What is the HAS-BLED score?
``` Assess 1 year risk of major bleeding in patients with AF who are anticoagulated Hyperension Abnormal renal/liver function Stroke Bleeding Labile INR Elderly Drugs/alcohol ```
54
Give some NOACs and their disadvantage
Rivaroxaban Apixaban No antidote if bleed - warfarin has vitamin K
55
Where do the anterior cerebral arteries supply?
Medial side of the frontal/parietal lobes and anterosuperior part of the cerebrum - cerebrum, opthalmic artery
56
Where do the middle cerebral arteries supply?
Majority of the lateral cerebrum
57
Where do the posterior cerebral arteries supply?
Medial and lateral areas of the posterior cerebrum - occipital lobes, cerebellum, brainstem
58
What supplies Broca's and Wernicke's areas?
Broca - expressive speech, normally in dominant hemisphere (left hemisphere if right handed) Wernicke - receptive speech Middle cerebral artery
59
What is TACI and PACI?
Total and partial anterior circulation infarct Total - affects areas of the brain supplies by ACA and MCA Partial - only ACA
60
When are TACI and PACI diagnosed?
TACI is all 3, PACI is 2: Unilateral weakness +/- sensory deficit of face, arm, leg Homonymous hemianopia Higher cerebral dysfunction - dyphasia, visuospatial
61
What is a homonymous hemianopia?
Loss of half the field of view on the same side in both eyes
62
What does proximal infarction of the anterior cerebral artery cause?
Paraplegia of lower limbs Sensory loss Incontinence
63
What does distal infarction of the anterior cerebral artery cause?
Contralateral hemiplegia and hemisensory loss with upper limb/face sparing
64
What does occlusion of the middle cerebral artery cause?
Contralateral hemiplegia with lower limb sparing Contralateral hemisensory loss and hemianopia Dysphagia if dominant hemisphere
65
What is a posterior circulation infarct?
Damage to cerebellum, brainstem
66
Features of a POCI?
``` CN palsy Contralateral or bilateral motor/sensory deficit Cerebellar dysfunction - nystagmus, ataxia Homonymous hemianopia (isolated) ```
67
What is locked-in syndrome caused by?
Infarction of the basilar artery
68
What are the 4 types of stroke in the bamford classification?
TACI PACI POCI Lacunar syndrome
69
What is a TIA?
Sudden onset of focal CNS phenomena due to temporary occlusion of part of the cerebral circulation, usually by emboli, lasting <24hrs with no permanent damage
70
Cause of TIA?
Atherothromboembolism from the carotid artery Cardioembolism post MI or in AF Hyperviscosity - sickle cell, polycythaemia
71
Signs of TIA?
Mimic same arterial territory of stroke | Amaurosis fugax- transient loss of vision in one eye, like a curtain caused by retinal artery emboli
72
Tests in TIA?
``` FBC, ESR, U+E, glucose, lipids CXR ECG Carotid doppler USS CT/MRI ```
73
Treatment of TIA? (5)
Control CV risk factors - BP 140/85, statins, diabetes, stop smoking Clopidogrel antiplatelet/aspirin Warfarin if AF Carotid endarterectomy
74
What is ABCD2 score?
Used to predict risk of stroke after TIA Age >60 1 Blood pressure >140/90 1 Clinical - unilateral weakness 2, speech disturbance without weakness 1 Duration of symptoms - >1hr 2, 10-60 min 1 Diabetes 1 If >4 see stroke unit within 24hr
75
What is a subarachnoid haemorrhage?
Type of haemorrhagic stroke - spontaneous bleeding into the subarachnoid space
76
Causes of SAH?
Rupture of saccular aneurysms e.g. Berry | Arteriovenous malformations
77
Risk factors for SAH? (5)
``` Smoking Alcohol Hypertension Bleeding disorders Post menopausal loss of oestrogen ```
78
Common sites for Berry aneurysms?
Posterior communicating with the internal carotid Anterior communicating with the ACA Bifurcation of the MCA
79
Associated conditions with SAH?
Polycystic kidneys Coarctation of the aorta Ehler Danlos syndrome
80
Pathogenesis of SAH?
Release of blood into subarachnoid space leads to rise in ICP which may limit bleeding Bleed sealed by clot but large risk of rebleed
81
Symptoms of SAH?
Sudden painful THUNDERCLAP usually occipital headache | Vomiting, collapse, seizures, coma
82
Signs of SAH?
Neck stiffness Kernigs sign - meningism Retinal, vitreous bleeds Focal neurology
83
What is Kernigs sign?
Extension of knee painful when thigh flexed at hip
84
What is a sentinel headache?
SAH patients may have experienced earlier milder headache - warning leak from aneurysm
85
Tests for SAH?
CT - STAR SIGN | LP if CT negative
86
What does LP look like in SAH?
Bloody early on | Xanthochromic - yellow - after several hours due to breakdown of Hb
87
Management of SAH? (4)
Support - fluids, aim for BP >160 to maintain perfusion Nimodipine to reduce vasospasm Endovascular coiling - cathether/CT angiography Intracranial stents/balloon for large aneurysms
88
Complications of SAH? (4)
Rebleeding Cerebral ischaemia Hydrocephalus Hyponatraemia
89
What is the GCS?
Glasgow coma scale to assess level of consciousness
90
Components of the GCS?
EYE OPENING - none, to pain, to speech, spontaneous VERBAL RESPONSE - none, incomprehensible, inappropriate, confused, oriented MOTOR RESPONSE - none, extending, flexing, withdrawal, localising, obeying 15 = fully alert. 3= coma/death.
91
What is a subdural haemorrhage?
Bleeding from bridging veins between the cortex and venous sinuses - vulnerable to deceleration injury, resulting in accumulating haematoma between the dura and arachnoid
92
Pathogenesis of SDH?
Haematoma raises ICP Shifts midline structures away from the side of the clot Tentorial herniation and coning if untreated
93
Cause of SDH?
Trauma - particularly deceleration but can be minor/long ago trauma - up to 9 months Can occur from dural metastases
94
What are the cortical bridging veins?
Veins which drain the underlying neural tissue and puncture the dura mater to enter dural sinuses
95
Layers of meninges?
Skull - dura mater - arachnoid mater - pia mater - brain
96
Risk factors for SDH? (4)
Elderly - brain atrophy makes veins vulnerable Alcoholics Epilepsy Anticoagulation
97
Symptoms of SDH? (5)
``` Fluctuating level of consciousness Insidious physical/cognitive slowing Sleepiness Headache Personality change ```
98
Signs of SDH? (3)
Raised ICP Seizures Localising neuro symptoms late onset i.e. unequal pupils
99
Tests for SDH?
CT/MRI shows clot and midline shift | CRESCENT SHAPED BLOOD OVER 1 HEMISPHERE
100
Management of SDH?
Irrigation/evacuation - burr hole craniostomy
101
What is epidural haemorrhage?
Extradural bleed - between bone and dura - usually due to rupture of middle meningeal artery
102
Causes of EDH?
Fractured temporal or parietal bone lacerating MMA Typically after trauma to a temple lateral to the eye Tear in dural venous sinus
103
Clinical features of EDH? (5)
``` Deteriorating consciosness after head injury that initally had no loss of consciousness, or initial drowsiness that resolves LUCID INTERVAL hours/days Then decreased GCS from rising ICP Vomiting, fits, confusion, headache Brisk reflexes, upgoing plantar ```
104
Late features of EDH? (5)
``` Bilateral limb weakness Ipsilateral pupil dilation Coma Irregular breathing Death ```
105
Tests in EDH? (2)
CT BICONVEX rounded SHAPE from skull Skull XR may show fracture LP CONTRAINDICATED - decrease in ICP = herniation
106
Management of EDH? (2)
Stabilise | Clot evacuation +/- ligation of vessel
107
Features of frontal lobe damage? (4)
``` Personality change Loss of executive function Confabulation Motor problems Broca's aphasia ```
108
Features of temporal lobe damage? (5)
``` Vision problems Hallucinations Wernicke's aphasia Impaired memory/learning Deafness ```
109
Features of parietal lobe damage? (6)
``` Sensory loss Loss of proprioception Vision problems Dyslexia, dyscalcula Agnosia Spatial disorientation ```
110
Features of occipital lobe damage? (5)
``` Homonymous hemianopia Hallucinations Color agnosia Movement agnosia Blindness ```
111
Features of cerebellar damage?
``` DASHING Dysdiadochokinesis (impaired rapidly alternating movement) Dysmetria (past pointing) Ataxia Slurred speech Hypotonia Intention tremor Nystagmus Gait abnormality ```
112
What is cataplexy?
Sudden and transient episode of muscle weakness, triggered by emotions such as laughing or crying Normally coexists with narcolepsy
113
What is narcolepsy?
Irresistible attacks of inappropriate sleep, possibly with hypnogogic hallucinations and sleep paralysis
114
What is raised ICP?
Increase in the contents of the cranium
115
Causes of raised ICP? (6)
``` Tumours Head injury Haemorrhage Infection Hydrocephalus Cerebral oedema ```
116
Signs/symptoms of raised ICP? (5)
``` Headache worse on coughing, leaning forward Vomiting Altered GCS - drowsy Falling pulse and rising BP Papilloedema ```
117
Investigation of raised ICP?
Bloods, CXR CT head LP if safe
118
Management of raised ICP? (5)
``` Stabilise - if intubated, hyperventilate Mannitol - osmotic agent Corticosteroids if oedema Neurosurgery if focal cause such as bleeding - craniotomy Treat cause ```
119
What is hydrocephalus?
Accumulation of CSF in the brain, causing raised ICP Can be congenital or caused by infection, tumour, trauma Drain
120
What is neurofibromatosis?
``` Genetic disorder (autosomal dominant) causing benign tumours to form on nerve tissue, Nf1 and Nf2 NF1 much more common ```
121
Diagnosis of NF1? 2 of...
``` >6 cafe au lait spots >2 neurofibromas Freckling of axillae or inguinal regions Optic glioma >2 lisch nodules Distinctive osseous lesion i.e. sphenoid dysplasia First degree relative with NF1 ```
122
What are cafe au lait spots?
Flat, coffee coloured patches of skin seen in 1st year of life, increasing in size and number with age
123
What are neurofibromas?
Dermal - small gelatinous nodules, may itch | Nodular - arise from nerve trunks, firm, clearly demarcated, may cause paraesthesia
124
What are lisch nodules?
Brown/translucent mounds on the iris
125
Complications of NF1? (6)
``` Learning disability Nerve root compression GI bleeds Scoliosis Renal artery stenosis Malignancy - optic glioma, sarcoma ```
126
Management of NF1? (3)
MDT Yearly cutaneous survey and BP Can excise some troubling lesions
127
Diagnosis of NF2?
Bilateral vestibular Schwannoma on MRI/CT AND First degree relative with NF2 with Either unilateral vestibular Schwannoma, or one of Neurofibroma/meningioma/glioma/schwannoma
128
What is a Schwannoma?
Schwann cell tumour - vestibular is on vestibular nerve (=acoustic neuroma) affecting balance and hearing Sensorineural hearing loss
129
Complications of NF2?
Tender Schwannomas of cranial/peripheral nerves | Meningiomas, gliomas
130
Management of NF2?
Hearing tests annually MRI brain if hearing problems Surgery for vestibular Schwannomas
131
Features of encephalitis?
Odd behaviour, decreased consciousness, focal neurology or seizure Preceded by infectious prodrome, usually viral
132
Causes of encephalitis?
Viral - HSV, CMV, EBV, VZV | Non viral - bacterial meningitis, TB, malaria
133
Tests for encephalitis? (5)
Blood cultures, throat swab, MSU CT with contrast LP - increased protein, WCC, decreased glucose EEG
134
Management of encephalitis? (3)
Aciclovir IV for 2 weeks Supportive Symptomatic - phenytoin for seizures
135
Emergency features of meningitis? (4)
Headache Pyrexia Neck stiffness Altered mental state
136
Common causative organisms of meningitis?
Neisseria meningitidia or streptococcus pneumoniae
137
Early features of meningitis? (4)
Headache Leg pains Cold peripheries Abnormal skin colour
138
Late features of meningitis? (5)
``` Meningism Decreased consciousness Seizures Non blanching purpuric rash Signs of sepsis ```
139
What are signs of meningism? (3)
Neck stiffness Photophobia Kernigs sign
140
Signs of sepsis?
``` Temp >38 or <36 Tachycardia >90 Resp rate >60 High or low WBC Presence of infection ```
141
Management of meningitis?
IM Benzylpenicillin in community Cefotaxime IV Rifampicin for contacts
142
What is Horner's syndrome?
Triad of miosis (pupil constriction), partial ptosis (drooping upper eyelid), anhydrosis (ipsilateral loss of sweating)
143
Cause of Horner's syndrome?
Interruption of facial sympathetic supply | e.g demyelination, thoracic outlet obstruction (lung tumour)
144
What is bulbar palsy?
Diseases of the nuclei of the cranial nerves 9-12 in the medulla
145
Signs of bulbar palsy?
``` LMN lesion of tongue and muscles of talking and swallowing Flaccid fasciculating tongue Jaw jerk normal/absent Quiet, hoarse speech Difficulty chewing, choking ```
146
Causes of bulbar palsy? (4)
MND Guillian Barre MG Brainstem tumours
147
What is corticobulbar palsy (pseudobulbar)?
UMN lesion of the muscles of talking/swallowing
148
Cause of corticobulbar palsy? (3)
Bilateral lesions above the mid pons - MS, MND, stroke
149
Signs of corticobulbar palsy? (6)
``` Slow tongue movements Slow deliberate speech Increased jaw jerk Increased pharyngeal/palatal reflexes Weeping unprovoked Incongruent giggling ```
150
What is Bells palsy?
Abrupt onset of complete unilateral facial weakness - CN 7 - and other symptoms, diagnosis of exclusion
151
Symptoms of Bells palsy? (8)
``` Facial weakness Numbness/pain around ear Hypersensitivity to sound Decreased taste Sagged mouth one side, upturned the other Drooling Speech difficulty Watery eye ```
152
Tests in Bells palsy?
Bloods (viral antibodies) MRI (SoL, stroke, MS) Nerve conduction tests
153
Management of Bells palsy? (5)
Most fully recover spontaneously Prednisolone within 72hr speeds recovery Protect eye - dark glasses, artificial tears if drying, tape to close at night Surgery if eye closure is long term problem Plastic surgery if no recovery Botulinum toxin
154
What is Guillain Barre syndrome?
Acute inflammatory demyelinating polyneuropathy | Most common acute polyneuropathy
155
Cause/mechanism of GBS? (3)
Immune mediated, post infectious Campylobacter jejuni, CMV, EBV... Infection causes antibodies that attack nerves
156
Symptoms of GBS? (5)
1-3 weeks after an infection, symmetrical ascending muscle weakness in limbs Paralysis Proximal muscles more affected - trunk, resp, CNs Back pain, limb pain Sweating, arrhythmias Progressive phase 4 weeks then recovery
157
Investigations for CBS? (2)
Nerve conduction studies - slow | LP - high protein
158
Management of GBS? (3)
Ventilatory support if respiratory paralysis IV immunoglobulin for 5 days Possible plasma exchange
159
Prognosis of GBS?
85% recover, 10% unable to walk at 1 year, 10% overall mortality
160
What is Parkinsonism?
Triad of tremor, rigidity and bradykinesia
161
What type of tremor is common in Parkinson's?
Pill rolling of thumb over fingers | Worse at rest
162
What type of rigidity is common in Parkinson's?
Cogwheel rigidity - jerking stop-start during passive movement Increased when asked to perform an action with the opposite limb Leadpipe rigidity - sustained stiffness
163
What features of bradykinesia are common in Parkinson's?
Slow to initiate movement Slow, low amplitude repetitive actions i.e. blinking Mask like expressionless face
164
What is the typical Parkinson's gait?
Reduced arm swing Shuffling steps with flexed trunk Freezing at obstacles/doors
165
Causes of Parkinsonism?
``` Antipsychotics Parkinson's disease HIV Post flu encephalopathy Trauma ```
166
What is Parkinson's disease?
Extrapyramidal movement disorder characterised by resting tremor, rigidity and bradykinesia
167
Motor symptoms of PD? (6)
``` Cogwheel rigidity Pill rolling tremor Postural instability Shuffling gait Reduced arm swing Difficulty initiating movement ```
168
Non motor symptoms of PD? (9)
``` Reduced smell Constipation Hallucinations Frequency/urgency Drooling Depression REM sleep disorder Dementia Mask like expression These can present years before motor symptoms. ```
169
Peak age of onset of Parkinsons?
65
170
Risk factors for Parkinsons? (4)
``` Age Male Pesticides Genetics if early onset NON SMOKERS ```
171
Pathology of Parkinsons?
Mitochondrial DNA dysfunction causes degeneration of dopaminergic neurons in the substantia nigra, associated with lewy bodies Decreases striatal dopamine levels
172
Management of Parkinsons?
Exercise Medications Treat neuropsychiatric complications e.g. depression, dementia Deep brain stimulation Surgical ablation of overactive basal ganglia circuits
173
What genes are associated with early onset Parkinsons?
PARK 1-11 genes
174
What are Lewy bodies?
Tangles of alpha synuclein and ubiquitin
175
What medical therapy is used in Parkinson's? (5)
``` Levodopa with dopa-decarboxylase inhibitor Dopamine agonists Anticholinergics - help tremor MAO-B inhibitors COMT inhiibtors ```
176
What is levodopa? Side effects?
Dopamine precursor, replacing lost dopamine Dyskinesia, on/off effect, psychosis Efficacy decreases with time and need bigger doses, with more side effects
177
What is levodopa given with?
Dopa-decarboxylase inhibitor prevents PERIPHERAL metabolism of levodopa into dopamine
178
Give some dopamine agonists, why are they used?
Ropinirole, bromocriptine | Can delay starting l-dopa and allow lower doses of it
179
What is apomorphine?
Strong dopamine agonist | Even out end of dose effects
180
What are MAO-B inhibitors?
Rasagiline | Inhibit dopamine breakdown, alternative to dopamine agonists
181
What are COMT inhibitors?
Entecapone | Lesson off time in end of dose effects, inhibit dopamine breakdown
182
What is Parkinson's plus syndrome?
Parkinson's disease features, with atypical features and poor response to l-dopa
183
What is Huntingtons disease?
Autosomal dominant progressive neurodegenerative disorder presenting in middle age
184
Early symptoms of Huntingtons disease? (3)
Irritability Depression Poor coordination
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Later symptoms of Huntingtons disease? (4)
Chorea Dementia Fits Death within 15 years
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Pathology of Huntingtons disease?
Atrophy and neuronal loss of striatum of basal ganglia and cortex Genetics - expansion of CAG repeat on chromosome 4
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What is chorea?
Excessive irregular movements flitting from one body part to another - dance like
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What is genetic anticipation?
Found in trinucleotide repeat disorders | Successive generations have earlier onset and more severe disease
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Management of Huntingtons?
Genetic testing and counselling No treatment affects progression - possible antipsychotics Tetrabenazine for movement Antidepressants
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What is myasthenia gravis?
Autoimmune disease mediated by antibodies to nicotinic acetylcholine receptors interfering with the neuromuscular junction
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Mechanism of mysasthenia gravus?
Antibodies to nicotinic acetylcholine receptors Deplete working post-synaptic receptor sites at the neuromuscular junction Prevents the end plate potential becoming large enough to trigger muscle contraction
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Antibodies in myasthenia gravis?
ACh-R (against acetylcholine receptor? | MuSK (against muscle specific receptor kinase)
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Associations of myasthenia gravis?
If under 50, commoner in women and other autoimmune diseases and thymic hyperplasia If over 50 commoner in men and associated with thymic atrophy, RA, SLE
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Presentation of myasthenia gravis? (7)
Increasing muscular fatigue Ptosis Diplopia Myasthenic snarl (corners of mouth cant pull up) Peek sign (separation of eyelids when eyes closed) Voice fades when talking Wasting long term
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Order of muscles affected in myasthenia gravis? (6)
``` Extraocular Bulbar (chewing/swallowing) Face Neck Limb girdle (hips/shoulders) Trunk ```
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Investigations of myasthenia gravis? (5)
Antibodies - Anti-AChR, MUSK Decreased muscle response to repetitive nerve stimulation CT thymus Ice test - ptosis improves by >2mm after ice to shut lid Tensilon test - give edrophonium and weakness improves if MG
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Treatment of myasthenia gravis? (3)
Symptom control - anticholinesterase (pyridostigmine) Relapses with prednisolone, possibly with azathioprine/methotrexate (immunosuppress) Thymectomy if <50 and badly controlled disease
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Why give anticholinesterases in myasthenia gravis?
Prolongs acetylcholine action by inhibiting cholinesterase
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What is a myasthenic crisis?
Weakness of the respiratory muscles during a relapse, triggered by lack of medication, infection, stress
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Management of a myasthenic crisis?
Ventilatory support Give plasmapharesis/IB immunoglobulins Treat trigger i.e. infection

3A REVISION (17 decks)

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